Tuesday, December 1, 2009

Exercise Therapy Best for Knee Pain

For patients with severe knee pain, supervised exercise therapy is more effective at reducing pain and improving function than usual care, finds a study published on bmj.com.

Patellofemoral pain syndrome is a condition in which pain occurs at the front of the knee during or after exercise and is a common reason to visit the doctor. Women are more likely to be affected than men, and symptoms usually start during adolescence when participation in sporting activities is high.

General advice is to rest during periods of pain and to avoid pain provoking activities. This "wait and see" approach is considered usual care.

A recent study reported only limited evidence for the effectiveness of exercise therapy with respect to pain reduction, while there is conflicting evidence with respect to functional improvement.

So researchers based in the Netherlands investigated the effectiveness of supervised exercise therapy compared with usual care in 131 patients aged between 14 and 40 years with patellofemoral pain syndrome.

A total of 131 participants were included in the study, 65 to a supervised exercise program (intervention group) and 66 to usual care (control group). Both groups received similar written information about the syndrome and similar instructions for home exercises, as well as advice to refrain from painful activities.

Patients rated their recovery, pain at rest, pain on activity, and function scores at the start of the study and again at three and 12 months.

After three months, the intervention group reported significantly less pain and better function than the control group. At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain at rest and pain on activity, but not function.

A higher proportion of patients in the exercise group than in the control group reported recovery (42% v 35% at three months and 62% v 51% at 12 months), but these results were not significantly different between the two groups.

This study provides evidence that supervised exercise therapy for patellofemoral pain syndrome in general practice is more effective than usual care for pain at rest, pain on activity, and function at three and 12 months, say the authors. However, supervised exercise therapy had no effect on perceived recovery.

Further research is needed to understand how exercise therapy results in better outcome, they conclude.

Tuesday, November 24, 2009

Causes of ‘Runner’s Knee’

From professional athletes to weekend warriors, the condition known as “runner’s knee” is a painful and potentially debilitating injury suffered by millions of people – although until now, it has been unclear just what causes it.
But new research from the University of North Carolina at Chapel Hill has zeroed in on what appear to be the main culprits of the condition, formally known as patellofemoral pain syndrome.
The study is believed to be the first large, long-term project to track athletes from before they developed runner’s knee, said study co-author Darin Padua, Ph.D., associate professor of exercise and sport science in the UNC College of Arts and Sciences.
“Earlier studies have usually looked at people after the problem sets in,” Padua said. “That means that while previous research has identified possible risk factors related to strength and biomechanics, it’s been unclear whether those caused the injury, or whether people’s muscles and the way they moved changed in response to their injury.”
The research appears in the November issue of the American Journal of Sports Medicine.
Runner’s knee – the bane of many types of exercise, from running to basketball to dance – affects one in four physically active people. If unchecked, it can lead to more serious problems such as patellofemoral osteoarthristis.
“Patellofemoral pain syndrome can be devastating,” said Padua. “The pain can severely curtail a person’s ability to exercise and the symptoms commonly reoccur. That said, athletes often have a high pain threshold and may ignore it. But if they do, their cartilage may break down – and if that gets to the point of bone on bone contact, nothing can be done to replace the damaged cartilage.”
Padua and his colleagues studied almost 1,600 midshipmen from the United States Naval Academy. Researchers analyzed participants’ biomechanics when they first enrolled at the academy, then followed them for several years to see if they developed patellofemoral pain syndrome.
A total of 40 participants (24 women and 16 men) developed the syndrome during the follow-up period. The study found:
• Participants with weaker hamstring muscles were 2.9 times more likely to develop the syndrome that those with the strongest hamstrings
• Those with weaker quadriceps muscles were 5.5 times more likely
• Those with a larger navicular drop (a measure of arch flattening when bearing weight) were 3.4 times more likely
• Participants with smaller knee flexion angle (those whose knees bent less on landing during a jump test) were 3.1 times more likely
Padua said the pain associated with the condition could be explained by those different factors coming together to create a focal point of pressure between the kneecap and the underlying bone.
“Overall, these people generally have weaker quads and hamstrings. As a result, they don’t bend their knees as much when doing task, such as running or jumping. That means the contact area between the kneecap and the femur is smaller, so pressure is focused and pinpointed on a smaller area.
“Also, the more a person’s arch falls when bearing weight, the more their whole leg may rotate inwards. That will mean their kneecap won’t track properly, leading to yet more pressure and more potential pain.”
Padua said the good news is that the study appears to confirm that if people can change the way they move and improve their leg strength, they can prevent or correct the problem.
Everyday athletes can also spot for themselves whether they are at risk: if their knee crosses over the big toe when squatting; the arches of their feet collapse when landing from a jump; and if they do not bend their knees much when they land, they stand a greater chance of developing the syndrome, Padua said.
The researchers are now looking into which exercises are best for improving the biomechanics involved. They have also developed a simple screening tool, called LESS (Landing Error Scoring System), for identifying people most at risk of runner’s knee and similar conditions, and of suffering ACL (anterior cruciate ligament) injuries.

Thursday, September 17, 2009


A study comparing images of the knees in people who did and didn’t have previous injuries to the anterior cruciate ligament suggests that people who tore their ACLs are more likely to have a smaller ligament than do similarly sized people who have never injured a knee.

Researchers calculated the total volume of the ligaments based on magnetic resonance images of human knees. The ACLs among those with previous injuries were, on average, about 10 percent smaller than were ACLs among those without an injury.

In those with previous injuries, the uninjured ACL in the opposite knee was measured for the study. Their ligaments were compared to the ACLs in uninjured people of similar height and weight.

Those who had torn their ACLs had experienced noncontact injuries, meaning the injury occurred during some sort of movement of the body rather than because of a blow to the knee.

Researchers caution that the retrospective study does not mean that a smaller ACL will necessarily result in injury. Instead, they say the research offers more clues about the variety of factors – such as activity level, neuromuscular coordination, gender and muscle strength – that appear to be contributors to ACL injury.

In this group of participants, weight was the strongest predictor of ACL volume.

“If you compared two people of the same weight, based on our data set, we would expect the injured person had the smaller ACL,” said Ajit Chaudhari, assistant professor of orthopedics at Ohio State University and lead author of the study.

Knowing that the knee’s anatomy can influence susceptibility should help researchers who are trying to figure out why ACL injuries occur and who is most likely to experience these injuries, Chaudhari said. Most study results guide the assignment of a percentage of risk to one or more factors associated with torn ACLs, but to date no research had looked solely at the size of the ligament in injured and non-injured knees.

The research is published in a recent issue of the American Journal of Sports Medicine.

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“If you have a weaker ACL, it’s more likely to tear if all other factors are equal,” he said. “If being larger in size means the ACL has more fibers, then that would make it stronger. If the individual building blocks are of similar strength, then it comes down to how much total tissue there is.”

The anterior cruciate ligament, responsible for rotational stability in the knee, is located behind the kneecap and is one of four ligaments that join the thigh and shin bones. Noncontact tears of the ACL tend to occur in athletes when they pivot, stop quickly or land from a jump. Previous research suggests that college-age women athletes are at three- to 10-times higher risk of tearing their ACLs than their male counterparts, depending on the activity, but scientists have not determined why this is.

“Comparisons of the volumes of ACLs between men and women have been done, which have suggested that ACL volume may matter. Studies have also found that female ACLs had fewer fibers than male ACLs that were tested. But even with those findings, any differences between males and females could be a coincidence. There are so many variables that interact that you can’t really tell what’s causative unless you compare people who have had an injury to those who haven’t had an injury,” said Chaudhari, also director of Ohio State’s Sports Biomechanics Laboratory.

He and colleagues took MR images of the knees of 54 participants, who were divided into two groups. Volunteers with previous injuries were matched with uninjured participants of the same age, gender, height and weight.

The previously injured participants’ healthy knees were imaged for the study. Chaudhari said the fibers of a torn ACL tend to fray like a rope, meaning the volume of injured ACLs could not be measured in a meaningful way. Chaudhari recently presented related research that indicated that there is no significant difference in the size of two ACLs in the same body.

Researchers used the MR images to determine the outline of each ACL under the guidance of an orthopedic surgeon experienced in operating on injured knees. They validated this method of determining ACL volume by practicing the measurement technique on five pig knees obtained from a butcher.

Of the 27 injured participants, 16 had smaller ACLs than their matched controls. Overall, the injured group had an average ACL volume of 1,921 cubic millimeters, while the control group had an average volume of 2,151 cubic millimeters.

In this group of participants, weight and height were strongly correlated as potential variables affecting the size of the ligament.

Chaudhari said that based on what is currently known about the fibrous makeup of the ligament, it’s no surprise that a smaller ACL is more susceptible to injury.

“If you have a weaker ACL, it’s more likely to tear if all other factors are equal,” he said. “If being larger in size means the ACL has more fibers, then that would make it stronger. If the individual building blocks are of similar strength, then it comes down to how much total tissue there is.”

It’s too soon to consider knee imaging as a way to screen potential athletes, Chaudhari said, because of the high expense and the fact that knowing the size of the ACL still doesn’t tell the whole story of how the knee will react to activity.

“I would certainly not say in any way, shape or form that people should start using ACL size as a determinant of whether they should play any sport,” he said.

But what it does tell researchers is that there might be more than one way to go about trying to prevent knee ligament injuries. While many prevention efforts focus on the strength of muscles surrounding the knee, Chaudhari and other researchers hope to study whether the ACL itself can be made stronger, or larger, or both, while a child is still growing and developing.

Thursday, August 13, 2009

Blood Clots Follow Knee Replacement!

Scientists Find New No-Needle Approach to Prevent Blood Clots
Researchers test new treatment to prevent clots, save lives after joint replacement; Results in latest issue of New England Journal of Medicine
OU Public Affairs

Oklahoma City, OK -- OKLAHOMA CITY – The dean of the University of Oklahoma College of Public Health and a team of scientists worldwide have found a better way to prevent deadly blood clots after joint replacement surgery – a major problem that results in thousands of unnecessary deaths each year. The research appears this week in the New England Journal of Medicine.

The research team, which includes scientists from Oklahoma, Denmark, Australia and Canada, set out to find a better way to prevent blood clots without increasing the risk of bleeding. Blood clots, known as deep-vein thrombosis (DVT), affect the large veins in the lower leg and thigh. If the clot breaks free and moves through the bloodstream, it can lodge in the lungs, a condition known as pulmonary embolism (PE), which is often fatal. Pulmonary embolism is the most common preventable cause of sudden death after surgery.

Current preventive treatments include uncomfortable injections and one oral anti-clotting medicine that is difficult for patients and physicians to manage. Researchers wanted to find something better.

In a double-blind study of more than 3,000 patients, researchers tested a new type of anti-clotting drug called Apixaban, which is an oral medication. The medicine proved just as effective at preventing blood clots and reduced the risk of bleeding by half. Most importantly for patient convenience, it was much easier to use.

“This is a major step in our fight to prevent DVT and the many unnecessary deaths each year caused by blood clots after joint replacement surgery. We now have a better treatment that reduces the risk of bleeding, and a patient no longer has to endure injections by needle,” said Gary Raskob, Ph.D., a lead researcher on the project and dean of the OU College of Public Health.

Raskob, who is a renowned expert in the field, said as our population ages, the number of hip and knee replacements will skyrocket in the coming years, so an easier to use and safe preventive medicine is essential. According to the American Academy of Orthopaedic Surgeons, more than 700,000 primary total hip and knee replacements are performed each year in the United States, and that number is expected to grow to more than 3.5 million by 2030.

On average, 1 percent to 3 percent of people undergoing total joint replacement will end up with a symptomatic deep-vein thrombosis (blood clot in the legs) or a pulmonary embolism (a blood clot in the lungs).

Apixaban is now being studied in Phase III clinical trials and, if approved by the U.S. Food and Drug Administration, will be an important option for patients having joint replacement surgery.

Thursday, July 16, 2009

Hip exercises fight osteoarthritis in the knee joints

Study to assess hip exercises as treatment for osteoarthritis in the knee joints

Goal is to prevent the disease from progressing

Researchers at Rush University Medical Center are testing a novel regimen of hip-muscle exercises to decrease the load on the knee joints in patients with osteoarthritis. The goal is not only to relieve pain but also, possibly, to halt progression of the disease.

"Each time you take a step, a load, or force, is placed on the knee joints. How much load depends not just on your weight, but also on the way you walk and the alignment of your leg," said Laura Thorp, PhD, assistant professor of anatomy and cell biology at Rush Medical College and principal investigator for the study. "If we can appropriately alter the gait patterns of patients with osteoarthritis, we can minimize the load and relieve pain.

"Ultimately, we're hoping we can prevent the disease from advancing. No treatment currently exists that can stop osteoarthritis from progressing in the knees, other than joint replacement surgery."

Osteoarthritis is the most common form of arthritis and a significant source of disability and impaired quality of life. A higher-than-normal load on the knees during walking is a hallmark of the disease, associated with both the severity of the osteoarthritis and its progression, according to Thorp.

Thorp is enrolling patients with mild to moderate osteoarthritis in their knees in a research study to determine the effectiveness of certain hip exercises in treating the disease. Study participants have their knees x-rayed and undergo an initial assessment in Rush's Human Motion Laboratory to measure the load on their knee joints while walking. Participants then follow a specific regimen of hip exercises for four weeks under the direction of Charles Cranny, clinical manager of outpatient physical therapy.

The exercises focus on strengthening the hip abductor muscles, such as the gluteus medius, a broad, thick, radiating muscle that helps to stabilize the pelvis during ambulation. In patients with osteoarthritis in the knees, these muscles tend to be weak, causing the pelvis to tilt toward the side of the swing leg when walking, instead of remaining level with the ground, which increases the load on the knee joints. Strengthening these muscles helps the pelvis and the knee remain in better alignment, and thereby lessens the load.

After the four weeks of supervised physical therapy, participants are reassessed to determine whether the load on the knees has decreased, and whether the pain has subsided.

The trial continues for another four weeks, with patients exercising at home to determine whether the adjustments in gait can be maintained.

According to Thorp, exercise regimens to date have focused largely on strengthening the quadriceps and hamstring muscles, which stabilize the knee joint but likely do little to correct alignment with the rest of the leg or alter the load on the joint.

Preliminary evidence in the present trial has already shown that a decrease in load is attained with hip-muscle exercises.

"By lessening the load on the knees, we can remove one of the major known risk factors for the progression of osteoarthritis," Thorp said.

Monday, April 13, 2009

Osteoarthritis of the Knee: A Guide for Adults

1. Introduction
Treatments for osteoarthritis of the knee can help reduce pain. They can also help you stay active. Most people can find a treatment plan that works for them. A combination of treatments often works best.

This guide can help you learn about options. It can help you come up with a treatment plan that works for you. This guide covers ways to help you feel better. It also covers research about treatments that usually don’t help.

2. About Osteoarthritis
Osteoarthritis is common in the knee joint. It happens when cartilage in the joint wears down.

Cartilage is a rubbery tissue at the end of bones that allows the joint to move easily. With osteoarthritis, cartilage breaks down over time. The knee can become painful, stiff, and swollen.

The knee contains a small amount of fluid that lubricates the cartilage. It also helps cushion the joint. With osteoarthritis, this fluid does not work as well, so it can be hard to move your joints.

3. Fast Facts for Treatments That Help
Fast Facts on Pain Relievers
There is no cure for osteoarthritis.
Staying active and losing weight are ways to help you feel better.
Some people need to take pain medicine to stay active and control the pain.

4. Treatments That Help
Getting active and staying at a healthy weight are important for everyone with osteoarthritis of the knee. Some people also may need to take pain medicine to help lower pain and keep them moving.

Getting Active
Exercise is a great way to improve your health. You may think that exercise is not good for osteoarthritis. But it is. Being more active and staying active can help you have less pain and move more easily.

Walking, swimming, and water aerobics are good choices for people with osteoarthritis. Talk with your doctor or nurse about making an exercise plan that works for you.

Your doctor also may recommend physical therapy. Physical therapy is a special exercise program done with a trained professional. The exercises help you move and be flexible. They also can help reduce knee pain.

Getting to a Healthy Weight
Losing weight can help take the stress off of your knees. Each pound lost will help. Staying at a healthy weight can help keep you more active and moving.

Pain Medicine
Medicines can help relieve the pain of knee osteoarthritis. Some people need to take pain medicine to stay active. There are pain medicines that work for osteoarthritis. Your doctor or nurse may recommend over-the-counter or prescription drugs.

If you want to learn more about choosing pain medicine for osteoarthritis, the Agency for Healthcare Research and Quality has published another guide that may be useful to you. That guide is called Choosing Pain Medicine for Osteoarthritis: A Guide for Consumers (2007).

5. Fast Facts for Treatments That Usually Do Not Help
Fast Facts for Treatments That Usually Do Not Help
Glucosamine and chondroitin usually do not reduce pain or improve knee movement.
Joint lubricant shots (not the same as cortisone shots) usually do not reduce pain or improve knee movement.
Arthroscopic knee surgery usually does not reduce pain or improve knee movement.

6. Treatments That Usually Do Not Help
This information comes from a government-funded review of research about three treatments for osteoarthritis of the knee. Research shows that these treatments often do not help people who have knee osteoarthritis.

Glucosamine and Chondroitin
Glucosamine and chondroitin are nutritional supplements. People take them to help build new cartilage. Glucosamine and chondroitin are not regulated as drugs in the United States, so their quality may vary. Minor side effects include upset stomach, diarrhea, and headache.

Research studies tell us that more than half the people with osteoarthritis taking glucosamine and chondroitin improve. They have less pain and better movement. But in these studies, the same number of people who do not take the supplements also improve. This means that glucosamine and chondroitin are not the reason that some people improve.

Joint Lubricant Shots
Joint lubricant shots are not the same as cortisone shots. In this treatment, a gel-like material is given by a shot into the knee joint. Usually three to five shots are given over a few weeks. It is also called viscosupplementation (VIS-co-SUP-luh-men-TAY-shun).

Possible side effects from joint lubricant shots include minor infection, pain, and swelling. These side effects last a short time and go away without treatment. It is rare, but these shots also can cause swelling and pain that do not go away on their own. This happens with about 2 out of 100 people who get the shots. If it happens, medicines or another procedure may be needed.

Many research studies have compared people getting the shots with those who do not. These studies have found that most people getting the shots do not have much improvement. The shots usually do not reduce pain or improve knee movement.

Arthroscopic Surgery for Osteoarthritis
Arthroscopic (ahr-thruh-SKOP-ik) knee surgery is a minor surgery. Doctors insert a flexible tool into the knee joint. They then rinse the joint. Sometimes they smooth out the cartilage and remove loose pieces. Possible problems can happen after surgery, like pain, swelling, and infection. Blood clots in the legs also can happen.

Research shows that arthroscopic knee surgery usually does not reduce the pain of knee osteoarthritis. Doctors may use arthroscopic surgery for other types of knee problems, like sports injuries. It is sometimes helpful for those problems but not for knee osteoarthritis.

7. Things to Think About
Am I getting the right amount of exercise?

A small increase in activity several times a week can increase your strength and help with osteoarthritis symptoms.
The goal is to help with joint movement. Exercise does not need to be difficult. What’s important is to get moving.
Find a kind of exercise that fits your lifestyle.
How can I get the most out of my doctor visits?

Plan for the visit by writing down what you want to talk about.
Make sure your doctor or nurse knows all the medicines, vitamins, and supplements you take.
Take a list of questions you want to ask.
What should I ask my doctor or nurse?

How bad is my knee osteoarthritis?
What options are available to decrease my knee pain?
How will this treatment help me?
How will I know the treatment is working?
What are all the possible side effects?

8. Source
The information in this guide comes from a detailed review of 86 research reports. The review is called Treatment of Primary and Secondary Osteoarthritis of the Knee (2008) and was written by Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center.

Thursday, March 5, 2009

Knee Warm-Ups

Pick an option: the prospect of months on crutches and a season on the sidelines, versus taking 10 minutes to do a short, simple, structured warm up. For athletes, particularly school-aged athletes, the choice should be clear.

What’s more, the choice appears to be even clearer for young players whose movements and biomechanics make them more susceptible than their teammates to potentially devastating knee injuries, according to a study involving young soccer players conducted by researchers at the University of North Carolina at Chapel Hill.

“Soccer players and other young athletes have a fairly high incidence of injuries, especially involving the anterior cruciate ligament, or ACL, a ligament critical for knee stability,” said Darin Padua, Ph.D., associate professor of exercise and sport science in the UNC College of Arts and Sciences. “For some reason, girls seem to be at greater risk of ACL injuries. You hear about a lot of these injuries in basketball, too.”

Padua and his team from the exercise and sport science department and from the UNC Gillings School of Global Public Health worked with the Triangle United Soccer Association and 173 youth soccer players (boys and girls, ages 10-17) on 27 teams in Durham and Chapel Hill, N.C., to see how their movements might contribute to injury risk. They videotaped the players jumping and landing, both before a new warm-up routine was introduced, and afterwards, to see what changes had occurred.

They found that those who had the poorest movement quality at the beginning of the study were the most likely to benefit from the exercises, according to the study, published in the March issue of the American Journal of Sports Medicine.

The intervention involved warm-up activities designed to increase players’ flexibility, balance and strength, as well as their foot planting, jumping and cutting skills, since previous research has shown that approximately 70 percent of ACL injuries are the result of such noncontact movements. The routine took 10 to 12 minutes before every game and practice, and was used in place of the jogging and stretching warm ups the players had been using previously. Details about the exercises are available at http://www.unc.edu/sportmedlab/publications.htm (under the “Knee Injury” section); or at http://www.unc.edu/sportmedlab/docs/knee/distefano/Appendix%201.pdf and http://www.unc.edu/sportmedlab/docs/knee/distefano/Appendix%202.pdf.

“The players who had the poorest movement quality at the start of the study — those who landed stiff-kneed or knock-kneed when they jumped, or who landed on their heels or one foot before the other — benefitted the most from the intervention,” Padua said. “This was true for both boys and girls.”

“This shows that warm-up exercises that enhance flexibility, balance and strength can double as injury prevention programs by successfully modifying players’ movements,” he said.

The study was designed to see if a general, or “one-size-fits-all,” warm-up routine was effective for all team members, or if individualized programs were more effective. They found similar results for players in both the general and individualized programs. Both were effective, Padua said.

Researchers also noticed that the older children in the study responded better to the warm-up exercises than the younger ones did.

“That’s a take away from this study,” Padua said. “The younger kids may need to be trained differently. Things that are successful in older populations may not work in younger children.”

Other authors on the paper, all from UNC, are Lindsay DiStefano, doctoral candidate in human movement science; Michael DiStefano, social research specialist in exercise and sport science; and Stephen W. Marshall, Ph.D., associate professor of epidemiology.

For more information, visit: www.unc.edu/sportmedlab or http://ajs.sagepub.com/.

Saturday, February 28, 2009

ACL Reconstruction with Different Techniques

Studies Evaluate the Anatomy and Stability of ACL Reconstruction with Different Techniques

An improved understanding of the anatomy of the anterior cruciate ligament (ACL) in recent years has generated a renewed interest in the evaluation of surgical techniques to repair the knee ligament. In a study to be presented at the 2009 American Orthopaedic Society of Sports Medicine Specialty Day in Las Vegas, researchers analyzed various aspects of two of the most common ACL reconstruction techniques.

“Studies have demonstrated improved movement and stability with restoration of the native anatomy of the knee. However, the surgical technique to achieve the best movement and stability outcomes remains controversial”, says lead author Asheesh Bedi, MD of the Hospital for Special Surgery in New York City.

Bedi worked with senior mentors Dr. David W. Altchek and Dr. Riley J. Williams on studying the anatomy and stability of ACL reconstructions using transtibial versus anteromedial portal drilling techniques on 19 cadaveric knees. Femoral socket position was characterized using high-resolution 3D-fluoroscopy with transtibial and anteromedial portal drilling. “While anteromedial portal drilling allows for excellent access and restoration of the femoral ACL footprint, there is a significant learning curve. There can be an increased risk of shorter femoral tunnels and wall blow-out intraoperatively” says Dr. Riley Williams, the senior author and Associate Attending Surgeon at the Hospital for Special Surgery.

Follow-up studies have evaluated the biomechanical stability of ACL reconstructions completed with transtibial and anteromedial portal techniques. “The anteromedial portal drilling technique allowed for better restoration of native ACL anatomy and knee stability compared to conventional transtibial techniques. We also found that re-reaming of the tibial tunnel is a bigger issue than has been previously recognized with transtibial drilling” says Dr. David Altchek, senior author and Co-Chief of the Sports Medicine Service at the Hospital for Special Surgery.

Bedi and Altchek will be presenting the second part of their study at the 2009 AOSSM Annual Meeting in Keystone, CO. “Continued research into the best techniques for ACL stabilization are ongoing and a vital part of getting athlete’s back into play at a quicker rate. We are working to define these techniques in the lab and have them translated into the operating room” says Altchek.

Tuesday, February 10, 2009

Exercises To Prevent ACL Injuries

The nation’s first – and only – program aimed at taking a wide-scale community prevention approach to decrease non-contact anterior cruciate ligament (ACL) tears among female high school athletes is working, and as a result, is being expanded in Rochester, New York. The program, called PEP (Prevent injury, Enhance Performance), targets the prevention of one of the most serious knee injuries that can sideline athletic careers among females, who are at six to nine times greater risk than males to sustain an ACL tear.

Organized by University Sports Medicine (USM), the PEP program is being rolled out to 119 high schools in Section V, an area that covers all Monroe, Ontario, Seneca, Livingston, Allegany, Steuben and Wayne counties in upstate New York. The expansion, made possible by a $161,000 grant from the Greater Rochester Health Foundation (GRHF), will cover junior varsity and varsity female athletes playing soccer, volleyball and basketball – the three main sports with high incidences of ACL tears. USM officials expect to train about 11,180 athletes on nearly 700 teams during the two-year program.

GRHF provided the seed money for USM to introduce the program to Monroe County high school athletes in January 2007. Since that time, USM athletic trainers have worked with 1,137 female athletes on 71 teams, and preliminary results are promising.

“We would typically expect to see about two ACL tears per 100 participants, or about 58 non-contact ACL tears for the 2,900 athletes we have been working with,” Michael Maloney, M.D., director of USM, said. “To date, we’ve seen only 10 non-contact ACL tears, so this data is very promising. I’m grateful that with additional funding from the Greater Rochester Health Foundation, we are able to significantly expand the reach of our program, and help even more female athletes stay in the game and attain their goals, whatever they may be.”

The program has steadily been gaining national attention. In 2008, the NCAA posted an interactive segment on ACL injuries to its website, which included a feature on USM’s PEP program.

Mystery Surrounds Female ACL Tears
The numbers on female ACL tears are astounding. Over 1.4 million women have been afflicted in the past 10 years alone — twice the rate of the previous decade. It is estimated that more than 30,000 high school and college age females will rupture their ACL every year. In the last 15 years, ankle sprains have decreased by 86 percent while knee ligament injuries have increased by 172 percent.

Much speculation exists on the cause of the higher non-contact ACL injury rate in females, with hormones, biomechanics and environment some of the common culprits named. While researchers have been unable to definitively pinpoint the exact cause for the increased incidence in females, they have been able to develop a series of specific stretching, strengthening, flexibility and balance exercises that have been shown to significantly reduce injury rates.

“PEP works by retraining the nervous and muscle system in female athletes to be more efficient, and as a result, reduce the potential for non-contact ACL tears,” said Andy Duncan, P.T., A.T.C., director of sports rehabilitation at USM.

It consists of a specialized warm-up program that must be completed two to three times a week, and includes exercises and training to increase muscle strength, plyometrics (active strengthening like jumps), agility, balance and flexibility. The program takes about 20-25 minutes to complete.

“We stress quality versus quantity with the girls. These exercises are so precise that they must be done properly or they will not receive any benefit at all,” Duncan said. “In effect, we are re-teaching the muscles how to fire and respond to signals from the nervous system. At the end of six weeks, if the program is done correctly and consistently, these athletes will have a much better chance at preventing an ACL tear.”

Beginning in the summer of 2009 USM athletic trainers will use a “train-the-trainer” approach to educate team coaches/representatives on the benefits and components of the PEP program. The sessions will be interactive, including demonstration and participation. Videos detailing each exercise will be given to each team to help guide the athletes through the program.

Sample PEP Exercises
• Warm-ups: Jog, slides, backpedals
• Strengthening: Lunge walk, ball bridge, calf raise
• Plyometrics: Lateral, front/back and single leg hops, rebound jumps, scissor jumps
• Agility: Shuttle and pivot runs
• Stretching Hamstrings, quads, calves, groin and hip flexors

Tuesday, February 3, 2009

Exercises to strengthen your quadriceps

It may be uncomfortable at first, but doing exercises to strengthen your quadriceps after you’ve had knee replacement surgery due to osteoarthritis is critical to your recovery. In fact, it can boost the function of your new knee to nearly that of a healthy adult your age.

That’s the finding of a University of Delaware study published in the February issue of Arthritis Care & Research.

The authors include Lynn Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at the University of Delaware, Stephanie Petterson, clinical faculty at Columbia University, Ryan Mizner, an assistant professor at Eastern Washington University, Jennifer Stevens, an assistant professor at the University of Colorado at Denver, and Drs. Leo Raisis, Alex Bodenstab, and William Newcomb of First State Orthopaedics in Newark, Delaware.

“It sounds logical that exercises to strengthen your knee should be a component of your post-operative physical therapy after a total knee replacement, but it’s not the convention at all,” says Snyder-Mackler.

“There are all of these old wives’ tales that strength training is a detriment to the patient and that the new knee should be treated delicately,” Snyder-Mackler notes. “Our study demonstrates that intensive strength exercise as outpatient therapy is critical to begin three to four weeks after surgery.”

Nearly 500,000 knee replacements, also known as total knee arthroplasties, are performed every year in the United States to treat severe knee osteoarthritis, the loss of the cushiony cartilage padding the knee. The joint disease leaves its sufferers with persistent pain and limited function, resulting in an overall diminished quality of life.

While knee replacement alleviates the pain of osteoarthritis and improves function, patients exhibit impaired quadriceps strength and function for such activities as walking and climbing stairs, and the levels remain below those of healthy people of the same age.

In a randomized controlled trial at the University of Delaware’s Physical Therapy Clinic conducted between 2000 and 2005, 200 patients who had undergone knee replacements were given six weeks of progressive strength training two or three times a week starting four weeks after surgery. Half of the group also received neuromuscular electrical stimulation (NMES).

Their function was compared to that of 41 patients who received conventional rehabilitation and home physical therapy. Quadriceps strength, knee range of motion, and gait were measured in such tests as timed up and go, stair climbing and a six-minute walk.

The group in the progressive strength-training program showed significant improvement in quadriceps strength and functional performance. They also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the group that underwent conventional rehabilitation.

“This study clearly demonstrates the importance of surgeons encouraging their patients to be compliant with progressive quadriceps strengthening during their rehabilitation to enhance their clinical improvement and function post-total knee replacement,” notes Dr. Leo Raisis, a total joint surgeon and adjunct associate professor at the University of Delaware.

“Why undergo a $25,000 elective surgery and then not do as much as you can to get the most out of it and improve your quality of life?” Snyder-Mackler says. “Older people are incredibly motivated—they hurt after the surgery and they want to be better. They need to do this.”

Saturday, January 31, 2009

Supplements no better than placebo

Supplements no better than placebo in slowing cartilage loss in knees of osteoarthritis patients

In a two-year multicenter study led by University of Utah doctors, the dietary supplements glucosamine and chondroitin sulfate performed no better than placebo in slowing the rate of cartilage loss in the knees of osteoarthritis patients.
This was an ancillary study concurrently conducted on a subset of the patients who were enrolled in the prospective, randomized GAIT (Glucosamine/chondroitin Arthritis Intervention Trial). The primary objective of this ancillary study was to investigate whether these dietary supplements could diminish the structural damage of osteoarthritis. The results, published in the October issue of Arthritis & Rheumatism, show none of the agents had a clinically significant effect on slowing the rate of joint space width loss —the distance between the ends of joint bones as shown by X-ray.
However, in line with other recent studies, the researchers observed that all the study's participants had a slower rate of joint space width loss than expected, making it more difficult to detect the effects of the dietary supplements and other agents used in the study.
Rheumatologist Allen D. Sawitzke, M.D., associate professor of internal medicine at the University of Utah School of Medicine, was lead investigator. "At two years, no treatment achieved what was predefined to be a clinically important reduction in joint space width loss," Sawitzke said. "While we found a trend toward improvement among those with moderate osteoarthritis of the knee in those taking glucosamine, we were not able to draw any definitive conclusions."
More than 21 million Americans have osteoarthritis, with many taking glucosamine and chondroitin sulfate, separately or in combination, to relieve pain. The original GAIT, led by University of Utah rheumatologist Daniel O. Clegg, M.D., professor of internal medicine, was a multicenter, randomized, national clinical trial that studied whether these dietary supplements provided significant pain relief to people with osteoarthritis in the knees. GAIT found that the supplements produced no more pain relief than placebo (New England Journal of Medicine, February 2006), although a subset of the original GAIT participants with moderate to severe osteoarthritis knee pain appeared to receive significant pain relief when they took a combination of glucosamine and chondroitin sulfate.
In this ancillary study, GAIT patients were offered the opportunity to continue their original study treatment for an additional 18 months, for a total of two years. Participants remained on their originally assigned GAIT treatment: 500 mg of glucosamine three times a day; or 400 mg of chondroitin sulfate three times a day; or a combination of the two supplements; or 200 mg of celecoxib daily; or a placebo.
X-rays were obtained at study entry and again at one and two years. Joint space width was measured on 581 knees from 357 patients. None of the trial groups showed significant improvement. The group taking glucosamine had the least change in joint space width, followed by the groups taking chondroitin sulfate, celecoxib, placebo and the combination of both dietary supplements.
The total joint space width loss over two years for each group was:

0. 0.013mm (glucosamine)
0. 0.107mm (chondroitin sulfate)
0. 0.111mm (celecoxib)
0. 0.166mm (placebo)
0. 0.194mm (glucosamine and chondroitin sulfate)

The interpretation of the results was problematic because the placebo group's joint space width loss was much less at two years than the 0.4mm the researchers' expected. Based on other large studies published in scientific journals, the researchers hypothesized that a loss of 0.2mm or less at two years would mean a slowed rate of cartilage loss. However, because the reduction in rate of joint space loss for all the groups was under the 0.2mm threshold, the researchers concluded none of the agents significantly slowed the loss of joint space width.
Josephine P. Briggs, M.D., director of the National Center for Complementary and Alternative Medicine, one of the study's funders, said although no definitive conclusions can be drawn about the two dietary supplements yet, "the results of the study provide important insights for future research."
Clegg said the trial shed light on osteoarthritis progression, techniques that can more reliably measure joint space width loss, possible effects of glucosamine and chondroitin sulfate, and on identifying patients who may respond best as further studies are pursued.

Thursday, January 29, 2009

Exercise Good For Bad Knees

Exercise Plays Large Role in Recovery from Knee Replacement and the Occurrence of Osteoarthritis
Two new studies found that exercise may be a factor in recovering from a total knee replacement (total knee arthroplasty or TKA) and knee osteoarthritis (OA). One study involving a progressive quadriceps strengthening program after total knee replacement found that it enhanced clinical improvement almost to the level of healthy older adults. The other study, the first to examine the relationship between four components of physical activity and the incidence of knee OA in older adults, found that certain types of activities were linked to an increased risk of the disease. The studies were published in the February issue of Arthritis Care & Research (http://www3.interscience.wiley.com/journal/77005015/home).

Nearly half a million total knee replacements are performed each year in the U.S. to treat severe knee OA, which is on the rise due to an increase in the elderly and overweight populations. Although knee replacement improves function, patients continue to have impaired quadriceps strength and function for activities such as walking and climbing stairs, which remain below those of healthy people of the same age. Rehabilitation targeting these areas has not been studied well and is not routinely prescribed.

A randomized controlled trial led by Lynn Snyder-Mackler of the University of Delaware and funded by the National Institutes of Health involved 200 patients who had undergone a knee replacement and 41 patients who received conventional standard of care (inpatient rehabilitation and home physical therapy). The 200 patients received six weeks of progressive strength training two or three times a week that targeted knee extension, range of motion, kneecap mobility, quadriceps strength, pain control and gait. Half of this group also received neuromuscular electrical stimulation (NMES).

The results showed that those who did the strength training program had significant improvements in quadriceps strength and muscle activation, functional performance and self-reported function and that they also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the standard of care group. There were no significant differences between the group that just did exercise and the group that did exercise plus NMES.

“Our data suggest that individuals who do not undertake an intensive rehabilitation program following TKA are clearly at a disadvantage,” the authors state. They point out that quadriceps strength is related to functional performance and was the single greatest predictor of function for activities such as rising from a chair or climbing stairs. Functional performance typically peaks about three years following surgery and slowly declines in the following 10 years. “Failing to obtain adequate functional recovery may accelerate functional decline and predispose these individuals to an early loss of functional independence as they age,” the authors conclude.

Another study published in the same issue and led by Led by Marjolein Visser of VU University Medical Center in Amsterdam involved almost 1,700 men and women ages 55 to 85 years old of the LASA study that were assessed over a 12-year period for knee OA. Their physical activity was evaluated with a questionnaire that included information on frequency and duration of physical activity over a two-week period. Intensity, mechanical strain, turning action and muscle strength scores were created for each activity.

During the follow-up period, 28 percent of participants developed knee OA. Activities with low muscle strength (such as light household work) or high mechanical strain (such as dancing or tennis) were associated with an increased risk of knee OA, even after adjusting for demographics, health, and early life/current physical activity, as well as the other components of physical activity.

The study did not find an association between the level of overweight and mechanical strain in the incidence of knee OA. “This finding could indicate that the higher risk of knee OA in obese persons may be explained by factors other than increased mechanical strain, and higher levels of physical activity may not negatively affect knee health in heavier respondents,” the authors state.

The authors caution that before these results can be translated into advice for health professionals on daily activities for older adults, further studies need to be conducted to clarify the optimal amount of daily activity necessary for healthy joints for each component of physical activity.

Articles: “Improved Functioning From Progressive Strengthening Interventions After Total Knee Arthroplasty: A Randomized Clinical Trial With an Imbedded Prospective Cohort,” Stephanie C. Petterson, Ryan L. Mizner, Jennifer E. Stevens, Leo Raisis, Alex Bodenstar, William Newcomb, Lynn Snyder-Mackler, Arthritis & Rheumatism (Arthritis Care & Research), February 2009.

“Physical Activity and Incident Clinical Knee Osteoarthritis in Older Adults,” Lisanne M. Verweij, Natasja M. Van Schoor, Dorly J.H. Deeg, Joost Dekker, Marjolein Visser, Arthritis & Rheumatism (Arthritis Care & Research), February 2009.

No Joint Benefit From Glucosamine Or Chondroitin

September 29, 2008
No Joint Benefit From Glucosamine Or Chondroitin
If glucosamine and chondroitin provide any relief from osteoarthritis 572 study participants weren't enough to prove it.

The dietary supplements glucosamine and chondroitin sulfate, together or alone, appeared to fare no better than placebo in slowing loss of cartilage in osteoarthritis of the knee, researchers from the Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) team report in the October issue of Arthritis & Rheumatism.[1] Interpreting the study results is complicated, however, because participants taking placebo had a smaller loss of cartilage, or joint space width, than predicted. Loss of cartilage, the slippery material that cushions the joints, is a hallmark of osteoarthritis and its loss is typically measured as a reduction in joint space width—the distance between the ends of bones in a joint as seen on an X-ray.

Rather than slowing down the decay we really need ways to stop and reverse it. Some sort of stem cell therapy is the best bet. Gene therapy might end up helping but I expect benefits from stem cells sooner. Further out nanobots will do joint repair. I hope at least one of these becomes available before any of my joints start to ache.

Glucosamine might provide a small benefit. But if glucosamine does provide a benefit it is not so large that it shouts out.

Rheumatologist Allen D. Sawitzke, M.D., associate professor of internal medicine at the University of Utah School of Medicine, was lead investigator. "At two years, no treatment achieved what was predefined to be a clinically important reduction in joint space width loss," Sawitzke said. "While we found a trend toward improvement among those with moderate osteoarthritis of the knee in those taking glucosamine, we were not able to draw any definitive conclusions."

A whole lot of people suffer pain from osteoarthritis. How many do you know that live with constant osteoarthritic pain?


Chondroitin is a molecule that occurs naturally in the body. It is a major component of cartilage -- the tough, connective tissue that cushions the joints. Chondroitin helps to keep cartilage healthy by absorbing fluid (particularly water) into the connective tissue. It may also block enzymes that break down cartilage, and it provides the building blocks for the body to produce new cartilage.

A number of scientific studies suggest that chondroitin may be an effective treatment for osteoarthritis (OA). OA is a type of arthritis characterized by the breakdown and eventual loss of cartilage, either due to injury or to normal wear and tear, and commonly occurs as people age. Chondroitin supplements have been shown to decrease the pain of OA. Some researchers think it may actually slow progression of the disease, unlike other current medical treatments for OA. (Many people take either acetaminophen or nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen, for OA pain). However, so far studies have not shown conclusively that chondroitin helps repair or grow new cartilage, or stops cartilage from being further damaged. Chondroitin is often taken with glucosamine, another supplement thought to be effective in treating OA.

Therapeutic Uses



Results from several well-designed scientific studies indicate that chondroitin supplements may be an effective treatment for OA, particularly OA of the knee or hip. In general, findings from these studies suggest that chondroitin:

Reduces OA pain
Improves functional status of people with hip or knee OA
Reduces joint swelling and stiffness
Provides relief from OA symptoms for up to 3 months after treatment is stopped
However, the largest clinical trial so far, the 2006 Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), sponsored by the National Institutes of Health, showed conflicting and somewhat confusing results. The study of about 1,600 people with OA of the knee found that glucosamine and chondroitin did not reduce pain in the overall group, although it did appear to lessen pain among those with moderate-to-severe OA of the knee. The study has raised questions for further research. Since glucosamine and chondroitin were combined in this study, it is not possible to determine the effect of chondroitin alone. In addition, researchers are now studying whether the glucosamine-chondroitin combination may in fact help those with more severe OA.

Most studies have shown that chondroitin needs to be taken for 2 - 4 months before it shows effectiveness, although some improvement may be experienced sooner. Glucosamine and chondroitin can be used along with NSAIDs to treat OA.


Other conditions for which chondroitin has been suggested include preterm labor, Alzheimer's disease, heart disease, and osteoporosis. However, no studies have yet evaluated these claims.

Dietary Sources

There are no significant dietary sources of chondroitin, so people who want to take it must take supplements.

Dosage and Administration

Chondroitin is commonly sold as chondroitin sulfate in capsule or tablet form. It is often combined with glucosamine and sometimes manganese as well. Manganese is a trace element necessary for normal bone health. While the total amount of manganese from foods and supplements should not exceed 11 mg per day, several combination supplements for arthritis (containing glucosamine, chondroitin, and manganese) contain more than that. Read labels carefully, and consider choosing a supplement without manganese.

Chondroitin Slows Progression of Knee Osteoarthritis

Osteoarthritis (OA) causes disability and is a major public health problem. A new study examined the effect of chondroitins 4 and 6 sulfate (CS) on OA progression and symptoms. CS, unlike other chondroitin sulfate products sold as dietary supplements in the U.S., has been approved as a prescription symptomatic slow acting drug for OA in many European countries. The study was published in the February issue of Arthritis & Rheumatism (http://www3.interscience.wiley.com/journal/76509746/home).

Led by Andre Kahan of the University of Paris Descartes in Paris, the randomized, double-blind, placebo-controlled study involved 622 patients with OA from France, Belgium, Switzerland, Austria and the U.S. Patients had knee X-rays at the time of enrollment and at 12, 18 and 24 months. The X-rays were evaluated for joint space loss and patients were also assessed for OA symptoms and pain.

The results showed that "long-term administration of CS over 2 years can prevent joint structure degradation in patients with knee OA," the authors state. Joint space loss was significantly reduced in the CS group, fewer patients had progression of joint space width, and CS reduced pain in those taking it compared to the placebo group. CS was well-tolerated and there were no significant differences in the frequency of adverse events between the two groups.

The study showed that there was faster improvement regarding pain during the first year in the CS group compared to the placebo group. This may be due to the fact that all of the patients had pain symptoms, so the effect of CS was more noticeable early on. Since those who took a placebo also had decreased pain in the first year, it may also be due to the natural course of the disease. The authors note that the study involved CS, which is used as a prescription drug and that the results cannot be generalized to other chondroitin sulfate products or compounds, such as those available in the form of dietary supplements.

The decrease in joint space loss shown in this and another recent study involving 300 patients, suggests better outcomes for OA patients, according to the authors. They conclude: "Further studies with longer followup and different outcome criteria are warranted to assess whether the beneficial structural changes associated with CS demonstrated in our study are predictive of improvement in the long-term clinical progression of OA."

Article: " Long-Term Effects of Chondroitins 4 and 6 Sulfate on Knee Osteoarthritis," Andre Kahan, Daniel Uebelhart, Florent De Vathaire, Pierre Delmas, Jean-Yves Reginster, Arthritis & Rheumatism, February 2009.

Tuesday, January 13, 2009

Greater Quadriceps Strength May Help Bad Knees

Studies on the influence of quadriceps strength on knee osteoarthritis (OA), one of the leading causes of disability among the elderly, have shown conflicting results. In some studies, decreased quadriceps strength is associated with greater knee pain and impaired function, while other studies show mixed results on the effect of quadriceps strength on the structural progression of knee OA.

Most studies to date have used X-rays to indirectly measure cartilage loss in knee OA and have focused on the tibiofemoral joint (the main joint in the knee where the thigh and shin bones meet). A new study has examined the effect of quadriceps strength on cartilage loss (measured using magnetic resonance imaging [MRI]) at both the tibiofemoral joint and the patellofemoral joint (where the thigh bone and knee cap meet) as well as on knee OA symptoms. The study was published in the January issue of Arthritis & Rheumatism (http://www3.interscience.wiley.com/journal/76509746/home).

Led by Shreyasee Amin, M.D., M.P.H., of the Mayo Clinic, the study involved 265 men and women participating in a 30-month study of symptomatic knee OA. At the beginning of the study, participants underwent MRI of their more painful knee and measurement of quadriceps strength for the same knee. They were also asked to rate the severity of their knee pain and their physical function was assessed. The knee MRI and assessments of their knee OA symptoms were repeated at 15 and 30 months. A measurement of knee alignment was also performed.

The results showed that greater quadriceps strength had no influence on cartilage loss at the tibiofemoral joint even in those with knees that were out of alignment. However, stronger quadriceps were shown to protect against cartilage loss in the lateral compartment (outer part) of the patellofemoral joint, a site of frequent cartilage loss, pain and disability in patients with knee OA. The study also showed that those with the greatest quadriceps strength had less knee pain and better physical function than those with the least strength.

Previous studies had also shown no overall protective effect of greater quadriceps strength on cartilage loss at the tibiofemoral joint. The protective effect against cartilage loss at the lateral compartment of the patellofemoral joint is a new finding that needs to be confirmed in future studies, but does provide evidence as to the benefit of having strong quadriceps muscles in patients with knee OA. “Our findings, which also include an association of greater quadriceps strength with less knee pain and physical limitation over followup, suggest that greater quadriceps strength has an overall beneficial effect on symptomatic knee OA,” the authors state. This effect may be due to a strengthening of the vastus medialis obliquus (a quadriceps muscle that pulls the kneecap inward), that may stabilize the kneecap and help prevent cartilage loss behind part of the knee cap.

Although the study did not involve exercise training to strengthen the quadriceps, there have been several short-term studies that show that improving quadriceps strength has a beneficial effect on knee pain and function. “While our findings suggest that maintaining strong quadriceps is of benefit to those with knee OA, further work is needed to determine the type and frequency of exercise regimen that will be both safe and effective,” the authors conclude.

Article: “Quadriceps Strength and the Risk for Cartilage Loss and Symptom Progression in Knee Osteoarthritis,” Shreyasee Amin, Kristin Baker, Jingbo Niu, Margaret Clancy, Joyce Goggins, Ali Guermazi, Mikayel Grigoryan, David J. Hunter, David T. Felson, Arthritis & Rheumatism, January 2009; 60:1; pp.189-198.