Question: I am developing increasing pain in my wrist and thumb, especially when I try to open large, jars, (i.e., pickles or mayonnaise). Am I getting carpal tunnel syndrome?

Answer: It is more likely that you are in the early stages of osteoarthritis affecting the base of your thumb. Wearing a thumb spica splint at night may greatly decrease your daytime pains. Over the counter analgesics, such as naproxen or ibuprofen may help in addition to the splint use.

James B. Slattery, M.D.

Board Certified – Orthopaedic Surgery

Question: Do I need a knee replacement?

Answer: Knee replacement is an operation that is usually performed for severe knee arthritis. It involves removing the damaged joint surfaces and replacing them with an artificial knee that is not painful. The most important question to ask in determining if you need a knee replacement is “How much is my knee arthritis interfering with my life?” In most cases, we would try every other treatment alternative for your arthritis pain first, including medication, changing your activity level and knee injections. If these do not work, then knee replacement may be an option. Our goal is to make your knee functional and as pain-free as possible so that you can get back to the things you enjoy doing. In severe arthritis, knee replacement may be the best way to accomplish that goal.

Jason Shinn, M.D.

Board Certified – Orthopaedic Surgery

Question

I have been told I have torn cartilage in my knee and need surgery. Is that necessary?

Answer

Not always. There are two types of cartilage in the knee — hyaline cartilage and meniscal cartilage. Damage to hyaline cartilage is associated with arthritis and typically does not necessitate surgery. On the other hand a tear in the meniscus is often treated with surgery called arthroscopy. Arthroscopic surgery allows the treatment to be performed on an outpatient basis. Using a small video camera called an arthroscope for visualization, the torn cartilage can be repaired or “cleaned-up.”  This helps to relieve the pain associated with these tears and often hastens recovery and function.

Andrew Rocca, M.D.
Board Certified - Orthopaedic Surgery

Written By Andrew F. Rocca, M.D.

Essential for mobility and often over utilized, the knee joint becomes susceptible to problems and injury. One type of knee injury commonly seen in an orthopaedic clinic is a meniscus tear. The knee is made up of three bones: the femur (thigh bone), the tibia, (shin bone) and the patella (knee cap). The meniscus, is a half moon-shaped, wedge-like cushion that lies between the bones in your knee joint allowing your weight to be equally distributed across the bones. Made up of cartilage, the wedges not only stabilize the knee, but also allow the joint to smoothly slide and move in many directions. When the meniscus is torn or damaged, you lose part that cushioning system; your weight is no longer applied evenly across your bones, so grinding and wearing occurs as bone meets bone. After time, arthritis of the knee joint develops as the stressed bones take on more of the burden your weight.

Meniscus tears are most commonly caused by trauma (athletic injuries) and the aging process (as we age our cartilage becomes brittle). When the injury occurs in athletes, the patient typically describes a “popping” sensation in their knee when participating in a sporting event. Surprisingly, most people are still able to walk after tearing their meniscus, and we often see athletes return to the field after this type of knee injury. The seriousness of the injury is not apparent until later when the knee becomes inflamed, feels painful, tight, and may be quite swollen.

Symptoms of a torn meniscus may include, but are not limited to:

• Knee pain
• Knee swelling, commonly referred to as “water on the knee,” or technically an “effusion”
• Hearing a popping or clicking within the knee
• Limited motion of the knee joint

Treatment after initial injury should follow the RICE formula: Rest, Ice, Compression and Elevation. If the knee recovers fully after RICE treatment, then no other treatment may be necessary. However, if there are still problems with the knee, a piece of the meniscus may be torn or loose and floating around inside the joint causing the knee to lock, slip or pop. In some cases, the knee will catch or lock and the patient will have to manually manipulate the joint to straighten it.

Unlike the athletes, older patients often do not experience trauma when they injure their meniscus. Instead, the wear and tear on the joint over the years weakens the meniscus until one day a degenerative tear appears. If you think you have a torn meniscus, you should see your doctor to have this evaluated further.

Your exam will include your physician taking a careful history of your symptoms, palpating the joint and noting areas of tenderness. X-rays and a MRI may also be ordered by your physician to better visualize what is occurring inside your joint.  If a meniscus tear does appear on your MRI, the next step is to determine treatment, and most pointedly, whether or not surgery is indicated. Sometimes an individual is not a good surgical candidate or his or her meniscus tear symptoms are minimal, in this case we can take a “wait and see” approach. Surgery is sought when the knee becomes problematic and interferes with day to day activities.

If surgery is indicated, your surgeon will recommend either a meniscus repair (repairing the tear) or a partial menisectomy (trimming and removing the torn or loose pieces of meniscus in your joint), based on your specific injury. A meniscus repair is an attempt to fully restore the structure, and because it is a more extensive surgical procedure requires a longer recovery. The failure rate is higher with meniscus repair because the delicate meniscus tissue lacks an adequate blood supply and does not heal well. If the repair is successful however, the joint is healthier in the long run. When the injured tissue has completely lost its blood supply or is tattered beyond repair, a partial menisectomy is performed. Menisectomy quickly relieves the most bothersome symptoms, has a faster recovery than meniscus repair, but, because a portion of the knee’s cushioning is removed, will not reduce the risk for further progression of arthritis.

Both meniscus repair and partial menisectomy are arthroscopic surgeries. The arthroscope gives your surgeon a clear view the interior of your knee with the benefit of only a couple of small incisions, each approximately one centimeter in length. Using tiny instruments your surgeon can trim frayed areas, suture tears and remove fragments of the meniscus that have broken loose. The outcome of the surgery depends on several factors, including the severity of the particular injury, the degree of damage and associated arthritis. As mentioned earlier, recovery is dependent on the type of surgery (repair vs. partial menisectomy) but most report only needing a couple of days off from work until they are up again.  Further recovery and return to more aggressive activities or physical labor, however, often takes longer and physical therapy may be beneficial for recovering full function of the knee in the six to eight weeks following surgery. 

Please note that although arthroscopy can effectively treat many problems, you may have some activity limitations even after recovery. A return to intense physical activity should only be done under the direction of your surgeon. 

Written by Edward M. Jaffe, M.D.

The Anterior Cruciate Ligament (ACL) is one of the most important structures that provide stability to the knee. When the knee is forced into positions that stretch the ACL beyond its normal length, this important ligament can tear. These injuries may occur during sports, typically while changing directions with the planted foot not rotating or during a collision with the force on the outer (lateral) or front (anterior) part of the knee. Often times the tear is accompanied by an audible “pop”.

The most common symptoms after an ACL tear include pain, swelling of the knee, and an inability to bear weight. Once the initial swelling and pain resolve, typically after a few weeks, there is often a sense of instability or “giving way” of the knee.

Once the initial pain and swelling have resolved and knee motion has improved, your orthopedic surgeon can help you decide on the treatment option that is best suited for you. As the technique of surgical reconstruction for torn ACLs has improved, along with refined post-operative physical therapy methods, more and more people opt for surgical reconstruction. The primary indications for surgery are a desire to return to an active lifestyle or continuing knee instability with normal daily activities.

Since a torn ACL will not heal on its own, surgical treatment requires replacement of the torn ligament with another structure. My surgical technique for reconstructing knees with torn ACLs has evolved over the years. Early on I would use a portion of the patients own patellar tendon with attached bone fragments. Over the last couple of years I have treated about one hundred patients with a technique that uses a strand of cadaver tendon that is twice as strong as the previously used patellar tendon. These tendons are obtained from organ donors and are provided in sterile conditions from companies that are accredited by a national organization of tissue banks. Surgical techniques provide secure fixation of the tendon graft which allows early weight bearing. The incisions with the new procedure are cosmetically desirable (less than one inch in length), and the patient goes home the same day as surgery. Patients that had the older technique on one knee and the newer technique on the opposite knee greatly appreciate the decreased pain and quicker recovery period. The newer techniques have greatly improved the surgical and recovery process for patients with ACL injuries.

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Living with the Degenerative Knee

As the population gets older, doctors are placing more emphasis on a healthy lifestyle to slow down the ravages of time. Proper diet and exercise help prevent high blood pressure, high cholesterol and obesity that lead to heart disease, diabetes and stroke, the leading causes of death in our society.

Unfortunately, many of the exercise programs used to maintain good health put direct stress on our joints, particularly the weight bearing joints of the hips and knees. The knees, especially, are susceptible to the stresses of repetitive exercise.

Factors that cause malalignment of the knee such as bowlegs or knock-knees, as well as athletic injuries in our youth frequently result in degenerative arthritis as we get older. Some of the exercises we do to stay healthy aggravate the arthritic condition. Resulting pain frustrates many who are trying to lose weight and stay fit.

Fortunately, there are ways to stay aerobically fit, lose weight and remain lean and strong, even with arthritic joints.

This is the conservative regimen I recommend to my patients with arthritic knees before they resort to surgery:

1. Change your lifestyle to accommodate your joint

Avoid high impact loading exercises, such as running and jumping. Forego sports such as basketball and tennis, which also aggravate arthritic joints. Many of my patients are ex-football players who have put on a great deal of weight since their playing days. Others are obese for other reasons. It is essential that those carrying extra weight take some measures to decrease the load on their weight bearing joints. This always involves changing dietary habits. Most of us eat far more calories than we actually need and do not pay enough attention to the carbohydrate content of our meals. Fad diets almost never work. The most reliable regimen for losing fat is a combination of burning a few more calories a day through exercise and consuming a few less calories, particularly fat and carbohydrates, in our diet.

2. Exercise

A. Strength training

As we age, we tend to lose lean body mass, or muscle tissue. Although our weight may remain stable, we may be getting fatter simply by losing our muscle and increasing our percentage of fat. The fad diets that promise weight loss in a short period of time usually are based upon losing water for a few days and then losing muscle mass rather than fat. Doing some sort of resistance training is essential to keep one’s lean body content. This may be accomplished by various machines found at local health clubs and gyms, use of free weights and simple exercises using one’s own body weight, such as push-ups, sit-ups or partial squats, all of which can be done in one’s home. A membership in a health club, if it is used, may be one of the best investments you will ever make to insure good health. Since muscle is more metabolicly active and consumes more calories than fat, it not only makes you stronger but promotes and maintains weight loss.

B. Aerobics

Aerobic exercise helps weight loss, promotes cardiovascular fitness and decreases some of the factors related to heart disease, such as high blood pressure and cholesterol levels. High impact exercises, such as jogging or running are stressful to the knee, and definitely aggravate degenerative arthritis.

The bicycle, either stationary or road bike, is the best aerobic exercise for those with arthritic knees. You are sitting and non-weight bearing, and it is a smooth non-jarring motion. You should select a resistance level that is comfortable for your knees. Increase the RPMs rather than the resistance on the pedals if you want to work harder.

Swimming or running in water with a floatation devise are both excellent aerobic exercises, and there is very little stress on the knees. However, because the water is supporting your body it is not the best type of exercise if weight loss is your primary goal. The elliptical machines, ski machines and rowing machines found in most health clubs are also excellent devices for cardiovascular training without undue stress on the knees. They are not quite as effective as the bicycle because they are weightbearing.

C. Walking

While it is a relatively safe way to exercise and burn calories, it is detrimental to arthritic knees because it involves repetitious loading of the joint. For patients who like to walk for exercise, I recommend that they alternate their walking with a bicycle, swimming or some other aerobic activity that does not repetitively stress the joint.
The general principle of aerobic exercise is that one burns 100 calories per mile of activity, regardless of how slow or fast one walks. Two and a half miles of cycling is equivalent to one mile of walking.

3. Braces

Some individuals get support from the knee sleeves that are available in most stores. Those with arthritis confined to primarily one compartment, either medial or lateral, can benefit from an unloader brace that can be prescribed by any orthopaedist. The unloader brace is Designed to unload the arthritic compartment and move the weight bearing stress to the other compartment. The brace is more effective for those with medial compartment disease (bowlegs) rather than lateral compartment disease. However, it works to some degree for either. It is used only when involved in athletic activities, such as tennis or walking. It does not have to be worn when lifting weights. It is one fairly simple measure that may allow one to extend their recreational activities in racquet sports and skiing.

4. Medications

Almost everyone with degenerative arthritis of any joint is taking some sort of nonsteroidal anti-inflammatory agent. The best over-the-counter medications are Aleve and Ibuprofen. Both are generally effective as anti-inflammatories but can cause some gastrointestinal problems, such as ulcers, if taken over an extended period of time. The Cox-2 inhibitors Vioxx, Celebrex, Bextra and Mobic are currently popular because they produce fewer GI problems.

However, they are more expensive and their anti-inflammatory properties are no better than older medications, such as Motrin and Naprosyn. Many insurance plans now will not pay for the Cox-2 inhibitors unless the individual has shown serious side effects from the sue of the less expensive nonsteriodals.

Keep in mind that these medications do not alter the progression of the arthritic process. Although you may have less pain, your arthritis may be getting worse.

5. Supplements

Several supplements are available at any health food store, grocery or pharmacy that may decrease arthritic pain or slow the arthritic process. The most widely known is Glucosamine Chondroitin Sulfate. These substances are part of the building blocks of articular cartilage. There is some scientific evidence that they may actually retard the arthritic process. They can be bought separately but work better when used together. This supplement is generally well tolerated by the stomach, although the Glucosamine has been known to increase one’s resistance to Insulin. The best brand name is Cosamine DS, because it is pharmaceutically pure and is the brand that is being used in all the medical studies.

Glucosamine Chondroitin is not a quick fix. It most be taken approximately two months before any decrease in pain is noted.

MSM is another supplement found in most health food stores that decreases arthritic symptoms. It is included now in combination with the Glucosamine Chondroitin products.
Omega 3 Oils are also readily available and effective for a multitude of reasons, both to decrease heart disease and joint pain.

6. Injections

Hyaluronic Acid (Trade names: Synvisc and Hyalgan) is a high molecular weight dextran that may relieve arthritic joint pain. Three injections into the joint over a two week period are felt to work by increasing the viscosity of the synovial flulid making it more slippery, as well as having some anti-inflammatory effect. It is moderately expensive and can be used every six months if it is effective. As with other medications, Synvisc and Hyalgan are more effective when the arthritis is not too advanced.

Cortisone is a powerful anti-inflammatory injected by physicians into painful arthritic joints. It is effective in helping relieve an acute flare-up of a degenerative process, particularly when there is synovitis or water on the knee. It is generally best not to inject a single joint more than three to four times in a year.

Conclusion

The healthy lifestyle, including exercise and diet, while not curing degenerative arthritis, will at least help you cope with it.