Arthritis of the knee is a very common condition and on of the most common causes of pain and disability around the world. Arthritis of the knee when not further specified, usually implies osteoarthritis rather than rheumatoid arthritis or other inflammatory joint conditions. Over the years many ideas with respect to arthritis of the knee have become accepted among the general public and even doctors. The general thinking is that arthritis of the knee is a normal process of aging and also due to excessive body weight. More importantly many people think that there is not much that can be done with respect to arthritis of the knee until the knee become so dysfunctional or painful that a total knee replacement is necessary.
This line of thinking cannot be further from the truth. There are two main problems with this very common approach. The first problem is that people are unnecessarily dealing with pain and disability. The second problem is that people tend to become less active because of their pain leading to a worsening of their arthritic condition and a general decline in fitness and health.
There are many non surgical and non drug treatments available for arthritis of the knee which can eliminate pain and increase function as well as prolong the life of the arthritic knee. The effective treatments for arthritis of the knee include comprehensive physiotherapy, custom made orthotics and insoles, glucosamine/chondroitin supplements, hyaluronic acid injections and osteoarthritis unloading knee braces.
Not all knees are the same and not all treatments will work for each knee. A detailed assessment of each patient is required to put together a plan of approach that will be successful. At the Toronto Centre for Sports Medicine, Dr. Jack Hakoun has been treating arthritis of the knee for 32 years and has incorporated all of the latest effective approaches to osteoarthritis of the knee. It is not uncommon for people to come into the Toronto Centre for Sports Medicine believing that they need a knee replacement and leave on the same day with an improved ability to walk and with much less pain. These people can often delay knee surgery for years or never have the need for surgery. Their pain is significantly reduced or eliminated and their functional activity and strength are improved. Less pain, improved function and improved health without surgery.
Orthotics or custom made insoles can be used to treat many condition and can be quite useful if properly prescribed. There are many practitioners and many facilities which provide custom made orthotics. A knowledgeable practitioner and comprehensive history and physical examination is key to the appropriate prescribing of orthotics. A full examination extending from the feet to the spine is necessary as orthotic can change the alignment of the lower extremities and spine. A sports medicine physician should have the knowledge and skill to perform such an examination. Patients with abnormalities of the knees hips or back may respond adversely to orthotics. A full assessment will determine whether orthotics may potentially cause issues. One common area of concern is the prescription of orthotics with a lift on one side to correct a difference in leg lengths. Often times we see patients with heel lifts that in fact do not have a leg length difference but rather a rotation in their pelvis. This is not an uncommon occurrence. Make sure your practitioner performs a full assessment of your biomechanics for best results with orthotics. If a leg length discrepancy is “discovered” make sure it is confirmed by several methods of measurement which a qualified practitioner should be able to perform. As a rule we never prescribe a leg length correction or heel lift for custom made orthotics unless we have confirmed the discrepancy with several different measurements and on different occasions.
While everyone seems to be watching the Olympic athletes compete, some of us may think just how far from being an athlete we are. This could not be further from the truth. Although the Olympics and professional sports competitions get a lot of publicity the underlying notion in sports medicine is that an athlete is someone to tries their best. If you take money out of the picture, that is what is left and what constitutes the root of the athlete. Winning is only part of it. To many athletes, winning is performing at their personal best. We are not all created equal from the physical standpoint and therefore competition is already skewed. Competing against yourself to push your personal best to the next level is the ultimate competition and the source of the ultimate reward.
At the Toronto Centre for Sports Medicine we applaud all of our past current and future patients for their efforts in maintaining a healthy lifestyle by including physical activity in their lives.
At the Toronto Centre for Sports Medicine, all of our patients are athletes.
Discovering the connection between a computer monitor and painful running occurred recently when a 33 year old accountant came in with a few month history of pain in the chest within running a few minutes. Despite taking a few weeks off to rest, the symptoms did not improve. Investigations carried out before being assessed at our centre included chest x-ray spinal x-ray and a cardiac stress test. All of the investigations were negative. With a proper sports medicine assessment it was evident that this accountant, like many others, uses two monitors and is constantly rotated to one side through the thoracic spine when working. After a few years of this type of positioning, the spine fixes itself in the same rotated pattern. With running there is a symmetrical rotation required through the spine. With the spine pre-rotated in one direction, the normal rotation during running is inhibited. This in turn causes a strain in the spine and its connection to the corresponding rib. This strain produces pain along the course of the affected rib causing chest pain with running. The treatment: appropriate physiotherapy including a review of office ergonomics, suggestions for improvement and reduction of the spinal rotation with exercises to maintain proper posture and spinal alignment.
We see patients who have been referred to us for lack of progression with their physiotherapy program performed elsewhere. Generally you should notice an improvement in your condition over any two-week period. No improvement over two weeks indicates that there may be something wrong with your program. Here is a checklist we use to determine why you may not have seen improvement in your condition with your current physical rehabilitation program.
Did the you have a specific diagnosis? Who made the diagnosis, a sports medicine doctor or physical therapist? Was your diagnosis based on any special tests such as x-rays ultrasound or MRI?
How often did you attend therapy and for how long? Did you perform the required exercises appropriately and with the prescribed frequency?
Does your program include hands on treatment and exercises or only passive modalities such as ultrasound, interferential current, laser and some exercises? Were you treated by a registered therapist or a physiotherapy assistant?
Did you refrain from activities that aggravate your condition?
Without a diagnosis only symptoms are being treated. By not performing the prescribed exercises you most likely will not progress. If you do not have a comprehensive physiotherapy program including hands on treatment your treatment may be lacking essential components. By participating in aggravating activities you are setting back your recovery.
If your physiotherapy program has not resulted in an improvement of your condition a review of these factors and your condition is recommended.
Ever wonder why many medical organizations and associations use the symbol of a snake on a staff for their logo? If you check the Bible in Numbers 21-9 you will see that G-d told Moses to make a fiery serpent and put in on a pole to heal those who had been bitten by snakes in the desert sent to punish them for complaining of their situation. They would be healed by looking at the snake. These individuals were bitten because they acted in an evil way by complaining about their condition in the desert. Evil speech is often associated with the snake. Why would a copper snake heal the condition associated with it?
Well the lesson here is that when you are sick or injured you have to connect with root cause to completely heal from the condition and prevent recurrences. Getting to the root cause of sports medicine problems is essential for physiotherapy and other treatment interventions such as custom foot orthotics and custom made or over the counter braces to work effectively.
At the Toronto Centre for Sports Medicine, we are often assessing patients who have not responded to programs of physical rehabilitation or who have received orthotics or braces at other facilities . The most common reason for lack of response is that the underlying cause was not dealt with initially. Many people come to us without a diagnosis despite having had extensive treatment and interventions.
The story of the snake on the pole and the use of this symbol by many medical organizations reminds us to always search for the underlying cause as the best approach to treating an illness.
While teaching a medical student today I had the opportunity to demonstrate how one should never treat findings noted on investigations such as radiographs (x-rays), ultrasound or MRI unless they correspond with the patient’s history and clinical findings.
A patient referred for a meniscal tear of the knee confirmed by MRI with the request to help manage their knee pain until the surgeon could see her in 5 months. As required we took a detailed history and performed a comprehensive physical exam. The patient had significant tightness of the soft tissues around the knee cap causing restricted knee flexion range which could mimic a meniscal tear. Standard tests for meniscal tearing were negative. After performing some techniques used by physiotherapists to release the tight knee cap the patient had much less pain with walking and could flex the knee to a greater extend and with less pain. This patient benefited greatly from a sports medicine consultation and has been directed to have physiotherapy for the knee. I suggested that the surgeon’s appointment be kept for now but most likely will not be needed.
The patient was very happy and the medical student learned a great lesson.
Sports medicine embodies the concept of optimizing your function no matter what level of functioning you are at currently. This is accomplished by identifying and dealing with the underlying cause of your problem. The next step is setting up the appropriate building blocks to provide you with the strength and flexibility of mind and body to achieve full recovery and prevent recurrences. Tapping into your own body’s resources for healing and improvement is the general guide for treatment provided by various professionals including sports medicine doctors, physiotherapists and massage therapists.