Knee Report- Knee Disease, knee joints and exercise: injury and prevention

Introduction Knee disease and problems seem to be universal. But I believe we can walk comfortably, from birth to death, without suffering from the painful effects of knee disease.

The knee is perhaps the most important joint in the body. Of all the joints, this one absorbs the most weight and distributes the greatest force. It’s no wonder that the knees are so prone to trouble from injury and disease.

Arthritis is the most commonly known joint / knee disease. It inflames and attacks our joints, causing stiffness and discomfort that can be so severe as to be physically crippling.

 There are hundreds of different types of arthritis, the most common osteoarthritis (OA) and rheumatoid arthritis (RA). Osteoarthritis is the physical deterioration of the cartilage around areas of the bones that meet to form a joint.

Cartilage is a remarkable substance—one thousand times more slippery than wet ice and able to cushion the weight of our bodies as it presses our bones together. Cartilage performs this difficult task better then any substance, organic or synthetic, known to man.

But when our cartilage deteriorates, our joints ache and become inflamed because the protective barrier is no longer there to protect one bone from grinding against another. Painful as this may be, osteoarthritis is not a lethal disease. But the pain can become so debilitating that individuals may choose to have total knee replacement surgery to regain the free movement and lifestyle they had before the pain.

The medical community typically recommends knee replacement surgery only as a last resort, but it can greatly benefit the patient if they are a good candidate. However, doctors and I agree that this radical surgery might be avoided if the patient can feel better and manage the discomfort at lower levels through exercise.

As a fitness and exercise professional, I suggest that a regimen of proper exercise can even eliminate the need for total knee replacement in some individuals.

 Purpose of Study

The purpose of this study is to provide Governor Christine Gregoire with helpful information on the multi-billion-dollar business of knee replacement surgery.

Doctors will never run out of patients who need this procedure, but minimizing their numbers will lower the cost of health care in Washington and the United States by billions of dollars.

Scope of Study- My research was conducted over two weeks with a focus on the study of available literature about knee replacements and arthritis.

In addition, it includes my professional experience in the physical training of my clients who have seen reductions and even the elimination of chronic knee, back neck and shoulder pain as a result of my recommended exercise regimen.

 All of the individuals I trained were evaluated by their doctors as physically suited for exercise.

Methods and Procedures

My primary research comes from my training at the National Academy of Sports Medicine. Supplementary research comes from academic literature and professional documentaries credited for continuing education for the medical professional.

Discussion

Osteoarthritis (OA), rheumatoid arthritis (RA), and tears of the anterior cruciate ligament are the three most commonly knee injuries.

Osteoarthritis

Osteoarthritis is the physical deterioration of the cartilage around areas of the bones that meet to form a joint. Cartilage is a remarkable substance—one thousand times more slippery than wet ice and able to cushion the weight of our bodies as it presses our bones together.

Cartilage performs this difficult task better then any substance, organic or synthetic, known to man. But when our cartilage deteriorates, our joints ache and become inflamed because the protective barrier is no longer there to protect one bone from grinding against another.

 Rheumatoid arthritis- Rheumatoid arthritis is an autoimmune disease (a disease where the body’s immune system attacks itself) whereby the white blood cells, instead of attacking only harmful bacteria and viruses, also attack the protective pouch-like coating around the knee, called the synovium.

This protective pouch holds fluid that lubricates the knee and provides a means by which nourishment can reach its working parts. When this happens, the synovium swells and weakens the ligaments and muscle surrounding the joint.  There is no cure for RA, but progression of the disease can be slowed and pain reduced with medical treatment.

Tears of the anterior cruciate ligament

Anterior cruciate ligament injuries, better known as tearing the ACL, is different from arthritis, in that they must be surgically repaired for the leg to function properly. There is no other means by which to fix an ACL tear.

The anterior cruciate ligament connects the femur (the upper leg bone) to the tibia (the larger of the two bones in the lower leg) and prevents the lower leg from extending too far forward.

The ACL works in cooperation with three other ligaments in the knee: the posterior cruciate ligament, the lateral collateral ligament and the medial collateral ligament.

Exercise

There are several different post-operative treatments for the three knee ailments described in this report, and therapeutic exercise is at the top of the list according to medical professionals. Not only is exercising the best post-operative treatment, but also the best preventive treatment. Osteoarthritis and ACL tears typically occur within joints that are not functioning properly.

With osteoarthritis, the patient typically has an imbalance among the muscles and tendons controlling the movement of the knee.

With this condition, the knee operates improperly, increasing the strain on the knee cartilage and ligaments as well as the likelihood of injury.

According to sports medicine expert Dr. Brian Halpern, MD of Sports Medicine New Jersey, “The strength of the muscle groups surrounding the knee is key to knee health– the more support you’re able to generate in these muscle groups, the more stable the whole mechanism is, and the less strain there is on the joint itself. A program of strengthening and flexibility for the muscles around the leg,” he explains, “is the single most effective preemptive strike you can make against knee pain.”

NSAIDs

NSAIDs, or non-steroidal anti-inflammatory drugs, reduce inflammation in a joint and decrease pain. Typically, all rheumatoid arthritis patients take some form of NSAID, such as generic versions of ibuprofen, aspirin, and naproxen.

Indomethacin and meloxicam are examples of prescription NSAIDs. These kinds of medications, while alleviating pain, may also cause intestinal bleeding and ulcers in the stomach lining.

Some NSAIDs are coated with a protective outer layer, and claim that it will protect your stomach lining as you digest the pill. However, studies have shown that the coating does not work as it claims. In a natural scenario, the lining of the stomach protects itself from ulcers by producing a protective enzyme.

The body produces a different enzyme to stimulate inflammation in damaged tissue. Unfortunately, the NSAIDs do not distinguish between these two enzymes, so while they block the production of the enzyme that causes inflammation, they also block the enzyme that protects the stomach lining.

So even if you injected the NSAID straight into your bloodstream and the drug never touched your digestive tract, you would still be vulnerable to bleeding ulcers from the use of drugs like aspirin and ibuprofen.

Biological response modifiers

Alternatives to NSAIDs, such as etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and anakinra (examples of biological response modifier drugs) control symptoms of rheumatoid arthritis by controlling inflammation, which may stop the degeneration of the joint.

These medications are effective, but also very expensive and must be taken by injection once or twice a week, a method that presents a risk of a infection at the injection sites, which can lead to all sorts of problems.

In addition, disorders such as multiple sclerosis, epileptic seizures, and inflammation of the nerves around the eye have been linked to the drug Enbrel.

Surgery

Total knee replacement surgery becomes a viable, last-resort option for people who have not responded to other treatments. It involves the complete replacement of the knee joint with an artificial one, typically made of metal, ceramic, and plastic.

An artificial joint lasts up to only 20 years, which is why surgeons do not like to perform this procedure on anyone below sixty years old. Younger recipients of an artificial knee typically outlive the replacement, and will need another surgery called a “revision”.

Younger patients are more active then elderly ones and are thus more prone to wearing out the artificial joint allot sooner then twenty years.

Surgery for a torn anterior cruciate ligament involves retrofitting the torn ACL tissue with additional support and reattaching the ligament to the knee. ACL tears do not require total knee replacement.

Muscle Imbalances

Muscle imbalances exist in many different forms, and among the most common is a lower extremities distortion. The lower extremities of the human body consist of the foot, ankle, calves, quadriceps (the muscles on top of the upper leg) and hamstrings (the muscles on the back of the upper leg).

An example of lower extremity distortion is the condition commonly known as “knock knees”, where the knees rotate inwards toward each other, and where the ankles tend to pronate or roll inward while walking.

This motion is unbalanced and unnatural to the body; it can cause inflammation from added friction to the cartilaginous surfaces, as well as excess stress on the ligaments that hold the parts of the knee together.

Without correction, the cartilage wears down to the bone and osteoarthritis begins. Correcting the muscle imbalance will realign the harmful joint motion and eliminate the added friction to the joint, allowing it to heal and operate smoothly again—provided there is sufficient cartilage remaining.

Another common cause of knee pain is due to tight iliotibial (IT) bands. IT bands are muscle-tendons that run the length of the outside of the upper leg. When the IT band becomes too tight, the tendon pulls on the outside of the knee causing knee pain in that area.

Reciprocal Inhibition

When your arm curls a dumbbell from your waist to your shoulder, you are contracting the muscles of your biceps. At the same time, the muscles opposite the biceps—the triceps—relax to allow the biceps to contract.

Conversely, when you uncurl your arm and lower the dumbbell to your waist, the triceps contract and the biceps relax. This is a demonstration of “natural reciprocal inhibition”. Muscle imbalances are caused by unnatural reciprocal inhibition, when one set of muscles remains in a prolonged contracted state while it’s opposite remains relaxed.

In extreme situations, a set of muscles may even atrophy, having become so weakened that they cannot counteract the pull of their opposite muscles. An example of this would be a situation in which a person was unable to fully straighten their arm.

In this scenario, the triceps would have become so weakened that they couldn’t contract enough to counteract the force of their contracting biceps. And just like the elbow of an arm, the knee joint is affected greatly by the muscle relationships surrounding it.

If the muscles are out of balance (as with a tight IT band, for example) the knee will move improperly and place excessive strain on its working parts and wear down the cartilage.

Myofascia

The fibers of a muscle run in a single direction. But when a muscle sustains a small tear, which is a normal occurrence with exercise, the muscle repairs itself by running fibers in multiple directions.

This creates a small knot in the muscle tissue. Above the layer of muscle is a layer called the fascia, which covers and protects the muscle and also aids in the formation of tendons that attach muscle to bone.

When this know forms, it adheres to the fascia much the way a scab sometimes does to a bandage. This adhesion, called a myofascia, impairs the flexibility of the muscle, restricting and altering its range of motion. In effect, it limits a muscle’s ability to do its work properly.

Myofascias can develop under all sorts of circumstances from the simple daily use of our muscles, and from remaining in the same position for extended periods, such as sitting at a desk or driving a car.

Myofascias can also develop from injuries to our muscles and joints. In these circumstances, there may also be scar tissue surrounding the injured joints that further inhibits the natural movement of its component parts.

How understanding can reap the benefits of exercise

If a patient is helped to understand concepts like “reciprocal inhibition” and the importance of a balanced relationship between contracting and relaxing muscles, I believe that, with proper exercise, they can reduce physical discomfort from knee problems by 50%. And with further understanding of myofascia, and how muscle adhesions can affect muscle movement and efficiency, I believe they can see a 75% reduction in knee pain with the application of proper exercise.

Stretching a tight muscle can help counteract the effects of reciprocal inhibition. Located between the muscle and the tendon is the Golgi tendon organ (GTO). When the GTO is activated during a muscle stretch, it helps ensure a muscle does not stretch too far too quickly by seizing up and tightening the muscle.

When a stretch is held for 20 to 30 seconds, however, the GTO tells the brain it is safe to relax the muscle fibers and the muscle can stretch further.

But if myofascia knots are present in the muscle being stretched, it limits the amount of flexibility that can be gained from stretching. As long as the myofascia knots are allowed to remain, the muscle will remain tight, the benefits of stretching will be limited and the condition of reciprocal inhibition will continue.

In order to break up the myofascia knots in the muscle, the person can roll the affected muscle over a foam cylinder on spots that feel tender. The tender spots are where myofascia exists.

After keeping pressure on those spots for 30 to 60 seconds, the GTO releases its hold on the muscle, relaxing the muscle fibers and allowing them to become realigned.

When this happens, they also release from the fascia that was stuck to the muscle. This creates instantly enhanced range of motion, flexibility and relief of joint tension.

Once these adhesions have been released in the stronger muscles, the weaker muscles must be exercised to balance their strength. Over a period of four weeks of proper retraining, the muscles will regain their balance and the knee will move with the correct motion once again.

As long as the knee pain was caused by muscle imbalance, the pain should disappear as long as the person continues to exercise in a manner that allows the muscles to enjoy a full range of motion, free of adhesions and muscle imbalances.

Conclusion

Not all knee problems are the same. Some people can defer, or even eliminate, the need for knee surgery with proper exercise. The key is to exercise before serious knee problems start, because once knee replacement surgery is required, it is not a condition that can be reversed.

Cartilage is a precious and limited resource. Only in unusual circumstances does it regrow, and then only in a very limited way. The exercise plan described in this report will not help cartilage regrow. The exercise plan described in this report will help prevent cartilage loss, recovery of the joint after surgery and post-operative physical therapy.