Is Medial Knee Damage Permanent?

author : AMSSM

comments : 0

Is there any hope for running again, other than surgery?

Member Question:

"A sharp pain in the knee forced me to stop a run short. A persistent bruise and discomfort convinced me to have it checked out. Doc suspected MCL tear and ordered MRI. After review of the MRI the surgeon advised me to stop running. Permanently. I've damaged the cartilage on the medial side of the femur. Badly enough he said I'll risk need of knee replacement if I continue running. Is there any hope that I will run again without replacement surgery? Is there anything I can do, or is this a life sentence to stop running?"

Answer by Emanuel Elias, M.D.
Member AMSSM

Given your persistent medial knee pain with no obvious history of acute trauma, known cartilage damage on MRI and the threat of a knee replacement surgery, the likely cause of your knee issue is severe osteoarthritis (OA). OA is the most common cause of joint disease, and predominantly affects the weight-bearing joints, including the knees, hips, and spine, as well as the hands and fingers. In the knee, loss of joint space due to OA is usually seen on the medial side.

OA is caused by a combination of excessive “wear-and-tear” of the joint, abnormal mechanics, and background inflammatory processes. Our joints are basically where two bones meet, comprised of cartilage to protect the bone underneath and to reduce friction, synovial fluid for shock absorption, and ligaments and tendons to form a joint capsule to keep the joint intact.

As OA progresses, the cartilage wears away with resultant loss of joint space. Underlying bone also becomes exposed, leading to abnormal growth of bone and development of cysts and inflammation. There are abnormal changes within the joint fluid and surrounding ligaments as well. Unfortunately, damage from OA is irreversible. Joint replacement is the ultimate treatment for OA; however, the only indication for this surgery is pain despite conservative treatment.

You can have the most awful, severely degenerative-looking knees on imaging, but as long as your pain is reasonably controlled and function is preserved, then a total knee replacement is unnecessary. Conservative treatment consists of pharmacologic treatment and lifestyle modifications. A combination of the two are considered for an optimal treatment program, with the goal being reduction of pain and preservation of function.

Medication

Typical pharmacologic treatment consists of oral non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen, naproxen, etc.), topical NSAIDs (diclofenac gel), and intraarticular injection therapies. Intraarticular injection therapies include injection with corticosteroids and hyaluronic acid. Corticosteroids are strong anti-inflammatory medications that have been shown to effect pain relief for four to six weeks on average.

Injections

There is controversy surrounding cartilage damage resulting from frequent corticosteroid injections, however, three to four injections to an individual joint per year is considered safe. Hyaluronic acid injections, also known as viscosupplementation, are thought to improve the structural integrity of the synovial fluid and cartilage, although the exact mechanism is unknown. There are various different hyaluronic acid preparations available, the majority of which are prepared from Cockscomb, and these have been shown to provide perceived benefits for up to 6 months. Other injection therapies, although less commonly practiced, include prolotherapy and platelet-rich plasma (PRP), and are used to promote the body’s own healing responses.

Running Modifications

For lifestyle modifications, a reassessment of your current running goals and programming are imperative. You may consider working with a coach to help with your running mechanics, and to develop a more feasible training schedule to better cope with the pain. Physical therapy and cross training with low impact sports (swimming, cycling, etc.) may help protect the cartilage from further stress through targeted quadriceps strengthening and stretching for improved range of motion.

A heel wedge placed on the outside of your insole can help “open up” the medial knee, thereby decreasing stress there. If you are carrying extra pounds, weight loss will be particularly beneficial, not only because of the decreased direct pressure onto the knees, but because weight loss lowers the levels of circulating inflammatory cytokines, which plays a role in cartilage degradation.

- Emanuel Elias, M.D.

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date: December 17, 2015