CLINIC: Staring Down a Surgical Three-peat

Wed, 22 Aug. 2012 - 8:09 p.m. MT
Credit: ARA Staff - American Running Association

QUESTION:
I am a 140-lb, 5’ 10” male and I have had two arthroscopic knee surgeries to resolve a torn meniscus and frayed cartilage and bone chips resulting from a fall five years ago. The first surgery entailed drilling a hole in my femur to help blood supply rebuild the damage to my knee. I was consequently on one knee for more than eight weeks and suffered overuse injury to that knee. I racewalk, bike, and rollerblade currently, having been told never to run again. I have been diagnosed with a shifted kneecap in the originally injured knee, and my orthopedic surgeon wants to do major surgery to repair it. Is this really necessary? I have read a lot about similar problems being corrected through exercise. I should add that there is evidence of osteoarthritis as a result of the injury and my age (52). I have been a runner only since I was 24 and wonder is it really the case that I may never run again? Also, is surgery the only answer for the current patella abnormality?
 
David Dunst
Hollywood, FL
 
ANSWER:
Keep in mind that racewalking and biking are also notorious for producing patellofemoral pain. If you go for the surgery, your recovery time would be one year to 18 months. A proper flexibility program can often result in avoiding surgery. To a large extent this depends on the amount of space left between your kneecap and femur. This is called a “sunrise view” x-ray. It’s also useful to determine via x-ray criteria how severe your osteoarthritis is. There is a continuum from mild to severe. Surgery will not improve your ability to run, and even after a year and a half recovery it is important to use a cushioned shoe with orthotics and start on grass only. Most patellofemoral problems are caused by a tightness or contracture in the thigh muscle and iliotibial band. I have had seen senior runners who have taken tai chi or yoga and over about six months increased their flexibility to the point where they were pain free and running.
 
Robert C. Erickson, MD
Canton, OH
 
ANSWER:
There are a few problems here working in tandem that are hard to deal with and present a challenge for any orthopedist: a sprinter with hamstring tears, and a distance runner with wear and tear changes to not one knee but both now.
 
I recommend a second opinion, if you have not already sought this out, and then perhaps even additional opinions. In general, we try to avoid surgery until there is no other solution. Knee rehab exercises should be used seriously for three to six months before considering a surgical solution. I would look at whether a new MRI might be helpful here. Patella tracking problems can be nasty and take considerable experience on the part of the physician and surgeon. Try the use of a patella centering brace, and also strengthen your quadriceps before you try anything else. It is possible you will run again, but I would not expect the cure to be easy. Try to make maximal use of crosstraining, and always remember that there is life after running and joy to be found in a variety of activities.
 
Larry Hull, MD
Centralia, WA

(RUNNING & FITNEWS®May / June 2010 • Volume 28, Number 3)

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