Health & Fitness: Knee-Deep in Pain -- From therapy to surgery, growing numbers seek relief for their aching knees Health & Fitness: Knee-Deep in Pain -- From therapy to surgery, growing numbers seek relief for their aching knees (October 12, 2005)

By Lydia Anderson

Special to the Almanac

With 11 prior knee surgeries accrued from years of running, skiing, and playing soccer, tennis and golf, Menlo Park resident Craig Kammerer was running out of options to solve his knee pain.

"I haven't had cartilage in my right leg for 35 years and my left for about 25 years," Mr. Kammerer says. "I was deep into the bone and even walking was painful, let alone climbing stairs."

Vulnerable joints that are expected to carry more than their fair share of the body's weight and make 90-degree turns with ease, your knees will let you know when they are not happy. They may swell, wake you in the middle of the night, ache when you're walking down stairs, or limit your motion -- as almost 50 million Americans who suffer from knee problems know all too well.

The histories of many knee patients sound a similar theme of physically active lives resulting in knee pain, with variations in severity and range-of-motion capability.

Woodside resident Judy Byrnes used to ski, play tennis, hike and run marathons -- activities that took a toll on one of her knees. "About two years ago the pain in my knee got so severe that it even hurt when I was in bed," says Ms. Byrnes, who had arthroscopic surgery 25 years ago. "The knee joint was totally worn out, and I was having a very difficult time walking."

The causes of pain and restricted movement may include osteoarthritis (wear and tear of cartilage); rheumatoid arthritis, in which cartilage may be destroyed; chondromalacia (softening of the knee cap cartilage); meniscus tears; and ligament and tendon injuries.

Obesity has also been linked to the development of osteoarthritis in knees, a condition shared by 21 million Americans. "One pattern we see is obese patients who cannot link their knee pain to any incident," says physical therapist Joseph Villena of Health South, in Palo Alto. "The extra weight is simply starting to bear down on the joints."
Non-Surgical options

To ease the pain, those with aching knees often try one or more non-surgical options, such as weight loss, knee braces, physical therapy, shoe modifications, injections, steroids, acupuncture, and medications such as Tylenol, glucosamine or anti-inflammatory agents.

"It has been proved in the medical literature that acupuncture can greatly reduce the amount of pain medication a patient with osteoarthritis needs to take," says Dr. Emily Ratner, an anesthesiologist and co-director of the Stanford Center for Acupuncture. "Acupuncture increases range of motion in the knee and has been proven to be a good adjunct."

Yet, if there is still pain after trying some or all of these options, surgery becomes a viable alternative for many patients.
Surgery becoming more common

Every year more than 350,000 Americans undergo total knee replacement surgery to improve movement and relieve the pain in one or both knees. With a rapidly aging population and improved ways of performing the surgery, the numbers are expected to increase.

Dr. James Hartford, a Palo Alto Clinic orthopedist, believes estimated projections for total knee replacement surgeries are conservative. "The projection for 2040 is a half-million total knee replacements a year," Dr. Hartford says.

"I'm sure it will reach that number before then. Patients are living longer, and more people are playing sports into their 60s and 70s."

Ms. Byrnes' decision to have total knee replacement surgery last February was made after getting five doctors' opinions and finding continuous pain intolerable.

"When you can't stand it anymore, you'll do it," says Ms. Byrnes, who made the decision to go ahead with surgery after needing to rest from her knee pain every 20 minutes while Christmas shopping last December. "That was it."

For Mr. Kammerer, a lower quality of life also forced the decision. "I couldn't get through 18 holes of golf in a golf cart without significant pain, and I had been taking prescription anti-inflammatory drugs for 25 years," he says.

"It wasn't a question of whether to get replacements but rather when, and you want to wait as long as possible, since they will probably only last 20 years max."
What type of surgery?

In total knee replacement surgery, the knee joint is resurfaced and surrounding diseased bone and cartilage are removed. The area includes the lower end of the thighbone, the upper end of the shinbone, and the backside of the kneecap. These surfaces are replaced with a metal and plastic implant that simulates knee function.

Total knee replacement surgery has been done since the 1970s, but a less invasive surgical approach is gaining in popularity. The less invasive approach involves smaller incisions, and there's not as much moving around of surrounding muscle, which is intended to enable a quicker and less painful recovery.

Fewer than 5 percent of the knee replacements done nationally are of the less invasive variety, but if Dr. John Dearborn's practice is any indication, the procedure will become more common. Dr. Dearborn, an orthopedist and the medical director of the Center for Joint Replacement at Fremont's Washington Hospital, routinely performs about 40 minimally invasive total knee replacements per month.

This procedure "avoids the extensive dissection into the quadriceps tendon and the twisting of the quadriceps associated with the traditional technique," Dr. Dearborn says. An earlier return of knee flexion in the minimal surgery has been documented by prominent joint replacement specialists in this relatively new procedure, he adds.
Making choices

When choosing where and by whom to have a knee replacement, ask for information on the surgeon's experience, outcomes and complication rates.

A recent large study correlated more positive outcomes and less postoperative complications in patients treated by surgeons at hospitals where a minimum of 50 or more total knee replacements per year were performed.

Recovery from total knee replacement takes from four to 12 weeks, according to Dr. Hartford of the Palo Alto Clinic's Center for Joint Replacement, who does about 100 total knee replacements a year. He believes successful recovery from total knee replacement is therapy-dependent. "It depends on good pain control and good physical therapy."

The findings of a recent study published in the Journal of Rheumatology suggest that building up strong quadriceps -- a muscle system in the thigh -- prior to knee replacement surgery promotes better functioning a year after surgery.
Women's knees more vulnerable

More women than men get total knee replacements by a rate of 62 percent to 38 percent. Women athletes injure their knees at a rate three to four times that of male athletes.

Most anterior cruciate ligament (ACL) injuries occur in women ages 15 to 25; the incidence of ACL injuries in female basketball players is twice that of men, and in soccer, four times the rate of men. Some experts think the higher rate is due to the way in which women land flat-footed rather than on their toes, and women's tendency to use the quadriceps muscle more than the hamstrings.

"We have less strength in the hamstring, and our reaction time is slower than males," says Riekes Center physical therapist Paula Chan. "But it is training like anything else."
Strengthening the knees

With or without surgery, patients with knee pain need to strengthen their knees, and that's where physical therapists come into the picture. "Some patients don't want to have surgery and come to see us," physical therapist Joseph Villena says. "Be ready to work."

The physical therapist's goal is to break the pain cycle of arthritic conditions, regain some motion and strengthen the knee, he says. "There is pain, so you favor the leg, and it gets stiffer. The leg is apt to get more swollen, weaker, and that leads to more pain."

Mr. Villena encourages patients to work out in a pain-free environment, which may often be a weight-less environment such as a swimming pool. "If water comes up to your neck, it takes up to 75 percent of the weight off your knee," he says.
Recovery times vary

The recovery from total knee replacement surgery has been difficult for Judy Byrnes, and she has gone back for another surgery to extend the range of motion in her knee. "I never expected it to be so painful for so long," says Ms. Byrnes, who worked with a physical therapist after surgery and now works with a trainer.

Although he felt "knocked out for a while" after surgery, Craig Kammerer was back on the golf course within two months, and the knee swelling was gone by six months. He can walk the golf course without pain -- even 36 holes a day. "I will be back skiing this winter, but I will be more cautious than I was 20 years ago and stay out of the moguls."

For more information, log on at www.kneesociety.org. The American Physical Therapy Association publishes a free brochure entitled "Taking Care of Your Knees"; log on at www.apta.org.

Making your knees last a lifetime Tips from the experts

** Lose weight . Even being 10 pounds overweight exerts 60 pounds of extra pressure across the knee joint surfaces, writes Dr. James Fox, an orthopedist and author of "Save Your Knees." ** Ease up on workouts . Reikes Center physical therapist Paula Chan believes that if exercise hurts, it may be doing more harm than good. "If you have a joint issue, hurting won't help it," Ms. Chan says. ** Relax more on vacations . Playing four hours of tennis a day rather than a typical two hours a week may take its toll. You want to be walking when you arrive home, not hobbling. ** Modify your athletic program . Sports like basketball or tennis, in which there is pivoting and twisting, increase the pressure on the knee. "Sports for patients with knee problems include swimming, biking, golf and other low-impact activities," orthopedist John Dearborn says. ** Make adjustments . Although cycling is generally considered a beneficial way to strengthen knees, an inappropriate seat and position, poor pedal adjustment, wrong body alignment and overuse may all cause problems. ** Knee supports may help . Knee aids may help support the knee during exercise and at times when there is nagging pain. Get professional advice on what support would be useful for your particular pain or injury. For examples of supports, see www.muellersportsmed.com. ** Gain strength . Strengthen the knee's surrounding muscle groups -- the hamstrings and the quadriceps. Two simple exercises can be found at orthoinfo.aaos.org under Prevention and Treatment. Even if you end up with knee replacements, having strong leg muscles should help in recovery. ** Proceed with care . Get instruction in your activity of choice. For example, yoga can either strengthen the surrounding muscles of the knees or, if done poorly, blow knees out, writes Julie Gudmestad, a physical therapist and yoga teacher from Portland, Oregon. "Always check your alignment, and if you ever feel strain in your knees, back out of the pose and experiment until you feel the stretch in your hips or groins instead."

By Lydia Anderson

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