Ross is a 35 year old male with a hurting right knee. It hurts to walk, climb stairs and with nearly anything that involves weight bearing. For the last two years, Ross spent considerable time, energy and money trying to get his life back. He visited several physicians and therapists. He also worked with a personal trainer and a nutritionist. The results were less than optimal. He finally went to Dallas, Texas to see an orthopedist who said, “You are not a surgical candidate but the guy you need to see is in Austin.” Thus, I met Ross in November 2001.
His story isn’t all that different from the patients you see everyday. He recalls feeling some discomfort in his knee in 1999 but cannot relate it to anything specifically. It just gradually worsened despite a year of physical therapy. He can tell when the weather will change. His knee aches a day or so before a cold front appears. He elected to undergo a lateral release in 2000 which was followed by another year of rehab. In describing the rehab, he told me “I did a lot of exercise. All sorts of things but my leg never really felt very tired. But, if I tried to push it, my knee would hurt. Now, I think I may be headed to surgery. I am incredibly frustrated.”
Listening to a patient story is the ultimate multi-tasking, non-linear skill. Listening, thinking, reevaluating, probing, searching all done simultaneously. In Ross’ story you will hear one thing over and over; stiffness. The stiffness is of two different types. One lasts for several days at a time and the other for 30 or 40 minutes. The second type of stiffness occurs with static positions like sitting in a movie theater or riding in a car or sleeping. The key to successfully solving his problem involves understanding why Ross has the stiffness in his knee and what to do about it.
Since articular cartilage has no nerve supply nor blood supply, the stiffness is the joint’s only way to communicate. If it could speak, the joint might say, “Hey, you know all that running you’ve been doing? Well, you’re killing me down here!” Instead, it sends a slow, steady signal waiting for you to acknowledge it. Unfortunately, most of us do not know “jointese” (the foreign language of joints).
The stiffness of a joint lasting for days on end is primarily due to the shearing of cartilage cells creating fragments in the joint. These tiny fragments are absorbed by the synovium which in turn then becomes inflamed. The synovium swells and since it is highly innervated, the dull sense of aching and stiffness soon follow. The short-term stiffness, however, is entirely different. On the surface of articular cartilage, secreted by the synovium, is a surface-active phospholipid (SAPL). This SAPL’s job is to provide the lubrication we need in the joint and to prevent the layers of cartilage from melding themselves together or gelling. In the case of OA, the synovium does not produce as much SAPL and therefore, we feel stiff; the layers begin to gel until we get up and move.
The good news is OA can be improved with controlled loading exercise. Find the right load, the right number of repetitions, the right movement and things begin to improve. How do you know when a person’s joint is healthier? Sure, the pain subsides and the load bearing capacity increases. But, more important is the presence of stiffness. It’s the first thing to appear when things begin to deteriorate.
You may be wondering how to improve joint health or perhaps what I did with Ross. Tune in next week and discover the awesome magic of human movement.
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