THE CLINIC

Knee Surgery Does Not Mean Retire From Running

In 1997 I had arthroscopic knee surgery for a torn meniscus in my left knee. After a few months I was back to normal pace and distance. My left knee is fine today, but this week I had the same surgery on my right knee. I am 50 years old, and have been running for 30 years on paved streets. I run 40 miles a week, usually 6 or 7 miles at 7:00 pace. I usually try to work in a 10- or 12-mile run every few weeks.

For the first time, I harbor doubts that I'll be able to continue indefinitely, and would like to know your thoughts on my future running and competing. Will I damage my knees further, and can I expect recurring injuries in a few years?

Matt Shomsky
Fremont, CA

The critical issue isn't whether you've had the surgery, but what the findings were: do you have arthritis? What was the status of the articular cartilage? Based on the answers to these questions, your orthopedic surgeon can make activity recommendations. There is a multitude of low-impact aerobic activities you may try: bicycling, swimming, rowing, and cross-country skiing come to mind. But none of that may be necessary if all that the arthroscopy revealed was grade one or two chondromalacia, which is a softening of the cartilage.

Klaud Miller, MD
Evanston, IL

Don't let the history of two knee surgeries be a reason for despair. Speak to your orthopedic surgeon and find out the quality of the articular hyaline cartilage on your femoral, tibial, and patellar sides. That's the coating of the bones around the knee. If there are exposed bone patches, you might have to cut back on your running. If the coating is intact, then keep on trucking.

Rob Meislin, MD
New York, NY

It seems like you may be neglecting to cross train, which is an important aspect of a running regimen that helps make injury less likely. If your surgeon advises that you have a lot of wear and tear on your knee, I urge you to incorporate cross-training into your routine. I also would add that as a general principle, we don't wear out so much as rust out. If you don't have substantial knee disease, avoiding running will not be necessary, though after 50 slowing down a bit and easing up on the mileage may be a wise thing to do.

Larry D. Hull, MD
Centralia, WA

Hip Surgeries Compared: Resurfacing vs. Replacement

In a few weeks I am having a hip resurfacing operation. I have been told that there will be no restrictions on physical activity after the initial recovery. How does this procedure compare to hip replacement?

Randy Kotsis
Chapel Hill, NC

Hip resurfacing is less traumatic than hip replacement surgery. Since only the femoral portion should be involved, activity may not be affected in the same way that it is with total hip arthroplasty. Normal post-operative hip precautions such as extreme internal and external rotations of the joint are not as much of a factor. I feel that your primary recovery issues will be strengthening and maintaining range of motion.

Ron Kleinman, PT
Akron, OH

Hip resurfacing has been around for at least 25 years. It has some theoretical advantages. However, those advantages were never really confirmed in clinical practice. In my opinion, the only argument for a surface replacement over total hip arthroplasty is that if the hip resurfacing fails, it is easier to revise to a conventional total hip than to revise a conventional total hip to another conventional total hip. There was always an unacceptably high rate of loosening, avascular necrosis, and failure with the old resurfacing designs. One of my patients (age 45) had bilateral hip resurfacing at a major university, and both sides failed within two years and I had to revise them to conventional total hips. The older metal ball and plastic socket was inferior to the newer metal-on-metal designs of the last eight or so years.

There is still, in my opinion, an inevitable problem of avascular necrosis, where the bone underlying the prosthesis simply dies due to the disruption of the normal vascular supply by the metal cup. I think this is an unavoidable complication which will never be solved because of the intrinsic limitations of the anatomy. Most series report at least a 10 or 15 percent incidence of this complication.

I also caution you that I know of no published literature or scientific study that supports unlimited physical activity after any hip prosthesis, whether conventional total arthroplasty or resurfacing. While you can certainly do many things after major hip surgery, high impact activities such as running, jumping, basketball, and tennis definitely increase the chances of loosening.

If you are less than 55 years old, then a surface replacement has a few theoretical advantages, however limited. If you are older than 55, I see absolutely no benefit to a surface replacement. A conventional total hip arthroplasty will be far more predictable and will allow you to do everything you can do with a surface replacement. I do not believe there is any functional advantage to a surface replacement whatsoever. The restrictions and limitations after surgery are exactly the same. I am curious what advantages your surgeon feels the surface replacement will give you; in my opinion, there is a mild but definite increase in potential complications for very little potential gain.

Klaud Miller, MD
Evanston, IL

An Audible Hip Click, Without Pain

I have been running, skiing, and hiking for over 30 years; I'm 61 years old. I have recently developed a painless click in one hip which occurs when walking slowly on level floors. It doesn't happen when walking fast or going up or down stairs. I can't feel it and it hasn't hindered my exercise. Should I have someone look at it?

Jason Baumgarten
Grand Rapids, MI

The hip click, in my experience, is most commonly caused by the snapping of the iliopsoas tendon as it moves forward. The second most common cause is the tensor fascia lata snapping laterally over the hip bone. Both of these should not cause worry. However, there are other causes of clicking, such as limbus injury or a loose body. These should be treated to prevent subsequent degenerative changes. Certain tumors about the hip joint, such as an osteochondroma, might also require treatment. Consequently, because you are active and most likely hope to continue to be active for many more years, I would suggest that you get it checked out with a sports medicine doctor to be sure that the clicking is truly benign.

Michael Clarke, MD, FACS
Springfield, MO

Yes, a painless click is not something to worry about. If it is a frequent nuisance, it may merit an examination by a physician well-versed in clicks and their various causes. These are sorted into intraarticular and extraarticular causes, meaning inside the joint and outside of it, respectively. The iliotibial band (ITB) may be rubbing on the outer bony prominence of the hip. The hip flexor muscle (iliopsoas) may be rubbing over the pelvic wall. A labral (cartilage) tear may be causing a snapping of the hip as well.

Rob Meislin, MD
New York, NY

No Running While a Stress Fracture Heals

I am a 47-year-old, 135-lb female marathon runner with a competitive collegiate past (at shorter distances). A year and a half ago I developed lateral knee pain and soon after was diagnosed with patellofemoral syndrome. I was in physical therapy twice a week in the summer, during which the pain persisted but did not worsen. I continued to train for and race a half-marathon that fall. But by the winter, I had reduced mileage to 15 or 20 miles per week, without hard runs. I had an adjustment to my custom orthotics to no avail.

In January I was diagnosed with “atypical” patellofemoral syndrome and sent for an MRI. That revealed a small joint effusion and thin medial plica. My patella is laterally tilted and slightly laterally subluxed, and there is “moderate to marked” thinning and irregularity of the patellar cartilage, most prominently along the lateral facet. There are “broad areas of subchondral bone marrow edema.” The patellar retinacula are intact, as are my cruciate ligaments, quadriceps, and patellar tendons. They found no meniscal tears.

I have had two orthopedic surgical opinions since, and both say I am an ideal candidate for a lateral release of the retinaculum. Self-research on this arthoscopic procedure does not reveal favorable results to a pain-free return to running. I have taken the past six weeks to evaluate things and during that time, the knee pain has grown worse. Stairs are now a problem, and cycling and most exercise machines are painful.

The surgeons are optimistic but runners I have spoken to are not. The research indicates that certain ideal conditions need to be present in the injured knee for this surgery to be effective and not make things worse. Is surgery my only option? What happens if I push myself to run and pass on the surgery. Am I creating more problems?

Vera Gombeda
Providence, RI

There are innumerable names for problems related to the patella. The basic problem is a loss of the normal muscle balance that controls the patella. This goes under multiple names. The most common is patellar malalignment syndrome or patellar maltracking syndrome. It has also been called an excessive lateral pressure syndrome. It is commonly known as "chondromalacia" in the lay press but that is inaccurate. Chondromalacia is a pathological finding of wear and tear of the articular cartilage and is not a specific diagnosis. Something causes chondromalacia. Chondromalacia is not the problem, it is the result of the problem.

The MRI absolutely confirms your diagnosis. You have subluxation and tilt of the patella which has resulted in excessive pressure on the lateral facet of the patella and has caused premature wear of the articular cartilage. Whether this has crossed the magic line to be called osteoarthritis of the patellofemoral joint or not is probably irrelevant. You have pain and a degenerative process. The initial treatment for this is anti-inflammatory medication, ice, and straight leg raising exercises in an attempt to improve the balance of forces on the patella. A cortisone injection or even a series of hyaluronic acid injections would also be reasonable if one felt that this was truly arthritis. A brace can sometimes improve symptoms but is much less predictable. If nonsurgical care fails, then a subcutaneous lateral release is ordinarily the next step.

However, there is significant disagreement among orthopedic surgeons. While the subcutaneous lateral release would be successful in improving the alignment of the patella, it would also have absolutely no effect on the degenerative changes. It is unclear how much the degenerative changes are contributing to your current symptoms.

You could have perfectly normal x-rays after surgery and still have little if any improvement in your pain. Because of the degenerative changes, some orthopedic surgeons would advocate a tibial tubercle elevation, which has the capability of addressing the degenerative changes because it not only realigns the patella to take pressure off the lateral side, it also redistributes the forces proximal and distal to try to relieve some of the pressure on the worn area.

Therefore, while you are a candidate for subcutaneous lateral release, in my opinion, you are definitely not an ideal candidate. To a certain extent, it gets into philosophies. The arthroscopic subcutaneous lateral release is an outpatient procedure with a very low risk of complications when done properly but there is no question that the tibial tubercle elevation would have a greater chance of symptomatic improvement. However, the tibial tubercle elevation is an open procedure, requires several weeks in a cast, has a higher risk of infection, and the recovery time is longer.

In my opinion, running is not dangerous but certainly may be painful. You can rely upon the intensity of your symptoms. However, I am also not sure that any surgery, including the tibial tubercle elevation, would allow you to return to significant running. Under any circumstances, I would definitely avoid hills and StairMasters as much as possible because going up and down stairs and going up and down hills definitely aggravates patellofemoral pain.

G. Klaud Miller, MD
Evanston, IL

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