THE CLINIC

Surgery for Osteochondritis?

I am 52 years old, and have run for 22 years and played all kinds of other sports. I no longer run on pavement. My right knee was diagnosed with osteochondritis dissecans (OCD) and I had meniscus surgery on the same knee a year and a half ago.

[In OCD, which usually affects knees and elbows, a loose piece of bone and cartilage separates from the end of the bone because of a loss of blood supply. The loose piece may fall into the joint space, making the joint unstable. This causes pain and feelings that the joint "sticks."]

At the follow-up my surgeon recommended that I have Osteochondral Allograft Transplant Surgery (OATS). I still play volleyball regularly and occasionally will play a game of basketball. I can still jog slowly on a treadmill. Should I consider undergoing this procedure?

[During OATS, a size-matched donor graft (allograft) is obtained and the diseased cartilage is mapped, and a single, large cylinder of the poor cartilage and underlying bone is removed. The allograft donor cylinder is then inserted into the socket, restoring a normal joint contour.]

Arbi Cornish
New Haven, CT

There are many issues with osteochondritis and OATS procedure brings more into play. I assume that if allograft is anticipated there must be large OCD lesions, otherwise autograft tissue might be preferable.

I would probably avoid surgery until you do not have other options. Patella-centering braces, NSAIDS, quadriceps strengthening exercises, and cross-training would all likely be helpful. I would avoid stairs, hills, and the like and never train to excess. Some use glucosamine to their advantage and also injections of viscous material like Synvics.

In the right circumstances OATS is a good procedure. However, if the lesion is small with intact articular cartilage, the bone scan normal, and your symptoms minor, then the real value of the procedure is less evident.

Larry D. Hull, MD
Centralia, WA

In order to make an assessment we’d have to see your MRI as well as an A/P longstanding view of both lower extremities to determine the size of the OCD defect, your weight-bearing alignment, and associated intraarticular knee disease.

My experience with allograft osteochondral grafting have been very encouraging. Results, at least in the short term, are excellent.

Rob Meislin, MD
New York, NY

Does My Immune System Suffer Running Over 90 Minutes?

I am a 66-year-old male who has been running three or four days for the past six years. I average 20 to 25 miles per week, with one 9-mile run always included. I have been told that running up to 90 minutes enhances your immune system, whereas any more than that degrades your immune system. Is this rule of thumb accurate?

George Carrera
Boston, MA

Although I am personally not aware of the 90-minute rule you speak of, it is well documented that intense endurance exercise can temporarily impair the immune system. For example, several studies have shown that during the two weeks following a hard, long-distance race (i.e., 10K and up), 50 to 70% of runners may experience symptoms of upper respiratory tract infection (URTI). And, it seems that those who race faster and train longer and harder are more susceptible.

On the other hand, research shows that regular, moderate exercise at 60 to 80% of aerobic capacity, 45 minutes per session, four or more days per week does not increase the risk of URTI, and, in fact, may reduce the risk. Studies have also indicated that moderate exercisers have improved immune function compared to their sedentary counterparts.

I would describe your program as moderate, although you do one 9-mile run per week. If you are concerned about enhancing your immune system during training, you might try taking a replacement drink that provides carbohydrate and perhaps a little protein before, during and after your workouts,
particularly the longer ones.

Tom LaFontaine, PhD, ACSM RCEP
Columbia, MO

To Lose Weight, Walk The Flats

I am six foot four inches, 300 lbs. I'm trying to lose weight, and have been incline walking. I hope to start running in the near future. I had an MRI because I was experiencing some knee pain, and the radiologist at my site told me I have osteochondritis on the medial side of my right knee. Will this impede my ability to run once I reach 240 lbs?

David Steele
Willmington, DE

First of all, beware of incline walking. If you have a knee injury or pathology, incline walking may increase the stresses placed on the medial (inside) and anterior (frontal) aspects of the knee. I would recommend a walk/jog program or a walk/race-walk program over walking on an incline.

Use caution when running or walking outside, keeping in mind that the streets and sidewalks are canted to allow for rain drainage. Avoid downhill running. Change the direction of your route or sides of the street with each workout. This will allow each leg exposure to be "in the ditch" during training.

Osteochondritis should not impede your ability to begin a running program, but depending on the amount of degeneration, you may have increased knee pain. Inflammation will probably impede the speed of your progress.

Anne Felts, MS, ATC/L
Lawrenceville, GA

A common predisposition to osteochondritis, particularly on the medial side, is an abnormal forefoot position in which it is turned inward toward the midline. There is too much play in the forefoot as it plants, with excessive torque pressure concentrating medially upon impact. Therefore it’s important to consult with a podiatrist who is sophisticated about and experienced in dealing with runners.

Secondly, you should do exercises for the quadriceps muscles. Consult with someone on which way to point your foot when lifting weights with your legs so as to specifically strengthen the medial quadriceps.

After running, apply ice to the painful area for approximately 15 minutes. It can also be applied at night even when there is no pain.

Paul Kiell, MD
Far Hills, NJ

Groin Injury You Cannot “Run Through”

Last year I found a good chiropractor who recommended groin exercises known as the Active Release Technique, and it has helped in the healing of scar tissue in that area. However, in the last month, pain in the middle groin area became so severe that I could not perform any physical activity. After several examinations—including a CT scan, prostate exam, x-rays, and blood tests—an unusual injury was detected. It has been diagnosed as osteitis pubis, but in my case, there is a widening gap of the pubic symphysis, toward the bottom. [The pubic symphysis is the slightly moveable joint at the front of the pelvis.] Cartilage loss and bone damage are present, causing pain in that area.

My surgeon has never seen this condition before, since there was never any trauma to that area. It is most likely the result of being a runner for 25 years. The recommendation is rest and non-impact activities. My surgeon is actually doing research on the subject, to determine the actual cause a prescribe the right rehab program. I am scheduled to be re-evaluated in two weeks.

Is the degree of this injury common among distance runners? How long will it take to heal, and when can I return to running regularly? My own limited research on the subject has introduced me to cortisone and prolotherapy injections, various drugs and surgeries, and an extended period of rest as all possible remedies.

Terry Mott
Granada Hills, CA

Osteitis pubis is inflammation of the joint between the two halves of the pelvis that join in the front (pubic symphysis). It’s common in women immediately after pregnancy. It is very easily diagnosed by pointed tenderness in the exact middle of the pubic bone. If there is tenderness more than 1 cm on either side of the midline, it is something other than osteitis pubis. One may or may not see widening on x-ray. A bone scan is conclusive.

Treatment involves avoiding any activity that irritates it, plus simple o.t.c. anti-inflammatory medication. It usually responds within six or eight weeks of limited activity. This is one injury that you cannot “run through.” Bicycling is usually acceptable. Cross-country ski machines or rowing machines are also usually relatively comfortable. It rarely becomes a chronic problem.

G. Klaud Miller, MD
Rochester, MN

The pain in this condition manifests in the pubic region and lower abdomen, as well as along the inner thigh region, usually on both sides. It may occur for no identifiable reason, but is often due to overuse. Specifically, the repetitive back and forth or up and down shearing movements between the two halves of the pelvis.

Because they are joined infront by the pubic symphysis, it can become swollen and painful. Running sports that involve abrupt cutting and pivoting are often associated with the development of this condition. Unfortunately, it can sometimes become chronic. 

Tight hip adductor (inner thigh) muscles especially, but also hamstrings and weak lower abdominal muscles have been implicated as being responsible for osteitis pubis. I have not heard that it occurs in distance runners any more often than in other running athletes. For most musculoskeletal conditions, the longer the symptoms have been present, the longer it takes for them to improve. Since you have had groin pain symptoms for more than a year, improvement in your pain is most likely going to be gradual; it may require months, rather than weeks, before you can cautiously try to resume short-distance, slow running without aggravating your symptoms.

If you haven’t already doen so, a course of physical therapy is appropriate. This would involve your therapist finding and correcting any imbalances in muscle strength or flexibility that the initial evaluation may have revealed.

Brian Bowyer, MD
Cincinnati, OH

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