Carol in Glasgow, Scotland asks:
"I have a hole on the weight bearing part of my knee in my articular cartilage. I love running three to four times a week, but when I try to run faster it flares up so bad that I can not put any weight on it for days. When it settles I can run again. Could you tell me what treatment options I have? Should I give up running for good to prevent long term damage?"
Dr Christopher Piller, MD, Orthopedic Fellow, American Sports Medicine Institute and Dr Lawrence Lemak, MD reply:
" It sounds like this is most likely a full-thickness defect in the articular cartilage, with exposed underlying subchondral bone. There are several options of treatment.
"Conservative treatment options include weight control or loss where the individual is overweight, in order to reduce load bearing stress on the joint; avoidance of activities that cause pain and swelling (this may be over exercising or conversely remaining too sedentary); changing to low or no-impact aerobic exercises (such as cycling); using impact-absorbing running shoes and a lateral heel wedge if the damage is within the medial compartment of the knee (in order to transmit forces elsewhere throughout the joint).
"Other non-surgical treatment options include the use of unloader-type custom knee braces; medications such as acetaminophen, traditional non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors such as rofecoxib and celecoxib; viscous supplementation injections with hyaluronic acid (this increases lubrication within the joint); corticosteroid injections (for pain relief); and the use of oral supplements like glucosamine and chondroitin sulfate (substances involved in cartilage production and repair).
"Surgical treatment of symptomatic partial-thickness defects includes arthroscopic shaving to smooth and theoretically stabilize the damaged cartilage to prevent further degeneration. Some full-thickness articular cartilage lesions may not get worse, depending on the size and location in the knee. However most will, especially with continued high-impact aerobic activity.
" Surgical treatment options for full-thickness defects include arthroscopic abrasion or 'microfracture' arthroplasty. These techniques involve the surgeon carefully 'insulting' the joint surface tissue in order to promote a healing response from the body. Another technique involves transplanting round 'plugs' of cartilage and underlying bone from a non-weight bearing part of the knee to the area of the defect.
"Open surgical procedures include the use of autologous chondrocytes (the patient's own cartilage cells) cultured outside the body and replanted inside the knee under what is called a periosteal flap (on the surface of the bone). This requires two surgeries; one to harvest the healthy chondocytes with a cartilage biopsy, and the open transplantation 6 to 8 weeks later. Some surgeons are doing these procedures in conjunction with a staged osteotomy (operation to re-align the bones and thus change the loading characteristics of the joint) to permanently change the alignment of the leg, in order to unload the damaged compartment of the knee.
"These surgical procedures are more successful when the defect is small and still surrounded by healthy cartilage, so it might be best to consider surgery sooner than later if you wish to continue an active lifestyle and running. The type of procedure that is most appropriate for your injury can often only be determined at the time of arthroscopy, once a surgeon has had the opportunity to visualize the lesion."