Just about everything that lives and breathes also moves. Today's culture has become so sedentary that some actually compare the negative outcomes from sitting to what smoking was to the previous generation. Musculoskeletal injuries are one the most common reasons that patients seek medical attention and Osteoarthritis is a common finding. Dr. Rockett gives a very concise and readable explanation on how to treat it.
BY DR. SEAN ROCKETT
November 4th, 2018
“I can’t exercise anymore. You see, I have arthritis.”
I’ve had many patients enter my exam room, look me straight in the face and say that.
My mind drifts to some of the videos I’ve seen in the CrossFit Journal that show adaptive athletes and morbidly obese people exercising.
On further questioning, I find the patients are usually referring to hip or knee arthritis—the most common forms of arthritis—and I proceed to ask about their limitations. Most people say they can’t run or walk long distances anymore. I then ask questions about upper-extremity disabilities and abdominal or back issues, and I find that most people don’t have problems in these areas. I then concoct workouts and ask the patients to try them, get the heart rate up and see how they feel afterward.
I’ll also have CrossFit athletes come in and ask about modifications when they are in too much pain from box jumping, jerking or running. When I start talking about modifying movements and workouts, sometimes it hits people hard.
My goal as an orthopedic surgeon is to help people be comfortable and capable of functioning in all different aspects of life. I want to avoid surgery until it is necessary. I usually tell people they will know when they are ready for surgery based on pain, lifestyle adjustments and disability. As you will see in this article, exercise is important for everyone—even people who have been diagnosed with arthritis.
Think you can't work out if you have arthritis? Think again. (iStockphoto.com/rudisill)
The definition of arthritis is simple, but treatment is not.
Arthritis is the loss of cushion on a joint surface—period. The cushion—called articular cartilage—is an amazing multifaceted structure that allows us to walk, run, jump and lift without pain. It can absorb shock, improve gliding, nourish cells of the joint and produce fluid to help lubricate the joint surfaces.
Deep to the cushion is bone. If bone is exposed, this causes pain because nerve endings are located in the bone. When bone rubs against bone, the joint can become painful, swollen and stiff. Imagine sitting on a sofa without a cushion. The hard wooden planks don’t allow for shock absorption. There is no cure for arthritis, and treatment is directed toward pain relief.
In this article, we’ll use hip and knee arthritis as examples, though any joint in the body can develop arthritis and the symptoms are the same in every joint.
Diffuse arthritis is not to be confused with a localized chondral defect—a pothole surrounded by healthy tissue. This condition can be treated by drilling holes to stimulate bone-marrow healing, placing cartilage plugs or transplanting cartilage.
The treatment plan for arthritis is tailored to the patient. That means treatment is based on the patient’s age, duration of symptoms and other treatments that have been employed.
The pain can come on suddenly or gradually. It can develop suddenly, for example, if you fall from a height and land forcefully on your feet. The femur and the tibia can collide and create an impact called a bone contusion. This can also happen if a flexed knee is driven against the ground, cement or a stair.
An X-ray might show the arthritis, but it won’t show the bone contusion. An MRI can be ordered to look for a cartilage tear or bone contusion. Typically, bone contusions and cartilage tears can get better on their own. If the cartilage tear remains symptomatic, an arthroscopy can be performed. However, if severe arthritis is accompanied by an MRI that shows a meniscal tear, the arthritis is usually the source of pain, and surgery in the form of arthroscopy would not help.
CrossFit movements can be modified for everyone—regardless of physical condition. (Alicia Anthony)
After an initial diagnosis of arthritis, treatment usually starts with therapy exercises that include work on range of motion and strengthening—squatting, for example. Stronger quadriceps, hamstrings and glutes will improve function. An arthritic joint is going to stiffen up if the joint is not exercised—meaning ligaments will shorten and range of motion will decrease. “Move it or lose it” is definitely appropriate here.
Many studies show that exercise decreases symptoms in an arthritic knee (2,3,4).
CrossFit is perfect for people with arthritic joints because it pushes joint range of motion and also strengthens the muscles around those joints. For example, arthritic knees, ankles and hips will benefit from work on air squats.
Sometimes the range of motion of the joint will not allow a perfect air squat. To achieve general air-squat standards, ankles have to dorsiflex (toes move toward shin), knees have to flex beyond 90 degrees and hips have to rotate and flex. If one of these joints does not move as it should due to mechanical constraints, scaling with limited range of motion should be entertained. As always, the goal is to achieve better motion with practice and effort.
After exercise, supplements and natural anti-inflammatories such as turmeric can be tried. Creams and gels are popular as well. Medications such as acetaminophen, ibuprofen and naproxen can decrease pain. If pain persists, activity levels decrease and X-rays show definite joint narrowing with arthritis, then injections can be entertained. These are broken up into different categories:
Cortisone—Cortisone is a tricky substance because it can alleviate pain, but if it’s given too many times it can increase arthritis. Sparing use is reasonable, especially if the joint already has terrible arthritis.
Gel—Gel injections are designed to lubricate the joint and decrease the friction between the bones.
Platelet-rich plasma (PRP)—PRP has been shown to have some anti-inflammatory properties and can be used to treat arthritis, although studies show it works better on tendonitis.
Stem cells—Stem-cell injections might cause a decrease in pain by stimulating other cells to decrease inflammation.
CrossFit's focus on movement mechanics, full range of motion and functional strength make it an ideal program for older people who want to improve their health, maintain their independence and build stability around arthritic joints. (Megan Ellery)
If none of these options work, joint replacement can be considered. After a knee replacement, recovery is evaluated based on range of motion and return of strength. Typically, it takes six weeks to three months for a decent amount of strength to return.
For the CrossFit athlete with knee arthritis, rehab should be faster because of the increased muscle strength going into surgery. Exercises that can be performed early on in recovery—perhaps within two to three weeks—would be stationary biking or rowing. Patients should perform these activities cautiously and gently, with no stress. The focus is on range of motion without stressing the surgically repaired tendon. Squatting with no weight is also reasonable to improve strength and range of motion. Increased resistance and loading will be introduced when tendons are stronger.
Now comes the question about running, jumping and weightlifting. The answer is not really clear in the literature. Surgeons’ opinions vary because the literature is limited (5).
How long a knee replacement will last is partially determined by how long the cushion or polyethylene between the pieces of metal lasts. If one stresses the knee too greatly, then wear on the knee would theoretically be a factor. The material used now is much better than what was used when replacements were invented. However, if these materials break down from wear and release particles, the body attacks and releases macrophages, or cells to digest them. In doing so, these cells release enzymes that can cause erosion of the bone, so the bone-to-metal replacement interface can loosen. It is for this reason that people should probably not resume long-distance running or jumping from heights (1,7).
However, one study found no difference in symptoms or revision for high-impact sports versus low-impact sports in patients who had knee replacements, although two of the patients with revisions were weightlifters (6).
No matter what condition you have, a CrossFit trainer can create a program that will keep you moving. (iStockphoto.com/spondylolisthesis)
The main reason to have a knee replacement is severe pain from arthritis that is not reduced with conservative measures. Recovery time can be substantial, and before replacement is considered, any surgeon wants to make sure the arthritis is severe enough and the X-ray findings correlate with the level of pain. A replacement is indicated when the pain appears every day and limits essential movements such as climbing stairs, standing and walking. Knee replacements should not be performed for mild pain or nuisance pain relieved by other measures.
Knee replacement is a great surgery that allows people who have lost independence and function to regain their lifestyles. It can be a game changer for people who have been struggling and allow them a chance to walk pain-free again.
So joint replacement can make a significant difference and allow people to enjoy life and exercise again. CrossFit athletes should not be discouraged by a diagnosis of arthritis, and they should keep participating by using modifications to work around mild symptoms. When symptoms are severe, additional treatment measures can be considered, but recall that skilled trainers can modify the CrossFit program for people with any condition to help them keep moving in some way. Ceasing to exercise because of arthritis in one joint is not a wise decision, and those with arthritis are encouraged to work with doctors, care providers and trainers to find a way to stay active.
Chakravarty E, Hubert H, Lingala V et al. Long distance running and knee osteoarthritis. American Journal of Preventative Medicine 35(2): 133-138, August 2008.
Ettinger WH Jr, Burns R, Messier SP et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The fitness arthritis and seniors trial (FAST). Journal of the American Medical Association 25: 25-31, 1997.
Hunter D, Eckstein F. Exercise and osteoarthritis. Journal of Anatomy 214(2): 197–207, 2009.
Lo GH, Driban JB, Kriska AM et al. Is there an association between a history of running and symptomatic knee osteoarthritis? A cross-sectional study from the osteoarthritis initiative. Arthritis Care & Research Volume 69(2), 2016.
Recommendations for patient activity after knee replacement vary among surgeons. Orthopedics Today: November 2015
Sebastien P, Dham D, Stuart M et al. Sports participation doesn't affect TKA durability. American Academy of Orthopedic Surgeons Scientific Paper 507.
Vogel L, Giuseppe C, Basti J et al. Physical activity after total joint arthroplasty. Sports Health 3(5): 441-450, 2011.
About the Author: Dr. Sean Rockett is a board-certified orthopedic surgeon specializing in sports medicine. Dr. Rockett is a CrossFit Level 1 trainer and has been training at CrossFit New England since 2008. Dr. Rockett serves as assistant clinical professor at Tufts University School of Medicine, and he also enjoys being on the CrossFit Games Medical Team. He is the author of the blog 321gomd.com.