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Out of joint: Managing joint injury and pain

Repetitive use of joints, like when riding a horse, can cause permanent damage, but there are some things you can do to avoid wear and injury.

Say a horse fell with you when you were 19. Or a cow got you down when you were 35. Or maybe you just use your knees and shoulders all day, every day and they're starting to protest.

The question is, should you just keep gritting your teeth and put up with it, or is there something someone can do to make everyday life with your joints a little less painful?

Medical technology helps many people with a variety of orthopedic concerns from knees to shoulders to hips. However, orthopedic surgeon Whitney Robinson, MD, said before using new technologies, it's essential to have a good idea of the injury or problem, along with the reality of what can be accomplished.

"For example, the knee. There is a lot of talk about cartilage repair in the knee," said the Billings Clinic orthopedic surgeon. "There are actually two parts of the knee we call cartilage, so it can get confusing. One of these cartilages is the meniscus, in which we often see tears in active young people. The surface of the joint is also referred to as cartilage. We can distinguish between the two by calling one the articular joint cartilage and the other, the surface of the joint. Articular cartilage can be damaged in a variety of ways. However, the one that wears away at the surface of the joint can often be routine osteoarthritis or rheumatoid arthritis. Both are inflammatory and both wear away at the surface of the joint."

Robinson explained knee potholes, too.

"When people damage a joint through an injury, they might get a ding in the surface of the joint. We call this a pothole. We have a number of different options for potholes, and although none work spectacularly well, we can fix those. Keep in mind an injury is very different than the joint wearing away."

Farmers and ranchers will show up at the doctor when there is a definite problem. "I've been at the Billings Clinic for 25 years and I know when a rancher shows up and says his knee hurts, it hurts. I see ranchers and farmers who are 58 years old have arthritis," Robinson said. "Other than doing a joint replacement, there is not a lot I can do to replace cartilage for them. I can't paint on a new surface of the joint. I can't inject magic stem cells."

STEM CELLS

Robinson said there is zero data on the efficacy of isolating stem cells and injecting them into joints, which is a new procedure being tried in some places.

"I'm not opposed to technology, but I haven't seen that stem cell procedure actually work. I know it doesn't regrow the surface of the joint. Could it be that someday we will have true stem cells that can become cartilage cells and glue on? Maybe. Currently they are making what are called protein scaffolds. Doctors take a piece of cartilage from your knee, a medical company grows that in a lab and mixes it with a scaffold that's used to replace the pothole. We can make that work, but it doesn't make the joint healthy enough for someone to go back into active sports. There are disks to potentially fill potholes, but at this point, those are experimental."

For ranchers, a pothole in a knee might occur when they fall off a horse, resulting in a tear of the meniscus and a divot in the surface of the joint, which can be cleaned up.

"We will first try what's called a microfracture. What you do is poke the base of the pothole, which causes bleeding. The bleeding fills the pothole and then that blood turns to scar tissues which then becomes something that approximates the surface of the joint."

"Microfractures have limitations, but that's the primary repair we will try first," Robinson said. "But again, remember that we can do repairs to injuries — potholes can be filled up — but for the shoulder, knees and hip the algorithms are the same. When the joint gets worn away, it has to be replaced with metal and plastic."

The bad news? "There is not a lot I can do to slow down the progression of arthritis. We can try to make you feel better, but the process continues. Sure, you can inject a joint with hyaluronic acid, but that only provides relief short term. It doesn't regrow cartilage and it doesn't make arthritis disappear. It really won't change the natural process."

He pointed out knee replacement is the third most common surgery in the U.S.

"In general, knee replacements work pretty well. Your knee won't be as good as you once had, and you probably won't be playing basketball, but a knee replacement will let you get back to doing stuff. Ranchers develop what we call medial compartment arthritis, which is arthritis on the side of the knee. They are bowlegged. Ranchers generally have crooked knees, so we can straighten out those legs and get them back to riding horses and doing their work. Technology with knee replacement has been good."

As for prevention, Robinson's advice is don't gain excessive weight. "There is a strong correlation between body size and arthritis. The other advice is don't get injured. If you injure your knee jumping off a horse at the rodeo and hurt something, that will lead to arthritis. Don't get fat and don't get injured is the best advice I can give for avoiding arthritis."

The surgeon said there can be some relief with activity modification, but ranchers aren't big on going to the gym. Physical therapy may help, although it doesn't really make arthritis pain less. "There is not a lot of data that naturopathic medicine works, either. Once the arthritis process gets going, there is not a lot you can do. Sometimes we can go in and clean up arthritic knees, but that's about it," he said.

Robinson reiterated that using technologies like a scaffold — that is meant to be combined with cartilage cells and reproduced in labs — can sometimes be used to fix potholes caused by an injury, but not arthritis. "These new technologies are super expensive. I'm not a rapid embracer of technology, and I've seen a number of treatments and technologies come and go. Many products are rapidly promoted and get a lot of hype. That doesn't mean they work. Steer clear of 'miracle cures,'" he cautioned. "However there have been real improvements in existing products such as an improvement in plastic for replacements. Now a new joint can last 20-25 years." ❖