Sunday, May 27, 2018

Can You Keep Running With Bad Knees?

Picture by richseow from Flickr
I often get this question from my patients. Will running wear out my knees? And my answer to them is a definite no. Not if they don't have a preexisting knee condition.

It's been proven beyond reasonable doubt that running does not wear out your knees. Numerous studies found no evidence that runners were more likely to develop knee osteoarthritis while comparing groups of runners versus non runners.

In fact, runners seem less likely to develop knee problems due to the reduced weight and the ability of articular cartilage to get stronger due to the running (Williams, 2013).

No this is without doubt good news for runners without any knee problems.

What if the runner already have a knee osteoarthritis, where the natural shock absorption between the knees have worn out? If you keep running will you hasten the progression of the osteoarthritis?

Just because running doesn't wear out your knees and/ or cause osteoarthritis, that doesn't mean you're immune to it.

Personally I think that logic suggests that if the knee joint is already compromised, it is likely that the stresses that result from running could possibly worsen the wear and tear despite little evidence on the topic so far.

Hence, this newly published study which studied almost 5,000 subjects for nearly ten years is worth a read. In that group, there were 1,203 people over 50 years old who had osteoarthritis in at least one knee. 138 of these 1,203 people happened to be runners throughout the study period.

The subjects went through many diagnostic tests, including x-rays to find out how severe their knee osteoarthritis was. These tests were repeated four years later. Those who ran during this period of time did not have a faster progression of symptoms  than those who didn't run. There was little evidence to suggest that running was harmful in this study group.

This was contrary to what the authors expected. Running was not associated with worsening knee pain nor did their x-rays showed any worsening. In fact, the authors suggested that the runners had more improvement in knee pain compared to the non runners, suggesting that there may be a benefit to running from a knee health perspective in people who have knee osteoarthritis.

While comparing x-rays for "joint space narrowing", which indicates that the bones are getting closer together because the cartilage is disappearing, 23.6 percent of the non runners got worse in the study period, compared to 19.5 percent of the runners.

39.1 percent of the non runners had improvements in the knee pain compared to 50 percent of the runners. After adjusting for age, BMI etc, the runners were 70 percent more likely to see improvement in their symptoms.

Now before all you runners and non runners with osteoarthritis get too happy and carried away and start running like there's no tomorrow, bear in mind that there isn't much information as to how much distance the runners covered or any other differences in the running versus the non running group.

Please note that the runners were not told to go forth and run as much as they wanted. They were not given any specific instructions at all about running. The runners were presumably following their own urges to run and common sense plus advice from their doctors/ physiotherapists.

There was no mention whether they ran less frequently or shorter distances than they were used to. Did they have to stop and walk if their knees started hurting while running?

I've seen many patients with reduced and compromised mobility due to an arthritic knee and hence would hesitate to suggest they start running especially if they were not already runners to begin with.

I do observe that once the patients have osteoarthritis, it generally leads to a reduction in their physical activity which may then lead to an elevated risk to other chronic conditions like heart conditions and diabetes. I would definitely suggest they remain active through stationary bike riding (for safety reasons) and of course aqua based rehabilitation/ deep water running.

This study doesn't tell us that you can run through osteoarthritis with no consequences. It does however, offer some tentative support for letting your symptoms be your guide. It doesn't mean quitting for the runner with osteoarthritis. If there is no swelling and no pain, you can probably still run. But definitely, please modify the distance, intensity and frequency that you run.

It may mean substituting a bike or swim session for the run occasionally, trying a different shoe, different surface and/ or including a weight training session to get yourself stronger. If you can still find a running routine compatible with your osteoarthritis symptoms, the results of that study should reassure you that you're not making your knees worse by running.


Lo GH, Musa SM et al (2018). Running Does Not Increase Symptoms Or Structural Progression In People With Knee Osteoarthritis: Data From The Osteoarthritis Initiative. Clin Rheumatol. DOI: 10.1007/s10067-018-4121-3. Epub.

Williams PT (2013). Effects Of Running And Walking On Osteoarthritis And Hip Replacement Risk. Med Sci Sp Ex. 45(7): 1292-1297. DOI: 10.1249/MSS.ob013e3182885f26.

Oh my aching knee .....

Saturday, May 19, 2018

He's Back!

Recognize this handsome, young man? If you're Singaporean, you definitely will. The only Singaporean to ever win an Olympic gold medal.

Well he just came back to sunny Singapore and will be back for a little while. And Sports Solutions or Physio Solutions is always one of his first port of call.

Welcome home Jo! Always a pleasure to see you.

Saturday, May 12, 2018

Diagnosed With Hip Impingement But Still Completed the 6 Majors

My patient came and showed me her Abbott World Marathon Majors medal today. Yes, she's completed all the six AbbottWMM races in Tokyo, Boston, London, Berlin, Chicago and New York City. All this while having hip and low back pain and being diagnosed with FAI or femoralacetabular impingement (or simply hip impingement). She was actually contemplating surgery to "solve" her problem. 

You must be wondering what FAI is. It is a hip condition which occurs when there is a mechanical mismatch in the ball and socket hip joint between the "ball" in the hip and "socket" know as the acetabulum. There are usually three types of hip impingement as drawn by Aized below.

2 of the three types of hip impingement - CAM, Pincer 
Many normal people have "bumps" or slightly deeper sockets and these can potentially cause femoroacetabular impingement. This is the way we are made and develop. With sports or other aggravating movements, there can be increased friction between the acetabular socket and the femoral head leading to pain and decrease in range of motion.

FAI often presents as hip/ groin pain and limited range of hip motion, which is exactly what my patient has. Pain is often provoked with prolonged sitting, crossing legs, walking as well as during and after sports or exercise depending on the type of impingement. Pain can be felt deep in the groin and sometimes at the side of the hip or buttock.  There is usually a restriction in hip flexion and internal hip rotation.

Physiotherapists reading this will think of the L1-2 lumbar distribution to the lower back can cause similar pain and symptoms in the hip and groin. At least that was what I thought of straight away when checking and treating her lumbar spine made her better. Instead of treating her pain, I tried to find the cause of the problem and treat it instead. That's what we always do in our clinics.

To make the long story short, she didn't have her hip surgery. Laura was able to finish the 2018 London marathon to complete her 6 majors in a speedy 3:42 hrs (though she thought it was "slow").
She was the center of attention our clinic earlier today when everyone present admired her medal after she took her picture with me.

Here's a close up of her medal.

Monday, May 7, 2018

Young Athletes Are Not Small Adults

I've had a few worried parents message or call me on the past two weekends saying that their child has had sharp pain suddenly without any falls or accident. A common area of complaint is in the knee or heel.

After a few short questions and answers I am usually able to reassure the parent that their child is fine and nothing is really serious about the painful episode.

Often these young children/ athletes have growing pain. The long bones grow quite quickly (especially if they are having a growth spurt) and the muscles don't lengthen quite as quickly. When the child is active, this shorter muscle(s) often pull on the bony attachments and cause pain.

Their muscles usually will not have developed enough strength to compensate for the sudden increase in lever lengths.

My older boy who is eight plays football once a week. Other days he's at the playground running, jumping and climbing etc. He's growing taller and  his muscles are not always strong enough to generate the forces required to move his longer and now heavier legs. As a result, he often has this "growing pain" in the night especially after he'e been particularly active.

I just taped my older boy's leg last night
From treating all the young and teenage athletes in our clinics, we observe that it may take up to about nine months for the muscles to develop length and strength after a growth spurt in their bones.
This form the basis of injuries that these young athletes get. If the bones grow longer and the muscles don't quite catch up in length, the muscle will be relatively shorter and hence tighter.

The area most prone to overload is where the muscle attaches via the tendons to the bones. Hence these pain and injuries we see are growth related.  Common areas are where the Achilles tendon inserts in the heel bone (usually known as Severs disease, although it is definitely not a disease), and the patella tendon on the shin bone (Osgood Schlatters disease).

Other areas include the quadriceps tendon into the knee cap (Sindling Larsen disease) and the attachment of the hip flexors onto the pelvis.

It is usually due to overload of the tendon attachment to the bone from doing too much too soon (without rest) that causes these pain or injuries.

Majority of the time, most of these cases get better when the muscles "catch up" with the bone growth by lengthening and getting stronger.

Stretching the muscle may be worse sometimes as static stretching can place more traction forces on the tendon insertion on the bone. We tend to teach our young patients and their parents to use the trigger ball instead.

Correct strength training that is pain free often helps the muscle take load off the tendon attachment. Don't use a load that is too heavy.

Come see us in our clinics if your young or teenage child athlete needs help.