Steroid Injections Accelerate Damage To Joint Surfaces

Picture from Ortho Arizona

Many patients with knee osteoarthritis (OA) who come to see us in our clinics often tell us that they were given intra articular (inside the joint) corticosteroid injections (IACS). ICAS is a common treatment choice that is considered minimally invasive to delay knee replacements for patients with severe OA. 

Other than providing brief pain relief, the pain often comes back. I wrote earlier this year that steroid/ cortisone injections significantly increases the risk of tendon tears.

Perhaps it's time to think more than twice before you allow anyone to inject into you knee joint. Make it any other joint for that matter as latest published research shows that individuals who got IACS were twice as likely to have harmful effects on knee articular cartilage structure than those who received no or placebo treatment.

Different stages of articular cartilage damage

A group of researchers investigated the effect of IACS on articular cartilage structure in patients with knee OA using joint space width on x-ray and articular cartilage thickness with MRI.

They found 6 studies consisting of a total pf 1437 participants. The estimated effect of IACS on articular cartilage structure showed significant odds of it worsening as measured by joint space narrowing and articular cartilage thickness. The authors concluded that their meta- analysis showed that IACS increases the likelihood of knee joint deterioration.

Other than increasing the risk of tendon tears, steroid/ cortisone  injections into knee joints may be doing more harm than good by accelerating joint surfaces degeneration. The short lasting pain relief is definitely not worth the long term consequences of your articular cartilage degenerating. 

Reference

Ibad HA, Kasaeian A, Ghotbi G et al (2023). Longitudinal MRI-defined Cartilage Loss And Radiographic Joint Space Narrowing Following Intra-articular Corticosteroid Injection For Knee Osteoarthritis: A Systematic Review And Meta-analysis. Osteo Imaging. DOI: 10.1016/j.ostima.2023.100157

PS Sim Summits K2

Summit of K2

Yes, it was last month that many of you would have read about PS Sim reaching the top of K2 - the second highest mountain in the world after Everest.

Straits Times article on 240823

Well, she came by our clinic today and both MJ and Kaylee were both ecstatic to meet her. In fact, they have been asking about her ever since they have seen her pictures in our clinic. The 2 fan girls got to ask her whatever questions they wanted. And of course they wanted pictures with her (below).

Kaylee asked her to compare Everest to K2. In her words, "Everest is a walk in the park compared to K2". To which I replied that it's not a walk in the park definitely.

We are all inspired by you PS!! Please put up an exihibition/ show and tell of all your pictures/ videos from Everest, K2 and the rest of 7 summits, we will definitely come.

Hip Adductor Related Groin Pain

If you follow Aussie Rules Football (or AFL), yesterday was the 2nd second semi final with GWS Giants defeating Port Adelaide 93-70. Aized and I had to help Aussie Rules football players back when we were  doing our post graduate physiotherapy studies in 2003. I still follow the AFL league from time to time. AFL footballers often suffer from groin pain.

Other than AFL footballers, soccer (also known as football), rugby players and those who play badminton and squash etc are involved in rapid acceleration, deceleration and sudden changes in direction are all more prone to groin injuries.

Athletes with a previous groin injury are at a greater risk than those with no previous injury. This can be up to 2.4 times greater over consecutive seasons with football players (Haglund et al, 2006).

The hip adductors

Football players have a yearly incidence of adductor related groin pain of 10-18 percent. 53 percent of theses cases are from overuse. Groin injuries in male club footballers accounted for 4-19 percent of all injuries and 2-14 percent in women club footballers.

Different types or groin pain

It can be difficult to diagnose groin injuries since there can be many different complex causes. Hip adductor related groin pain is defined as hip adductor tenderness and pain with resisted hip adduction testing. It is also the more common causes of groin pain. Other than hip adductor groin pain, the iliopsoas, inguinal and pubic symphysis are other causes of groin pain (pictured above).

Exercise therapy is commonly prescribed for groin pain although there is no specific exercise protocol. Exercises, particularly adductor eccentric strengthening seems to be beneficial for pain reduction and return to sports at 16 week follow up in comparison to stretching, electrotherapy (ultrasound, interferential currents) and transverse friction massage.

We do see many patients with groin pain in our clinics. However, our approach to treatment is different. We do not get our patients to do the strengthening exercises when they are in the clinic. We prefer to treat them using mostly our hands instead. For example, for a patient with groin pain, they may also have a higher hip on one side (pictured below).

R hip lower

We can treat the hip with respect to the shorter side. Short in terms of length. It also depends on what our assessments show. The patients can do the strengthening exercises they need on their own. We treat what they cannot do themselves in the time they have with us. Come see us in our clinics if you have groin or hip pain.

References

Haglund M, Walden M and Ekstrand J (2006). Previous Injury As A Risk Factor For Injury In Elite Football: A Prospective Study Over Two Consecutive Seasons. BJSM. 40: 767-772. DOI: 10.1136/bjsm.2006.026609

Weir A, Brukner P, Delahunt E et al (2015). Doha Agreement Meeting On Terminology And Definitions in Groin Pain In Athletes. BJSM. 49: 768-774. DOI: 10.1136/bjsports-2015-09486

Yosefzadeh A, Shadmehr A, Olyaei GR et al (2018). Effect Of Holmich Protocol Exercise Therapy On Long-standing Adductor-related Groin Pain In Athletes. BMJ Open Sp Ex Med. 4: e000343. DOI: 10.1136/bmjsem-2018-000343

Avascular Necrosis

Picture by Frank Gillard from Radiopaedia

Seeing this x-ray reminds me of what I was suspected of having when I started having persistent knee pain back in early 2002, which then led me to having 3 knee surgeries. A doctor I consulted suspected I had early avascular necrosis in my lateral femoral condyle. 

Avascular necrosis (also know as osteonecrosis) is the dying of bone tissue due to lack of blood supply. Depending on where it is, it can lead to tiny breaks in the bone and cause the bone to collapse. This process can take years to occur.

A dislocated joint or a fracture in parts of the bone can also hinder or stop blood flow to a section of the remaining bone. This commonly occurs at the epiphysis (end part) of long bones at weight bearing joints. Some common sites include the femoral head, talus, humeral head, knee and the scaphoid bone (in the wrist).

Avascular necrosis is associated with long term use of steroid medications and injections and too much alcohol. Anyone can be affected. It tends to be most common in people between the ages of 30 and 50.

Repetitive trauma can also cause avascular necrosis. This is not as commonly discussed in the medical journals. This form of avascular necrosis is most common in athletes. Rafael Nadal has a chronic left foot ailment, Mueller-Weiss syndrome where there is avasular necrosis in his navicular bone. Young gymnasts that I have previously treated are also prone to this in the wrist, knee and hips.

The doctor I consulted for my persistent knee pain back then felt that my super high mileage  (I was training for the 100 km Trailwalker event in Hong kong and the full Ironman) caused my knee pain.

The cause of avascular necrosis brought on by trauma (or repetitive stress like running and jumping) is not fully understood. Genetics combined with certain medication (like corticisteroids), excessive alcohol intake and other diseases like sickle cell anemia and Gaucher's disease can play a role as well.

Fatty deposits (or lipids) in blood vessels can block blood vessels and reduce blood flow to bone as well. There are suggestions that long term and high doses of corticisteroids (like prednisone) can increase lipid levels in blood, reducing blood flow to the bones.

Some people have no pain or symptoms at all in the early stages of avascular necrosis. As it worsens, the affected joints may hurt when weight bearing. Eventually there may be pain even at rest. Pain can be mild or severe and develops gradually. 

Having too many alcoholic drinks over several years can also cause fatty deposits to form in blood vessels.

Certain medical treatments like radiation therapy for cancer can also weaken bone. Kidney transplant patients have also been known to be associated with avascular necrosis.

To reduce the risk of avascular necrosis, please limit your alcohol intake since heavy drinking is one of the top risk factors for developing avascular necrosis. 

Keep your cholesterol levels low as tiny bits of fats (lipids) are the most common substance blocking blood supply to bones. Stop smoking as smoking narrows blood vessels which will reduce blood flow.

For those doing repetitive sports, I always suggest running on softer surfaces like grass or sand. Do not be in a hurry to increase your mileage, your bones and joints need time to get used to the load.

Lessen the junk miles or better still ride the stationary bike or use the elliptical trainer to target different areas. Strength training is very important for your bone health.

Reference

Shah KN, Racine J, Jones LC et al (2015). Pathophysiology And Risk Factors For Osteonecrosis. Curr Rev Muscu Med. 8(3): 201-209. DOI: 10.1007/s12178-015-9277-8

Best Vehicle Seat Position For Driving

Picture from the European Spine Journal

The laundry (towels, bed covers, pillowcases) in our clinics get picked up twice a week for the past 16 years by a husband and wife team - Ray and Elaine. Elaine does the driving while Ray does the pickup and delivery of the huge laundry bags. I spoke to them and Elaine was complaining about her back pain after all that driving and I told her it's probably linked to her lumbar (lower back) load from all the driving and sitting in their van.

Picture from the European Spine Journal

A recently published study used a Christophy spine model (inclusive of head, neck and limbs, pictured above) and compared calculated lower back loads and muscle forces while driving to experimental data from previous studies. 

Using data from previous radiology studies, this Christophy spine model was tested in different driving positions with different back supports. The load on the lower back was then calculated with the various back supports and backrest inclination angles.

0 cm, 2 cm and 4 cm lumbar supports were used along with inclinations of the backrest from 23 degrees to 33 degrees (by 2 degrees intervals).  

Ready for the results? Especially for those of you who drive a lot.

The overall lower back spinal loads and muscular forces at the L3-L4, L4-L5 and L5-S1 decreased very obviously with the 4 cm back support, with the seat inclination angle set to 10 degrees. With the 4 cm back support, the overall lower back spinal load decreased by 11.3 percent while  muscular forces were reduced by 26.24 percent.

The recommended backrest inclination angles are between 29 to 33 degrees with a 10 degrees seat cushion to the horizontal. 

This is a useful study to explain the association of drivers' sitting postion and the change in lower back load. It helps provide a reference for the prevention of low back pain.

Now if someone can send these recommendations to car manufacturers to improve the design of vehicle seats, that would be great.

References

Christophy M,  Faruk Senan NA, Lotz JC et al (2012). A Musculoskeletal Model For the Lumbar Spine. Biomech Model Mechanobiol. 11: 19-34. DOI: 10.1007/s10237-011-0290-6

Gao K, Du J, Ding R et al (2023). Lumbar Spinal Loads And Lumbar Muscle Forces Evaluation With Various Lumbar Supports And Backrest Inclination Angles In Driving Posture. Eur Spine J. 32: 408-419. DOI: 10.1007/s00586-022-07446-x.

What Causes Running Injuries?

Navicular drop from Physiopedia

Recently we have seen more runners coming to see us in our clinics. A few are preparing for the Berlin marathon next month while others are preparing for ultras and the local Stan Chart marathon later in the year. What was common is their lack of gluteus medius strength, sudden increase in training load, change in running shoes amd not enough recovery.

How did my observation compare to a published research on factors associated with running related injuries? This group of researchers aimed to identify factors associated with running related injuries and also to evaluate their potential in injury screening.

274 recreational runners were recruited for their study. At baseline, running technique, clinical measures (strength, range of motion (ROM), foot position), impact loading, injury and training history were collected. These runners were followed up fortnightly for 1 year.

49 runners dropped out leaving 225 (84 females, 141 males) for the final analysis. 52 percent experienced a running related injury. Calf strain (15 percent), Achilles tendon injury (11 percent) and plantar fasciitis (9 percent) made up the largest proportion of injuries.

After adjusting for age, weekly mileage and sex, the following factors were statistically significant and associated with increased likelihood of injury. Previous injuries in the past year, less navicular drop, weaker hamstrings and measures of running technique (knee, hip and pelvis kinematics) were associated with increased likelihood of injury.

There were significant associations between running injuries and hip and knee kinematics like contralateral (opposite side) pelvic drop and increased knee inward rotation. All of which I have written about before in a previous post.

I was surprised that the calf constituted the highest proportion of injuries. I (falsely) assumed the knee would be the most common site of injury. Perhaps popularity in adopting forefoot and midfoot running styles (which takes load away from the knees but transfer them to the calf, ankle and Achilles) compared to heel striking which loads the knee more. 

Another study found shin splints and stress fractures followed by Achilles tendon injuries to be the most common diagnosis in recreational runners (Mulvad et al 2018).

Only the navicular drop test (not strength, ROM, foot positioning among the clinical measurements) was associated with injury. The navicular drop is a measurement of how much the navicular bone moves from a neutral sitting position to standing. The larger the movement, the larger the collapse of the arch of the foot. 

The researches found that the less navicular drop, the higher the chances of injury, a navicular drop <10mm increased injury odds by 2 times. Values of the navicular drop test in this study would place the uninjured runners in the "pronated" foot category and the injured runners in the "neutral" foot category.  

The researchers explained that uninjured runners may have a more flexible foot with increased capacity to absorb loads. This supports emerging evidence that flat feet may be protective in nature as compared to previous views that flat feet needs 'support'. 

One of my often copied Shoe Lists update

For years, podiatrists, coaches and shoe salesmen have looked at your foot type (to see if you have normal, low or high arches) (pictured above), then recommended that you have stability, motion control and cushioned shoes respectively. The rationale being that if you had high arches, you did not pronate enough and needed softer, well cushioned shoes while if you had low arches, you tend to overpronate and needed sturdy motion control shoes to control that overpronation. Runners with normal arches needed neutral shoes and were prescribed stability shoes. This method was deeply rooted in athletic circles and widely accepted. Time to bin that permanently.

 Also relate this to wearing orthotics. Patients are to told that orthotics help prevent the arch from "collapsing". This study shows that if the arch does not collapse (or drop) more than 10 mm,  you are twice as likely to get a running injury. Something to mull over for runners who have been told to wear orthotics. We (sports doctors, physiotherapists, podiatrists etc) MUST definitely reconsider running injury prevention and treatment techniques aimed at correcting 'overpronation' since there is no association between foot eversion (pronation) and running injuries in this study.

Previous injuries less than a year ago was a strong predictor of getting injured again. This may indicate that some runners have not regained original tissue strength or they have alterations in technique that increase their vulnerability to injury. 

References

Dillon S, Burke A, Whyte EF et al (2023). Running Towards Injury? A Prospective Investigation Of Factors Associated With Running Injuries. PLoS One. 18(8): e0288814. DOI: 10.1371/journal.pone.0288814

Mulvad B, Nielsen R, Ling M et al (2018). Diagnoses And Time To Recovery Among Recreational Runners In The RUN CLEVER Trial. PLoS One. 13(10). pmd:30312310. DOI: 10.1371/journal.pone.0204742

Statins And Their Effects On Tendons

Patella tendon pain

An article in today's Sunday Times (pictured below) mentioned that 50,000 people (or 1 out of 140) are at a very high risk of a heart attack due to an inherited gene mutation unless they take statins.

Sunday Times 200823

Statins (pictured below) are medications that reduce the levels of bad cholesterol or low level lipoprotein (LDL) in your blood and protect the insides of your arteries. When cholesterol is reduced, it lowers the risk of developing heart and circulatory diseases including stroke and heart attacks.

A study of 594,130 participants found that statin medications regardless of statin types were associated with a  significantly greater risk of all types of tendinopathy development compared with no statin treatment. This is inclusive of tennis elbow, trigger finger, rotator cuff tendinopathy, Achilles tendinopathy and De Quervain's (or radial styloid) tenosynovitis. There were 84,102 statin users and 168,204 non users (control) in that study (Kwak et al, 2023).

Tendinopathy is the term used now when there is pain and dysfunction in our tendons instead of tendinitis. It is associated with overuse in and around tendons and characterised by pain, reduced function and reduced exercise tolerance. There is seldom inflammation found in the tendons, it is more of a failed healing response of the tendon leading to disruption of collagen fibers in the tendon.

The oxygen consumption of tendons and ligaments during exercise is 7.5 times lower than skeletal muscles (Radak et al, 2013). This low metabolic rate and well developed anaerobic energy generation capacity are needed to carry loads and maintain tension for long periods when we are standing, moving and exercising. 

When blood flow (carrying oxygen) is restricted or reduced in tendons, it can lead to necrosis (or death) of the cells in the tendons. A low metabolic rate also results in slow healing after injury.

What we know about tendinopathy is that it does not improve with rest. The pain may ease but returning to activity/ sports is often painful again since rest does not increase the tolerance of the tendon to load. There is usually very little inflammation invloved in tendinopathy, hence it is not considered a classic inflammatory response. Anti inflammatory medication may help if you have very high pain levels, but it is still unclear what effect they have on the cells.

Tendinopathy can be caused by many different factors, the main factor being a sudden change in certain activities like running and jumping where the tendon is required to store energy. Some people are predisposed beacause of biomechanics (poor endurance or poor muscle capacity) or systemic factors (age, menopuase, elevated cholesterol and other metabolic factors). Predisposed people may develop tendon pain even with little changes in their activities.

Modifying load is very important in settling tendon pain. Reducing tendon load (at least in the short term) always helps.

Pathology on scans does NOT equal to pain. MRI scans often show tendon 'damage' (or abnormality) in people without pain. Even if you have 'tears' or 'severe' pathology DOES NOT mean you will have a better or poorer outcome. The pathology may not improve even with the best intentioned treatment (not on scans anyway), so treatment should be targeted at improving pain and function.

Tendinopathy rarely improves with passive treatments like massages, therapeutic ultrasound, injections and extracoporeal shock wave therapy (ESWT). Note that not all ESWT machines are the same. Most if not all physiotherapy clinics use hand held ESWT devices that do not require licenses. The doctor operated devices (with ultrasound imaging requiring a license to operate) usually cost over $250,000 versus the less than $40,000 cheaper versions that do not require licenses.

Eccentric (or lengthening) exercises seems to be the most evidenced based treatment for tendinopathy. This allows the tendons to be loaded progressively so they can develop greater tolerance that one needs for day-to-day activities or sports. I'm not a fan at all about getting our patients to do exercises, but even I had to do some eccentric strengthening exercise. The hands on fascia treatment I received definitely helped, but the individualised ecccentric exercise was the final part of the puzzle.

Tendinopathy responds very slowly to exercise, so patience is definitely needed while doing the correct eccentric exercises and it also needs to be progressed appropriately. Resist the temptation to accept 'short cuts' like injections and surgery.

References

Andres BM and Murrell GA (2008). Treatment Of Tendinopathy: What Works, What Does Not, And What Is On The Horizon. Clin Orth Relat Res. 466(7): 1539-1554. DOI: 10.1007/s11999-008-0260-1

Kwak D, Moon SJ, ParkJW et al (2023). Effects Of Statin Treatment On The Development Of Tendinopathy: A Nationwide Population-Based Cohort Study. Orth J Sp Med. 1197): 23259671231167851. DOI: 10.1177/23259671231167851

Radak Z, Zhao Z, Koltai E et al (2013). Oxygen Consumption And Usage During Physical Exercise: The Balance Between Oxidative Stress And ROS- Dependent Adaptive Signaling. Antioxi Redox Signal. 18(10): 1208-1246. DOI: 10.1089/ars2011.4498