“Conservative Care” is the name of the game

After my 12 mile run in Chicago last Friday I mentioned that I had some bad news about my knee. I have been mentioning the problems I’ve had with my knee off and on throughout the summer. I finally went in for a MRI a few weeks back and now have a definitive diagnosis. And it’s not pretty:

Articular cartilage damage (osteoarthritis) of my knee cap (the patella)

Source

You can see the cartilage covering the surface of the patella above.

At first I was freaked out, and I had reason to be! When I went in for my follow up appointment a week ago to talk about options, my doctor/surgeon in the Sports Medicine Department at UVa (who will remain unnamed) had the worst “bedside manner”. He walked in, talked for a total of 5 minutes about how I needed two surgeries, an arthoscopy to “clean out” the cartilage pieces and an osteotomy to realign my knee (this second one is a serious surgery, out for 5 months or more!). He was basically all doom and gloom, saying I should never run and that I could fracture my knee cap. I’ve spent the last week in a deep depression. Running is my love; if I lost it, it would be like a death (I don’t care how many other activities there are—swimming, biking, yoga, etc–nothing compares!)

Here are some things my doctor didn’t do:

He didn’t properly examine my knee/leg

He didn’t explain where the cartilage damage was adequately (mine is on my knee cap, which is good compared to cartilage damage on the tibia or femur)

He didn’t ask me many questions

He didn’t even know that I’ve only been running for 4 years!

So I decided to get a second opinion, this time with the renowned Dr. Wilder, chairman of the Physical Medicine and Rehabilitation/Runner’s Clinic at UVa. Dr. Wilder is the go-to guy for running and people travel from all over to see him. I had to beg my way in for an appointment. But I got an appointment and I went in this afternoon. Here’s all the things Dr. Wilder did right:

Even before looking at my MRI, he did a full history/examination. This included a physical exam as well as evaluating how I ran on a treadmill.

He asked about my full history of running and other sports

He asked whether my knee has gotten better or worse since “the accident” (my soccer game in late June), which if I haven’t mentioned it has slowly gotten better even as I up my running mileage.

He asked about what I have done to help my knee (so far just a cortisone shot, no PT).

He explained, in detail, about osteoarthritis (it turns out it just refers to some wear and tear and is pretty ubiquitous in adults), how it could have happened to me (probably from playing basketball and soccer growing up, not from running), and whether it will get worse from continued running (only a small chance it will!). After doing some research after my appointment, I did indeed find that “Degenerative arthritis changes (osteoarthrosis) on the rear of the kneecap occur often after a fall on the knee and with many smaller over-loads, however, in many cases the cause is unknown” (source). In my case, I probably hurt it some time in the past when I was playing basketball or soccer and it was just waiting to get snagged off/completely damaged (like it did during my soccer game in late June).

Ok, here’s the thing: I do have a serious injury to my cartilage. Cartilage never grows back and cannot repair itself. Once it’s gone it’s gone. I have a piece of cartilage that has snagged off (the size of a nickel) and now I’ve got a bit of bone exposure. OOohh, that sounds bad, eh? It is. But according to Dr. Wilder, not all is lost. And get this: I may not need any surgery at all. He told me that my other doctor was probably so quick to schedule multiple surgeries because, well, he’s a surgeon. My other doctor also seemed to have overlooked one crucial component. Something that doctor’s must try before some major surgeries. It’s what’s called CONSERVATIVE CARE.

Conservative care involves all the nonsurgical options that a patient should try first before resorting to surgery. For me these include cortisone shot (got it) and extensive PT to help any muscle imbalances or weaknesses (nope, haven’t done any). PT is an especially good option for me because Dr. Wilder says that osteoarthritis is not worsened (or most likely not caused) by running. Let me repeat that so that all the non-runners out there can understand (my family members and friends who don’t run all say that running has caused this): there is no correlation between cartilage damage and running, especially for amateur runners, like me. I really only run about 20 miles a week; Dr. Wilder said that if I was running 60 miles or more then maybe, just maybe, running would be a factor. Soccer and other high-impact sports can indeed contribute to cartilage damage so that much is clear. So Dr. Wilder’s ultimate recommendations?

1) Cancel the surgery I had scheduled for this Friday (his exact words I believe were, “if this was my knee I would not be having surgery before I tried other conservative care options”).

2) Sign up for physical therapy with one of the best at UVa (done–I meet with him next week)

AND

3) Keep running. WHAT??! Keep running? Seriously? Yeppers. According to the Dr., running will keep the tissues in my knee active which could lead to some repair and recovery. Further, the knee (or most joints in the body) has the ability in some cases to adjust and recover. I just need see how my body responds. He said not to run more than 20 miles/week and keep my long runs to about 10 miles or base them on how I feel. Ok, so that’s not enough to train for the Vegas Marathon. But it’s enough to do the half, no problem! So no need to change my plans to run with one of my good friends in December if all keeps going well. WAAHOOOooo! I’m just excited that I don’t need to have surgery this Friday.

All of this is in line with some research on cartilage damage behind the knee cap I have done after my appointment (remember, damage behind knee cap isn’t nearly as severe as damage of cartilage on femur or tibia):

Treatment: Treatment comprises relief from the painful activities until the pain is no longer experienced, after which gradual re-training can be commenced primarily aimed at strengthening the thigh muscles. There is no treatment that can restore the damaged cartilage on the knee cap. For children, treatment of chondromalacia (a softening of the articular cartilage) is non-operative, as the condition has a good prognosis in the younger age groups (article). Several different surgical treatments have been attempted with unsatisfactory results (article). (source)

So the lesson(s) of the day? Conservative care comes first. Oh, and always get a second opinion. Both doctors are extremely well-known but a surgeon is always, or almost always, going to recommend surgery first.

And now onto part of my new running playlist 🙂  I had a great 12 mile run listening to some of these songs in Chicago on Friday

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19 Responses to “Conservative Care” is the name of the game

  1. Carina says:

    So happy to hear there are so many non-surgical options that could help!

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  17. Carrie says:

    I am going to see Dr. Wilder on Monday. Glad to hear all the good things about him, hoping he can fix my ITBS.

    • Yes, he is GREAT! I was told by another doctor in Sports Med downstairs (who will go unnamed) that I wouldn’t run again after he saw my MRI. Dr. Wilder put me through a bunch of PT and conservative treatment options and I ended running my comeback marathon last October! My knee will never be 100% and it is an ongoing battle to keep running but he is the best! He’ll probably send you to see Eric in PT…he’s great as well! Best of luck with your ITBS, it is such a pain. I’ve had it on the opposite let because I slightly favor that leg now. Let me know how it goes!!!!!

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