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Cartilage problems
Q: I am having trouble walking. The doctor told me that there is no cartilage left in my knee and that bone is rubbing on bone. Can you recommend something that will help me?
Answered by Jack Farr M.D.
A: The report by your doctor of bone rubbing on bone suggests an advanced problem in the knee. The mention that there is no remaining cartilage also suggests that both the articular and meniscal cartilage are absent. As there are two types of cartilage in the knee, there is, at times, confusion between what a doctor says, and what a patient understands. For example, when the meniscal cartilage is removed many people think they are then, “bone on bone” when in fact, there is articular cartilage on the ends of both the femur and the tibia which may remain intact. There can be pain in the absence of a mensicus that may be addressed with meniscal transplant considerations. On the other hand, if the knee is indeed bone on bone, it is important to know how much bone is exposed and the underlying alignment of the knee.

Alternatives to Total Knee Arthroplasty when there is bone on bone may include realignment surgery or allografting. Carticel FDA indications only address exposed bone on one side of the joint: the femur, that includes the medial and lateral femoral condyles and the trochlea. In addition, you may be a candidate for the many non-surgical approaches to knee degeneration including strengthening exercises, medication, bracing, shoe inserts, activity modification and weight optimization. You should discuss the specifics of your knee damage with your knee doctor.

Q: I hurt my right knee several years ago. MRI reveals degenerative cartilage. I get an injection every three months and wear a brace. The knee hurts all of the time, but more so as the injection wears off. It is a treatment, but not a cure. Is there an alternative to this process?
Answered by Jack Farr M.D.
A: MRIs are becoming increasingly sensitive, but it is still difficult to precisely stage degeneration of the articular cartilage with an MRI. At times, an MRI may reveal that the damage is more severe than it really is ---or the opposite may be true. The information from the MRI is useful when combined with plain films (Xrays) to evaluate alignment and joint spaces. Further correlation with the history, clinical exam, and any prior arthroscopic pictures is extremely useful in planning a treatment program. Thus, the first step in exploring treatment alternatives is to fully understand your current pathology. When you know where the degeneration is located, it will then be possible to review specific options here on the FAQ section. With that information, you can discuss these options with your knee physician.
Q: How can I tell if I have cartilage damage?
Answered by Jack Farr M.D.
A: It is very difficult for a patient to make their own cartilage diagnosis. A knee surgeon is usually able to arrive at a cartilage diagnosis by careful history and physical examination. This may often even be more useful than an MRI in discussing treatment options. The next subset of your question regards whether you have damage to the meniscal cartilage or articular cartilage or both. Your knee surgeon can help determine the best diagnostic approach for your individual case.
Q: I had arthroscopic surgery on my left knee to repair torn cartilage. Are there exercises I can do to prevent this injury from happening again?
Answered by Jack Farr M.D.
A: It is extremely important for you to know what type of tear you had, and how it was repaired. Each type of tear has different healing potentials and rates of healing. Your knee surgeon has a plan to optimize healing first, followed by return to function. Unfortunately, you can re-tear the meniscus. To decrease this possibility, it is important to avoid knee instability. In general, good muscle conditioning optimizes knee function. Restored endurance is important as injuries often occur during periods of fatigue. Discuss what types of exercise you can do so as not to harm the repair with your surgeon. Also discuss specific activity or positional limitation to further decrease your chances of another tear.
Q: I've seen supplements that on the market for "joint health." Do they work? Would it be proactive to start using them before all the cartilage in my knees is gone?
Answered by Jack Farr M.D.
A: There are ongoing scientific studies to evaluate the various nutritional supplements. As of 2000, there is not enough scientific data to support proactive use of these supplements; however, I would agree with your proactive approach to knee health. Currently, the proactive person can help their knee’s longevity by optimizing their weight and strength and reviewing their activity level and type with their knee surgeon.
Q: Can I safely play sports with torn cartilage?

Answered by Jack Farr M.D.
A: In this setting, the use of the word cartilage usually refers to the meniscal cartilage. This pad of fibrocartilage is very important to maintain the long-term health of the knee. It would be unfortunate to have a small repairable tear extend to a non-repairable tear because of overuse and this should be the starting point for discussions with your knee surgeon.
Q: Eight months ago I had a four-plug cartilage transfer done on a lateral femoral condyle defect the size of a quarter. I've been working very hard (hiking three to six miles each day) to get my leg back, but still have significant pain. When can I expect to get relief? Will the knee always hurt?
Answered by Jack Farr M.D.
A: Autograft plugs have living viable articular cartilage so it is not a healing process at that level. Pain is always a concern, but when you state that you are hiking extensively this may be more stress than your joint is ready to accept. Discuss specific exercises with your surgeon. Hiking is a fine activity for general conditioning, but it does not specifically address each important muscle group in the lower extremity. If you are worried that the grafts are not functioning, also discuss that concern with your doctor.
Q: I have suffered severe knee pain and was told that the discomfort and swelling were due to a separation of cartilage from the knee bone. I was given Naproxin and told to ice my knee for the swelling. My knee has gotten progressively worse. I am in constant pain. What should I do?
Answered by Jack Farr M.D.
A: Severe knee pain has many possible causes. If you have the diagnosis of articular cartilage degeneration established at arthroscopy and there are no other causes, the next step will be to determine the extent and site of the degeneration. After considering your age, weight, activity level, and joint-specific factors, your knee doctor can discuss multiple treatment options. If you do not have a specific diagnosis, it is important to have one established by your knee doctor. General treatment directed at symptoms alone is not desirable---it is imperative that you have specific treatment based on an accurate knee diagnosis by taking into account your health status and desired activity.
Q: I had arthroscopic surgery two weeks ago to remove torn cartilage. My knee is still too weak to walk without a cane, and I cannot raise my leg off the ground when lying on my back. My first physical therapy appointment is not for another five days. In the meantime, do you have any dos and don’ts for me? Is it okay to pedal a stationary bike for exercise?

Answered by Jack Farr M.D.

A: Although two arthroscopic surgeries may have the same incisions and appear the same on the outside, there are many different problems within the knee that have different treatments. These conditions and treatments are specific to an individual patient. Therapy is planned to reestablish function without harming the joint. Only your knee surgeon knows these facts and thus, only your knee surgeon can suggest post-operative therapy. Having said that, it is important not to let the extremity “dehabilitate” and, therefore, a call to your knee surgeon to discuss home exercise would be appropriate while waiting for your appointment with the therapist.
Q: I've been told that I have no cartilage in my right knee and very little in my left one. The doctors say I need total knee replacements. I am 55 years old and I don't know what to do. What alternatives do I have? Is there anything else I can try?
Answered by Jack Farr M.D.
A: “Having no cartilage” in a knee means different things to different people. You need to establish the full extent of the degeneration and the site of the degeneration. If the entire knee is involved with exposed bone degeneration, then other than conservative treatment (for example: therapy, viscosupplementation/cortisone injections, shoe inserts, bracing, weight optimization, activity modification, etc.) there are few proven options other than joint replacement. If only a portion of the knee is involved and it is associated with malalignment, then realignment may be an option. If the degeneration is minimal, the knee may be a candidate for one of the cartilage restoration techniques. Your knee doctor can help you select a specific treatment plan for you and your knees.
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