Knee-Deep in Injuries

For Richard Glanz, the mind is willing, but the knees are not.

He first learned this on a basketball court years ago when he severely tore cartilage in his left knee driving to the basket. He repeated this lesson several more times, ripping the connective tissues in his knee once again while playing basketball and twice while playing baseball.

In all, Glanz, 43, has endured five knee surgeries--four on his left knee, one on his right. His first four were arthroscopic, and the last one, the worst by far, was the complete reconstruction of his left knee’s anterior cruciate ligament in January 1997.

“Every morning I wake up, [and] it’s snap, crackle and pop. It’s never going to be normal again,” says Glanz, a commercial real estate developer, who hopes to return to the squash and tennis courts soon.

Each year, about 5 million Americans seek treatment for bad knees, which are rivaled only by the lower back as the chief complaint among aging baby boomers, according to orthopedic doctors.

The rise in knee woes can be traced to America’s compulsion with fitness and an active lifestyle, doctors explain. A generation ago, it seemed most adults’ idea of exercise was mowing the lawn or chasing the kids around the house. Not surprisingly, these often overweight adults suffered the physical consequences of a sedentary lifestyle, most notably heart attacks, doctors say.

But in the last 20 years, Americans have dramatically changed their exercise habits. A growing body of research on the medical benefits of fitness and nutrition, recommendations by doctors to “get some exercise” and a youth-obsessed culture, spearheaded by baby boomers, have fueled the get-fit revolution, according to fitness observers.

The Downside to Better Health

An estimated 81.3 million Americans engage in fitness, sports or outdoor activities at least three times a week--more than at any other time in U.S. history, according to the San Diego-based American Council on Exercise.

It’s a no-brainer that all those people jogging, skiing and playing tennis translate into more injuries. Orthopedic doctors question whether the current rise in knee injuries is excessive, even given the larger number of sports enthusiasts. Too many recreational athletes, they say, particularly those over 40, unnecessarily risk injury by throwing themselves haphazardly into sports.

Many baby boomers fail to consider that as the body grows older, the knee ligaments--the tough band of tissues that holds the bones together and helps to control joint movement--become stiffer and more brittle. And more prone to injury.

The older the athlete, the more important conditioning and stretching become, doctors say. The two techniques are the best way to prevent, or reduce the severity of, a sports injury. But whether it’s hubris or laziness, not everyone does as they should.

“The biggest problem we have is with guys over 40 who think it’s still like their college days when they rolled out of bed Saturday morning after a night of drinking and played basketball all day and they were fine,” said Gary Losse, founder of the Oasis Sports Clinic in San Diego and a former team doctor for the San Diego Chargers.

“They’re unprepared, and that’s when they get the ligament injuries,” Losse said.

Boomer athletes also make themselves vulnerable to knee injury by their choice of activity. Lower-risk sports like swimming or cycling produce fewer injuries. But boomers who have clung to those higher-risk sports of their youth--football, basketball and soccer--are rolling the dice with each passing year.

These latter sports, which require jumping, cutting and pivoting, can wreak havoc with aging knees, doctors say. Many recreational athletes realize the increased risks but still hang on to to their favorite sport.

“It’s your personality, it’s your identity, and you make great friendships,” said Glanz, who still hikes and skis with his family.

A Choice Between Surgery and Sports

The price sometimes paid is a visit to the doctor’s office or emergency room. What happens next depends upon the person’s age, the extent of his injury and the willingness to change his lifestyle, doctors say.

In some cases, a person can avoid surgery if he is willing to accept the limitations of a damaged knee. But the trade-off may be abandoning most sports, wearing a knee brace and committing to a regimen of exercises to strengthen the knee.

But doctors are discovering few will make such a bargain.

“We’ve learned that people, even in their 40s and 50s, are unwilling to live with an unstable knee,” said Dr. Kevin R. Stone, a San Francisco physician who treats the U.S. ski team. “People don’t want to give up their lifestyles.” Less than 20 years ago, a 40-year-old patient espousing such sentiments might have been laughed out of a doctor’s office. The cruder surgeries of that day left patients with a three- to four-day hospital stay, six to eight weeks of crutches and a cast, banana-length scars, and at least a year of painful rehabilitation. Even then, the knee would never be close to what it had been.

But today, patients have benefited enormously from advances in physical therapy and improvements in surgical techniques and instruments. A person with a complete knee reconstruction can leave the hospital the same day, be off crutches in anywhere from one day to two weeks, have one or two scars the size of a pencil head and be fully recovered within six months.

The breakthrough came in the early 1980s with the development of arthroscopy, which allows doctors to repair knee damage with small incisions and the aid of a telescopic lens. The scope, as doctors call it, is especially effective in treating tears to knee cartilage (which keeps bone smoothly sliding on bone) and meniscus (which act as shock absorbers between bones to protect cartilage).

Oftentimes, damage to either the cartilage or meniscus, if undetected or untreated, can lead to the most common major sports injury--a torn anterior cruciate ligament, or ACL. Even though there are four ligaments that stabilize the knee, it’s usually the ACL that is blown out in a sport injury.

“The ACL is a devastating injury,” said Dr. Stephen Liu, an orthopedic surgeon at UCLA. Each year, about 250,000 ACL surgeries are performed (about 50,000 for skiing injuries). The key to a successful surgery is to find and attach a suitable substitute ligament. Depending on a person’s age, athletic interests and other medical factors, doctors usually borrow a portion of a ligament from one of three sources: a patient’s hamstring, a patient’s patellar tendon (the tendon that holds the kneecap in place), or a cadaver’s ACL.

Women Run Greater Risk of Injury

In an oddity that doctors don’t yet fully understand, women are suffering ACL injuries at a significantly higher rate than men when participating in similar sports. (However, because more men participate in sports that are tough on the knees, they suffer ACL trauma in far greater numbers than women.)

A 1994 study of ACL injury rates among 60 collegiate soccer teams found that women blew out their ACLs at a rate four times higher than men, according to Liu, who headed the study. Similar studies in America and Europe comparing ACL injury rates in sports like basketball and handball came up with nearly the same results.

Some doctors believe women may tear up their ACLs faster than men because of a narrower notch where the ligament passes through, which when hit with enough force can act as a guillotine. Others speculate that differences in the conditioning and strength of men and women explain the different injury rates.

However, most doctors concur with a study by Liu published in the prestigious Journal of Orthopaedic Research in 1996 that blamed hormonal differences for the injury disparity. Estrogen loosens a women’s ligaments during certain times in the menstrual cycle, thus making them more prone to injury, Liu found. (A study published this month by doctors at the University of Michigan supported Liu’s findings, stating that women face a higher risk of ACL injury during the ovulation phase of their menstrual cycle.)

In the coming decades, doctors say their techniques and surgical instrumentation will gradually improve, and they predict any breakthrough will involve finding replacement ligaments for ACL patients. Instead of using their own ligaments or a cadaver’s, human patients will be able to accept an animal’s ligament for their knee, doctors say. In addition to supplying a plentiful and inexpensive source for ligaments, animal transplants should reduce the pain of surgery and improve recovery time for patients, doctors say.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

THE ANTERIOR CRUCIATE LIGAMENT

The ACL is one of four ligaments that stabilize and make movement of the knee possible. There are collateral ligaments (not shown) on each side of the knee and two crossing ligaments deep inside the kneethe ACL on the front and the posterior cruciate ligament, or PCL, on the back. These attach to the end of the thigh bone (the femur) and the top of the shin bone (the tibia)

. TAKING A GRAFT

One of the most common methods in reconstructing a torn ACL involves grafting a portion of the patients own tendon. The graft comes from either the hamstring tendon or the patellar tendon, at right. The latter uses a bone-tendon-bone graft taken from the knee cap, or patella bone, the central and middle third of the patellar tendon, and the tibia. Two small incisions on the knee are made, and then the procedure is done arthroscopically.

RECONSTRUCTING THE LIGAMENT

A tunnel is drilled into the bottom of the femur and top of the tibia. The graft is threaded across the knee and secured in each of the tunnels to replace the original ACL. The graft can be secured with screws, bottom right, or with staples, sutures or buttons. The patellar tendon graft is secured by wedging a screw up into the tunnel next to the tendon, top right

Source: Johns Hopkins University department of orthopaedic surgery.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Tips for Saving Your Knees

Conditioning--Being in good physical condition is key to avoiding any physical injury, including the knees. Many knee injuries occur when a person gets overly tired.

Flexibility--Stretching helps loosen ligaments, which tend to become more rigid with age. Looser ligaments reduce the likelihood, or severity of, injuries.

Weightlifting--Strengthening hamstring and quadricep muscles help protect the knee ligaments by absorbing some of the workload.

Warm up/Cool down--Before exercising, warming up and cooling down encourages flexibility and prevents ligaments from tightening up.

Experience--Know your athletic limitations. Don’t push yourself if you feel overly tired. Also, avoid or be extra careful when participating in higher-risk sports such as soccer, basketball and skiing.