Rats. He's on to me!

Is there a 12-step program for addicted runners??

You gotta love a doctor with a good sense of humor. That's probably easier if the medical practitioner is an orthopedist than an oncologist, but the fact remains (for me, at least) that a little humor can help keep serious issues in perspective.

Laughter is the best medicine, and all that.

This entry is related to the last one because once I stopped masking all sorts of osteoarthritic aches and pains by giving up ibuprofen about six weeks ago, it was quite obvious that it was time to do something about my cranky knees.  < big sigh >

INITIAL WARNING

Two summers ago I injured my left knee after climbing several 14ers in Colorado. I was a little concerned about musculoskeletal damage but had no clue how seriously the diagnosis would affect my lifestyle.

It was an awesome run/hike on Mts. Belford and Oxford on 8-13-07 when I hurt my knee!

When we got back to Roanoke a few weeks later I made an appointment with one of the physicians at Roanoke Orthopaedics, a large practice with about ten orthopedists who are very specialized. Jim and I both had already had surgery with one of the foot specialists there and liked him. However, for my new knee problem I was referred to another doctor, Brent Johnson, who is very experienced in both knee and shoulder surgery AND is a sports medicine specialist.

It's been a good doctor-patient fit. That's important to me.

X-rays and an MRI in 2007 showed only a slight meniscus tear (relatively good news) but plenty of cartilage loss (bad, bad news) in my knee.  At that point I was clearly on notice that my cartilage was rapidly deteriorating -- probably in the other knee, too -- and I'd better modify my running. In addition to athletic alternatives, we talked about long-term treatments like physical therapy, viscosupplementation, and knee replacements.

Dr. Johnson was surprised that I wasn't in much pain back then except for the recent strain. What neither of us realized was just how effectively the ibuprofen was masking the arthritic pain. That treatment was fine until the ibuprofen began (possibly) causing the problems I talked about in the last entry and I decided it was in my best interest to get off the magic pills. 

You mean this isn't normal??!!  (September 2005)

Two years ago Dr. Johnson essentially said to come back when the pain got so bad that it was limiting my ability to comfortably do normal physical activities (he doesn't consider running ultras "normal," of course) and strongly advised me to run less and do more cross-training that puts less impact on my knee joints.

I CAN SEE CLEARLY NOW

Now I'm pretty stubborn and thoroughly addicted to running, but not totally stupid! I could see the writing on the wall.

So I modified my fitness program. For the past two years I've been running and hiking less hilly, mountainous terrain, incorporating more and more walking into my training to where I'm doing very little running, and covering fewer miles each month. I've learned to (mostly) enjoy flatter surfaces, shorter and fixed-time races, and more cross-training -- preferably aerobic activities that I can do outside, on trails, that produce some endorphins!

I try to be grateful for what I'm still able to do and not whine too much about it.

I've been in some denial, however, as evidenced by the mountainous 50Ks I ran/walked this past summer and the mountains I continued hiking in the Rockies:

Tahoe Rim Trail 50K in July

Turns out, that was kind of my "swan song" for ultra running.

As time has marched on, both knees have become more noticeably sore going down hills (even walking) and especially down steps and stairs. Even before returning to Roanoke in September or getting off ibuprofen, I made an appointment to see Dr. Johnson again so I could determine if it was time for knee injections.

Within a few days of getting off ibuprofen, the answer was obvious: it was time!

BONE ON BONE

The reality of my situation hit with full force when Jim and I consulted with Dr. Johnson at the end of September. He didn't order any MRIs this time; inexpensive X-rays clearly show the problem in BOTH knees:

Sue's knees  (September 2009)

I am now officially "bone-on-bone" on the inside of both knees. You can see them rubbing together in the photo above, at or maybe even past the stage where injections might help.

Bad news indeed.

But Dr. Johnson tried to "inject" some humor into the situation by comparing my knees with various car parts that need a periodic lube job or retread -- and my running-addicted brain to a computer that still needs some reprogramming! I'll delve into the "reprogramming" part in the next entry.

Here are some graphics of healthy versus arthritic knees from the Orthovisc website:

 

 

Ouch! That third picture looks worse than my knees feel, even without the use of ibuprofen!

ORTHOVISC: MY NEW FRIEND

Dr. Johnson's preferred type of injection is Orthovisc, a viscosupplement made of natural hyaluronan, which is found in healthy joint fluid. Injected into the knee, it helps to lubricate and cushion the joint so folks like me with serious osteoarthritis can continue or resume normal activities ("normal" -- there's that word again!). There are seven or eight different kinds of injections on the market now. Dr. Johnson prefers this one for several reasons, including its efficacy, cost, and ease of administration.

Orthovisc is injected 2cc at a time*** into the affected knee (in my case, both of 'em) over three consecutive weeks for a total of 6cc in each knee. There is a short animation here that shows how it oozes in and settles into what Dr. Johnson calls a "balloon" inside the joint. Although the fluid apparently absorbs into the body fairly soon, the beneficial effects last an average of six months.

There isn't a limit medically to the number of times you can get injections; Dr. Johnson has one patient who has received the series eight times. That guy's either well-heeled or has great insurance! It's not a cheap fix.

Nor does viscosupplementation work for everyone. Dr. Johnson gave 50-50 odds that it would be effective in my case. Even if my insurance hadn't covered it, I would have paid for the treatment out of pocket to see if it would help. Injections sure beat knee replacements if they'll work for several years!

And I keep hoping researchers will come up with something even better before I need knee replacements. With so many older folks now needing the surgery -- and millions more Baby Boomers like me waiting in the wings -- I'm surprised science hasn't produced a more permanent cushioning substance yet.

Graphic of a total knee replacement

*** Over the summer a friend told us about a new Synvisc injection that is given in only one injection. Dave was considering it so he wouldn't have to get the other type of Synvisc, which is administered in five injections. He figured it'd  be easier and cheaper with only one dose. When I asked Dr. Johnson about it, he said he won't use Synvisc One because it's just too much lubricant to go in all at once and would be too painful. He knows whereof he speaks -- he gets viscosupplementation in one of his own knees! As soon as I learned about my doc's very personal experience with this stuff, I trusted him even more.

AT LEAST MY REFLEXES ARE GOOD

I had to return to Dr. Johnson's office three more times to get the injections because they have to be specially ordered each time. Jim went with me for the first injection so he could see the procedure and cart me home if I was too sore to drive afterwards.

The whole process was much simpler than we expected.

Well, except for that little incident when Dr. Johnson hit a nerve the very first time he stuck the needle into one of my knees and I involuntarily jerked. Oops! The needle went flying and had to be replaced but fortunately the expensive Orthovisc was intact in the glass. Surprised all three of us! My leg went flying up just like he'd hit my "funny bone."

On his second try, I held my knee with my hands and didn't feel either the needle or the fluid going in. I did feel what the orthopedist describes as "pressure" when he injected the other knee (carefully!) but it didn't hurt.

Although one or both of my knees were a little sore right after each injection, they felt fine after a few hours. I wasn't allowed to do anything very strenuous for 48 hours, then I could resume all normal activities including walking, cycling, gardening, etc. When I realized how simple it was, I went in by myself for the second and third injections.

CHEAPER ALTERNATIVE??

Since Dr. Johnson has a good sense of humor and likes analogies, I seriously considered purchasing a can of Great Stuff™ to take in the second time and ask, "Wouldn't this be a whole lot less expensive??"

If you're not familiar with Great Stuff, there are several variations of the expanding foam that you can spray into different types of cracks and joints in your house to fill, seal, and insulate them -- kinda like Orthovisc does for knees, I thought!

I decided it wasn't worth the time to buy a can and then return it, so I just took in a picture and Dr. Johnson got a laugh out of it.

Hey, if you can't joke about things like this . . .

GUARDED OPTIMISM

I got my third and last set of Orthovisc injections three weeks ago. I can already tell a difference. That's very good!

Dr. Johnson said I'd know within six weeks if the lubricant works for me. Most folks who get relief from viscosupplements feel the best after 8-12 weeks; that's when the effect tends to peak. I'll try to remember to report how my knees feel at that point in my treatment.

I'm optimistic so far, but I realize that there could possibly be some placebo effect because I really want to put off knee replacement surgery as long as possible. Placebos aren't all bad, but considering how pricey Orthovisc is, I hope the device itself is really working. (Oddly to me, these lubricants are not classified as drugs but as "medical devices." Go figure.)

Despite what seems to me to be a high price for viscosupplements, they are considerably cheaper than the estimated $20,000+ each knee replacement would cost in the Roanoke area if I needed surgery at today's prices! No wonder my insurance company OK'd the Orthovisc injections.

Next entry: what little to no knee cartilage means to me in the long run (pun intended)

Happy trails,

Sue
"Runtrails & Company" - Sue Norwood, Jim O'Neil, and Cody the Ultra Lab

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© 2009 Sue Norwood and Jim O'Neil