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When an Old Injury Becomes a Problem
That old sports injury might need additional treatment if it still troubles you. Dr. Nirav Patel, Attending Orthopaedic Surgeon and Assistant Professor of Orthopaedic Surgery, discusses when replacement should be considered.
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Nirav Patel, MD
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Transcription:
When an Old Injury Becomes a Problem
Prakash Chandran (Host): Sure it’s fun to talk about your sporting injuries from your college days, but there comes a time when a hip or knee replacement needs to be seriously considered. We’ll discuss what goes into a knee or hip replacement, their common causes, and what to expect in recovery. Let’s talk about it today with Dr. Nirav Patel, an attending orthopedic surgeon at VCU Health. This is Healthy with VCU Health. I'm Prakash Chandran. So first of all, Dr. Patel, I'm curious as to what causes an injury from the past that might have been sustained years ago to become an issue warranting a joint replacement today.
Nirav Patel, MD (Guest): An injury from the past can injure various things, structures within the knee or the hip. Notably the cartilage or the surface. Perhaps in the knee it might be the meniscus or the shock absorber. Or, indeed, it may be the ligament within the knee. This can often alter the biomechanics of a joint which may be the hip or the knee. As we get older we tend to use, obviously, our joints more and more. This leads to uneven pressures and forces through the joint and can therefore lead to excessive wear and tear or what we commonly know as osteoarthritis.
Host: Dr. Patel, what are the types of injuries that you see that lead to needing a hip or knee replacement?
Dr. Patel: So specifically it can be injuries in high school and colleague, maybe sports. Often as we get older we have patients who participate in hobbies or recreational activities which may be on a regular basis or perhaps on a weekend basis. I see all types of different injuries. Not necessarily sports, but it can be hiking or walking or running. It can be simple things as falls and injuries to those ligaments or shock absorbers or the cartilage, which can result in ending up having osteoarthritis and then possibly the need for a joint replacement.
Host: Okay. What are some of the signs or symptoms that people experience that make you think that it’s time for a hip or knee replacement?
Dr. Patel: The biggest thing is pain. This can be pain during activity. Certainly if you're starting to get pain at rest or at night. That’s a serious indicator that something may need to be done as it’s very disruptive to quality of life. Allied to this is dysfunction. So the inability to not only just walk but depending on the function level, and I'm very particular with matching patient expectation and baseline function to dysfunction—so what they can't do—to try and restore that. So in a higher level patient, they may wish to walk for many miles compared to just getting to the grocery store. In addition, patients can complain of swelling. Certainly stiffness of the joints. Often there can be symptoms like locking where their knee, for example, commonly gets stuck like a door hinge, and they have to manipulate it to straighten it out. Also giving way or giving out. This can be from inherent ligament injury or instability of the joint, but also just wear and tear and osteoarthritis where there may be catching of the roughened surfaces of the cartilage causing pain and what we call pain inhibition in our muscles to switch off and the feeling that the knee may give out.
Host: So in the case that the people are experiencing the symptoms that you're mentioning, but they're challenged by the idea of hip or knee replacement surgery, what advice might you have for them?
Dr. Patel: I think it’s certainly worthwhile reaching out to someone like myself or an orthopedic surgeon who’s a specialist in hip and knee preservation and reconstruction. Coming to see someone like myself, I always try and preserve the joint if possible because of my background in sports but also joint reconstruction. What that means is that certainly in the beginning you try, I would recommend always in all my patients non-operative treatment, which basically means no surgery certainly in the beginning. This involves a few things such as simple analgesics or anti-inflammatories if possible. These can be oral or topical.
It can then move on to modifying activities. Usually with wear and tear or osteoarthritis, it’s low impact exercises such as swimming, cycling, elliptical, and avoiding things that reproduce the symptoms. For example in the hip and knee, things like bending, squatting can be a problem. Often patients have already stopped and won’t do a long walk, for example. Other things to consider are the use of walking aids. Potentially knee braces or knee supports. Maintaining low body weight as the hip and knee can take up to three to five times your body mass. So even losing one pound of weight can have significant positive repercussions for symptom relief because there’s less load going through those joints. For me, physical therapy is crucial because many of us are deconditioned. That can be from an athlete but also an elderly person. To stretch and strengthen the muscles within the limits of the joints. So not to cause pain, but certainly to try and offload those unhappy and painful joints. Injections can also be considered. These are all sort of part of the variety of treatment options that you’d consider before going down the route of the joint replacement where all these measures should be exhausted and the significant pain and function deficit.
Host: Yeah. Dr. Patel, you mentioned the background in sports. I understand that you used to be the assistant team physician of the Philadelphia Eagles. So I'm curious as to what advice would you have for people that have lead a more active lifestyle?
Dr. Patel: So I think some of the same advice applies to my more athletic patients. They're often in very good shape or good condition, but certainly to maintain good muscle stretching and strengthening continue with a program on the side in addition to their sporting activities. Maintaining a low body weight, which a lot of them have anyways. When there's an injury, I'm often a proponent to shut that sport down for a couple of weeks or so until they're assessed by someone like myself, for example, and achieve a diagnosis with some anti-inflammatories on board. Also rest, the application of ice, compression therapy if needed, and elevation. Then a gradual return to sport according to symptoms, usually under the guidance of a physical therapist. Like I said, it’s initial stretching program, then a strengthening program, and then ultimate sports specific training and a gradual return.
Now, if there is an injury or there’re persistent symptoms not improved with these measures, then further imaging is often is needed and consideration of surgery. That’s where the joint preservation comes in where I certainly would consider arthroscopic or keyhole procedures, for example, to deal with any meniscus or shock absorber tears or cartilage injuries and indeed ligament reconstruction.
Host: You know, it’s funny. You mentioned a gradual return to sports. But as someone who’s used to playing pickup basketball every Sunday, when I get injured the first thing I want to do is get back out on the court. I'm sure you see this all the time with athletes. So maybe talk about some of the risks involved in operating on that injury too soon.
Dr. Patel: Yeah. I think that’s an excellent point. Often athletes know even prior to coming and seeing a physician that the answer is to be shut down from sports, certainly for a temporary period of time to allow the body to heal and recuperate. The risk being if you go back too soon if the muscles are weak, the muscles are tight, the swelling that the injury could be prolonged but also they could pick up another injury because they're not performing to their highest level. I think going back too soon risks that and potentially the need for surgery, which could sometimes be avoided.
Host: Yeah. I think the important thing here is to go to see a specialist like you early and often because there are a number of different treatment options that are available that aren’t necessarily a hip or knee replacement. The longer that you let it go on, the more likely it is that you’ll need that hip or knee replacement, wouldn’t you say?
Dr. Patel: Yes, exactly. I think certainly a few days of treatment at home with the measures I described—simple protocol such as rest, ice, compression, elevation—with some anti-inflammatories. As long as the symptoms settle down, I think that’s reasonable. Any persistence of pain, swelling, functional deficit, or things like locking or giving way or giving out should warrant an early review by a specialist who deals with these injuries, like myself.
Host: In the case that you do need a replacement, maybe talk a little bit about the recovery time and how quickly people can get back to leading either their normal life or that active life that they once had.
Dr. Patel: Joint replacement, there are various types. The answer to that question depends on the type of replacement that I would do. Certainly if there’s one area—for example, the knee—that’s involved in terms of the osteoarthritis, for example, then I can replace just that part. It’s called a partial knee replacement. Alternatively if just the kneecap joint is just involved, I can just replace the knee cap. These operations have faster recovery times than the more conventional hip and knee replacement that I would do, which is a full joint replacement. In general, I describe the rule of twos to my patients. The rule of twos involves the surgery takes approximately one to two hours. You're in hospital for one to two days. The wound is kept clean for two weeks. But you're walking from the first day of surgery, with crutches often, with physical therapy. Then we here at VCU Health organize home health with nurses and therapists to come to your home to maintain that early range of motion and strengthening according to pain levels and to minimize swelling and to keep you active and mobile.
Going back to the rule of twos, a lot of the recovery is done within the first two months. Often my patients are off their walking aids off that time. Full recovery takes up to two years, but the majority of the recovery is done between six and nine months. It’s a little bit slower for knee replacements than hip replacements. I also do the revisions or redo hip and knee replacements. That is certainly challenging surgery and not done by all centers, but certainly done by myself and my colleagues here at VCU. In general, that surgery is a little bit more difficult for patients because the outcomes are slightly lower, and the complication risks are slightly higher. Therefore, the recovery tends to be a little bit more prolonged than the routine replacement surgeries.
Host: Alright, Dr. Patel, really appreciate your time today. That’s Dr. Nirav Patel, an attending orthopedic surgeon at VCU Health. Thanks for checking out this episode of Healthy with VCU Health. For appointments, call 804-828-0713 or visit vcuhealth.org/sportsmedicine. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.
When an Old Injury Becomes a Problem
Prakash Chandran (Host): Sure it’s fun to talk about your sporting injuries from your college days, but there comes a time when a hip or knee replacement needs to be seriously considered. We’ll discuss what goes into a knee or hip replacement, their common causes, and what to expect in recovery. Let’s talk about it today with Dr. Nirav Patel, an attending orthopedic surgeon at VCU Health. This is Healthy with VCU Health. I'm Prakash Chandran. So first of all, Dr. Patel, I'm curious as to what causes an injury from the past that might have been sustained years ago to become an issue warranting a joint replacement today.
Nirav Patel, MD (Guest): An injury from the past can injure various things, structures within the knee or the hip. Notably the cartilage or the surface. Perhaps in the knee it might be the meniscus or the shock absorber. Or, indeed, it may be the ligament within the knee. This can often alter the biomechanics of a joint which may be the hip or the knee. As we get older we tend to use, obviously, our joints more and more. This leads to uneven pressures and forces through the joint and can therefore lead to excessive wear and tear or what we commonly know as osteoarthritis.
Host: Dr. Patel, what are the types of injuries that you see that lead to needing a hip or knee replacement?
Dr. Patel: So specifically it can be injuries in high school and colleague, maybe sports. Often as we get older we have patients who participate in hobbies or recreational activities which may be on a regular basis or perhaps on a weekend basis. I see all types of different injuries. Not necessarily sports, but it can be hiking or walking or running. It can be simple things as falls and injuries to those ligaments or shock absorbers or the cartilage, which can result in ending up having osteoarthritis and then possibly the need for a joint replacement.
Host: Okay. What are some of the signs or symptoms that people experience that make you think that it’s time for a hip or knee replacement?
Dr. Patel: The biggest thing is pain. This can be pain during activity. Certainly if you're starting to get pain at rest or at night. That’s a serious indicator that something may need to be done as it’s very disruptive to quality of life. Allied to this is dysfunction. So the inability to not only just walk but depending on the function level, and I'm very particular with matching patient expectation and baseline function to dysfunction—so what they can't do—to try and restore that. So in a higher level patient, they may wish to walk for many miles compared to just getting to the grocery store. In addition, patients can complain of swelling. Certainly stiffness of the joints. Often there can be symptoms like locking where their knee, for example, commonly gets stuck like a door hinge, and they have to manipulate it to straighten it out. Also giving way or giving out. This can be from inherent ligament injury or instability of the joint, but also just wear and tear and osteoarthritis where there may be catching of the roughened surfaces of the cartilage causing pain and what we call pain inhibition in our muscles to switch off and the feeling that the knee may give out.
Host: So in the case that the people are experiencing the symptoms that you're mentioning, but they're challenged by the idea of hip or knee replacement surgery, what advice might you have for them?
Dr. Patel: I think it’s certainly worthwhile reaching out to someone like myself or an orthopedic surgeon who’s a specialist in hip and knee preservation and reconstruction. Coming to see someone like myself, I always try and preserve the joint if possible because of my background in sports but also joint reconstruction. What that means is that certainly in the beginning you try, I would recommend always in all my patients non-operative treatment, which basically means no surgery certainly in the beginning. This involves a few things such as simple analgesics or anti-inflammatories if possible. These can be oral or topical.
It can then move on to modifying activities. Usually with wear and tear or osteoarthritis, it’s low impact exercises such as swimming, cycling, elliptical, and avoiding things that reproduce the symptoms. For example in the hip and knee, things like bending, squatting can be a problem. Often patients have already stopped and won’t do a long walk, for example. Other things to consider are the use of walking aids. Potentially knee braces or knee supports. Maintaining low body weight as the hip and knee can take up to three to five times your body mass. So even losing one pound of weight can have significant positive repercussions for symptom relief because there’s less load going through those joints. For me, physical therapy is crucial because many of us are deconditioned. That can be from an athlete but also an elderly person. To stretch and strengthen the muscles within the limits of the joints. So not to cause pain, but certainly to try and offload those unhappy and painful joints. Injections can also be considered. These are all sort of part of the variety of treatment options that you’d consider before going down the route of the joint replacement where all these measures should be exhausted and the significant pain and function deficit.
Host: Yeah. Dr. Patel, you mentioned the background in sports. I understand that you used to be the assistant team physician of the Philadelphia Eagles. So I'm curious as to what advice would you have for people that have lead a more active lifestyle?
Dr. Patel: So I think some of the same advice applies to my more athletic patients. They're often in very good shape or good condition, but certainly to maintain good muscle stretching and strengthening continue with a program on the side in addition to their sporting activities. Maintaining a low body weight, which a lot of them have anyways. When there's an injury, I'm often a proponent to shut that sport down for a couple of weeks or so until they're assessed by someone like myself, for example, and achieve a diagnosis with some anti-inflammatories on board. Also rest, the application of ice, compression therapy if needed, and elevation. Then a gradual return to sport according to symptoms, usually under the guidance of a physical therapist. Like I said, it’s initial stretching program, then a strengthening program, and then ultimate sports specific training and a gradual return.
Now, if there is an injury or there’re persistent symptoms not improved with these measures, then further imaging is often is needed and consideration of surgery. That’s where the joint preservation comes in where I certainly would consider arthroscopic or keyhole procedures, for example, to deal with any meniscus or shock absorber tears or cartilage injuries and indeed ligament reconstruction.
Host: You know, it’s funny. You mentioned a gradual return to sports. But as someone who’s used to playing pickup basketball every Sunday, when I get injured the first thing I want to do is get back out on the court. I'm sure you see this all the time with athletes. So maybe talk about some of the risks involved in operating on that injury too soon.
Dr. Patel: Yeah. I think that’s an excellent point. Often athletes know even prior to coming and seeing a physician that the answer is to be shut down from sports, certainly for a temporary period of time to allow the body to heal and recuperate. The risk being if you go back too soon if the muscles are weak, the muscles are tight, the swelling that the injury could be prolonged but also they could pick up another injury because they're not performing to their highest level. I think going back too soon risks that and potentially the need for surgery, which could sometimes be avoided.
Host: Yeah. I think the important thing here is to go to see a specialist like you early and often because there are a number of different treatment options that are available that aren’t necessarily a hip or knee replacement. The longer that you let it go on, the more likely it is that you’ll need that hip or knee replacement, wouldn’t you say?
Dr. Patel: Yes, exactly. I think certainly a few days of treatment at home with the measures I described—simple protocol such as rest, ice, compression, elevation—with some anti-inflammatories. As long as the symptoms settle down, I think that’s reasonable. Any persistence of pain, swelling, functional deficit, or things like locking or giving way or giving out should warrant an early review by a specialist who deals with these injuries, like myself.
Host: In the case that you do need a replacement, maybe talk a little bit about the recovery time and how quickly people can get back to leading either their normal life or that active life that they once had.
Dr. Patel: Joint replacement, there are various types. The answer to that question depends on the type of replacement that I would do. Certainly if there’s one area—for example, the knee—that’s involved in terms of the osteoarthritis, for example, then I can replace just that part. It’s called a partial knee replacement. Alternatively if just the kneecap joint is just involved, I can just replace the knee cap. These operations have faster recovery times than the more conventional hip and knee replacement that I would do, which is a full joint replacement. In general, I describe the rule of twos to my patients. The rule of twos involves the surgery takes approximately one to two hours. You're in hospital for one to two days. The wound is kept clean for two weeks. But you're walking from the first day of surgery, with crutches often, with physical therapy. Then we here at VCU Health organize home health with nurses and therapists to come to your home to maintain that early range of motion and strengthening according to pain levels and to minimize swelling and to keep you active and mobile.
Going back to the rule of twos, a lot of the recovery is done within the first two months. Often my patients are off their walking aids off that time. Full recovery takes up to two years, but the majority of the recovery is done between six and nine months. It’s a little bit slower for knee replacements than hip replacements. I also do the revisions or redo hip and knee replacements. That is certainly challenging surgery and not done by all centers, but certainly done by myself and my colleagues here at VCU. In general, that surgery is a little bit more difficult for patients because the outcomes are slightly lower, and the complication risks are slightly higher. Therefore, the recovery tends to be a little bit more prolonged than the routine replacement surgeries.
Host: Alright, Dr. Patel, really appreciate your time today. That’s Dr. Nirav Patel, an attending orthopedic surgeon at VCU Health. Thanks for checking out this episode of Healthy with VCU Health. For appointments, call 804-828-0713 or visit vcuhealth.org/sportsmedicine. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.