By Brian Diaz
This time of year several of my clients wrap up their year with a fall event and then enter down time in their training. For some, that means a few weeks off around Thanksgiving or December; for others it means trying their hand at a more rigorous and directed strength and conditioning program. Most take some rest for the body parts that ail them the most; of those, some consider seeking a physical therapist or orthopedist to address nagging issues.
The most popular nagging issue for endurance athletes is overuse. And most often, overuse and stress on the knees. Some shrug it off. Another scope procedure, a little clean up, but there are clear answers to many of the wavering questions about what is actually best for the knees in particular. This is assuming they are not considering taking a more permanent break from running and adding more cycling, swimming, rowing, or paddling into their cardio routine. Let’s talk about a few of those options.
HYALURONIC ACID INJECTIONS
Dating all the way back to the 70’s physicians have used an intra-articular injection of hyaluronic acid (HA) for symptomatic knees including osteoarthritis. There are still physicians today who use this but more often it is in combination with some of the other interventions mentioned here. HA is a naturally occurring substance already present in the knee to lubricate and cushion the joint. Why not add more then? Unfortunately, HA injections, although anecdotally reported as effective, have been proven ineffective time and time again including a recent clinical review of almost 12,000 patients in 89 different trials.
PLATELET-RICH PLASMA INJECTIONS
This is what I consider the HA advancement. Platelet-Rich Plasma (PRP) injections are derived from the patients own blood. This difference when compared to HA, is enough to get my attention. The review of literature has a much more favorable outlook as several double-blind trials have found efficacy for this treatment on symptomatic knees some vs. both placebo and HA injections. Using your body’s own growth factors to regenerate tissue and diminish inflammation seems to hold at least a 60% chance of working across all the trials that found in a PubMed review.
STEM CELL INJECTIONS
Stem cell injections have become more readily used in the past 5 years. A minute portion of fat tissue is taken from your own body and spun down to the stem cells. This is often combined with a PRP solution and then injected back into the body. As for the stem cell therapy, the jury is still out. You have the same concerns that the authors of the clinical review article of HA had in terms of adding pressure inside the knee joint with additional solution containing cells. Some of those patients developed adverse effects from the treatment and increase in pressure. Very few studies exist on this procedure and the ones that do are small and vary from somewhat effective to inconclusive. Up to this point, not a single study in the PubMed review is statistically conclusive. This is a costly procedure that almost all insurances consider elective and likely going to cost you $2,000-$3,000. So in my opinion, stem cell injection is not worth it at this time.
Despite all the major advances in medicine over the past several years, there is still no single answer for what works best in the overused knee and developing osteoarthritis. Obviously, each athlete is different in terms of age, the level at which they are competing, and volume at which they are trying to achieve, etc..
My simple solution would be this, unless you are at your wits end and AFTER trying a) conservative approaches to strength and stabilization, b) a full functional movement screen to analyze other potentially contributing factors, and c) a gait and running assessment, then I would talk with an orthopedic surgeon. If the surgeon thinks you are a good candidate for arthroscopic debridement, I would add the PRP injection as well and then determine if you want to spend extra money for the stem cells. Hopefully you can find someone who understands your desire to return to the sport you love in the spring and will guide you the best they can.
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Brian Diaz is the head physical therapist and sports specialist at ActivEdge Fitness & Sports Performance. He is a Level II Certified TRX Suspension Trainer and a USA Triathlon Certified Coach. Follow him on Twitter (@JediTriathlete) or go to his website at ExperienceTheEdge.com for more exercise ideas.
