Out of joint: Managing joint injury and pain | TSLN.com
Rebecca Colnar
for Tri-State Livestock News

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Out of joint: Managing joint injury and pain

Repetitive use of joints, like when riding a horse, can cause permanent damage, but there are some things you can do to avoid wear and injury. Getty Images.

Say a horse fell with you when you were 19. Or a cow got you down when you were 35. Or maybe you just use your knees and shoulders all day, every day and they're starting to protest.

The question is, should you just keep gritting your teeth and put up with it, or is there something someone can do to make everyday life with your joints a little less painful?

Medical technology helps many people with a variety of orthopedic concerns from knees to shoulders to hips. However, orthopedic surgeon Whitney Robinson, MD, explains before using new technologies, it's essential to have a good idea of the injury or problem, along with the reality of what can be accomplished.

"For example, the knee. There is a lot of talk about cartilage repair in the knee," says the Billings Clinic orthopedic surgeon. "There are actually two parts of the knee we call cartilage, so it can get confusing. One of these cartilages is the meniscus, in which we often see tears in active young people. The surface of the joint is also referred to as cartilage. We can distinguish between the two by calling one the articular joint cartilage and the other, the surface of the joint. Articular cartilage can be damaged in a variety of ways. However, the one that wears away at the surface of the joint can often be routine osteoarthritis or rheumatoid arthritis. Both are inflammatory and both wear away at the surface of the joint."

Robinson explains about knee potholes. "When people damage a joint through an injury, they might get a ding in the surface of the joint. We call this a pothole. We have a number of different options for potholes, and although none work spectacularly well, we can fix those. Keep in mind an injury is very different than the joint wearing away."

Farmers and ranchers will show up at the doctor when there is a definite problem. "I've been at the Billings Clinic for 25 years and I know when a rancher shows up and says his knee hurts, it hurts. I see ranchers and farmers who are 58 years old have arthritis," Robinson says. "Other than doing a joint replacement, there is not a lot I can do to replace cartilage for them. I can't paint on a new surface of the joint. I can't inject magic stem cells."

Robinson comments there is zero data on the efficacy of isolating stem cells and injecting them into joints, which is a new procedure being tried in some places. "I'm not opposed to technology, but I haven't seen that stem cell procedure actually work. I know it doesn't regrow the surface of the joint. Could it be that someday we will have true stem cells that can become cartilage cells and glue on? Maybe. Currently they are making what are called protein scaffolds. Doctors take a piece of cartilage from your knee, a medical company grows that in a lab and mixes it with a scaffold that's used to replace the pothole. We can make that work, but it doesn't make the joint healthy enough for someone to go back into active sports. There are disks to potentially fill potholes, but at this point, those are experimental."

For ranchers, a pothole in a knee might occur when they fall off a horse, resulting in a tear of the meniscus and a divot in the surface of the joint, which can be cleaned up. "We will first try what's called a microfracture. What you do is poke the base of the pothole, which causes bleeding. The bleeding fills the pothole and then that blood turns to scar tissues which then becomes something that approximates the surface of the joint."

"Microfractures have limitations, but that's the primary repair we will try first," Robinson says. "But again, remember that we can do repairs to injuries—potholes can be filled up– but for the shoulder, knees and hip the algorithms are the same. When the joint gets worn away, it has to be replaced with metal and plastic."

The bad news? "There is not a lot I can do to slow down the progression of arthritis. We can try to make you feel better, but the process continues. Sure, you can inject a joint with hyaluronic acid, but that only provides relief short term. It doesn't regrow cartilage and it doesn't make arthritis disappear. It really won't change the natural process."

He points out that knee replacement is the third most common surgery in the U.S. "In general, knee replacements work pretty well. Your knee won't be as good as you once had, and you probably won't be playing basketball, but a knee replacement will let you get back to doing stuff. Ranchers develop what we call medial compartment arthritis, which is arthritis on the side of the knee. They are bowlegged. Ranchers generally have crooked knees, so we can straighten out those legs and get them back to riding horses and doing their work. Technology with knee replacement has been good."

As for prevention, Robinson's advice is don't gain excessive weight. "There is a strong correlation between body size and arthritis. The other advice is don't get injured. If you injure your knee jumping off a horse at the rodeo and hurt something, that will lead to arthritis. Don't get fat and don't get injured is the best advice I can give for avoiding arthritis."

The surgeon says there can be some relief with activity modification, but ranchers aren't big on going to the gym. Physical therapy may help, although it doesn't really make arthritis pain less. "There is not a lot of data that naturopathic medicine works, either. Once the arthritis process gets going, there is not a lot you can do. Sometimes we can go in and clean up arthritic knees, but that's about it," he says.

Robinson reiterates that using technologies like a scaffold—that is meant to be combined with cartilage cells and reproduced in labs—can sometimes be used to fix potholes caused by an injury, but not arthritis. "These new technologies are super expensive. I'm not a rapid embracer of technology, and I've seen a number of treatments in technologies come and go. Many products are rapidly promoted and get a lot of hype. That doesn't mean they work. Steer clear of 'miracle cures,'" he cautions. "However there have been real improvements in existing products such as an improvement in plastic for replacements. Now a new joint can last 20-25 years."

How to treat and prevent joint injuries

Dr. Kevin Dahl, a Sanford Health Orthopedic Surgeon located in Fargo, North Dakota, shares his knowledge about dealing with joint injuries.

Q: Are there better results if you go to see a doctor when an injury happens instead of just putting up with a pain till it gets better?

A: Most minor injuries likely do not require immediate attention. Joint injuries involving mechanical catching/buckling/significant swelling should be evaluated more promptly. Injuries involving aching/pain can be treated conservatively for a period to include anti-inflammatories, icing and activity modification.

Q: What’s the best way to treat a joint injury?

A: This depends on the injury. Common shoulder injuries would be rotator cuff tendonitis/subacromial bursitis, which can be treated with physical therapy/anti-inflammatories/possible cortisone injection vs. possible arthroscopic debridement surgery. A tear of the rotator cuff may require surgical repair with suture/anchors. The most common knee injury would be a meniscus tear; this usually has poor healing potential and requires an arthroscopic partial meniscectomy (removal of the torn portion of the meniscus).

Q: When should you see a doctor about joint injury? What are the signs?

Again – injuries involving mechanical symptoms – instability/catching and significant swelling should be more promptly evaluated. Other injuries can be treated conservatively for a few weeks period to see if symptoms will improve.

Q: Should you use heat or ice?

A: Injuries involving swelling and inflammation should be initially treated with ice – this will help numb the pain as well as decrease swelling/inflammation. Injuries greater than a day old and involving muscle aches can be treated with heat.

Q: Is there anything practical that farmers/ranchers can do to avoid joint damage?

A: Unfortunately, most joint damage is osteoarthritis, which is caused by a combination of chronic wear and tear as well as having a genetic component (some people are more predisposed). Utilizing ice and anti-inflammatories at the end of the day can keep the symptoms to a minimum.

Q: Is there anything to reduce the change of injury, such as alternating hands while pitching hay?

A: Alternating hands and taking breaks can help limit repetitive use injuries. As for articulating/angled stirrups – I have no personal experience with this – however, an orthopedic colleague with experience does feel that using an unfamiliar saddle or standard stirrups can put a lateral stress on the knee and cause increased knee pain. He believes the angled/articulating stirrups can absolutely decrease knee stress and pain.

Q: What are some of the more common farm/ranch related joint injuries you see?

A: The most common farm injuries I encounter are hand injuries due to use of farm equipment and power tools. Another very common injury specific to the knee would be a meniscus tear – a cartilage shock absorber in the knee between the femur and the tibia. As we age, the meniscus softens and more easily tears with minor twisting injuries