Knee Osteoarthritis with Simon Kelly

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly of Insync Physio in Vancouver. We're going to talk about osteoarthritis. Something that's probably rampant in the population. Something that has, I get more grey hairs, I start to wonder about things around this particular subject. So Simon, tell me what's the deal with osteoarthritis.

Simon: Thanks for having me. Absolutely, like osteoarthritis, a lot of people are well aware or have heard the term arthritis any way for sure and osteoarthritis is more, to be honest, it's sometimes healthy, not healthy, but we all get a bit older and sort of, we do develop some wash terminology can be like degenerative, osteoarthritis, wear and tear. They all kind of mean the same thing, but I think sometimes our terminology can get a bit out of hand as well. So it is just wear and tear and break down of cartilage. 

Now, one thing I like to let people know is that once the cartilage is worn out, they know physio can really get it back, which you can really increase the longevity of your joint by increasing the muscles around that joint and maybe the joint evolve. I'll speak about the knee in this video just for simplistic reasons. So like the real hard part about osteo, so that's osteoarthritis sorry. And it's not to be confused with rheumatoid arthritis, which are autoimmune diseases and that's kind of the body attacking instead of a little bit. So it's  a little bit different from that. 

Osteoarthritis generally, you know, it usually affects the older population. It's rare that, you know,  it would present gradually. People will come in and say, Oh, I just suddenly have pain in my knee. And generally they're pointing to the inside of their knee because that compartment gets loaded more than the outside compartment of the knee. Some people do complain about pain behind the knee cap as well. That can be put in with patellofemoral pain syndrome, but usually it's a bit of wear to the cartilage behind a knee cap as well. And some people would present with the three different components. The inside of the knee, the outside and  behind the kneecap. 

But anyway, it would be gradual in onset. People would be like I can't remember doing anything, no specific event. And it usually points to the inside of the knee. So usually what we do is when they come into clinic, first of all, we do take a history. We look at the age of the person. Could be mid fifties sometimes, maybe late fifties and onwards. What's important to know osteoarthritis is it is painful. But not all the pain is bad in that it's okay what I said to have 2 out of 10 pain are 3 out of 10 pain when you're doing your activities. 

I had a guy in recently, actually, I kind of link it to this case study. He was a 58 year old man loves his tennis and obviously quite worried about like is his joint degenerating? What can he do moving forward and wanted to be proactive. So I told him, look, it has a bit of wear on the joint, not to be worried about the terminology. But you can also settle, pain isn't always linked to the where prior to the joint, it can be linked to just a bit of over activity. He was doing a bit of tennis in his case, so maybe more higher impact then just normal squats or when your foot is fixed on the floor.

So, and, but he was also doing like, again, it's nice weather now at the moment here in Vancouver. And he went from like zero to like hero of like five days in a row of tennis and Vancouverites love the outdoors. Just like a woman in the previous videos. So they love to run a lot and get out a lot and I don't blame them in the pandemic.

Like if he came in with a very swollen knee in his case, I asked him what he was doing. And he told me he was playing tennis five times a week and cycling two or three times a week. So really had to address the load his knee was on. Obviously he was 58 years old. He had a previous MCL injury, which is the ligament on the inside your knee. So he was wearing a big brace with two metal bars down, either side of his knee, which is good for MCL strain or injury. It prevents the knee from kind of going from side to side. But Ironically, he thought it was still an MCL injury, but I tested him in clinic, we do a few tests and his MCL was pretty good.

So it was really just early onset osteoarthritis that we were dealing with. So he just had to, the plan for him was just to offload. Maybe again, don't play a tennis five days in a row. Even if the weather is good. I know you like the weather and we'll probably get some rain next week here. Well, like if you just went to like Monday and again, every Wednesday or Thursday, and they'll be cycled on the alternate days, his knee might not have swelled up at all.

So the real trick osteoarthritis, even if you are feeling a bit of pain with your activities like 3 out of 10 is okay, but like, I don't want his knee ballooning up swollen like he presented to me in clinic. That's just too much and that can really progress the disease that much quicker actually. So like, he'd be looking at a knee replacement like, I dunno exactly maybe three or five years, as opposed to maybe 10, 15 years. If he's to play tennis at that level, where his knee is swelling up, which is just not ideal.

However, too little load is also detrimental because I used the analogy like astronauts in space. You go up into space, like you just lose all your bone density. So like gravity and weight is actually quite important for new bone growth. Every 10 years, our body makes new bone growth until we die. You stop growing between the ages of 17 and 25, but they keep regenerating every 10 years.

So it's also not going to like, not load the joint at all. So the real trick is to load the joint pain, 2 or 3 out of 10 on a pain scale, 10 being excruciating pain and zero being no pain. And it's kind of what we're seeing in the research is okay without obviously ballooning up of the knee and obviously like not giving it kind of time to rest. So it really is getting that  happy medium again. 

No w in clinic obviously you have to assess all of that. And then we do a lot of exercises. A lot of the time it's actually the hip muscles that become weak that cause the knee to kind of turn inwards. That puts the load down through that kind of inside compartment of the knee.

That's why they point their finger to the inside of the knee. It's in your glute medius, it's the name of the muscle, we've all heard of the glutes and glute minimus. That keeps the pelvis level in single leg stance. It also pushes the knee back into neutral. Prevents a kind of caving inwards. So a lot of the exercises are geared towards the joint above because it's mostly weakness in the hip. And a little bit in the knee, but mostly in the hip that we need to kind of correct. 

So when someone comes in, we'll look at the biomechanics of the body. We'll sort of get the load more neutrally distributed down through the lower limb, and then we'd obviously allow the person, I like to get the person to do their activities. In his case, it is tennis. It was high impact. You know, he's only 58. I want him to have enjoyment out of tennis. So I'm not going to cut it out completely because I don't believe he needs to cut it out completely. He just needs to cut it down and drastically for a while initially. Like maybe once a week he could go twice a week and then his knee could last him 15, 20 years.

Mark: And what's the typical treatment protocol for him to get to a place where the pain is minimized, maybe not gone, but just minimized.

Simon:  Absolutely Mark. So, and you're right with the minimize there. A timeline, rough timeline it's not as long as the tendinopathy, mostly four to six weeks. All depends on how would a patient adheres to like the knowledge that you kind of pass on as well. If they really like in his case, actually, I saw him just during the week. He'd cut down his tennis. He'd done what I told him. And he had no swelling at all on the next visit. He'd stop wearing his knee brace because he doesn't need it to, because of the old ligament injury he thought he had. And he understood like, you know, a little bit of calm weight is important, but not to be ballooning up.

So you know, that was almost like a magic trick he felt, I felt it as well. It's almost like a magic trick, but just because he was loading it in such a different manner to like doing the weekend warrior stuff on it, you know? So I usually just treat that like four to six weeks, you could argue it is a bit of a lifestyle. He will need to monitor his knee from this point onwards. With or without me, you know, it has kind of reared its head. If he keeps continuing at that point, his knee will decline much quicker. But if you kind of just alters those few bits, his knee could last him like 10, 15, more years, maybe even longer. Obviously it depends on his activities and whether he wants to play a tennis in two or three years. And at that point you might want to look at maybe lower impact activities, more like biking. Also depending on how we would present maybe in three or four years time. 

Mark: And what would be the kind of typical hip exercises that you would prescribe? 

Simon: So yeah, we do a bit of single leg bridging again. I kind of spoke about it before. A lot of glute medius exercise, kind of like single leg stance. We call them hip hikes. So you're kind of standing on the edge of step and let your hip drop down and then you pull it back up. So this glute medius pulls this hip back into neutral. That's kind of what happens.

We call it a trendelenburg gait. Usually it's hard to see though the early stages of osteoarthritis, but you know, you're 80 year old women, you know, you really notice it.  They try to step on their pelvis, but their pelvis is dropping because it can't keep it level in order to take a step. If that makes sense, but we really want to prevent getting to that stage.

And obviously if it does get to that stage, you do have to get, like it's usually pain that people get a hip replacement for eventually. But that's maybe a conversation for another day, but at times, like it depends on your age. You probably don't want to get a hip replacement at 90, just because you might get an infection or something in clinic, so it's better to kind of choose. Usually have a 20 year life span. So a lot of people might get a knee or hip replacement around 65, 70, and that would probably do them their lifespan. As opposed to like maybe 88 and then, you know, because there's a bit more comorbidities. People are kind of struggling at that moment in time. So that's just something that you'd have to discuss with the individual, depending on how it presents.

 Mark: If you're noticing some pain in your knee, could it be osteoarthritis? Come and see Simon Kelly at Insync Physio. You can book an appointment at insyncphysio.com. Easy one click, boom, boom. You can find the opening and where works for you get in there. Get to see him.  Get some treatment. Get the pain minimized or you can call to book at (604) 566-9716. Thanks Simon. 

Simon: Thank you Mark.