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60-Second Guide to Knee Arthroscopy

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If you’re being considered for knee surgery, the chances are you’ll be having an arthroscopy: it’s the most commonly performed procedure in orthopaedics. But hang on… what exactly is an arthroscopy? And what happens when you go through one? Most people, understandably, have little idea. So I’ve prepared a very quick guide to unpack the topic. Here’s what you need to know…

Why exactly would you have an arthroscopy?

Let’s start with the least common reason. Occasionally arthroscopies are used for diagnosis. It might be that the results of a scan are unclear (‘plicas’, a folding of the joint lining, can be hard to detect, for example, especially in young people). In this case we might use an arthroscopy to investigate further. In the majority of cases, however, knee arthroscopies are performed with a clear treatment in mind. The most common are for torn or worn cartilage, or for sprains and tears of the Anterior Cruciate Ligament (ACL). But arthroscopies can also be used to remove loose bodies, treat arthritis or drain excess fluid, amongst other treatments.

What are the advantages of having one?

Put simply, an arthroscopy is less invasive than traditional ‘open’ surgery. It’s called Keyhole Surgery for a reason – the incisions are usually only around 6mm long. That means less likelihood of pain following the operation, and a swifter recovery time. Arthroscopies also carry a lower risk of infection than traditional surgery. In 95% of cases, however, they are carried out under a general anaesthetic.

How does the surgery actually work?

The operation involves two small cuts just below and either side of the kneecap. A camera probe is inserted into one of the cuts – usually the outer, ‘lateral’ one. This relays footage to a TV monitor. An operating instrument goes into the other, ‘medial’ cut. The type of instrument deployed will vary depending on the surgery: a shaver is used for trimming cartilage; a resector is used to remove damaged tissue. Most arthroscopies take around half an hour to complete.

What happens on the day of surgery?

On the day, you will come into the hospital and meet your surgeon and anaesthetist. They will consult any scans, outline the operation and answer questions. You’ll then meet a nurse, who will take you through the necessary paperwork. Then you’ll be taken to the Anaesthetic Room and given an injection via a cannula to put you to sleep. A breathing tube enables you to breathe easily while under anaesthetic. When you wake up, you’ll be in recovery.

Will it be painful?

As with all forms of surgery, arthroscopies result in some discomfort after the operation. Happily there’s a lot we can do to help, using simple pain relief. Most of our patients receive codeine-based co-codamol for the first few days of their recovery. That deals very effectively with most post-operative pain. But paracetamol or ibuprofen can also be sufficient.

How long will it take to recover?

One of the most positive things about an arthroscopy is that swifter recovery time just mentioned. Most patients are able to go home on the same day as their operation, and are able to drive again within three to five days. You should be able to resume all normal activities within two weeks. For this reason, amongst others, it’s a very popular form of surgery.

Stress Awareness Month: 3 ways that stress causes shoulder pain

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Stress is one of the great problems of our age. It seems to be everywhere, from anxiety disorders in our schools to absence in the workplace. The Health and Safety Executive estimates that over half a million people suffered from work-related stress, depression or anxiety in 2016/17. From an orthopaedic perspective, stress is difficult to measure. What exactly is it doing to the body? The physical effects are sometimes hard to define. But in essence, I think there are three major ways that stress can affect our major joints. Let’s take a look at its impact on shoulders…

Stress can lead to inactivity

When we’re stressed, we tend to stop looking after ourselves so well. The trips to the gym suddenly fall by the wayside. Our eating regime deteriorates. We stop going for those walks that had been part of our lunchtime routine. From the body’s point of view, these kinds of drops in activity can have a considerable impact. Bodyweight increases (or decreases). Joints become stiffer. Muscles start to weaken and even waste – we know from experience with surgery that muscles begin to deteriorate within hours of underuse (which is why physiotherapy and exercises are so vital after an operation). Where shoulders are concerned, losing muscle bulk can cause instability issues or even frozen shoulder.

Stress increases tension

An obvious point, but stress really does seem to do something to our muscles. The science here is tricky to tease out, but essentially when we are stressed we tighten up – perhaps due to the ‘flight or fight’ response that makes our body tauten to protect itself from physical danger (one way we might define anxiety is as a hypersensitivity to threat). Over time this tension can feel very uncomfortable, perhaps even painful. Physically, it can also cause knock-on effects around the body. If you’re carrying tension in your neck and shoulders, you may overcompensate by using other parts of the body – by deploying your scapular (shoulder blade) to elevate the arms, for example, or the thoracic spine to reach objects above shoulder height. Doing this could result in new pain in those areas. It will also upset the natural rhythm of your shoulder – which should be, roughly, one third scapular-thoracic, two-thirds ball-and-socket.

Stress creates a vicious circle

The final point is a psychological one, but it’s important. Stress creates a heightened awareness of pain – so if you’re carrying a shoulder injury, it may cause you to focus greater attention on the painful symptoms in that area. This in turn can heighten stress. So a kind of feedback loop of discomfort is created. I sometimes observe this in shoulder patients after surgery. Stress can cause them to have a heightened perception of their pain; and in some cases that heightened perception may lead them to change, or to break off, their rehabilitation regime. This isn’t always ideal, since it can lengthen the recovery process when it might be better to relax and persist with the exercises.

So… if you are experiencing stress, what should you do? The first answer is to examine the roots of your stress. And the first way to do that is to talk. For anxiety, that might mean confiding in a friend – or seeking professional help through your GP or a counsellor. For stress that’s causing obvious physical problems in the shoulder and neck area, you might choose to speak to a physiotherapist. They will be able to help you unpack the issues: how things should be working, where the pressure points are, what kinds of exercises you could take up to alleviate the problems. Or of course you could book in with us for a check-up. I am always happy to analyse the issue, talk through the options and advise on the next steps.

Why is my shoulder hurting when I run?

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With the London Marathon just around the corner, some of us will be cranking up our exercise in a big way over the next few weeks. Once upon a time, that was me. I ran the London Marathon in 2003. And I must say I loved the experience – although I haven’t forgotten the excruciating effort involved in all those hours of training.

When it comes to pain and running, knees are the obvious problem area. But of course they aren’t the only body parts that can suffer during extended exercise. In clinic, I sometimes hear my running patients mention painful shoulders. It’s a less common complaint, certainly. But it does happen.

So what’s going on?

The answer requires a little biology. At the very top of your arm is that familiar ‘ball-and-socket’ joint, the ball part being known as the humeral head. When you run, the humeral head rides up against another area called the ‘rotator cuff’; this is a tightly-packed set of muscles that sits around your shoulder joints like the cuff of a shirt. Now if something happens to those muscles – let’s say you suffer an ‘impingement’ injury, where they catch against underlying tissue or bone – then your body will start warning you something has gone awry. The obvious time it will do this is during strenuous exercise; the impact jolts passing through your feet and up your body could be the trigger for irritation. It’s just possible that the sprinting or jogging action itself – where your arms are pumping up and down, with repetitive forward flexion – could predispose you to a shoulder condition. But in practice, it’s likely that pain during running is an alert for a problem that’s already there.

What can I do about it?

If your shoulder pain is related to an underlying condition, the short answer is that you’ll need to get it checked out by a GP or physiotherapist. On the other hand, if your symptoms are relatively new and benign, there are a number of things you might do to address the issue in the short term. One is to work on your posture. Office jobs can often contribute to rigidity and tension in the shoulders. This might be causing you to tuck in the shoulder blades as you jog, pulling them away from their natural running position. So try consciously to relax your shoulder muscles; some people like to shake their arms from time to time to loosen tension. Another short-term modification you could try is to alter your running routes. Consider reducing the distance a little, or avoiding major inclines on your route, to see if the pain improves. Overall I’d say a mixture of on-road and off-road running is a great way to build up strength and recruit different kinds of muscles across your body, but if you are carrying an injury then it would be best to stick to flat surfaces – or even a treadmill – until the symptoms improve.

In need of in-depth advice about your shoulders? We are always happy to investigate any problems you might be experiencing. Just click on the link to make contact and we will be glad to help.

Marathon running: Five tips from a knee surgeon

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Is distance running bad for the knees? This is one of those joint-related debates that never quite goes away – especially at this time of year, as the athletics world laces up its trainers for events like the London Marathon.

Anecdotally, you often hear people say that running a marathon is a recipe for knee trouble. But the science isn’t actually so clearcut. When we look at athletes who run and train at competition level, we don’t tend to find a high rate of knee injuries. In fact a number of recent studies have suggested that regular long distance running may actually be beneficial for the knee joints.

But… a reality check: most of us aren’t world-beating professional runners! That means we do need to exercise some caution when it comes to training for a marathon. So how would a knee surgeon (and occasional marathon runner!) approach it? Here are my top tips…

Don’t overdo it

How do knee injuries most commonly occur? Answer: through sudden bursts of new activity. If you’re taking up long distance running for the first time, for example, or coming back to it after a decade out, be careful not to ask too much of your knees at the start. Equally, if you’re switching from road running to uneven grass and tracks, take it easy – at least to begin with. Choose a steady training plan and build up gradually.

Test the muscles

Warm-up routines are interesting. Do they prevent injuries? The medical picture is fairly mixed – though I know many runners swear by them. Some gentle flexibility exercises before you run are undoubtedly a good thing, however. Here we’re talking about things like flexions (bending), extensions (straightening) and gentle hip stretches. Doing a quick ‘self-screening’ to check your muscles are comfortable is a good way to prepare for a long run. Which leads to the next point…

Listen to your body

If you start to experience any discomfort while running, slow down and minimise impact on the joint until you get home. Then rest for 48 hours. Apply some ice if there’s swelling. Take some simple pain relief such as ibuprofen if needed. Once you feel ready to resume exercise, build up gradually again. Perhaps try to lessen the hills and inclines on your first runs, or use a treadmill to get your knees working on a more even surface.

Take pain seriously

Persistent or severe knee pain may indicate a more serious problem. For new runners, a common culprit is patellar tendinopathy (sometimes known as Jumpers’ Knee). This is where the tendon underneath your kneecap becomes inflamed through overuse; you tend to feel it as a pain at the front of the knee, just below the kneecap. A sharp pain on the medial (or inner) side of the knee, on the other hand, could indicate a meniscus problem. If you do experience these kinds of pains, it would be sensible to get them checked out.

Invest in footwear

While I don’t want to sound like an advertising exec here, decent shoes are important! Particularly if you’re planning to spend a lot of time in them. So make sure your runners have good padding and protection. Spongy, shock-absorbent soles will help to spread the impact as you pound the track; there’s good evidence that arch support can prevent injury, too. Serious running shops offer video-based ‘gait analysis’ of your running style – if you’re new to the whole discipline of long-distance running, this might be a good place to start.

The big freeze: frozen shoulder… and how to fix it

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First an apology: frozen shoulder isn’t really caused by the weather. (I know – it seemed like a good headline at the time…) Winter-related puns aside, though, I felt it would be worth exploring the condition in a bit more detail. Why? Because it’s really very common. In fact frozen shoulders account for around 20% of my shoulder impingement patients (an impingement is where tissue ‘catches’ on neighbouring bone or tissue in the shoulder). So if you have been struck down with it, you’re not alone. And the good news is that there’s plenty we can do to fix it.

What is frozen shoulder?

Frozen shoulder is a term that gets rather bandied around by the general public. But it does have quite specific criteria for diagnosis. Also known as adhesive capsulitis or shoulder contracture, it’s essentially a stiffness of the ‘capsule’ – the ball-and-socket joint at the centre of your shoulder. Ordinarily, the tissue surrounding the capsule is soft and flexible. When frozen shoulder sets in, however, it becomes thick and inflamed. The tissue tightens around the joint, like shrink wrap.

What causes it?

We aren’t entirely sure. One possibility is trauma. An accident may cause a person to stop moving their arm; frozen shoulder sets in afterwards. Another possibility is that it’s a bodily protective mechanism, perhaps in response to trauma. But sometimes it just seems to arrive out of the blue. One thing we can say is that frozen shoulder is more common in patients with diabetes, and in people suffering from Dupuytren’s disease, a condition in which thickened tissue forms in the hands and fingers.

What does it feel like?

The first thing you will feel is a diffuse pain, deep down in the shoulder. Soon after that, the joint will stiffen and you will lose external rotation of the arm. So movement becomes restricted, and not just because it’s too painful to move the shoulder: you will physically struggle to move the joint at all. This can continue even after the initial pain and inflammation has passed, because the capsule tissue has become thickened, fibrotic and shrunken.

What can I do about it?

There are a number of ways to treat frozen shoulder. One of the key things is to keep the joint moving. In the early stages, it’s tempting to put the arm in a sling and rest – but that’s not recommended. This is one of those conditions where you need to ‘tell your shoulder who’s boss’. Small, frequent movements are better than once-a-day heroic movements. And physiotherapy can help tremendously; we will happily recommend you one, if needed. Anti-inflammatory pain relief and steroid injections can also free up joint movement.

Is surgery an option?

Time is often the greatest healer with frozen shoulders, and many patients find that the condition passes over the coming months, even without treatment. But in more severe cases, when pain relief, steroids and physio aren’t working, we can recommend surgery as an alternative. One common option is a manipulation under anaesthetic – literally pushing the shoulder through a range of movements to get it moving again. Another option is an arthroscopic release, where a tiny probe is used to remove the restrictive capsule tissue. Whatever the outcome, we can explore all the options in detail if you come for an appointment.

Time to get in trim? Your knees will thank you for it!

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January is that time of the year when thoughts turn to waistlines. Which is natural, because most of us find it rather difficult not to overindulge at Christmas: cold winter nights and excellent food go together like, well, brandy butter and Christmas pudding.

But as a new year dawns and the resolutions start to come out of hibernation, this is also a good time to reassess – to think again about our lifestyles and, in particular, the impact that weight can have on health. Perhaps there’s something in the air; this time last year the National Obesity Forum ran a useful awareness week to coincide with the post-Christmas health push

So… does being overweight affect the knees?

The short answer is: yes it does. When it comes to load-bearing, our knees have to deal with more pressure than most parts of the body. This is particularly true during movement: the knee joints act as fulcrums, which means our leg muscles need to generate a lot of power to overcome the force of the weight above them. As I pointed out in my blog last month, this is even more pronounced on steps. When you walk up or down a flight of stairs, the force of bodyweight going through your knees will be multiplied by a factor of six. That’s a lot of extra force!

What kinds of knee problems does obesity cause?

The main impact of excess weight is on cartilage. Cartilage is the rubbery tissue that lines the joints and keeps them moving smoothly. It’s a tough material, but not bulletproof. Under the strain of excess weight, it can split and ‘delaminate’. That in turn can lead to osteoarthritis, where the bones rub against each other and the joints become increasingly swollen and painful (Click on osteotomy)]. So obesity increases the wear-and-tear that can lead to osteoarthritis.

How much weight is too much weight?

This is a difficult one to answer, since the rate at which your knee cartilage wears away is related to the cartilage you’re born with. Some people have very strong collagen in their cartilage, which makes their joints more naturally resistant to wear-and-tear. Others aren’t quite so fortunate. In either case, certain types of repetitive activity will put more strain on joints than others – ladder work or long-distance running are two obvious examples. Another problem with obesity is that it can limit access to surgery; some NHS groups require patients to have a body mass index (BMI) of 30 or under before they can be referred for routine operations. If a patient in that situation has knee surgery taken off the table (so to speak), it can create a kind of vicious circle.

What can I do about it?

The good news is that you can make a big difference to your knees with small lifestyle changes – and now is the ideal time to start. In clinic, I take a ‘soft’ approach to weight loss. We see quite a few patients with high BMIs at Chris Bailey Orthopaedics, and very often they’ve heard all the weight warnings many times over before they come through the door. So I prefer to focus on the positives. You can make a huge difference to excess joint strain by losing a small amount of weight. Just take it slowly and build up the exercise: swimming and cycling are particularly good, since they put less pressure on the joints. Why not think about signing up for a class today? When it comes to knees, a little goes a long way.