What are the risks of injecting cortisone into the groove under the knee cap?

Hi Gary. I'm a long time middle and long-distance runner now in my late 40s and was wondering about the risks of cortisone injected into the space between the patella and femoral end where the groove is? I've worn off the cartilage to the bone in an area about 5 mm in diameter.

I take glucosamine/chondroitin, ibuprofen occasionally, and have had a Synvisc shot in that area (6 mo. ago). I run about 5 days/wk for a total of 20-25 mi and about half of that on soft surfaces and half on pavement. Anything you could tell me would be helpful. Thank you.
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Gary:

For some reason cortisone injections are back in high fashion.  Cortisone injections are now the most common inquiry I receive nowadays.  Is it because it is a procedure that wannabe surgeons (who never quite made the grade) can apply in the comfort of their consulting rooms? Is it because it is lucrative procedure?  Is it because it is a quick-fix solution with consequences that show up long after there can be any kind of come back?

Cortisone injections to the articular surfaces of the knee joint may give relief but potentially at a huge cost in the form of accelerated loss of joint surface tissues and further erosion of any bone that is already exposed.  You see, the way cortisone works is it kills off the tissue that is causing pain.  Dead tissue won't hurt but this is only buying the recipient a little time while the wear and tear continues (painlessly for a while).  Eventually there will be no option other than to stop running altogether and  to start saving for that Zimmer Frame!  If there is too much wear then even extended rest will not stop or reverse the further loss of healthy joint tissue.  There is a tipping point of no return and my advice is to stay well short of that. - wherever that point may be.  Your knees must serve you for 100 years, so it is madness to ruin them so early in your journey through life.  Love them and they will serve you well.

If you have wear and tear under the knee I suggest you consider doing something else other than running that is knee friendly, activities such as kayak paddling, mountain biking and swimming.  If you are going to run, keep the duration to about 40 minutes three times a week and do your main exercise riding a bike or paddling.  This is what I am doing myself after having had two major knee operations.  At 58 years my knees are feeling better than they were at 30 years.

I suggest that you find a good running coach who is familiar with "funny running" sprint drills.  The idea is not to turn you into a sprinter but to teach you drills that improve running style (Best described as "running tall").  Most older runners tend to run with their bottoms dragging behind them and never fully extending at the knees and hips.  This running style is not only inefficient but also wear-some on the knee caps.

Glucosamine and chondroitin when taken daily may assist but the benefits may not be seen for at least three months, so keep taking these.

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The advice in these articles is given freely without promise or obligation.  Its all about giving you and your family the tools and information to take control of your health and fitness.  Please give me your support by subscribing to my free email updates. Please shop at my Online Store. Please encourage your family and friends to do the same. While we may not always be able to compete with the big operators on price, we aim to more than compensate through personal service!


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A fast runner with painful knees

Hello Gary,

I just thought I would contact you with regard to some knee pain I've been experiencing for the past 2-3 weeks. It is occuring in my left knee and is generally experienced at the beginning of a run i.e. the first 800m to 1km (even at a very easy pace) and when performing strides (both after a warm-up and at the end of a longer run). Often in the course of a long run the pain will ease and won't bother me allowing me to continue, but in a 13km run yesterday I was also aware of it towards the end of the run and during downhill sections. When not running it is generally not an issue, but it is particularly uncomfortable when performing lunges on that side and single leg squats. Furthermore, when performing such exercises (both) knees tend to make rather disconcerting crunching and clicking sounds.
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Gary:
The most common cause of the pain you are describing is "Chondromalacia" (Refer illustration left).  It most often appears in runners in their 20's and is associated with an increase in training and competition, including doing unfamiliar running drills, including over-striding, bounding up steps.  Worst of all is running downhill.  Another cause may be sore calf muscles which cause compensatory flat-footed striding with the backside dropping to the ground similar in appearance to running in a seated position (Bent knees has the patellae grinding hard on their femoral grooves).

Anything that causes excess grinding of the patellae on the underlying femoral groove will cause knee pain and a feeling of grating or grinding under the knee cap.

The cause of chondromalacia is usually never just one thing: It is usually a combination of several things all coming together to cause excess wear that exceeds the body's ability to repair.  This includes lack of recovery time following hard races and following training.  An occupation that involves a lot of bending at the knee, walking down stairs and even sitting for long periods with the knees bent may compromise repair of wear of the underside of the kneecaps.

Nutrition is important.  If there are deficiencies or excesses of various nutrients, then repair may not be speedy and the repairs soft and weak.  Glucosamine and chondroitin may assist and well worth taking for a period of three months at the daily recommended dosage.  A Hair Tissue Mineral Analysis assists with determining any nutritional weaknesses may be contributing to wear exceeding repair.

If your knees are still bothering you, I think it is best to have a break of several days.  Do some swimming and aqua-jogging.  Get going with the glucosamine and chondroitin, ensure your diet is rich with protein and quality fats.  While you are settling the knees down, try to identify everything that might have contributed to the knee pain and work out how to avoid these in the future.  For example: Put in place the rule that you will have a relative rest day for every mile raced.  So, if you raced 10 miles today, you do no running for the next two days then gradually resume to full training over the remaining 8 days.  Got the idea?

Back to now: As your knees settle, resume running with care, just with jogging on a flat grassy surface.  Run tall as if you are held up by a bungy cord attached to the top of your skull.  If you have tight calf muscles, then get them massaged deeply and painfully on a weekly basis for as long as it takes for the deep massage to be pain-free.  Get your quads, hamstrings and gluteals done while you are at it.

It is important to be patient and thorough when dealing with any kind of knee pain.  Your knees have to last you many, many years.  Please don't ruin them while so young.

_______________________________________

About this website

The advice in these articles is given freely without promise or obligation.  Its all about giving you and your family the tools and information to take control of your health and fitness.  Please give me your support by subscribing to my free email updates. Please shop at my Online Store. Please encourage your family and friends to do the same. While we may not always be able to compete with the big operators on price, we aim to more than compensate through personal service!
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Does Glucosamine really work?

I saw your video on youtube about the different types of glucosamine substances for knee joints. I am 18 and trying to join the military, I have already had surgery on my knee to smooth out rough cartilage, my doctor says that genetically my cartilage is soft and thin, he says they look like the knees of a 40 yr old man (and im only 18 yrs old).

Image: Lorraine Moller - Strong legs from progressive conditioning during her early years.

I've been taking some Glucosamine Sulfate for awhile, it seems to help a little, what i was wondering is what type of glucosamine you would suggest for me, on you video you show the glucosamine for athletes, but since my cartilage is not the same as other young atheletes do you feel I should be taking the glucosamine for older joints? the one with higher MSM in it?

I've tried to do a lot of research on the internet about weather or not Glucosamine actually works, I have found some reports that say it only has a placebo affect, and some reports show that it does regrow cartilage, what do you think?
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Gary responds:
I assume that the surgery was for chondomalacia patella, which is a condition caused by excess wear of the underside of the kneecap. Even if there was roughening, shaving the surface is not the best option. It obviously has been of limited success given that you are seeking further assistance for knee care.

Please start your quest for healthy knees by reading the dozen or so articles here.

The comment that your knees are genetically soft and thin etc is a ridiculous statement to make and unhelpful. You are young. Your tissues are too thin and soft. This has nothing to do with genetics. It is an increasing problem worldwide as children are raised more like caged hens than anything else and fattened with GM corn.

The state of your cartilage is the result of your nutrition and the way you use your body. I have reproduced the photo above of Lorraine to show you a superbly conditioned and nourished athlete who ran huge distances from early teens to her mid 40's. Her early conditioning was tied to her young and growing body and progressive. She never had a significant knee problem. Many young athletes and their coaches throw the kids into hazardous competition situations without regards to the need to first prepare the body with progressive conditioning.

First rule of coaching: Do not injure!

A good coach will set their goal to get their athletes through to maturity (20+ years) without having suffered career limiting injuries or illness.

Nutrition is a badly neglected area and what advice there is tends to have been hijacked by the big food companies who dominate advertising in sports media and sports events. They drive academic training and research by commercial partnerships with academia. So, we end up with athletes being raised on corn syrup and colourings!

With regards to your weak cartilages, you need to look closely at what you are eating and ensure that your diet is nutrient dense by ensuring that most of what you eat is from fresh natural sources and home cooked (there is plenty of advice on this website about this). If you are living on Powerade, low fat milk, instant noodles and chicken for example, then how can you have strong bones? If you are not sporting a light year-round tan then the only outcome is bones, cartilages and muscles simular to those of a caged battery hen - soft!

Emulate the lifestyle of a free range hen - sun, daily exercise and a wide variety of healthy grubs!

Which Glucosamine is best?
In your case, the best one is Balance Joint and Cartilage Repair for Athletes. This is formulated for young joints that are being subjected to damage. It contains higher ratios of MSM and glucosamine and less chondroitin as compared to other formulations. The MSM and glucosamine are the principal nutrients for cartilage repair. Chondroitin helps hydrate the cartilages. A young joint does not need much of this nutrient, so there is not as much in this athlete formulation.

On the days you do not get sun I recommend that you take 4,000iu of natural vitamin D. If you are low in vitamin D (most people are very low nowdays) you will be prone to tendon, cartilage and bone problems.

Does Glucosamine work?
Yes it does. I have been prescribing these nutrition supplements for about 15 years and I have seen countless cases of benefit - benefit more often than not. Experts who say it does not work need to be challenged. For a start; does a surgeon or even a general doctor know much about nutrition? Not if they happened to fall asleep during the one hour of training they had on the subject and that might have been 20 years ago. When you read any research discrediting these products there are many questions to be asked, such as how advanced the arthritis was among the subjects, how much were they given and for how long, what about combinations of supplements, what measures were used and so on and so on.

Be consistent in taking the right glucosamine supplement for you for at least three months and to support this with a healthy diet and sensible exercise that does not do further damage to the joints.

Is the military the right career for you?
Basic military training, consisting of forced hikes with heavy gear on your back, leaping out of trucks and running obstacle courses and lots of squatting down, is hard on the knees. Having done my own stint in the NZ Army as a foot soldier and having a daughter who has recently completed a year in the army, I am familiar with the stresses and strains on the legs of the kind of basic military training which you will have to undergo without complaint.

My gut feeling is that it is better to avoid this kind of situation in which you are compelled to push the limits of your knees without respite. You may end up being one of the recruits who get medically pushed out. It may be better for you over the longterm to give your knees a couple of years of careful nurturing through progressive strenghtening and nutrition. You can review the military career once you are super fit and pain free.

If the military force you are considering joining has a history of torture, indiscriminate killings of civilians, assasinations, propping up of dictators and despots and planting itself in oil rich countries where it is not welcome, please reconsider your choice of career for our sake.

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An enthusiastic Novice Runner with Runner's Knee (Chondromalacia)

I'm just turned 32, 5' 11", 178lbs. I played gaelic football (similar to Australian Rules) many years ago but never at a really competitive level and my main exercise through life has been at the Gym - my fitness therefore peaks and troughs considerably.

Photo: Grete Waitz - Almost unbeatable over from 5km-42km

Recently my brother in law enticed me to get involved in road running and on April 17th this year I took it up in earnest. At the beginning I struggled to manage 2 - 3 miles in a session but very quickly have found my fitness increase and can now run 10 miles (once a week), my normal run is around 5/6. All of this led me to needing some major goal or focus, because I know that using fitness alone as a goal will be a short lived thing. I had therefore decided to run a half marathon in september with the possibility of a, slow, attempt at the Dublin Marathon in October.

A recent Gait analysis showed that while my right foot was more or less normal, my left foot noticeably over pronated, and I bought the relevant pair of supportive runners. However, my last two runs (Saturday was circa 9 miles, and today was circa 11 miles) have left me in pain in my left knee. A dull ache below the knee cap which intensifies when I walk down stairs for example. On sturday it vanished after a nights sleep but today i fear differently.

The dilemma I face is that while I can comprehend the possibilty of over use - is this now destined to be a weakness which will prevent me from achieving that goal? (I only want to do one!! 10k races will satisfy me after that!)

I'm attending the physio on Thursday, but would be interested in another persons opinion based on experience. Is this generally a case of let it recover and take the right preventative actions or a sign that what I'm trying to do is just going to be beyond me.

John
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Gary responds:
(Please have a good read of the many other articles related to this injury by following the keywords at the base of this article and heeding the treatment and training advice).

John, I have been running competively for more than 40 years and my favourite race distances are between 5km and 15km. While I have run more than a dozen marathons, all sub 3 hours, the reason I am still running well is that I gave up the longer races about 20 years ago.

Short races, especially the off road ones, are thrilling ways to thrash the body without doing lasting damage. Marathons are the modern version of the Middle Ages past-time of Monks who travelled the countryside in public displays of whacking their heads with planks of wood.

It takes about 8-10 years of solid training and racing over short distances before one can undertake the modern equivalent of Mediaval flagellation (the Marathon) without risk of lasting harm.

And there is lasting harm like worn out hips and knees, shot tendons, gristled muscles and chronic fatigue. Running is like anything healthy: There is an optimum level and too much of a good thing can do more harm than having too little. The marathon is too much for all but a few freakish elite. These elite usually weigh less than 60kg and have at least 8 years hard training behind them.

John, I am not telling you to not do a half or full marathon; what I urge you to do is to plan a very gradual buildup in strength and fitness over several years. Muscles and cardiovascular responses to running are quick; whereas strengthening of bones, cartilages, tendons and ligaments are very slow - years in fact. So, stick to the short, sharp distances and never exceed your capacity to heal and grow stronger between runs. If you get the cart before the horse and run a marathon too early, your knees may never be quite the same again, compromising your plan to then stick to the shorter distances.

Photo: Olympian Steven Ferguson

Finally, John, make sure you have a few alternative exercise forms that you do each week: Cycling, swimming, canoeing for example. Have these and you will never need to visit the physio ever again. As soon as you feel a niggle - STOP and switch to your alternative exercise for a few days before carefully resuming the offending activity. This is the best physio.

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A Soccer Player with Chondromalacia Patella and Swelling in the Knee

I'm 36 years old. I was diagnosed with a condition called CONDROMALICIA PATELLA in 2005. I'm a soccer player and in 2004 I was no longer able to bend my left knee all the way. I was still able to play soccer with almost no problem. I'm very competitive and played soccer until about October 2008 before surgery. In early 2008 I started experiencing swelling in my knee. It was later diagnosed as a bacteria infection which required my knee to be scoped on November 26 and November 28, 2008. Ever since I have not been the same. I have been unable to play soccer because of the pain and the swelling. My X-RAY show very little cartilage and meniscus tear.

Photo: Alama Moller kicking for a goal

In your opinion, do you think I can play soccer again? I just started taking glucosamine and chondroitin MSM from Whole Food store. Should I keep taking it or do you have another suggestion? I saw your presentation but I don't know which product applies to me. Thank you so very much for your help.
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Gary responds:

The first action is to double check that the infection has not come back. That you have little cartilage left, you are going to have to look after that knee very carefully for the rest of your life. It is approoriate that you explore healthy outdoors exercise that you can do post soccer.

Have a look at this video and do the exercise every 2nd day.

It will help ensure your knees are properly aligned. You could add a pair of Formthotics Shock Stop inner soles to your shoes and boots.

Take the joint food you have three times daily for at least three months then reduce to 1-2 per day ongoing. The one I sell that is suitable is Balance Joint and Cartilage Repair for Athletes. It is possible that more surgery may be needed for the cartilage tear; but give the Joint Food several months unless your orthopaedic surgeon advises earlier intervention.

Avoid activities that cause pain and or swelling for as long as it takes - even if it runs into years. Your knees must last a lifetime so do not wreck them any more than already.

Take up other activities that do not stress the knee like aquajogging, swimming, upper body weights, boxing (non-combat, upper body work), canoeing and so on. You may find working out on a rowing ergometer is fine on the knee and a great cardio, thigh and butt workout! After my own knee surgery many years ago, I took up kayaking and have loved the sport ever since. Use your injury as the opportunity to broaden your sporting and fitness horizons.

Once you are able to run pain free, gradually introduce soccer skills like dribbling and easy kicking. Only return to competition when you feel confident you can do so without undue risk of reinjury.

Photo: Bruce Moller - Porirua Grand Traverse Race 2009

Above all else be patient! At the same time remain positive and the best way to do that is to engage in meaningful exercise that protects and nurtures your dodgy knee while it heals properly.

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