Visco supplementation gaining ground in treating arthritic knee pain

Approximately five years ago, a friend of mine Bill Bryan, M.D. the team physician for the Houston Astros and I were attending a sports medicine conference when he asked me if I was using visco supplementation for any of my Boulder running patients with knee pain.

I answered, no, but it was obvious that he was. Come to find out that visco supplementation is very popular amongst the Major League Baseball catchers and was catching on with other types of athletes with knee pain with arthritic origins.

Since that time, I have aggressively been using visco supplementation in my athletic patient population, which includes participants in all sports.

The treatment of knee arthritis has changed dramatically over the past 25 years. The biggest advancement was the invention and use of the arthroscope. This eliminated the need to fillet open a joint for an otherwise simple and relatively benign surgery.

Physical therapy techniques have improved as well, such as early range of motion following injury and operations and sports-specific rehabilitation plans.

Less than five years ago, visco supplementation joined the treatment plan for the arthritic athletic knee. The purpose of this article is to examine the use of visco supplementation in the arthritic athletic knee, but first, we need to discuss some simple details about arthritis.

In the simplest terms, arthritis is any inflammatory process concerning articular cartilage in a joint. In the most severe terms, it is the total obliteration of the articular surfaces within a joint and, for this discussion, the knee.

So arthritis develops in a variety of degrees and from a variety of etiologies (causes). The pain and disability of arthritis is very personal. Your health care provider cannot see pain on an X-ray or on an MRI; they only show damaged or abnormal tissues; an X-ray may look normal, but the patient complains of arthritis pain and swelling.

In the knee, there are three areas of articular surfaces: the femoral condyles (end of the thigh bone), tibial plateau (top of shinbone) and the back of the patella (kneecap). To understand arthritis and how visco supplementation works, we need to look at the make-up of these articular surfaces (cartilage).

Think of it like a wheel and a tire. The wheel is the bone and the tire is the cartilage. This cartilage is like living, spongy Teflon. It is about 4 mm thick and devoid of nerves and vascularity. The nerves that read these pain sensations are all in the base bone plate to which the cartilage attaches, so a certain amount of cartilage damage has occurred to cause the bone plate nerve endings to sense pain.

With no direct vascular supply, the cartilage gains its nutrition from the synovial fluid, which lubricates the joint. As we age, the quality of our synovial fluid declines, becoming less viscous and less absorbing.

The actual cartilage is highly organized pillars of chondrocytes surrounded with a complex matrix glue-like substance. This matrix is made up of collagens, protein and proteoglycans. Some common proteoglycans are glucosamine, chondroitin and hyaluronan. The disease process of arthritis following injury to the articular cartilage includes dehydration of the cartilage and loss of proteoglycans. The quality of your synovial fluid declines with age and in the presence of arthritis. One of the primary ingredients of synovial fluid is hyaluronan.

Visco supplementation therapy is available through three products presently in the United States: Synvisc, Hyalgan and Supartz. They are all primarily alike, differing in purity, viscosity and molecular weight. I have used Synvisc and Hyalgan almost exclusively over the past four years among my athletic patients. The brand you might choose should be discussed with your health care provider.

So how does visco supplementation work? The product of choice is injected directly into your knee (Synvisc x3, Hyalgan x5) weekly for a prescribed number of times. The hyaluronan is absorbed directly into the damaged cartilage and mixes with your own synovial fluid to improve its lubricating, absorptive and cushioning qualities.

Some people get almost immediate relief while others take up to 60 days to achieve relief. The duration of relief, according to my patients, is from six months to two years. Seventy percent of my patients claim success and would or have asked for repeat treatments. Cyclists seem to benefit more than runners or hikers, but all claim benefits.

So who is a candidate for visco supplementation? Anybody with some degree of knee arthritis is a candidate. The healthier your knee, the better chance you have of great relief. The more damaged your knee, the more moderate the possible results.

The cost is approximately $1,500 per knee for the full treatment series; therefore, most use their medical insurance to help cover the cost. Most insurance companies require documented diagnosis of degenerative joint disease (arthritis), and a record of treatment including nonsteroidal anti-inflammatory medicines (Aleve or Advil), and aggressive physical therapy.

There is only one known real potential complication in the use of these products. Since the source of pure hyaluronan is chicken rooster combs, the patient cannot have any allergies to chickens or other aviary products. Beyond that, according to the manufacturers, there is a 2 percent or less chance of a spontaneous effusion (swollen knee) following injection. If the effusion does occur to you, it does not affect the potential success of treatment.

If you are a knee pain sufferer and suspect underlying arthritis as the cause and have failed to get better with nonsteroidal anti-inflammatory medications, physical therapy, life and/or training changes, ask your physician or health care provider if you are a candidate for visco supplementation.

You can also check out the Web sites for the three different current manufacturers. They are www.synvisc.com, www.hyalgan.com and www.supartz.com.

Andrew L. Pruitt, Ed.D is the founder/director of the Boulder Center for Sports Medicine. His professional appointments include the U.S. Olympic Training Center, U.S. Cycling Federation, 1996 Atlanta Olympics and the Bolder Boulder 10K. He is a retired bike racer. More information can be found at www.bch.org/sportsmedicine.

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