Knee Pain in the Runner: When Surgery is Necessary
Knee pain is a very common occurrence in runners. Rarely will you find a long-time runner who has not suffered a bout of some serious knee pain that may have sidelined them for a time. However, unlike contact athletes, our injuries rarely require a trip to the surgeons' office. Runners don't tend to blow out their ACL while sprinting towards the finish line, unless we decide to take out another runner on the way. Although our chronic overuse injuries can get us down and lay us up for a while, most would agree that they may still be better than going under the knife. However all runners, in particular us older runners, should realize that some knee injuries may require a surgery. Meniscus tears are the most common cause of knee surgery in a runner. When a tear is present, the majority of runners are unable to return to training until the diagnosis is made and surgery performed. But, luckily for most, the subsequent return to running can actually be quite rapid. Let's look at the case of Cindy.

Cindy is an active, fit, 52 year old patient of mine who has been a runner for 15+ years. Over the course of her running career she has done everything from 5k's to the marathon. Currently, she was running about 20 - 25 miles per week and enjoying her training. I had treated her in the past for knee cap pain with a course of physical therapy and she had done well. Then, last spring, she twisted her knee suddenly when getting out of her car. After that moment she noticed progressive pain on the inside of her knee. When she tried to run, she noticed a painful clicking sensation on the inside of her knee, followed by some mild swelling afterwards. She initially took some time off, tried ice and some anti- inflammatories and went back to the stretches she learned in physical therapy. However, every time she tried to return to running, the pain stopped her. She then started to have pain in her everyday life with any activity that caused twisting or pivoting of her knee.

When she came back to see me, Cindy had some mild swelling in her knee and was very tender to the touch on the inside of her knee. This was right along her inside knee joint. I could reproduce this pain by twisting her knee as well. I sent her for an MRI which did show a medial meniscus tear. We went forward with arthroscopic knee surgery and basically cleaned out the torn meniscus. She went through a 6 week course of physical therapy and then slowly returned to her running without the prior pain.

So what is the meniscus and how important is it? The meniscus is a C shaped piece of thick cartilage that acts as the shock absorber in your knee. It is the cushion between the thigh bone (femur) and shin bone (tibia). You have one on the inner side of the knee joint: the medial meniscus and one on the outer side of the knee joint: the lateral meniscus. The meniscus is often injured in a single, sudden twisting of the knee. However, as you age, the meniscus is not as sturdy and much more apt to tear with little trauma. It is not uncommon for one not to recall the exact cause of the injury, just start to feel the pain at a later date. As stated above, the pain is felt in the location of the tear. The medial meniscus is the most commonly torn, therefore, the pain is felt on the inside of the knee. The pain is worse with activity, especially any twisting motion of the knee. Knee swelling is common as is the sensation of catching or locking in the knee.

Typically at this age, the meniscus tears in a location that does not have any blood supply. Thus, it can not heal. For an active runner, the torn meniscus continues to cause symptoms until it is addressed. The diagnosis is typically confirmed with an MRI. The surgery is arthroscopic surgery which is minimally invasive performed via two-three small puncture holes. The surgery itself takes less than one hour and is outpatient. The torn parts of the meniscus that are tattered and catching are removed and trimmed. If a meniscus tear is ignored and one continues to run through the pain, the concern is that more of the meniscus will tear and then more will need to be removed at surgery. The more that is removed, the less cushion you have in your knee and the higher the chance of long- term arthritis.

For the motivated runner, the recovery time can be really quick. Rehabilitative exercises are started almost immediately after surgery. Hamstring and quadriceps strengthening are the key to a fast return to running. Many can transition to a stationary bike within 1-2 weeks, and potentially more vigorous exercise and then running after about 6 weeks. So, don't despair if you have these symptoms and need to visit your orthopaedic surgeon. With a quick diagnosis and timely surgery, you can back out there on the roads without barely skipping a beat!