More than 600,000 knee replacements are performed annually in the U.S., according to The Journal of Bone & Joint Surgery. That number is expected to swell to 3 million by the year 2030, the publication’s study reported, partly because people are working longer and obesity is on the rise.

But while knee replacements are becoming a popular elective surgery, some studies estimate 20 percent or more of recipients aren’t pleased with the result. Medical experts question whether replacement surgery is being done too soon – or whether some people need a new knee at all.

SURGERY SHOULD BE A LAST RESORT

Surgery should only be done as a last resort. A knee replacement can be life-changing, but they can also be painful, wear down prematurely and become infected.

If you have debilitating pain and difficulty walking because of degenerative arthritis, surgery may be your best option no matter your age. Otherwise, there are sound reasons to avoid a knee replacement, or at least to postpone it until a more appropriate time.

THREE REASONS TO AVOID OR DELAY KNEE REPLACEMENT SURGERY

• Plastic debris. A total knee replacement consists of metal moving on plastic. The plastic wears down over time, and that can be a pain – physically and financially – to patients who may have to get the prosthesis replaced once, twice or more. The plastic debris accumulates in the knee joint. The more active you are, the heavier you are, the more debris. The white cells, which attack foreign invaders, start attacking the surrounding bone. When it’s time to replace the plastic joint, we also have to replace the bone – and that’s a significant and unpleasant surgery.
• A prosthesis doesn’t last 30 years. This is a key reason why I think younger replacement candidates should wait as long as possible. A total joint replacement in a 70-year-old patient will typically last 15 years. With the average life expectancy being 85, chances are this would be the only knee replacement that patient would need. But for a 40-year-old who’s more active, it may only last 10 years. And remember, recovery is challenging. So it’s better to wait for technology to catch up. As it does, the better the knee replacements will be.
• Other remedies may work. Many people experiencing chronic knee pain are overweight or obese. A healthy diet and exercise program can bring the weight down and take pressure off the knees. Also, a hinged knee brace, supplements that aid in repairing worn cartilage, and injections such as cortisone or hyaluronic acid could reduce pain and restore quality of life.

There are ways to at least buy time. And there are patients who were told they needed a knee replacement, but with conservative therapy options, happily discovered otherwise and returned to their favorite activities without pain.

Dr. Victor Romano (www.romanomd.com) is an orthopedic surgeon in Oak Park, Ill., and the author of Finding The Source: Maximizing Your Results – With and Without Orthopaedic Surgery. He is board-certified in orthopedics and sports medicine with over 25 years of experience in the field. He graduated cum laude from the University of Notre Dame and completed medical school at the University of Loyola-Chicago.

For many Americans, joint discomfort is that dark cloud hanging over all those sunny, summer plans. But it doesn’t have to be that way. Our friends at Cosamin for Joint Health have put together some essential travel tips to help make sure your next vacation is also a break from joint discomfort.

TRAVEL TIPS FOR JOINT COMFORT

Consider Space
No, we’re not suggesting you visit the Moon. We mean consider the personal space you have on the way to your destination. If you’re flying or taking a train, pay a little more for a seat with extra legroom so you can stretch out. If that price point is too high, try to get an aisle seat so you can easily get up and move around periodically. Keeping your joints limber while you travel is essential for arriving at your destination in comfort so you can get the most enjoyment out of that well-earned vacation.

Roll With It
When it comes to efficiently moving your belongings while you travel, nothing beats a quality rolling bag. By diverting extra weight from your body and reducing heavy lifting, you are taking all that unnecessary pressure off your joints. For even more joint relief, do your best to not over pack so transporting your luggage will be as cool and breezy as that ocean view.

Give It A Rest
It may sound like redundant advice for someone on vacation, but take some time to relax. If your trip involves a lot of walking and movement, be sure to plan some time-outs, whether it’s grabbing a refreshing beverage at a trendy cafe or stopping for a delicious snack. Even if you’re not particularly hungry or thirsty, the “people watching” is always worth the time.

Honesty Is The Best Policy
Chances are you’re not the only one on this vacation and that’s great! What is not great is lying to yourself or your travel partners about your comfort level. If you need a break or want to give that whitewater rafting lesson a pass, let your loved ones know. They will be happy to not see you in discomfort.

New Shoes, You Lose
Going on a more active vacation is probably not the best time to buy new shoes. Instead, go with a trusty pair that offers good support and a lot of traction. If you do want to purchase a new pair, do your research and find shoes designed to distribute weight and reduce stress on your joints. Be sure to give yourself a few weeks to break them in and ensure you are not adding to your discomfort.

Supplement Your Enjoyment
Take a premium glucosamine & chondroitin joint supplement that is clinically proven to help promote joint comfort and mobility both home and abroad. For those planning a more active getaway, a joint supplement specially formulated for faster action will help ensure comfort stays with you every step of the way. Just remember to pack enough pills to get you through your adventure!

For more information about how to improve your joint health, check out How Cosamin Works or talk to your physician about the benefits of Cosamin, a premium joint health supplement.

A release from the university reported that according to Dr. Sadanand Fulzele, bone biologist in the Department of Orthopaedic Surgery, the differences may help explain why the disease is more common in women. The discovery also points toward a more targeted way to diagnose and treat this “wear and tear” arthritis thataffects more than 30 million Americans and is fundamentally a destruction of the cartilage that provides padding between the bones.

The release quotes Dr. Monte Hunter, chair of the MCG Department of Orthopaedic Surgery and a coauthor of the study, as saying, “It’s a huge problem.” Today’s treatment addresses symptoms, such as inflammation and pain, and the bottom line for some patients is knee replacement. Clinicians like Hunter would like to provide patients additional options for diagnosing and treating this common malady of aging.

Synovial fluid is known to provide clues about joint health, so MCG researchers decided to look at what messages cells in the region were sending and receiving by looking inside traveling compartments in the fluid called exosomes, says Fulzele, corresponding author.

“What we found is there is no change in the number of exosomes, but a change in the microRNA cargo they carry,” Fulzele says.

They isolated the mostly round exosomes in discarded human synovial fluid from patients with and without osteoarthritis. They found in the males that 69 microRNAs were significantly downregulated and 45 were upregulated. In females, however there were 91 downregulated versus 53 upregulated.

Females just seemed more impacted: In total, they had more than 70 biological processes altered compared to males who had closer to 50, the researchers report.

Fulzele and Hunter suspect that the gender differences they found in exosome content helps explain gender differences in disease incidence and that estrogen was key to the differences.

Particularly in the females, they found microRNA that should be sending messages that are good for the joints, like promoting estrogen signaling and collagen-producing cells, turned off or otherwise altered.

Lower estrogen levels, like those that occur following menopause, prompt production of more cells that destroy bone. In this environ, those bone-consuming cells also tend to live longer, which can result in a net bone loss. Conversely, reduced osteoarthritis risk is considered a benefit or hormone replacement therapy.

MCG researchers’ hypothesize that estrogen plays an important role in determining which microRNAs the exosomes contain. In fact, when they used aromatase inhibitors to reduce the availability of estrogen, they found a small lineup of microRNAs decreased in number. When they treated cartilage cells from healthy females with exosomes from males and females with osteoarthritis, significantly fewer healthy cartilage cells lived after exposure to the exosomes from patients with disease. Expression of genes that make the extracellular matrix that is the framework of cartilage went down while expression of genes that promote inflammation increased.

They only found one microRNA, MiR-504-3p upregulated in both male and female osteoarthritis patients. Although it’s unclear what MiR-504-3p does, Fulzele thinks it degenerates cartilage, which is the crux of osteoarthritis. In future studies, they will use MIR-504-3p inhibitors to remove it from the equation and try to determine the function of this tiny piece of RNA.

All cells excrete exosomes as one way to communicate. They carry cargo like protein, lipids as well as microRNA, which can impact the expression and actions of many different genes. In the case of the synovial fluid, Fulzele says the exosome source is likely cells in the synovial membrane that lines the joints and produces the fluid. Wear and tear that comes with aging, and can be accelerated and aggravated by injury, can inflame the membrane, which may alter the cargo in the exosomes and the messages they carry, Fulzele says.

Knee replacement becomes the endgame for patients whose dwindling cartilage can literally translate to one bone rubbing against another.

“People understand bone on bone when they hear that,” Hunter says of the potentially excruciating and debilitating pain that may result. Early interventions include icing a swollen knee, taking anti-inflammatories and avoiding activities that are hard on the joints, says Hunter. They can also inject hyaluronic acid, the major component of synovial fluid, into the knee in an attempt to normalize the environment.

Today, a diagnosis is made based on the joint pain and stiffness patients report, a physical exam and X-ray. Physicians also often examine the synovial fluid, Hunter says. When a knee is swollen and warm to the touch, they will extract some of the fluid to look for problems other than wear and tear, like an infection and/or uric acid crystals, Hunter says. The crystals could be an indicator of gout, a type of arthritis that results from the body’s reaction to excessive levels of uric acid, which results from the breakdown of purines, chemicals found in meat, poultry and seafood.

Hunter hopes that soon he and his colleagues will also examine exosomes in the fluid for indicators of that patient’s specific instigators of cartilage destruction. They then hope to devise a cocktail – potentially a mix of microRNA inhibitors and joint health promoting microRNA mimics delivered in manmade exosomes – that can be injected into the knee to target and help resolve the debilitating destruction.

MCG researchers already are exploring ways to block the microRNAs that are causing destruction.

Other key collaborators include Dr. Ravindra Kolhe, molecular pathologist in the MCG Department of Pathology, and Dr. Mark Hamrick, bone biologist in the MCG Department of Cellular Biology and Anatomy.

While osteoarthritis is considered normal wear and tear, it’s multifactorial, says Hunter, the Dr. Charles Goodrich Henry and Carolyn Howell Henry Distinguished Chair at MCG. “There is a genetic component. Some of us have stronger cartilage than others. Some of us are made differently so the angle of our joints puts more pressure in some places.”

Risk factors include injury, overuse, increasing age, obesity, a family history, as well as being female, according to the Centers for Disease Control and Prevention. Sports with repetitive high impact, like running and basketball, can increase the risk.

A release from the publisher notes that the researchers found that if the procedure were restricted to patients with more severe symptoms, its effectiveness would rise and the practice would become economically more attractive than its current use.

According to the release, about 12% of adults in the US are affected by osteoarthritis of the knee. The annual rate of total knee replacement has doubled since 2000, mainly due to expanding eligibility to patients with less severe physical symptoms.

The number of procedures performed each year now exceeds 640,000 at a total annual cost of about $10.2bn (£8.3bn, €9.6bn). Yet health benefits are assumed to be higher in those with more severe symptoms before surgery.

So a team of researchers based in the US and the Netherlands set out to evaluate the potential impact of total knee replacement on quality of life in people with knee osteoarthritis.

They also wanted to estimate differences in lifetime costs and quality adjusted life years or QALYs (a measure of years lived and health during these years) according to level of symptoms.

They analyzed data from two US studies – 4,498 participants aged 45-79 with or at high risk for knee osteoarthritis from the Osteoarthritis Initiative (OAI) and 2,907 patients from the Multicenter Osteoarthritis Study (MOST).

OAI participants were followed up for nine years and MOST patients were followed up for two years. Quality of life was measured using a recognized score of physical and mental function, known as SF-12, and using some osteoarthritis specific quality of life scores.

They found that quality of life outcomes generally improved after knee replacement surgery, although the change was small. The improvements in quality of life outcomes were higher when patients with lower physical scores before surgery were operated on.

In a cost effectiveness analysis, current practice was more expensive and in some cases seemed even less effective compared with scenarios in which total knee replacement was performed only in patients with lower physical function.

“Given its limited effectiveness in individuals with less severely affected physical function, performance of total knee replacement in these patients seems to be economically unjustifiable,” write the authors.

“Considerable cost savings could be made by limiting eligibility to patients with more symptomatic knee osteoarthritis,” they add.

“Our findings emphasize the need for more research comparing total knee replacement with less expensive, more conservative interventions, particularly in patients with less severe symptoms,” they conclude.

A release from the pubisher notes that the findings may be helpful for clinicians as they decide which treatments are best for different patients. Additional studies on the mechanisms involved the sex differences observed this study may also help researchers develop new treatment strategies for patients.

The release quotes lead author Dr. Emily Bartley as saying, “Many questions still remain as to why women with knee osteoarthritis are more sensitive to painful stimuli than are men. While therapeutic approaches to control pain are only beginning to take these sex differences into account, there is still quite a bit of research yet to be done to help reduce this gender gap and improve clinical therapies for men and women alike.”

The first week of this riddle, the patient and her mother reported the patient’s symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendation

The doctor ordered an  X-ray of Julia’s knee and an MRI, and referred Julia to a physiatrist and a sports medicine doctor. The second week, we learned the results of Julia’s X-ray and MRI, and specialists did exams and conferred with the PCP. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Marina O., the ballet teacher, nailed the diagnosis! Julia does indeed have chondromalacia, the softening and wearing away of the cartilage in the kneecap. This condition is fairly common among teenage ballet students. Although the long-range prognosis is good, the short term issues for would-be ballerinas can be distressing. Julia needs to reduce strenuous activates, which probably means she won’t be able to fulfill her dream this year of dancing on pointe in the “Waltz of the Flowers” in her studio’s annual “Nutcracker”. Predictably, she burst into tears when I broke that news to her as gently as possible. I did reassure her that she would no doubt be in fine shape again for the studio’s annual Spring Showcase in May. Julia turned out to be a real trouper who volunteered to help with the “Nutcracker” boutique and also help with costumes and props and rehearsed the younger children in the production. Her mother says that made her proud of her daughter, as well it should have.

In the meantime, I recommended that Julia take Advil or another OTC pain reliever if she had severe pain, but I cautioned that she shouldn’t do that too often. She agreed and did comply with my instructions. I also used this opportunity to discuss the importance of good nutrition and exercise in healthy bone growth and avoiding osteoporosis down the line.

The prognosis for Julia is good, meaning that operative treatment probably won’t be necessary. For more severe cases, these are possibilities: arthroscopic debridement (lavage or cleaning out and washing and rinsing out the knee; articular resurfacing, surgical correction of any instability; removal of the patella.

In addition, as Lillian G. mentioned in Week Three of this Riddle, quadriceps exercise are valuable. Julia went to a physical therapist who specializes in dancers and she performed the exercises religiously at home even after the appointments ended. As a result, she will be a stronger and better dancer in the long run. Here is Julia’s take on the whole episode:

“Of course I’m disappointed about the not being in the ‘Nutcracker’ this year, but I have no intention of giving up dancing! If anything, this problem with my knee has made me more passionate about ballet than ever. I read a quote from George Balanchine that goes ‘I don’t want people who want to dance I want people who have to dance.” That describes me perfectly! I’ll get through this and then ‘On with the dance’!”

Come back to ThirdAge.com next Thursday when we’ll introduce a new medical riddle!

The first week of this riddle, the patient and her mother reported the patient’s symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

The doctor ordered an X-ray of Julia’s knee and an MRI, and referred Julia to a physiatrist and a sports medicine doctor. The second week, we learned the results of Julia’s X-ray and MRI, and the  specialists did exams and conferred with the PCP. This week, we’ll let you know what some people have suggested as possible diagnoses. Next week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

Some Guesses as to What the Diagnosis Will Be

“I’m betting that the diagnosis is not the kind of tumor mentioned during the First Week of this Riddle! Wow! I hope I’m right. Anyway, here’s my guess: Maybe Julia has a chronic injury of her anterior cruciate ligament or ACL, or maybe a partial tear with some involvement of meniscus or cartilage tears. I studied ballet until I was 16 years old, and I kept quiet about my knee pain that started when I was 15 and landed really hard out of a jump on a stage that wasn’t “spring” or “floating.” When I finally gave in and told my teacher about the pain, it turned out that the meniscus was causing the pain and that the ACL issue could be serious down the road if the whole thing did tear. Ligaments don’t have any blood flow so you can’t feel pain if they tear but the ‘joint mice’ – little bits of meniscus cartilage that were trying to regrow – were jamming my knee and that really hurt. End of story, I have an arthroscopy to get the joint mice vacuumed out and I went to physical therapy to strengthen my quadriceps in order to prevent a full ACL tear. The quads are the four groups of muscles on the front, back, and sides of your thigh. I quit dancing when I went to college and took up swimming, which was safer for me. I wasn’t all that good at dancing anyway! So now I’m in my 50s and the ACL has never torn. Best of all, I’m pain free!”

— Lillian G.

“Could Julia have an infection such as chronic Lyme disease or maybe autoimmune arthritis? My cousin had knee pain from Lyme disease after she went camping with her family in Connecticut, and my sister has knee pain from rheumatoid or autoimmune arthritis. We have no idea what caused it! The doctor says it’s ‘idiopathic’, meaning no known cause.” But Julia’s kind of young for that, I think.”

— Jean R.

“Maybe Julia has a stress fracture. I know the doctor said Julia isn’t anorectic, which could cause bone loss, but my totally healthy and normal weight daughter got a stress fracture of her fifth metatarsal, her pinky toe, from dancing ballet on pointe when she was fifteen. The sports medic said my daughter’s foot had grown and that the pointe shoes were suddenly too tight. The only treatment was rest after some initial ice. My daughter missed out on ‘Nutcracker’ that year, which broke her heart, but she came back the next season. Whew!”

— Millie S.

“I’m a ballet teacher, so my guess is that Julia has chondromalacia. That’s a condition in which the cartilage in the knee cap wears away. However, I can tell you that Julia must have been going to a reputable dance school since she wasn’t put on pointe until she had sufficient training and her bones had ossified enough to take the stress. Full ossification doesn’t happen until about age 16 to 18 in girls, but the bones are strong enough in most students at about 10 or 11 to withstand the rigors of pointe work. I have my young students wiggle their noses with their fingers to teach about cartilage, and then I have them say ‘The inside of my toes is as soft as my nose.’ Then I explain that the cartilage in noses and ears and other places in the body always stay soft but that the cartilage in other places such as bones eventually gets hard or ossifies.”

— Marina O.

“My son, an avid soccer player, had a growth plate fracture in his knee when he was 14. Maybe that’s Julia’s diagnosis, although we were told that this type of fracture is much more common in boys than in girls. Also, growth plates close earlier in girls than boys. The growth plates are near the ends of children’s long bones. Even slight injuries can cause fractures since these plates are very soft. Adults would just get a joint sprain, but kids can get fractures that need immediate medical attention to prevent the limb from ending up crooked or too short.”

— Natalie T.

To be continued . . .

Come back to ThirdAge.com next Thursday when the doctor will reveal the actual diagnosis and treatment plan.

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.

Last week, the patient and her mother reported the patient’s symptoms. The doctor proceeded with the examination using the components of the classic S-O-A-P notes, which are as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

The doctor ordered and X-ray and MRI, and referred Julia to a physiatrist and a sports medicine physician. This week, we’ll learn the results of the X-ray and MRI, and find out what what happened during Julia’s appointments with the specialists.

The X-ray of Julia’s knee was normal, as the doctor had suspected it would be. Yet the MRI, which allows for grading or scoring of the cartilage, showed a high signal and evidence of small joint effusion or fluid.

Both the physiatrist, an MD with training in physical medicine, and the sports medicine specialist performed the same tests and physical exam that Julia’s PCP had done. The three doctors then consulted with one another and felt they agreed on a diagnosis. The sports medicine specialist, who often treated ballet students as well as the professional dancers in the city near where Julia lived, was particularly sure he knew what was wrong with Julia’s knee.

To be continued . . .

Come back to ThirdAge.com next Thursday to find out what some people have guessed the diagnosis might be.

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.

We’ll start this week by letting you know what the patient and her mother told her PCP and how the doctor proceeded with the examination. Next week, the PCP and specialists will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient and Her Mother Report the Symptoms

Claudia, age 55, brought her 14-year-old daughter, Julia, to the doctor because the teenager was complaining of fairly severe knee pain as well as difficulty climbing stairs.

As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Claudia and Julia told the PCP:

Claudia: “I’m so worried about Julia! She’s my surprise gift, the baby I had when I was 42 and our sons were already 10 and 12 years old. People will joke and call Julia the ‘caboose kid’ or my ‘menopause baby’, but those terms are so negative. Yes, the pregnancy was unexpected. However, my husband and I were beyond thrilled to have a daughter. The boys adore her, too. Julia has been a treasure since the day she was born. She was ‘good baby’ and she wasn’t a ‘terrible two’ at all. I won’t take credit for any of that. She just came this way! That’s exactly why I’m very concerned now. She absolutely never complains so that fact that she opened up and told me about the pain in her knee has to mean this is serious. She’s a budding ballerina, and she kept the pain to herself as long as she could because ‘Nutcracker’ rehearsals start in September at her dance school. She has been hoping to be cast a one of the young ‘Rosebuds’ on pointe with the older girls in ‘Waltz of the Flowers”. She’s been on pointe since she was 11 after training from the time she was in pre-ballet at age four. Maybe I should stop going on and on and let Julia speak for herself!”

Julia: “My mom is right that I was keeping this to myself and praying the pain would just go away. My dance teacher has taught us that if we ever have pain or minor injuries we should practice RICE – rest, ice, compression, elevation. I started putting ice on my knee and wrapping it with an elastic bandage and then putting my foot up on some pillows on a chair next to my desk when I was doing my homework. My teacher said to do this for fifteen minutes at a time with a two-hour break for 72 hours. After that time period, the therapy is no longer considered valid. I sneaked the ice upstairs to my room in a plastic bag every evening and followed my teacher’s instructions. The only thing I didn’t do was the ‘R’ for rest. I kept taking class during my ballet summer intensive because I wanted to be in shape for ‘Nutcracker’ auditions in the fall. Now, though, I can barely make it up the stairs to my room, and I also have to climb stairs at my school. Classes start at my ballet school on September 15th and the auditions are on September 19th. I really hope you can find out what’s wrong so I can try out for ‘Waltz of the Flowers’! That has been my dream ever since I was a little girl.”

While knee pain is rarely a medical emergency or associated with life threatening implications as so many of the diagnoses we have discussed previously in this column, it can be career threatening or just simply hugely impactful to a young adolescent’s life.

However, I am reminded of a young woman who came to me for knee pain. She turned out to have an osteosarcoma or bone cancer and required amputation. So to say knee pain is never life threatening is just not so. My patient was not a dancer. She was an active exerciser and runner who had months of intermittent but progressively worse pain in her knee. She was told knee pain was common in girls and simply tried to “live with it”. When I saw her for the first time I detected a subtle swelling in the area just above her patella. Fast forward through ultrasounds, an abnormal CT scan then MRI (done less often when I was first started in practice) and the diagnosis was made after a surgical biopsy. So never again would I suggest knee pain is not worthy of serious attention to exclude a serious cause, even in young adults!

This is why Julia’s doctor took her concerns seriously and spent extra time with Julia trying to get to the root of the problem. She first asked about the nature of the pain – when did it begin, what makes it worse or better, does it hurt her at night or when asleep, any associated swelling or history of injury or other medical conditions? Was her pain worse going up or down stairs? Or only after long periods of sitting? Was it more stiffness or pain? What happened if she knelt for long periods, as can happen in some choreography for groups or “corps de ballet”?

Julia recalled that the pain wasn’t sudden onset. She just gradually noted that when going up or down stairs at home and school, her knee would begin to hurt around the front of her kneecap. The pain could be severe at times, but she had no swelling or pain at night. She had never had an injury or accident and had never previously dislocated her knee.

Julia took no medications, including no birth control pills that can be associated with thrombophlebitis, a condition that occurs when a blood clot blocks one or more of the veins, typically in the legs, but knee pain is usually posterior and not anterior for that condition.

Her periods started at age 12 and they have been regular since, meaning she has no amenorrhea and that bone maturity had occurred. She had no history of anorexia, which can be linked to osteopenia, a precursor to osteoporosis that can result in severe bone loss.

During the physical exam, the doctor found normal height and weight and a very mild effusion, meaning fluid within the right knee joint, detected when the doctor was able to “ballot” the patella, meaning tap the patella (kneecap) with both hands compressing the knee in attempt to bring any fluid to the front of the knee joint. The doctor found no crepitus or crackling of knee joint with motion, and Julia had full normal ROM (range of motion) of the joint. She did have mild pain when the doctor compressed her patella.

Although the doctor knew that a plain X-ray rarely helps in the diagnosing of knee problems, she ordered a knee X-ray to assess integrity of joint space, maturity of bone growth, and rule out rare bone and joint diseases. The doctor also ordered an MRI that would allow for grading or scoring of the cartilage. A high MRI signal means abnormal cartilage.

The doctor referred Julia to a physiatrist, an MD with training in physical medicine, as well as to a sports medicine physician.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the results of Julia’s X-ray and MRI, and to find out how the physiatrist and sports medicine specialist continued the quest for a correct diagnosis of Julia’s condition . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.

People who suffer from chronic pain often fall into a downward spiral of self-pity, depression, and inaction. They feel like they are being drowned in a whirlpool that saps all their strength.

But Dr. Liza Leal, a physician in Houston and one of the nation’s leading experts on managing chronic pain, says it doesn’t have to be that way.

“You are not powerless,” says Leal, the author of Live Well with Chronic Pain. “You must realize that you have a series of major choices to make and first and foremost is that YOU have to choose to live well.  And once you realize the power of choice, you can start addressing the real facts and the many viable options that are available to you.”

Leal stresses a three-tiered approach that she has refined over many years of clinical practice:

 Improve Your Knowledge of General Health Principles – Learn all you can about matters such as proper nutrition, nutritional supplements, exercise, sleep, and how to motivate yourself and keep a positive mental outlook.

 Identify and Learn About Your Particular Condition – Sit down with your doctor and figure out what condition may be causing your chronic pain. Then learn all you can about how you can deal with that condition. Read, take seminars, do a ton of Internet research, talk with other people, join a support group – get out there and learn all you can.

Create Your Individual Action Plan – Create a plan that identifies a series of steps you can take every day. You might realize that you need to do something about your weight. You might want to start exercising or stretching every day. You might want to go on a reasonable diet and develop an exercise plan. Learn what factors affect your pain and what pain management methods work best for you.

Leal says that the people who are most successful at reducing pain level do so after focusing on improving important bodily functions such as circulation and overall cardiovascular health, muscular strength, and mobility.

“These are the most important first steps,” she says. “You draw a line for yourself, and then learn effective techniques to keep you walking that line.”

Dr. Liza Leal knows first-hand the devastation of chronic pain and that restoration is possible. While in medical school she developed rheumatoid arthritis, causing her to be wheelchair bound, potentially derailing her medical career. Today, Leal is out of the wheelchair—thanks to her unique comprehensive approach to pain management. To learn more about her work, visit http://livewellwithchronicpain.com.