The reason cartilage has a poor regenerative capacity is due to its lack of blood flow. Articular cartilage is one of the only structures in the body that doesn’t have a direct blood supply. It is the oxygen and nutrients in our blood that help to repair and regenerate damaged tissue in other parts of the body.
For cartilage repair and cartilage regeneration to take place, it relies on absorbing nutrients from the fluid in the knee, commonly known as ‘synovial fluid.’
The problem is, the levels of this fluid start to decline with age, causing cartilage to become brittle as the nutrient supply depletes. As you can imagine, a brittle structure struggles to absorb force as efficiently as a soft structure.
This means that over time, articular cartilage becomes vulnerable to tearing or wearing down, leading to joint pain and a diagnosis of knee cartilage damage or knee arthritis.
Prolozone Therapy is a form of prolotherapy that involves the injection of an activated form of oxygen combined with nutrients.
As described earlier on, cartilage hasn’t got a blood supply, so it doesn’t receive a direct supply of oxygen and nutrients in the same way that many other parts of the body do. Prolozone Therapy helps to provide this supply with the aim of promoting cartilage regeneration.
The activated form of oxygen is called ‘medical ozone,’ which has been shown in studies to stimulate the production of chondrocytes, which are the cells the body uses to repair and regenerate cartilage.
In addition to this, Prolozone therapy helps to strengthen and repair ligaments and tendons in the knee that may be under strain from compensating for the articular cartilage damage.
The natural treatment also has immediate anti-inflammatory and painkilling benefits.
Knee cartilage tissue is composed of specialized cells called chondrocytes that produce a large amount of collagenous extracellular matrix. Cartilage matrix has both proteoglycans and collagen fibers within it. It is an elastic, flexible structure that covers the ends of the bones. Its mechanical properties allow it to act as a shock absorber during weight-bearing activities, such as walking and running. There are three types of human cartilage:
Knee articular cartilage is made up of fibrocartilage, as it is more durable and can withstand more weight than the other forms.
As described above, cartilage cells become brittle as we age and they start to wear down.
Age also affects the health of the supporting soft tissue structures of the knee which include muscles, tendons and ligaments. We rely on these structures to keep our joints stable, especially when there is knee cartilage damage.
It is estimated that genetics plays a role in between 35% and 65% of cases of osteoarthritis of the knee. The rest of the cases are due to a previous knee injury.
The way that genes have an effect is not very well understood by the scientific community. It is thought that there are many environmental factors that may influence the expression of our genes. These include obesity, repetitive stress on the joint, type of occupation.
This means that you may have a genetic weakness in your cartilage, but it may not end up with osteoarthritis if you eat the right foods, don’t take part in repetitive exercise, and don’t have a job that puts stress on your joints.
Repetitive impact is one of the most common causes of joint pain and knee cartilage damage.
Sporting activities such as long-distance running can weaken the cartilage in the joint and start to cause small lesions. This normally occurs past the age of 50 when the levels of synovial fluid start to decline.
The risk of a cartilage injury increases in runners who fail to stretch regularly. Muscles play a large role in acting as shock absorbers for each running stride, so if they are tight, much of that shock ends up transferring into the knee. If a repetitive activity continues after a knee injury has been diagnosed, then it can prevent any cartilage regeneration from taking place.
There are two different areas of misalignment that have the biggest influence on the development of knee articular cartilage damage or knee osteoarthritis:
Limping from a sports injury or a back spasm can cause the pelvis to go out of line. A misalignment of the pelvis can shift one leg upwards, causing both legs to appear at different lengths.
It causes an uneven distribution of body weight during the 6,000 to 10,000 steps an individual takes each day, which over time can start to wear down the cartilage in one or both of the knees.
It also forces the knees to function at an angle that they weren’t designed to, preventing any cartilage regeneration from taking place.
Foot arch –
The angle of the arch of the foot has a direct influence on the angle of the knee. Weak ligaments in the feet or weak calf muscles can cause them to flatten.
This can then cause a ‘knock-kneed’ deformity and put pressure on the inside aspect of the knee joints. Over time, this uneven pressure starts to cause knee cartilage damage.
Previous injuries can cause weakness and instability in the knee joint. Instability causes additional friction in the joint, which can speed up the process of cartilage degeneration.
Meniscus tear: A meniscal lesion is the most common form of knee cartilage damage. The menisci are crescent-shaped structures that sit on top of the articular cartilage in the knee. Their role is to help disperse body weight evenly throughout the knee. They are most commonly caused by a sports injury that involved twisting or pivoting awkwardly.
If a tear in one of the menisci doesn’t heal properly, then it can lead to further injury and additional force transferring into the articular cartilage. If individuals opt to have surgery on their meniscus then it can have a long-term negative effect on healthy cartilage.
Ligament tear or sprain: A previous injury in a knee ligament can cause it to become loose. The primary role of a ligament is to help to stabilise a joint during movement.
As mentioned above, the more unstable the joint is, the more friction occurs in the cartilage.
Muscle tear: If a previous soft tissue muscle tear wasn’t treated properly at the time of the injury, then scar tissue can form at the site of the tear as the body attempts to heal it on its own.
Scar tissue struggles to absorb force very well, so it can affect a muscles ability to absorb shock from weight-bearing activities such as walking and running.
If the scar tissue is located in any of the muscles that attach into the knee, then it can cause some of this shock to be redirected into the knee joint and increase the likelihood of an articular cartilage injury.
An arthroscopy procedure is a form of keyhole surgery that involves trimming and removing parts of the meniscus or knee cartilage if they have become trapped.
This type of surgery can cause an imbalance in the knee and speed up the process of arthritis. Removing one part of a structure in the knee causes other parts to work harder and become damaged over time.
Excessive weight gain can put pressure on the knee joints, causing them to work harder than they were designed to.
This pressure causes small chondral cracks to appear in knee cartilage and eventually leads to it breaking down.
Obese individuals don’t tend to perform much physical activity in their daily routine. As a result, the muscles around the joint become weak and are unable to support the cartilage properly, causing knee pain.
Common inflammatory foods include sugar, gluten and dairy. In sensitive individuals, these foods can affect the health of the gut lining.
The gut lining is supposed to act as a barrier, helping to protect us from chemicals and substances in our food that can potentially be harmful to the body.
Sugar, gluten and dairy can cause the lining to become more permeable, which leads to some of these harmful substances absorbing into the bloodstream. They then end up travelling into the knee joint and start to cause inflammation.
Chronic inflammation can lead to knee cartilage becoming weak and fragile.
The two most common forms of bacterial cartilage defects are Lyme arthritis and septic arthritis.
Lyme Arthritis –
A form of arthritis that occurs in the late stages of Lyme’s disease. Lyme’s disease is a bacterial infection that is spread to humans via tick bites. Knee cartilage damage and degeneration occur when the bacteria invade the joints and create inflammation.
Septic Arthritis –
This is a form of infection that is caused by either germs in your bloodstream travelling to the chondral aspect of your joint, or germs directly entering your body from an injury.
The condition that is most commonly associated with urate crystals is gout.
It occurs when you have high levels of urate acid in your blood. These high levels cause the formation of crystals in your joints, most commonly in the knee and big toe.
If they stay in the joint for too long, they can cause inflammation and lesions, eventually knee cartilage damage. An individual with gout will complain of sharp intense attacks of pain.
Beer and red meat are known to increase levels of uric acid in the blood.
There are certain autoimmune conditions that involve the immune system attacking the structures in your joints. The following autoimmune conditions can cause arthritis and knee cartilage damage:
The treatment we offer here at ProHealth Clinic not only helps to repair and regenerate cartilage but also helps to treat the root cause of the condition. By treating the root cause, we can ensure an individual experiences long-lasting results with our treatments.
Both an X-ray and MRI scan (magnetic resonance imaging) can help to identify articular cartilage damage. The added benefit of an MRI scan compared to an X-ray is that it can pick up specific characteristics of the cartilage injury and the underlying subchondral bone, such as subchondral bone bruising, osteophytes or other articular cartilage defects. A doctor or orthopaedic consultant will decide which scan is right for you.
The aim of physiotherapy is to improve the health of the muscles around your knee. The stronger and more flexible they are, the better support they can provide for the knee cartilage.
One of the main supportive muscles is the quadriceps, as they attach around the front of the knee. They help to stabilise the joint during movement and act as a shock absorber during weight-bearing activities.
A physical therapy program will involve a combination of strengthening, stabilizing, and stretching exercises. Follow-up sessions will also help other injured areas around the knee that the cartilage degeneration may have had an influence on.
Exercise and weight loss –
Gentle non-weight-bearing forms of exercise can be a great way to maintain the health of the muscles around an arthritic knee and damaged cartilage.
Types of non-weight-bearing activities include cycling and swimming.
Going for short daily walks can also be good, only if it doesn’t cause any pain. If you go for a walk and you are in pain, then you tend to adopt a limping posture which can cause problems with your hip and back over time.
Exercise not only helps to keep your muscles strong but it also helps to flush inflammation out of the joint and reduce the pressure.
A great by-product of exercise is weight-loss, which can help to take the pressure off your knee cartilage during weight-bearing activities such as walking and climbing stairs.
Stem cell injection –
A stem cell injection procedure is a form of cell therapy that involves drilling into your bone marrow in your hip to extract stem cells to reinject into your knee joint. The aim is to stimulate chondrogenic cells, cartilage regeneration and tissue repair. The clinical term is the chondrogenesis of mesenchymal stem cells. There are many ongoing clinical trials being performed on the effectiveness of this treatment in combination with biomaterials. A biomaterial is a substance that has been engineered to interact with a part of the body to help repair it.
Platelet-rich Plasma (PRP) injection –
This procedure is another form of cell therapy and regenerative medicine. The aim of platelet-rich plasma is to promote tissue regeneration through stimulating chondrogenic cells. The procedure involves taking between 30-60mls of blood from the patient. It is then placed into a centrifuge that helps to separate the red blood cells from the platelet-rich plasma. The plasma, which is thought to contain growth factors, is then injected into the knee joint.
Clinical trials have shown it to have a positive effect on the health of cartilage.
Cartilage tissue engineering –
Cartilage tissue engineering is an advanced form of stem cell therapy used to repair tissue in the body. It combines chondrogenic cells with biomaterials and growth factors in an attempt to stimulate chondrogenic cells and cartilage regeneration.
Fibrin scaffolds are another form of tissue engineering treatment is that is being used to help with articular cartilage repair.
Hyaluronic acid injection-
Hyaluronic acid, also known as hyaluronan, is a part of synovial fluid. The role of Hyaluronan is to help to lubricate the knee joint and act as a shock absorber. It can’t stimulate new cartilage or repair tissue but it can help to improve the mobility of the knee joint.
Steroid injection –
This treatment involves the injection of anti-inflammatory medication to help to reduce swelling in a damaged part of the body. Unfortunately, the effect is only temporary, and patients normally have to go back for a top-up. The negative effect of this is that multiple steroid injections have been shown in studies to weaken damaged cartilage and cause problems in the underlying bone. As a result, many sports medicine practitioners and orthopaedic surgeons are looking for alternative ways to treat patients with knee cartilage damage.
For that reason, a steroid injection should only be used as a last resort if the other treatments mentioned above haven’t worked.
Oral Medication –
Medication can be either over-the-counter or prescribed, depending on the level of knee pain an individual is experiencing. Unfortunately, there are many side-effects associated with taking painkillers and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.
Short-term effects: Drowsiness, constipation, nausea.
Long-term effects: vomiting, diarrhoea, heartburn, stomach bleeding and ulcers.
One of the main issues is that an individual can build up a tolerance over time. Much like a steroid injection, pain management medication should be a last resort option.
Due to the risks and side effects of surgical techniques, it is important to try all non-surgical avenues first before you look into the below procedures.
Arthroscopic lavage and debridement
An arthroscopy procedure is used when a piece of cartilage has become loose within the joint. The keyhole operation involves an instrument called an arthroscope being used to examine the joint and then a saline solution helps to clean it out. The loose cartilage fragments are then removed with a shaver. The problem with an arthroscopy is that it doesn’t repair the cartilage injury, it can only help with managing the pain.
A meniscus transplant is only recommended if the meniscus has worn away or been removed. It is an arthroscopic procedure that involves a donor’s meniscus being stitched to the patient’s knee.
Bone marrow stimulation
The aim of bone marrow stimulation is to attempt to stimulate new cartilage by making small holes in the bone to release bone marrow. This causes a blood clot to form over the damaged cartilage surface, in the hope that it stimulates chondrogenic cells. The issue with this technique is that it may have a limited lifespan before the cartilage repair is undone and starts to wear away again.
Autologous Chondrocyte Implantation (ACI)
This is a two-week long process that starts with surgically removing healthy cartilage cells from a good part of the knee. The cells are then taken to a laboratory to grow for around six to eight weeks.
The next stage involves another surgical procedure called an arthrotomy, where the newly grown cells are implanted into the damaged part of the cartilage.
The issue with this procedure is that it can have a negative effect on the part of the knee that had cells taken from it. For this reason, it is only offered to younger people with knee cartilage damage.
ACI knee surgery is also known as Matrix-induced autologous chondrocyte implantation (MACI).
Mosiacplasty and allograft osteochondral transplantation
A form of knee surgery that helps to replace damaged cartilage by using small rods of healthy cartilage from a donor. If the donor has come from another part of the same patient’s knee then it is referred to as an autograft.
Microfracture is an arthroscopic procedure that involves small holes being made into the knee bone. The aim of making these holes is to promote bleeding and stimulate cartilage growth.
The aim of this procedure is to stimulate cartilage growth through implanting an absorbable frame made up of collagen and proteins.
A similar procedure to mosaicplasty, it involves a graft being taken from a donor to implant into the knee cartilage damage. The graft is sterilized before the surgery and cut to the exact shape of the damage.
This procedure involves rasping damaged areas to promote bleeding with the aim of promoting cartilage regeneration.
Knee replacement surgery
It is a type of surgery that involves replacing a damaged or degenerated knee joint with artificial material. The clinical name of the surgery is ‘arthroplasty.’ There are two types of knee joint replacements:
Statistics state that knee joint replacement surgery is much less successful than hip joint replacement surgery.
Complications of surgery
The main issue with surgery is that scar tissue can build-up where the incisions are made. This scar tissue can lead to long-term stiffness and imbalances which can lead to knee pain. Surgery can also cause damage to local blood vessels. Surgery should always be a last resort option if conservative treatments haven’t work. It is important that you seek medical advice from several different consultants before deciding which surgical road to go down.
The good news is that there are several safer non-surgical solutions that can be explored before considering surgery. At our clinic, we offer a comprehensive approach to treating knee cartilage damage which combines both Prolozone Therapy and rehabilitation exercise.