You have got to be kidding me. 2 years. 24 months. That is the amount of time that it can take cartilage to form, mature, and adapt to the stresses I’ll likely place on it. Microfracture surgery forms new cartilage and rather than replace cartilage and hence the recovery is excruciatingly slow, long, important, and individualized. The recovery will depend on location, size, depth, quality of surrounding cartilage, age, BMI, health, nutrition, goals, motivation, surgery success, and more. Basically, it is highly individualized – so one must recognize that the existing evidence and information out there (this blog post included) is not 100% applicable to your situation. Still, I hope to provide some insights into my thought process about recovery as I progress through the different stages of recovery. There will likely be many ups and downs through the process as well, which will hopefully prove instructive (read: Amelia Boone’s great recent blog post highlighting how to persevere in the up and down process of recovery).
Currently, I am in phase 1 of the recovery, the (chondrocyte) proliferation phase. After the surgeon poked a few holes in my femur the bone marrow hopefully formed a clot over the area which cartilage was missing. The goal here is to have those stem cells turn into the best possible cartilage making chondrocyte cells as possible. Not all chondrocytes are the same, studies have shown that some are better than others, just as some muscle cells, neurons, or endothelial cells are “better” than others. With microfracture one of the reasons inferior firbrocartilage forms normally instead of matching the existing superior articular cartilage is because the chondrocytes that form in the blood clot are inferior to the chondrocytes which reside in existing high quality articular cartilage. Thus, one of my strategies is to use interventions which either make superior chondrocytes and to keep the chondrocytes from dying off if at all possible during this initial 4-6 week phase of recovery. My second strategy is to mitigate the many negative side effects of nearly zero load and essentially having my left leg immobilized for the this first 4-6 weeks. Limb immobilization can cause atrophy of skeletal muscle, connective tissue, metabolic capacity, and overall loss of cardiovascular fitness.
To do so I have researched and adopted 3 strategic approaches which I hope will work together to improve the quality of my newly developed cartilage and lessen the negative impacts of no weight bearing. They are:
- Mechanical stimulation
- Nutritional supplementation
- Passive heat
6-8 hours/day. 6-8 weeks. Let’s start with mechanical stimulation. There is good biological rationale for that mechanical stimulation increases the number of chondrocyte cells formed from stem cells and the quality of these cells as determined by the type and quantity of collagen and proteoglycans secreted by these cells. The way I am doing this is continuous passive motion or CPM. Evidence in animals clearly shows that 6-8 hours/day of CPM machine decreases the loss of proteoglycans, increases the formation of chondrocytes, may increase blood flow to the joint (the cartilage normally received very little blood flow and thus nutrients), may lower inflammation, allows more chondrocyte protective proteins to be formed, and overall better recovery (here, here). However, most of the studies don’t say exactly how much CPM time is ideal or if CPM works better for specific types or sizes of cartilage defects (here). Again, it’s individual. Irrespectively of the limitations, my goal has been mechanical stimulation through mainly CPM with a move towards limited partial weight bearing starting at 2 weeks. I started CPM movement the day after my surgery and have been very consistent with 6-8 hours/day in the “machine”. I will likely continue for another 3 weeks for 6 weeks total.
Besides eating fresh foods, non-processed foods, low glycemic index foods, and a variety of vegetables and meats I have a few added supplement strategies not normally applied on a day to day basis.
Push Protein (20-30 grams/meal): This is a basic one. Every meal should have 20 – 30 grams of high quality protein. Typically for me its eggs in the morning, a protein shake (without added sugar) for lunch, and some sort of meat (chicken, pork, grass feed ground beef) for dinner on a salad. See a review here.
Glucosamine and Chondroitin Supplements (2 x per day, 1.5 & 1.2 g respectively. Kirkland USP certified brand): The literature on glucosamine and chondroitin is unequivocal to say the least. Typically, this supplement is used for osteoarthritis to protect against further cartilage degradation rather than rebuilding the cartilage. Still, while I am non-load bearing I can except that the existing cartilage may degrade without normal loading. Glucosamine and chondroitin are reported to reduce the expression of cartilage degrading proteins (MMP-3) and inflammatory proteins that are detrimental to chondrocyte cell health as well. (References here, here)
Curcumin (Meriva-SF, 500mg 2x day): Curcumin is a compound found in turmeric and actually has extensive research documenting its effects. The major biological effect of curcumin is to reduce inflammation and cell division across many different tissues. My specific interest is because of reports that it reduces the progression of osteoarthritis (reference here), improve chondrocyte cell survival, reduce inflammation, and prevent collagen degradation (reference here). Other evidence suggests that curcumin may improve the differentiation of chondrocytes, critical to a successful microfracture surgery (reference here and here). There is also evidence it prevents weight gain and metabolic dysfunction following cessation of exercise (here).
Gelatin (~10g/day): The synthesis of soft tissue such as cartilage, ligaments, and tendons suffer from low blood flow. Recently the role of the amino acid proline in stimulating ligament collagen formation was shown in a wonderful set of very applied studies by Dr. Keith Baar at UC-Davis (reference here). Most of the gels used in joints use a gelatin like matrix to improve the cellular environment for chondrocyte health and differentiation (reference here, here, . While I did not have a matrix put into my knee, I am putting plenty of jello into my body in hopes that some of the gelatin finds its way to my developing chondrocytes. In addition I am hoping that the gelatin mitigates some of the loss of connective tissue occurring due to non-weight bearing for an extended period of time.
Passive Heat (Sauna)
4-5 times/week, 20 – 40 minutes, 150 – 170 Degrees Fahrenheit. The last part of my current therapy is sauna time. I think the sauna is a useful tool for most people and has many, many different beneficial effects. My rationale is based on studies that have shown:
- Increased in aerobic capacity and fitness, without training. Likely due to increase blood volume. (here)
- Increased expression of cellular protective proteins, heat shock proteins, which are also associated with increased longevity and removal of damaged proteins (here)
- Increased differentiation of stem cells into chondrocytes (here)
- Heat shock protein can increase in chondrocytes (here)
- Decreased in atrophy and better muscle function in response to non-weight bearing (here).
My dose is based on the idea that you need to be uncomfortably hot to raise your core temperature to an appropriate stimulus level. While in the sauna I started to include small exercises to keep my heart rate up at a level I typically see on a steady state aerobic run for 10-15 minutes.
There are problems with many of the studies used as rationale above. Some are in animals and cell culture models, while others use a small number of people or people with very different condition than I have. I’ll never know whether my exact protocol is better or worse than any other. I can’t live my life as repeated experiments to find out definitively what the best approach is. Instead, I have developed a plan that I think gives me at least a better chance of improving my long-term outcome. That placebo alone is worth the trouble of researching and implementing such a plan. So I continue to sit in my continuous passive motion machine, eating my jello, and preparing for my next sauna session while visualizing healthy abundant chondrocytes laying down plenty of articular-like cartilage.
Additional Selected References
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Hedley, A. M., Climstein, M., & Hansen, R. (2002). The effects of acute heat exposure on muscular strength, muscular endurance, and muscular power in the euhydrated athlete. Journal of Strength and Conditioning Research, 16(3), 353–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12173948
Scoon, G. S. M., Hopkins, W. G., Mayhew, S., & Cotter, J. D. (2007). Effect of post-exercise sauna bathing on the endurance performance of competitive male runners. Journal of Science and Medicine in Sport, 10(4), 259–62. https://doi.org/10.1016/j.jsams.2006.06.009
Miyabara, E. H., Nascimento, T. L., Rodrigues, D. C., Moriscot, A. S., Davila, W. F., AitMou, Y., … Mestril, R. (2012). Overexpression of inducible 70-kDa heat shock protein in mouse improves structural and functional recovery of skeletal muscles from atrophy. Pflügers Archiv – European Journal of Physiology, 463(5), 733–741. https://doi.org/10.1007/s00424-012-1087-x
Tsuchida, W., Iwata, M., Akimoto, T., Matsuo, S., Asai, Y., & Suzuki, S. (2017). Heat Stress Modulates Both Anabolic and Catabolic Signaling Pathways Preventing Dexamethasone-Induced Muscle Atrophy In Vitro. Journal of Cellular Physiology, 232(3), 650–664. https://doi.org/10.1002/jcp.25609
Kuhlenhoelter, A. M., Kim, K., Neff, D., Nie, Y., Blaize, A. N., Wong, B. J., … Roseguini, B. T. (2016). Heat therapy promotes the expression of angiogenic regulators in human skeletal muscle. American Journal of Physiology – Regulatory, Integrative and Comparative Physiology, 311(2), R377–R391. https://doi.org/10.1152/ajpregu.00134.2016
Isaka, S., Someya, A., Nakamura, S., Naito, K., Nozawa, M., Inoue, N., … Kaneko, K. (2017). Evaluation of the effect of oral administration of collagen peptides on an experimental rat osteoarthritis model. Experimental and Therapeutic Medicine, 13(6), 2699–2706. https://doi.org/10.3892/etm.2017.4310
Shaw, G., Lee-Barthel, A., Ross, M. L., Wang, B., & Baar, K. (2017). Vitamin C–enriched gelatin supplementation before intermittent activity augments collagen synthesis. The American Journal of Clinical Nutrition, 105(1), 136–143. https://doi.org/10.3945/ajcn.116.138594
Henrotin, Y., Clutterbuck, A. L., Allaway, D., Lodwig, E. M., Harris, P., Mathy-Hartert, M., … Mobasheri, A. (2010). Biological actions of curcumin on articular chondrocytes. Osteoarthritis and Cartilage, 18(2), 141–149. https://doi.org/10.1016/j.joca.2009.10.002
stErZi, silvia, GiordaNi, laura, MorroNE, M., lENa, E., MaGroNE, G., scarpiNi, claudia, … foti, calogero. (n.d.). The efficacy and safety of a combination of glucosamine hydrochloride, chondroitin sulfate and bio-curcumin with exercise in the treatment of knee osteoarthritis: a randomized, double-blind, placebo-controlled study. Retrieved from https://www.minervamedica.it/en/getfreepdf/ZzUOnSDjLWsPWNDRgx%252FUot5SsiknW%252Bo%252BtIigbv8NFqzI%252B9udcuLOPYEtlriNX54r%252BNNu7fX%252FMpkxI32wonjX4w%253D%253D/R33Y2016N03A0321.pdf
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Ko, J.-Y., Sun, Y.-C., Li, W.-C., & Wang, F.-S. (2016). Chaperonin 60 regulation of SOX9 ubiquitination mitigates the development of knee osteoarthritis. Journal of Molecular Medicine, 94(7), 755–769. https://doi.org/10.1007/s00109-016-1422-3
Chen, J., Li, C., Wang, S., Schmitt, G., & Madry, H. (2014). Periodic Heat Shock Accelerated the Chondrogenic Differentiation of Human Mesenchymal Stem Cells in Pellet Culture. PLoS ONE, 9(3), e91561. https://doi.org/10.1371/journal.pone.0091561
Gracitelli, G. C., Moraes, V. Y., Franciozi, C. E., Luzo, M. V, & Belloti, J. C. (2016). Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults. In G. C. Gracitelli (Ed.), Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD010675.pub2
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