Does exercise cause wear and tear in knee cartilage?

It almost seems intuitive that exercise would cause joint wear. After all we are all used to mechanical devices deteriorating with use so the same would be expected of the body’s moving joints. However this may not be as simple as it appears. The body is a living structure that responds to stress. Muscle, bone, tendon, ligaments and cartilage / bone interface increase their strength in response to load provided that the load is not excessive. These are adaptive changes that occur over a long number of years rather than weeks. So a simple answer to the common question is exercise bad for the joints? is probably not. Indeed the benefits in most cases out weigh the possible negatives.

But maybe this is not so simple.

There is now as always a push to exercise more. So maybe a person in their 40s decides to take up exercise and with great enthusiasm they launch in to running. TV reality programmes have pushed this line, perhaps without proper advice and screening. This can lead to trouble. For a person who may not have taken any exercise for over 10 years a sudden increase in activity can lead to trouble. Over the years with little activity the cartilage and cartilage / bone interface have become soft. There may even be some of the articular cartilage coming loose and is ready to break off. Now you start running 5k and that is what will happen. It is not the running as such that caused the problem but the inactivity for a long number of years that has weakened your cartilage and now it is not able to take the stress of running.

So the message is to listen to your joints. If there is pain and swelling you may be overdoing it for your particular body structure. Think about non joint stressing exercise first like swimming and cycling and if you can don’t let this happen at all by taking regular exercise all your life from a young age.

The clear message for young people is don’t think that you can take up exercise in later life and redress the damage that has been caused by a prolonged period of inactivity.

Chances are if you are over 40 years of age that it is rotator cuff tendinopathy, a rotator cuff tear, acromio-clavicular osteoarthritis or a frozen shoulder.
In fact it could be a combination of any of the above.

Rotator cuff problems are very common. They start with pain in the upper arm and the top of the shoulder. Typically there is catching pain on reaching behind for something like in the car. There can be darts of pain and also dull aching. The dull ache is typically worse at night and can prevent sleep. It seems to be worse on lying down. It can settle for no particular reason after a few months. Perhaps physiotherapy can help this or it eases itself with time anyhow.
We used to think that this was a mechanical problem of the rotator cuff rubbing off the acromion bone and ligament on abduction but it is probably more complex than this. With the normal aging process there is breakdown of the fibres of the cuff. There is degeneration of the tendons and this sets up a repair / breakdown cycle. Pain chemicals are also involved.

If the pain persists for 2 months or so it will be worthwhile getting a MRI scan to assess the situation. The MRI will show the condition of the rotator cuff tendons and tell if there is an actual tear in the tendon. This is commonly in the anterior part of the supraspinatus tendon. It can occur with the normal aging process and can also be helped on its way by a fall which will cause a sudden failure of the tendon.
A tear of the rotator cuff may be a common finding in MRI of the shoulder and is seen in 50% of patients aged 60 years. If it is associated with pain I feel that a rotator cuff repair is a good operation for pain relief. In over 80% of cases the pain in the shoulder caused by a rotator cuff tear can be relieved by rotator cuff repair.

If there is no rotator cuff tear then there are simpler options available. Typical impingement pain may be a sign of a failing tendon that will go on to tear. An injection of steroid in the sub acromial space is certainly worth a try and can have a dramatic effect in about 50% of patients. A second injection can be used if the first one had a good effect. There are concerns about injecting of steroids. My opinion is that there is no hard evidence on how many injections can be given. I would usually stop at 2 and then move on to another treatment option but if the patient really did not want to go on to surgery then there is no reason not to have 5 or 6 injections or more. I am reluctant to give steroid injections to people who are involved in heavy work as I have seen that with the pain relief from the injections patients can go on to rupture their tendons from aggressive manual work. However if I have discussed this possible complication and the patient is going to take it easy I see no reason not to use this useful treatment.

For those that do not improve with injections then surgery to trim the acromion and decompress the sub acromial space is a good option. I find the pain relief after this procedure to be somewhat variable and may be not as good as in rotator cuff tears strangely. Some patients get a dramatic improvement and some others continue having pain. However it is certainly worthwhile persevering with rehab and giving the shoulder at least a year to settle after this surgery.

Rotator cuff surgery and sub acromial space surgery can often be combined with resection of the acromio clavicular joint. This joint when arthritic causes pain around the joint itself and also to the side of the neck. It can also cause impingement type pain. It can be resected arthroscopically by removing 1cm of the clavicle. The space then fills up with scar tissue and this prevents the arthritic bones from rubbing together.

A frozen shoulder is just that and I prefer this term to adhesive capsulitis as I am not sure if there is an inflammatory process involved. Usually for no reason the capsule of the shoulder joint becomes fibrotic, thick and stiff. The typical shoulder is frozen and there is very little movement with a solid end feel and no give in it. The patient could wait 1 to 2 years for it to thaw out or have arthroscopic surgery. I prefer to release the capsule arthroscopically as I believe that this cuts and releases the thickened capsule. With a manipulation, I see with the arthroscope that the capsule does not tear but it pulls the labrum with some bone from the glenoid off the glenoid itself and this is how movement is achieved. It is for this reason I prefer to see that it is the actual capsule that is cut by doing the procedure arthroscopically.
There may not be a dramatic improvement in movement but it starts the process of rehabilitation. Gradually the pain levels decrease and the movement increases. I find arthroscopic capsular release a good treatment option in a frozen shoulder.

Shoulder pain is usually caused by rotator cuff problems, acromioclavicular osteoarthritis and a frozen shoulder in middle aged patients.

In my next blog I will discuss shoulder problems in the younger age groups where there is a somewhat different spectrum of pathologies.

With the Olympics 2012 over for nearly 2 weeks Ireland has settled back to normal very quickly. I wonder has the euphoria totally dissipated. It is expected that those with a casual interest in sport will settle down very quickly and move on to the next event. But what are the lasting implications of Ireland’s participation?

Do we as a country have to decide what level we wish to participate in the Olympics at?
If it is possible to decide on that then we can decide on what funding is needed to achieve our aims because the Olympics has taught us if we needed to be taught that success requires investment.
The British cycling team are to be admired for setting out their stall, committing to the plan and bringing home the medals. None of this could be done without the massive funding they got. Still their achievements are magnificent.
The Irish Boxers success is a tribute to the clubs that organise boxing, train youngsters and bring them to national standard. The next step requires serious funding for the high performance team. We have all enjoyed their fantastic success and hope that the money can be found to continue it.
OK money is tight and it is worthwhile spending money on high performance in sport. The evidence of increased participation in sport and the trickle down effect is poor. What can’t be quantified is the feel good effect in the general population and the national pride generated by success.
The country needs to continue to invest in top level sport. This needs to be targeted to sports where we have a realistic chance of success and sports with some general appeal.
Sports organisations and individuals can tap in to the feel good factor by offering something to companies in the way of sponsorship deals. This is something that has a lot more to offer. Sports people need to be innovative in seeking sponsorship from small businesses that now may look favourably on small, niche deals. The private sector can and is willing to help high performance sport in Ireland.

In fact you are probably saving yourself the hassle.

How cold does the ice need to be?

Can I put it against my skin?

How long do I apply it for?

You could save yourself all this and just not bother applying ice at all as for me it is not really the killer application.

What I do like is elevation. Decrease the swelling in the knee by increasing venous return and especially by not allowing that nasty bruising to go down the front of the shin bone after ACL surgery. This is really sore. Then it tracks around to the back and in to the calf and you are off to the hospital for a DVT scan.

Elevate your leg 2 feet higher than your head when at rest for the first week after anterior cruciate ligament surgery and by and large you will avoid all this trouble.

If you want to slap a bit of ice on as well for 10 or 15 minutes fine but don’t beat yourself up if this is too much trouble as it really does not make any difference.

I also think that cryo chambers are a waste of money in treating any injury. You know the ones where you go in to the freezer at -110 degrees C. I can’t find any decent scientific study to show that they have any influence on healing of sports injuries. Fine if individuals want to waste their money on them but people who give money to sports clubs should be careful that their money is not wasted on these treatments.

Another treatment that you need to think about is the non steroidal anti inflammatory tablet. To some people the goal of all treatment is to stop inflammation. But remember there is no healing without inflammation. A natural process that has evolved over millions of years must be stopped at all costs by the small brown tablets according to some therapists.

So start thinking of inflammation as a good thing and remember that it is necessary for the healing of your injury and surgery. You might want to control it a little but not turn it off altogether.

They occur more often in the older player and in players who have already suffered a previous leg injury. As with all sport injuries the incidence increases with the hours of play and the level played at. In rugby the incidence has been shown to be 5.6 injuries per 1000 hours of play and in semi-professional soccer players at 3.0 injuries per 1000 hours of play. There is evidence that injuries occur more often in the second half of games and perhaps a warm up after half time would be a good idea. High volumes of training in the week preceding a match have been shown to increase the incidence of muscle tears. The reinjury rate could be up to 30.

Passive and active warm-up and muscle stretching before training and competition have been advocated as effective injury-prevention strategies, even though there is limited evidence to demonstrate that these activities reduce the incidence of muscle strains.

Hamstring strengthening has been shown to reduce the incidence of hamstring muscle strains. In our experience at the Sports Injury Surgery athletes in Ireland playing at relatively high levels in all sports have poor hamstring strength as measured by Biodex Isokinetic Testing and have an imbalance between their Quadriceps and their Hamstrings with an overemphasis on quadriceps muscle strength.

We have also found that core stability and proprioception is poor. It has been shown that training in core stability and proprioception will reduce the incidence of muscle tears in the legs.

Studies have also shown that identification of muscle imbalances with an isokinetic measuring device such as the Biodex and then correcting these imbalances with a focused training programme will reduce the risk of hamstring muscle tears.

We advocate the use of the Nordic Hamstring Strengthening exercises to reduce the risk of tears and then retesting on the Biodex machine to prove that the hamstring muscles have indeed strengthened.

Tears can also be treated in the initial stages with platelet injections. see Platelet Therapy for more information. This technique uses the body’s own growth factors in the blood to promote healing.

Lifestyle

The first line of treatment is to look at your lifestyle. In general exercise is good for your joints. You should have your muscles in peak condition for your age. You can see your physio to discuss an exercise programme that is specific for you. It is wrong to believe that avoiding exercise will help. Of course you will have to be sensible and if an activity is particularly painful then this should be avoided. You should try to substitute another activity to stay fit.

Extra weight is a burden on your joints and perhaps a reduction in your weight should be considered. What specific foods you eat do not affect your joints and there are no specific foods that are good or bad. In general the fitter and stronger you are the less pain you will have from your arthritis even though the actual wear does not change.

Medication

You may be prescribed anti-inflammatory drugs. These can be used for short term periods. They can reduce swelling but mainly act as painkillers. They do not really affect the course of the disease. Paracetamol is a pain killer and is not classified as an anti-inflammatory drug. It is the first drug that should be used for pain. It can be used regularly and has relatively few side effects.

It is uncertain if Glucosamine actually improves the cartilage in osteoarthritis. It seems to improve pain. It is considered a supplement rather than a drug. The American Academy of Orthopaedic surgeons recommends that glucosamine and/or chondroitin sulfate or hydrochloride not be prescribed for patients with symptomatic osteoarthritis of the knee.
This recommendation was based on a report from the Agency for Healthcare Research and Quality. The report was based on one random controlled trial and six systematic reviews on the use of chondroitin sulfate, and/or glucosamine, or hydrochloride among patients with osteoarthritis of the knee.
The random controlled trial found that glucosamine and/or chondroitin did not have any clinical benefit, though five of the six systematic reviews concluded that glucosamine and/or chondroitin are superior to placebo.
Since the Random Controlled Trial is stronger science than the systematic reviews, the AAOS based their decision on the one study.

Surgery

If the wear is not advanced then an arthroscopy can be useful. It is difficult to predict the outcome in the arthritic knee. Some people do very well. In general an arthroscopy gives temporary relief. An arthroscopy is particularly good for catching and locking symptoms.

If the wear is more severe a total knee replacement is the best treatment. It is a very good operation for pain and function is very good also. 1 in 20 patients will have a problem with a knee replacement. This may be infection or loosening. The knee replacement can last up to 15 years. It will wear more quickly with more use and then it can be replaced. It may not be as easy to replace the knee for the 2nd time.

Apart from the knee replacement there are other operations that may be suitable for you. Not every knee is suitable and the operations are in themselves as big as a knee replacement. You can discuss this with your surgeon.

The following is a summary of the recommendations in the American Academy of Orthopaedic Surgeon’s clinical practice guideline, The Treatment of Osteoarthritis (OA) of the Knee. This guideline was explicitly developed to include only treatments less invasive than knee replacement (arthroplasty). This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners.

GRADING THE RECOMMENDATIONS
Following data extraction and analyses, each guideline recommendation was assigned a grade that was based on the total body of evidence available using the following system:
A: Good evidence (Level I Studies with consistent finding) for or against recommending intervention.
B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.
C: Poor quality evidence (Level IV or V) for or against recommending intervention.
I: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.
Final grades were based upon preliminary grades assigned by AAOS staff, who took into account only the quality of the available evidence. Workgroup members then modified the grade using the ‘Form for Assigning Grade of Recommendation (Interventions)’ shown in Appendix VIII

CONSENSUS DEVELOPMENT
The recommendations and their grades of recommendation were voted on using a structured voting technique known as the nominal group technique.25 We present details of this technique in Appendix IX. Each recommendation was constructed using the following language which takes into account the final grade of recommendation.
Guideline Language Grade of Recommendation
We recommend A
We suggest B
An option C
We are unable to recommend for or against I

Patient Education and Lifestyle Modification

Recommendation 1
We suggest patients with symptomatic OA of the knee be encouraged to participate in self-management educational programs such as those conducted by the Arthritis Foundation, and incorporate activity modifications (e.g. walking instead of running alternative activities) into their lifestyle.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 2
Regular contact with self help groups to promote self-care is an option for patients with symptomatic OA of the knee.
Level of Evidence: IV
Grade of Recommendation: C

Recommendation 3
We recommend patients with symptomatic OA of the knee, who are overweight (as defined by a BMI>25), should be encouraged to lose weight (a minimum of five percent (5) of body weight) and maintain their weight at a lower level with an appropriate program of dietary modification and exercise.
Level of Evidence: I
Grade of Recommendation: A

Rehabilitation

Recommendation 4
We recommend patients with symptomatic OA of the knee be encouraged to participate in low-impact aerobic fitness exercises.
Level of Evidence: I
Grade of Recommendation: A

Recommendation 5
Range of motion/flexibility exercises are an option for patients with symptomatic OA of the knee.
Level of Evidence: V
Grade of Recommendation: C

Recommendation 6
We suggest quadriceps strengthening for patients with symptomatic OA of the knee.
Level of Evidence: II
Grade of Recommendation: B

Mechanical Interventions

Recommendation 7
We suggest patients with symptomatic OA of the knee use patellar taping for short term relief of pain and improvement in function.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 8
We suggest lateral heel wedges not be prescribed for patients with symptomatic medial compartmental OA of the knee.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 9
We are unable to recommend for or against the use of a brace with a valgus directing force for patients with medial uni-compartmental OA of the knee.
Level of Evidence: II
Grade of Recommendation: Inconclusive

Recommendation 10
We are unable to recommend for or against the use of a brace with a varus directing force for patients with lateral uni-compartmental OA of the knee.
Level of Evidence: V
Grade of Recommendation: Inconclusive

Complementary and Alternative Therapy

Recommendation 11
We are unable to recommend for or against the use of acupuncture as an adjunctive therapy for pain relief in patients with symptomatic OA of the knee.
Level of Evidence: I
Grade of Recommendation: Inconclusive

Recommendation 12
We recommend glucosamine and/or chondroitin sulfate or hydrochloride not be prescribed for patients with symptomatic OA of the knee.
Level of Evidence: I
Grade of Recommendation: A

Pain Relievers

Recommendation 13
We suggest patients with symptomatic OA of the knee receive one of the following analgesics for pain unless there are contraindications to this treatment:
Paracetamol [not to exceed 4 grams per day]
Non-steroidal anti inflammatory drugs (NSAIDs)
Level of Evidence: II
Grade of Recommendation: B

Recommendation 14
We suggest patients with symptomatic OA of the knee and increased GI risk (Age >= 60 years, comorbid medical conditions, history of peptic ulcer disease, history of GI bleeding, concurrent corticosteroids and/or concomitant use of anticoagulants) receive one of the following analgesics for pain:
Paracetamol [not to exceed 4 grams per day]
Topical NSAIDs
Nonselective oral NSAIDs plus gastro-protective agent
Cyclooxygenase-2 inhibitors

Level of Evidence: II
Grade of Recommendation: B

Intra-Articular Injections

Recommendation 15
We suggest intra-articular corticosteroids for short-term pain relief for patients with symptomatic OA of the knee.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 16
We cannot recommend for or against the use of intra-articular hyaluronic acid for patients with mild to moderate symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: Inconclusive

Needle Lavage

Recommendation 17
We suggest that needle lavage not be used for patients with symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: B

Surgical Intervention

Recommendation 18
We recommend against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: A

Recommendation 19
Arthroscopic partial meniscectomy or loose body removal is an option in patients with symptomatic OA of the knee who also have primary signs and symptoms of a torn meniscus and/or a loose body.
Level of Evidence: V
Grade of Recommendation: C

Recommendation 20
We cannot recommend for or against an osteotomy of the tibial tubercle for patients with isolated symptomatic patello-femoral osteoarthritis.
Level of Evidence: V
Grade of Recommendation: Inconclusive

Recommendation 21
Realignment osteotomy is an option in active patients with symptomatic unicompartmental OA of the knee with malalignment.
Level of Evidence: IV and V
Grade of Recommendation: C

Recommendation 22
We suggest against using a free-floating interpositional device for patients with symptomatic unicompartmental OA of the knee.
Level of Evidence: IV
Grade of Recommendation: B

Meniscus: this is a crescent shaped fibrocartilage that is between the bones in the knee joint. It acts as a shock absorber. We are taking weight through the meniscus on every step we take. It is therefore no surprise that theses structures can wear and eventually tear even through normal life.

There are actually 2 in the knee. If worn or torn they cause pain on the side of the knee where the problem is along the line of the joint. The pain is worse when twisting or bending. Sometimes there is a build up of fluid in the knee.

They can also be torn in a sudden twisting injury or on bending down. Then they can actually get stuck in the joint causing locking.
About ½ of people with an anterior cruciate ligament tear also have a tear of a meniscus.

The diagnosis can be made by a proper history and examination. An MRI can be useful in a small number of cases if there is any doubt after the examination. In fact the MRI is most useful when the patient has little trouble and needs the reassurance of a normal scan to get them back to full activity.

A tear can only be treated by an arthroscopy. At the arthroscopy the tear is usually trimmed back with power tools and electrosurgery devices. In a small number of cases there is a smooth tear that will hold a stitch well. In this situation the tear can be repaired with special stitches that are placed inside the knee while it is viewed on the monitor without the need for open surgery (keyhole surgery). This happens most commonly in the younger patient with a sudden injury.

When a tear is trimmed back the patient can usually return to full activities after 4 weeks.

When a tear is repaired with stitches it will take at least 3 months before the patient can go back to sport.

Cartilage: there is confusion when talking about cartilage injuries. The meniscus is also called cartilage but it is the covering cartilage of the bones that we are talking about here. The ends of the bones in the knee are covered by hyaline cartilage. This varies from about 3 to 5 millimetres in depth. Again we are walking and running taking weight through the cartilage every day. It can wear. This starts as a softening, then fissuring and then the cartilage starts to break up. It can start to come away from the bone and leave it exposed.

I am not sure that increased levels of activity cause this wear as it can be seen in sports people and in people who do very little. It can also be seen in any age group.

Cartilage wear can lead to swelling and pain in the knee. However it does not affect everyone in the same way. Some have a lot more trouble than others with similar levels of wear.

Cartilage wear is diagnosed by a history and examination. An x-ray is the best investigation as this will give the best indication as to whether the patient needs a knee replacement or not. Obviously there is no point in having arthroscopic surgery (keyhole surgery) if you need a knee replacement. I find that MRI is very poor at demonstrating early cartilage wear and I feel that it is not needed as a routine investigation.

In the early stages it can be treated with rest and physiotherapy. If not settling an arthroscopy can make a great difference. Loose cartilage and cartilage about to fall away from the bone is removed with the arthroscopic shaver. The edges of the damaged cartilage can then be treated with an electrosurgery ablator which seals it.

Sometimes some small holes can be placed in the underlying bone to release the bone marrow with its stem cells. These cells have the ability to grow a scar like cartilage over the defect. This is called the microfracture technique.

This treatment can slow down the progression of the wear and relieve pain and swelling. However not surprisingly not all knees are sorted out and wear can continue. Patients who continue to have a lot of trouble may need a knee replacement.

Return to full sports is more uncertain after cartilage injury. It usually takes 3 months and it is very advisable to have the muscles in peak condition as this will protect the knee. Some people may decrease their activity level because they are just not able to do what they did before because of swelling and discomfort in the knee.

At the present time techniques to replace and regenerate hyaline cartilage are been used on an experimental basis and they have not yet been clearly shown to definitely benefit the patient. It is likely however that sometime in the next 5 years a good, safe, beneficial technique will emerge from the research.

It is possible to have excellent pain relief with over the counter pain killers that you can buy in the pharmacy or even the corner shop.

It is important to know what the actual name of the drug in the packet is and not just the brand name. I will refer to the actual drug name in all cases. You should ask your pharmacist for help in finding out what the actual drug is. The actual drug name is on the leaflet inserted in every packet. This keeps things simple and avoids using 2 of the same drugs even though they have different brand names.

You must not take any tablets that you have had an allergic reaction to in the past.

The first drug to use is Paracetamol. This is best started before the operation at a dose of Paracetamol 1g 4 times in the day. Check on the packet what 1g is but it is usually 2 tablets. As always you can check with your pharmacist if in doubt.

Continue the Paracetamol 1g 4 times a day after the operation. If you still have pain then you add a different drug as well as the Paracetamol rather than stopping the Paracetamol.

The next drug to add is Ibuprofen at a dose of 400mg 3 times a day. Again check with your pharmacist about the different brand names of this drug and the dose.

Do not take Ibuprofen if you have a history of stomach problems.

Both Paracetamol and Ibuprofen come with added Codeine and you may find these a little stronger if needed. Again ask your pharmacist.

In summary you can take

Paracetamol 1g 4 times a day

And

Ibuprofen 400mg 3 times a day

These drugs can be bought in the pharmacy and the corner shop without prescription. They will provide very good pain relief after orthopaedic surgery. If you have other pain medication at home contact me to ask if it is OK to use it. It is very likely that this medication will be fine for you.

Breandán Long

You may have some pain in the knee after discharge. I have put local anaesthetic in the knee, which will probably last for 6 hours. Take tablets such as Paracetamol, Solpadeine, Aspirin or Nurofen before it gets too bad. Any painkiller that you have for a headache will be good.

You may get some discomfort from the wounds through which the instruments were put.

Click For Pain Relief Advice

It is best to take things easy for 3 days at least and not to walk too much. It might be from 1 to 6 weeks before you can go back to work depending on your job. It is unlikely that you will be able to drive for the first week.

You can put your full weight on the leg and walk around as normal when you feel up to it.

You could put a bag of ice over the bandage for 20 minutes at a time to decrease pain and swelling.

Some swelling in the knee is common after the arthroscopy. It might take 4-6 weeks for this to settle down.

The crepe bandage and wool wrapped around your knee should be taken off 2 days after the operation. If it feels too tight it is no harm to take it off sooner than this.

If there is a tubigrip bandage on your knee instead of the crepe bandage please leave this on for 1 week.

The sticking plasters underneath should be left on for 1 week after the operation. Do not get them wet. You can take them off yourself or wait for the clinic.

There are no stitches in the wounds. Sometimes the wounds ooze a little blood.

Straight leg raising exercises. Lift your leg about 30 degrees when lying down. Hold for 30 seconds. Do 10 repetitions.

If the knee becomes hot or red contact us straight away.

If you have any problems do not hesitate to contact us.