MANAGING KNEE PAIN BEFORE KNEE REPLACEMENT SURGERY

By Chris Carmichael, Founder and Head Coach of CTS

The days are numbered for my right knee. I’ve known for a long time that I would eventually need a knee replacement. I suffered a compound fracture of my right femur in 1986, cracking it between the femoral condyles at the distal end. In the ensuing surgeries I lost an inch of leg length on the right side and over the past few decades the surgeries and the leg length discrepancy have put extra stress on my knee. Staying active has been the best medicine, but during the past year or so the pain level has increased to the point that it’s been keeping me from being as active as I’d like. At the same time, I love summers and I didn’t want to cancel some long-planned adventures, so I scheduled the surgery for January and have been focusing on pain management so I could enjoy the long summer rides. Everyone manages pain differently, but here’s what’s been working for me.

Activity

Movement is essential for keeping the synovial fluid that lubricates your joints moving so it can reduce friction. While it might seem logical to stop exercising and reduce the movement of my right knee, that’s the exact opposite of what doctors and physical therapists recommend. Personally, I have found that consistency matters more now than ever. I don’t need to ride hard or stress my knee, but some exercise each day is far better than none. I experience the worst knee pain the day after a day when I am totally inactive. That’s when it feels stiff and painful on a ride. And even during a ride, if I take a prolonged break the pain returns and then it takes about 10 minutes of easy riding until it dissipates.

Range of motion exercises

Along with consistent activity, I have been incorporating exercises to maintain my knee’s normal range of motion. On the bike my knee only moves within a prescribed range of flexion during the pedal stroke. Off the bike I make sure to include exercises that flex and extend my knee past the range of my pedal stroke. I particularly feel the benefit of this when I walk up along flight of stairs or hike on steep trails.

Cortisone

As a component of my long-term treatment plan, my doctor recommended a small number of strategically timed cortisone injections. My doctor and I discussed the fact that a knee replacement was going to be necessary within 12-18 months, and therefore he was okay with providing 2 cortisone injections – spaced out by at least 6 months – to reduce inflammation and provide some pain relief while minimizing the chance for additional damage to cartilage in my knee. They worked quite well and allowed me to continue with the two strategies mentioned above.

Although the cortisone worked, I wasn’t impressed by the results of another procedure. At the beginning of this process my doctor recommended that I try a procedure that injects platelet rich plasma (PRP) and stem cells into the joint. The idea is that the platelets signal the body that repair is needed in the area, and then stem cells get to work creating the necessary tissues. In my n=1 experience, I felt little to no pain relief after the procedure and it was quite expensive.

Pain Relievers 

My doctor has prescribed me a low dose of Celebrex for a long time to reduce inflammation in my right knee. Celebrex is a prescription non-steroidal anti-inflammatory drug (NSAID), and the research on NSAIDs is clear: endurance athletes should avoid using them during training and long events, and avoid using them for prolonged periods (like for chronic pain). You can read more about the research findings and references here. In light of this, I avoid medications like ibuprofen (Advil) and naproxen (Aleve). My doctor and I discussed the risks of Celebrex for me, and we have monitored for potential side effects, but I am really looking forward to no longer taking Celebrex.

RICE

Although the scientific justification for Rest, Ice, Compression, and Elevation (RICE) as a treatment for inflammation and pain due to a chronic injury is not as strong as it is for the treatment of acute joint injuries, I include it as part of my regimen on days when I perhaps push too hard on the bike or otherwise aggravate my knee.

CBDa

Knowing that I was in for a 12- to 18-month period gradually worsening pain, one of my biggest goals was to avoid the need for opioid medications. Although opioids can be very effective for alleviating acute pain, they are not recommended for chronic or long-term pain management, in part because of the risk of addiction and overdose. I’ve previously written about these dangers here and here. Instead, and in addition to the strategies mentioned above, I decided to commit to a consistent regimen of supplementation with CBDa from Planetarie. As I wrote about in a previous blog, I’ve been impressed by Planetarie’s water-based process for extracting CBDa from hemp. There are thousands of CBD companies out there, but only one using water-based extraction instead of using harsh chemicals and/or heat. CBDa is a “raw” or less processed cannabinoid; the harsher processes convert CBDa to CBD.

Interestingly, of all the strategies above, the CBDa is the one people question the most. It turns out that CBD skepticism is remarkably common. According to a 2021 report published by Statista, 22% of respondents didn’t trust the product or manufacturer. Another 22% didn’t believe CBD would help them. And a smaller (8%) group of respondents believed CBD would make them high. The report detailed additional misconceptions about CBD, the most striking of which was that 57% of respondents believed CBD would show up on a drug test (presumably employer or government drug testing, as the survey audience wasn’t specifically athletes). Twenty-six percent of respondents equated CBD with marijuana, which contains the psychoactive ingredient, THC, and wouldshow up on a drug test.

These reasons for being unwilling to try CBD or CBDa echo the concerns I’ve heard from athletes I’ve talked to about my journey toward knee replacement surgery, which is unfortunate. I’m not going to oversell the benefits of CBD or CBDa. I don’t think it’s a panacea. I think consistent use of CBDa as a component of my post-exercise recovery and pain management regimen has helped me manage pain and stay more active as I wait to have surgery on my knee. For instance, since starting to use CBDa, I’ve been able to reduce the amount of Celebrex I take. This makes sense, considering that CBDa and Celebrex are both selective COX-2 inhibitors.

I also know that, of the reasons and misconceptions in the Statista report that keep people from trying CBD (or preferably CBDa), the legitimate one is distrust of the product or manufacturer. If you get it from a reputable company, neither CBD nor CBDa will get you high or trigger a positive workplace or sport drug test. However, those risks increase when the products aren’t independently tested because it’s impossible for you as a consumer to know if the product actually contains what it says on the label. That’s another reason I trust products from Planetarie and why CTS has a partnership with the company. Their products are third-party tested, a certificate of authenticity is available for every batch, and they document the entire “chain of custody” from farm to product.

Altogether, the strategies above have allowed me to have a productive and enjoyable summer riding my bike, hiking, and hanging out with the people closest to me. That said, I am really looking forward to January and the prospect of pain-free cycling and hiking once I complete the post-surgery rehab. Unfortunately, during knee surgery the surgeon can’t make my femur an inch longer to correct the leg length I lost back in 1986. I asked, but he said that’s only an option during a hip replacement, which I (thankfully) don’t need.