When it comes to the crunch
Keith Robertson, fly-half for the Hong Kong Rugby Football Union, has a swollen right knee that is full of fluid. 'Can you see it?' he asks, poking it with his forefinger and making a putty-like indentation appear. 'It's pretty much a mess.'
Before, he used to kneel, sit on his ankles and stretch his quadriceps before a game. Now, he says, doing that is too painful. Past injuries and osteoarthritis, diagnosed in December, are responsible for the 24-year-old's knee problems. But so far it has not stopped him from playing fast and furiously on the pitch.
Osteoarthritis, also known as degenerative joint disease, is the most prevalent form of arthritis worldwide, affecting more than 135 million people. By comparison, rheumatoid arthritis is the second most common arthritic condition, affecting 20 million.
Osteoarthritis is a progressive disorder of the joints. It is indicated by a gradual wearing down of cartilage. It inflicts severe pain and stiffness in joints, typically in the knee or hip. The pain often hinders everyday functions. There may be a rubbing, grating or crackling sound when the joint is moved, and the pain is often worse after exercise.
The cause of osteoarthritis is not known, although it is mainly related to ageing. It typically occurs during middle age. But, as Robertson has shown, it can also affect young people. In fact, experts say they are seeing more patients with signs of the disease at a younger age.
Janice Morton - director of physiotherapy at Asia Medical Specialists, an orthopaedic and sports medicine practice - says signs can start to show up in people in their 20s and 30s. 'Osteoarthritis doesn't favour any age and can be present in individuals as young as 20 or as old as 80,' Morton says. Anyone who spends a great deal of time on their feet, works a desk job, plays a high-impact sport or carries heavy machinery is at risk. This is due to factors such as poor posture, inappropriate footwear, inadequate sports training, sports injuries, obesity and genetics.
More than half of all sports injuries involving ligament reconstruction lead to a diagnosis for osteoarthritis.
Many believe that the rising incidence in younger populations is due to better technology and knowledge in the therapeutic category, including wider use of MRI for earlier detection. Others credit an increase in leisure time, and the attraction of contact sports and activities such as downhill skiing.
'Weekend warriors are often a problem because they may not be conditioned for high impact or contact sports,' says Dr Jason Brockwell, medical director of Asia Medical Specialists.
Robertson, the injured fly-half, suffered his first significant injury at the 2006 Doha Asian Games when he was 19. 'My studs got caught in the ground and I twisted around, tearing my lateral meniscus,' he says, referring to the cartilage in the outer side of the knee.
The next year, he joined the Hong Kong Rugby Sevens team and suffered a second injury, tearing the meniscus all over again. This time, the injury could not be repaired. Robertson continued on the pitch with only 30 per cent use of his meniscus, which acts as a shock absorber for the knee.
Since 2005, Robertson has muddled through pain and stiffness with anti-inflammatory medicines, buttressed by intense training and physiotherapy to strengthen muscles surrounding the joint.
But things got even worse last year, when he was hit hard from the side. Dr Daniel K.H. Yip, Robertson's orthopaedic surgeon, says it 'completely devastated' his knee. 'It was a grade-three tear to his medial collateral ligament, which provides stability. That's important for the game Keith plays,' Yip says.
In December, Yip performed surgery on Robertson's knee to clean it and assess his ability to continue playing. That's when he saw the first signs of osteoarthritis. 'It was like a patch of grass missing. There was a divot where the cartilage had disappeared,' he says. 'We need to fill that patch up, but Keith needs to give us at least six months of his time for that.'
The harsh truth is that there is no known cure for osteoarthritis. But there are a variety of treatments that may delay its progression and offer some relief from the pain.
In the early stages of treatment, the patient may be asked to stop high-impact sports, and undertake physiotherapy to strengthen muscles around the joint. This helps preserve what remaining 'shock-absorbing' cartilage is left.
Unfortunately, the human body does not regenerate cartilage, but doctors today can encourage scar cartilage or fibrous cartilage in the knee through a procedure called chondroplasty, or micro-fracture surgery, a safe, effective and minimally invasive procedure performed by arthroscopy.
'A micro-fracture will give a return of 90 per cent of Keith's previous performance, but only if he allows himself the six-month recovery time,' Yip says. It is hard to convince an active patient to do this.
'I'll probably do it some time soon,' Robertson says, 'whatever it takes to stay in the game.' For now, the fly-half can take heart in the fact that he is 'years away' from a total joint replacement, according to Yip - and that his passion will tide him through the pain.
Pain is a sign for treatment
'While many people in pain may be in the dark about osteoarthritis, ignoring pain is a big mistake. People should pay attention to symptoms which are easy to detect,' says Janice Morton, director of physiotherapy at Asia Medical Specialists. 'Sitting in a cramped class or the cinema, or walking down steep hills and feeling significant pain in a knee joint is often the first sign.'
If a kneecap has been pulled out of its groove, grinding wears down the protective cartilage, causing intense pain. This condition, known as patellofemoral syndrome, is very prevalent in Hong Kong, and is treatable if identified early enough.
Risk factors for osteoarthritis
Flat or over-pronated feet
Weak hip rotators
Engaging in high-impact or contact sport
Sports injuries involving ligament reconstruction
Obesity - it's especially hard on weight-bearing joints
Poor posture - prevalent in desk jobs
Work involving repetitive motion or heavy machinery