By Bill Roland – There are many riders who love to feel the cool autumn breeze hit their face while they are on their bikes whether it is around the neighborhood or on a 60-mile venture with dozens of friends in a peloton. Unfortunately, there are quite a few men and women who have been extremely active throughout their lives and suddenly face tremendous pain in one or both of their knees which may bring a halt to enjoying one of their favorite hobbies. Eventually they go to their orthopedic surgeon, explain the situation and ask the Doctor, “Will I ever be able to ride again?”
Each patient has a unique set of circumstances concerning the patella and the surrounding bone, tissues, cartilage and tendons but in nearly every case after a thorough exam by an orthopedic surgeon, they are informed, “knee replacement surgery will give you the opportunity to return to riding.” The major causes of debilitating pain include meniscus tears, cartilage defects and ligament tears. In general the surgery consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow motion of the knee. In most cases, there is a great deal of pain, sacrifice, and attention to therapy necessary to achieve full recovery.
An Experienced Athlete/Surgeon Shares His Views
Eric Heiden M.D. was a five-time gold medal winner in speed skating at the 1980 Winter Olympic Games in Lake Placid, NY. Six-years later he was a member of the 7-11 team in the 1986 Tour de France. Following that he attended Stanford Medical School, earned his M.D. in 1991 and currently he is an orthopedic surgeon who specializes in sports medicine with emphasis on knee and shoulder surgery. He and his wife, Dr. Karen Heiden, have offices in Salt Lake City and Park City. As an orthopedic surgeon, he finds that his experiences in skating and cycling help him form a unique connection with his patients, many of whom are injured athletes. Recently, Dr. Heiden was kind enough to give Cycling West an exclusive interview and discuss openly the issues of knee replacement surgery and whether patients can continue to enjoy riding the bicycle after surgery.
When asked whether X-rays or MRI (magnetic resonance imaging) determined the primary factors if knee replacement surgery is necessary, Dr. Heiden explained the value of each. “In almost all cases,” he said, “X-rays are more important than MRI because X-rays give us a better indication of how much articular cartilage is left. MRI’s provide incidental information but the X-rays, standing views, give us a good estimate of the situation regarding articular cartilage and that is important.”
In addition to articular cartilage, he also addressed the importance of the pain tolerance the patient is feeling in his or her knee, “Actually, it is a combination of subjective and clinical findings to see if the patient will benefit with knee surgery. A big determining factor is the patient’s expectations along with what we see in the X-rays. If an athletic patient tells us that he wants to run marathons or ski the bumps, it is the physician’s role to temper their expectations. These devices are wonderful but there are limitations so we must know how active the patient plans to be in the future.”
Assuming the doctor and the patient have decided the surgery is a “go”, Dr. Heiden said there is one important factor before the patient is rolled into the operating room. “I think it is important,” he explained, “that the patient tries to prepare himself/herself by getting in as good a cardio-vascular condition as possible. It is important for rehab to go into the procedure as fit as possible.”
Many patients go into the surgery and have heard that post surgery exercises are important but many are not quite sure what they should do. Dr. Heiden wasted no time in articulating the importance of post surgery exercises. “In general,” he commented, “the patient has to be very dedicated to the post operative outcome. Obviously, it is highly important to have the right procedure planned, but 90 percent of a good outcome is due to the rehabilitation and physical therapy. They must spend time every day working with the knee. On my part, it is important that I give them a good idea before surgery of what they are getting themselves into. I also tell my patients that the progression is slow, but with dedication and commitment they will have a good outcome.”
In most cases, the patient tries to ease off pain medication, withstand the swelling and pain, and begin light stretching. Within a week, most are walking with a cane and gradually putting weight on the leg that was operated upon. Dr. Heiden expressed his thoughts about the preferred exercises. “The very best exercise is riding a bicycle or a stationary bike following surgery,” he advised. “When it comes to knee rehabilitation, there is nothing better. For recovery of soft tissues, bicycles are a great rehab device. Other excellent exercises are swimming and a rowing machine, but first by a long shot is the bicycle or the stationary bike.”
Dr. Heiden was asked about how soon a patient should get back into these physical therapy workout sessions following surgery. “In general,” he suggested, “the first six weeks it is important to work on range of motion rather than strength and conditioning. By that I mean pedaling at a slow rpm and a very light resistance. At this stage, heavy resistance is out of the question. There are goals that you set and time periods. To meet that goal, it is important to get that knee to bend and move as freely as possible. Following the first six weeks, it’s time to get back to more of an rpm that is consistent with your regular riding but I would recommend adding light resistance. After three months, the patient reaches the point where he or she should be able to get back to riding and working out at a pace they like and will enable them to get back into shape again. After six months, riders should be pretty darn close to complete knee recovery.”
As the interview came to a close, Dr. Heiden was asked if there was anything else he would like to add. “This procedure is very successful,” he said, “and to be successful you have to make sure you are dedicated and committed to that perioperative period following surgery.” Now that sounds like good advice from a highly successful orthopedic surgeon who happens to have five gold medals and a resume that includes riding in the Tour de France.
She Was Determined to Ride in the 2016 Pelotonia
In order to provide the readers with more information, I talked with two patients who have had this surgery. This reporter recently moved to Salt Lake City from Columbus, OH where I was an active rider. Many bicycle enthusiasts in the Western states may not be aware but for the last eight years there has been an extremely popular and noteworthy event home-based in Columbus called The Pelotonia. Each year on or about the first weekend in August, thousands of bicycle riders participate in a ride that was founded in 2009 with the objective to fund life saving cancer research. Each rider who participates in the 100-mile ride on Saturday and the 80-mile return to Columbus on Sunday is responsible to accumulate $2,500 in donations from friends, relatives, business associates or anyone willing to donate toward the cause to cure cancer. One hundred percent of the funds raised go directly to cancer research at the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital. Since the advent of the Pelotonia ride in 2008, the cyclists have raised over $121 million; this year there were 7,749 riders participating and over $15 million has been donated.
One avid cyclist in particular is a cancer survivor named Cathi Nelson of Galena, OH. She had been a participant in all seven of the Pelotonia rides since its inception but in the fall of 2015 the pain in her right knee became unbearable. After extensive testing (X-rays and Synvisc-One injections) under the guidance of Kurt Unverferth, M.D., Cathi remembers the advice she was given. “Dr. Unverferth,” she recalled, “said that because it was bone on bone, and the knee joint was deteriorating, the only solution was to have a complete knee replacement. He said it would continue to deteriorate and the pain would not subside. At that time, a good night’s sleep was hard to achieve.”
It was decided to have the procedure done on Friday, January 29, 2016. Cathi found the post surgery to be tolerable at first but within a few days, it was extremely painful. “I really started to doubt whether I would ever get back on my bike. The swelling was intense, the rotation of my knee was nil and it was locked straight. I wondered if I would regain my mobility in time to begin training for the Pelotonia.”
As spring approached, Cathi realized she might not be able to ride the 180 miles on August 6-7. “During March and April, I started pushing myself, doing twice the amount of physical therapy recommended, in the hopes of getting back on the bike as soon as I possibly could. I did not have full rotation of the pedals until the end of May. I didn’t start going up measurable hills until July.”
By early July, Cathi had progressed to the point where she knew that she would be ready for the challenge of riding 180 miles in two days. “I just spent a lot of hours in the saddle spinning it out,” she remembered. “As a matter of fact, the more I rode the bike, the better my knee felt. It wasn’t as tight or restricted as it had been previously. At that point, I knew I could grind it out.”
Following the two-day event in early August, Cathi reflected about undergoing knee replacement surgery in January and in just over six months she had successfully accomplished her goal. “I am really looking ahead to having a year under my belt, although I still have some restrictions with my knee. My doctor reassures me it takes close to one full year to acquire total healing. I look forward to have the opportunity to participate in many activities without pain. Cycling is at the top of the list.”
An Aggressive Athlete Survived Many Operations
Another patient of knee replacement surgery is Dave Richards, resident of Salt Lake City. Dave is a 64-year-old life long cyclist, a successful architect, and a professional photographer who has provided many excellent photographs that have appeared on the pages of Cycling Utah / Cycling West. Dave’s background is filled with a plethora of sports and physical activities that indicate he has truly demanded a lot out of his body, especially his knees.
“Basically I have participated in many sports,” he explained, “and I was never one to go lightly. I have had eight surgical procedures on my knees, the first one when I was 13 years old. My first knee replacement, the left one, was in 2001 when I was 49. At that time, knee replacement surgery was more common with people much older. I imagine most of the patients were in their retirement years. The hardest part was finding a surgeon who understood that I had a need to be very active. At that time, there were different knee designs. Some were based on adhesive cement while others were based on a combination of adhesion and a mechanical fit. Stryker Corporation out of Kalamazoo, MI designed both of my prosthesis. They have holes in them for bone embedment and the bone grows into it. The other designs, for the senior folks, would rely on adhesive material whereas the mechanical fit was supplemented with adhesive material.”
Dave’s right knee was replaced in 2005 but fortunately the procedure was not as complicated due to the fact there was far less damage than the left knee. “I raced in college,” Dave said, “and I still ride recreationally. After long, hard rides the knees might be sore and occasionally I ice them, but generally not too much pain from riding. Skiing is a lot harder on both of my knees. Sometimes it’s the right or the left; it varies a bit.”
Regarding advice to someone with pain in one or both of their knees, Dave said that he was big on getting information to find out what is going on. Rather than ignore it, he always wanted to know why he was feeling a certain pain in either knee. “I’ve been a knee patient since I was 13,” he chuckled, “believe me, it wasn’t by choice. For cyclists, if they are having pain, it’s worth going to a doctor to find out why. I would also recommend a proper bike fit. I think that is critical. A good bike fit will help your knees, whereas a bad bike fit will damage them. For example, if the saddle is too low and the rider has a tendency to push big gears, that would put a lot of strain on the patella at the top of the pedal stroke. Proper bike fit and proper technique are important.”
Although he has always been active in many sports, Dave identifies the one that has helped him recover from his operations. “As far as recovering from knee surgery,” he said, “I totally agree with Dr. Eric Heiden. Cycling is the best exercise most patients can do following knee surgery. I heard a story that Tiger Woods had knee surgery in Park City years ago and his surgeon, Dr. Tom Rosenberg, recommended that he should spend extensive time riding a stationary bike. Months following surgery, there were rumors out that a golf writer asked Tiger how things were going with the rehab exercises on his knee. Tiger responded with a great one-liner, ‘I feel as though I’m going to win the Tour de France!’ “
Dave continued to point out the advantages of cycling as a major exercise following a knee replacement surgery. “The great thing about cycling,” he explained, “is that it is a low impact exercise. The patient is not pounding the knee, and it continually flexes the joint, which circulates the synovial fluid around, which lubricates the joint. My advice to most fellow patients would be to prepare a list of questions for the doctor prior to the appointment. That enables the doctor to better understand the patient’s expectations and concerns.”
There have been many alterations regarding the construction of the knee prosthesis and how it assists different patients. “Replacement surgery has changed quite a bit since I had mine in 2001 and 2005,” Dave recalled. “More patients demand to remain active and the newer designs of the implants have allowed a bigger range of motion than the older ones. Getting your range of motion back is probably the most important part of a successful rehab. Everybody struggles with that and the faster you are at getting your range of motion back, the happier you will be overall.”
If you are a candidate for knee replacement surgery or you know someone who is having severe pain, please know there is a solution to your problem and your days of riding your bike in that cool, fresh air are far from over.
Bill Roland is an avid bicycle rider who recently transferred from Columbus, Ohio to Salt Lake City. In the 1980’s he was the editor of The Golf Traveler Magazine published here in Salt Lake City. Two years ago he published a biography entitled, “Champagne Tony Lema:Triumph to Tragedy.”