Nutrition - Don't ignore it!!

[mjeffrey]

Building on fsugirl's "Dont ignore it Series" . Hope it helps.

Muscle atrophy is a common problem with injuries around the knee. From the beginning I wanted to avoid this as much as possible and so adopted basic bodybuilding strategies to mitigate the effects of injury.
I’ve done weight training for about 30 years now, not for bodybuilding but just to as one part of normal fitness and over the course of the years I've done some research on the best strategies. Essentially for building muscles you need 2 things, adequate nutrition and some (progressively increasing) stimulus to the muscles. If you miss one then the results are either poor or negative.

My strategy was to try to keep exercising the muscle while keeping up a good level of nutrition, particularly protein. I figured (just a guess no real scientific evidence to back this up) that if there was adequate protein (really amino acids) floating around then the body wouldn’t feel the need to cannibalize the under-used muscles.

Exercising in the early days meant using the NMES machine I bought for the purpose. These machines are commonly called TENS machines but this is not really accurate although many, like mine do both. See http://en.wikipedia.org/wiki/Electrical_muscle_stimulation
See also the section on regulation if you are in the US.

Once I could do leg exercises I added leg extensions http://www.exrx.net/WeightExercises/Quadriceps/LVLegExtension.html
leg presses http://www.exrx.net/WeightExercises/Quadriceps/LVSeatedLegPressH.html
and leg curls http://www.exrx.net/WeightExercises/Hamstrings/LVLyingLegCurl.html
plus some calf raises.

Second the nutrition. In recent years I started using protein shakes because it just got to be too much effort to eat so much protein (and I don’t plan the main meal). I was (and still am) philosophically opposed to protein shakes (not a great fan of supplements) but they are really convenient. In fact I never make a shake, I sprinkle the powder on some muesli and stir in some skimmed milk. Choose the right brand and it is really delicious and a little bit addictive . Most people just make shakes, some use milk, some water. Personally I’d stick to milk (much nicer) if you’re not lactose intolerant.

I buy this by mail order (it is available in the UK and US):
http://www.myprotein.com/sports-nutrition/impact-whey-protein/10530943.html and seems to be well regarded. Not sure how independent these people are but for what it's worth myprotein scores well for quality and value https://labdoor.com/rankings/protein

p.s. check the ingredients, all these products typically use an artificial sweetener and artificial colourings/flavourings. I’ve found MyProtein tends to use the less controversial ones.
I tried a lot of flavours (they have sample packs) but now stick to the basics: Vanilla Strawberry, Chocolate and Unflavoured (which I use to dilute the others - they are a bit sweet for my taste). I always buy “whey concentrate”, isolate is quite a bit more expensive and a bit pointless.

How much protein do you need? Well it is not an exact science and if you want to split up your current diet into macronutrients go ahead. I did in the beginning but now I just add about 3 scoops of protein each day (remove these calories elsewhere).
Timing is moderately important for muscle building. Post exercise has been found to be an important time when muscles rebuild after the stress of the exercise so I always add some of the protein then.

The OS remarked that I have remarkably little muscle atrophy (in fact both legs atrophied to some extent). Anecdotal but I wondered if there was some scientific evidence to back this up. A quick google found this http://www.ncbi.nlm.nih.gov/pubmed/19935843 I don’t have the full article but here are the conclusions:
Based on results from acute and chronic studies in humans in a wide variety of wasting conditions, we propose that resistance exercise training combined with appropriately timed protein (likely leucine-rich) ingestion represents a highly effective means to promote muscle hypertrophy, and may represent a highly effective treatment strategy to counteract the muscle wasting tassociated with aging and chronic disease.

Also interesting a linked article on BCAAs. You can buy BCAAs as a nutritional supplement. I recently started using them pre-workout and they taste disgusting .
 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321450/

[morgana]

Well written mjeffrey, and informative.  Thanks so much for sharing!

In 2008 I did  a lot of protein, and went back to my favorite diet.  This involves a lot of fruit, with protein in the form of protein shakes, or added to yogurt or peanut butter (love peanut butter on apples or pineapple).   

Anyway, although I am not a nutritionist, or have any background in that field, I found that using a variation of a weight training diet, that I didn't end up with a huge weight gain (I actually lost some). 

Despite working out as hard as pt/dr would recommend there was still quite a bit of muscle atrophy. BUT for 12 weeks non weight bearing I think it could have been much, much worse.   Still totally stunned at my traitorous glutes, they did return to full strength.   

[charlottekatt]

...and a caution -- at some point one wants to stop eating like one is trying to take in enough calories for rapid/good bone healing.   

[mjeffrey]

Thanks for the kind words Morgana. You motivated me to do part 2 for vitamins and minerals which I've been putting off as I needed to do a bit of research, but luckily I found a great article by someone more qualified than me who has done all the hard work .

I'm a natural sceptic (science training) and the benefits of taking additional vitamins and minerals can be difficult to quantify scientifically. Human nutritional studies are notoriously unreliable, due to the large number of confounding factors it is difficult to design an effective study. And often it is the interactions between nutrients which are important. It is not uncommon to have conflicting results from studies.

My personal take on this uncertainty is that the evidence of the benefits of supplementation is reasonable and even if I'm wrong there isn't much downside if you don't go crazy on dosage. So for a little investment I'm willing to risk the time and money.

This is the article I mentioned above that did all the hard work. I thought it was great, not too technical but with references to back up the assertions. It was a lot to digest (pun intended) so I pulled out some snippets
http://www.betterbones.com/bonefracture/speedhealing.pdf

Each stage of the fracture healing process brings with it increased nutritional demands. For starters, the whole process requires a great deal of energy—which is generally supplied through the intake of calories in food. Next, healing requires the synthesis of new proteins, which is dependent upon an ample supply of amino acids derived from dietary proteins. An adequate blood supply is also mandatory for fracture healing, so anything that diminishes blood flow (such as smoking or poor circulation) slows the healing process

According to this paper there is also evidence that NSAIDs slow bone healing (aspirin, ibuprofen etc), so maybe good to avoid those in the beginning.

The same author also has a paper titled "20 key nutrients for bone health" which I found pretty interesting:
http://www.betterbones.com/bonenutrition/20keybonenutrients.pdf

Discussion on RDA's

Keep in mind that these systems and the nutrient values they represent were established to cover nutritional adequacy for most folks, not for optimizing health! The common therapeutic dose for healthy and strong bones may be higher for most, and significantly higher in “special need” cases.

Being injured makes us "special need" cases so the RDA may not be sufficient.

This is also interesting

While no scientist has yet conducted a clinical trial using all 20 key nutrients for fracture healing, several studies have found multi‐nutrient therapy to reduce complication and found fracture patients given complex multi‐nutrient supplementation containing protein, carbohydrates, amino acids, sodium, potassium, calcium, magnesium, chloride, trace minerals, and fat soluble vitamins, had only a 15% rate of complications as compared to a 70% complications rate among the non‐supplemented group

Being active, my approach has been to try to eat well but take a multivitamin/mineral supplement each day to fill in any gaps from potentially nutrient-poor food. I have tried a few brands, my current one is this: http://www.nowfoods.com/ADAM-Superior-Mens-Multiple-Vitamin-60-Tablets.htm which seems to have quality ingredients. These all-in-one tablets are OK but they miss certain things which I add separately:

• magnesium. You need too much to fit in a multi and if they include it, then it is usually magnesium oxide which is useless due to low bioavailability. I take Magnesium Citrate 250mg per day (solved my leg cramping problems on long mountain bike rides).
  
• calcium. also take a lot of space in a multi and so either there is not much or in a non-bioavailable form but I get plenty from milk so don't supplement
  
• vitamin d3. recent research indicates that the RDA is way too low (I take 10000 IU per week). Make sure you get sufficient of the co-factors which help the effectiveness and prevent the downsides. http://www.vitamindcouncil.org/about-vitamin-d
  
• omega-3. I take 2 grams a day. These are great value if you are in the UK/Europe  http://www.naturesbest.co.uk/fish-oil-1100mg-p516 but I would also consider these http://www.nowfoods.com/Ultra-Omega-3-180-Softgels.htm if you could get them for a reasonable price here.
  

As for quality I go for the low/mid range like Now Foods and Healthy Origins. Solgar is at the top end (they can seem reasonable per tablet but check the serving size!). Personally I avoid the supermarket brands (but with no real justification).
I have a friend who buys his from http://www.iherb.com/ and has them delivered to Europe, he was very happy with the service and choice.

Anyway hope there was some practical information on supplements that someone finds useful.

cheers
Mark

[Madyakker]

Thanks Mark,
All great info there, I certainly started on a multivitamin and mineral but never thought that I might need doses slightly higher than the RDA. Glad that I am off the NSAID's as well. The only thing I would add is that since 5 months in I also drink 1 or 2 glasses of tonic water a day to stop my muscles cramping as much (suggestion of my physio).

[beefrank]

Great comments and summary Mark.

On NSAIDs, at my 6-week consultation the OS told me that the swelling and redness around my knee were indicators of the body repairing itself, and were probably made worse by over exercising. He then prescribed a 6-month program of NSAIDs to control the symptoms. I deferred to his superior knowledge and experience in the rush rush rush of the consulting room, but your comment suggests that my instinct was correct that while NSAIDs might suppress the uncomfortable symptoms of the repair process they might also slow the process down.

[WonkeyDonkey]

When I had my HTO in 2011, I was told to stop taking my NSAID'S in order to help the bone healing, as they slow the bone healing down. With that I stopped and have not taken them since.

[morgana]

Not advocating taking NSAID's, but pretty sure the NSAID's can be documented from multiple angles. 

An OS friend indicated that use of NSAID's for pain could slow the healing process, but living with the pain can also slow the healing process since physical pain zaps/saps your energy pretty dramatically.  Such a fine line between discomfort and pain.


Again, Mark thanks so much for starting this thread, doing so much homework and finding the links for it.  Well done.

[beefrank]

After convincing myself that NSAIDs were not providing a benefit I stopped taking them a week ago. That turned out to be a wrong decision. Within a few days pains appeared around and under the knee, and I couldn't help starting to limp again. The symptoms were similar to those I experienced about six weeks ago. I then restarted NSAIDs supplemented by fish oil (9g/day), which is a strong anti-inflammatory. Less than 24 hours later the new pains went away, and have stayed away for the past four days!

The pharmacist also suggested that calcium and vitamin D (to improve calcium absorption) supplements might aid in improving bone strength, but then changed his mind because I probably wouldn’t need them – milk with cereal for breakfast and relatively high exposure to sunlight probably suffices. On reading about the relationship between calcium and vitamin D in the diet, it appears that high protein intake might also be associated with calcium leaching from bones, and too low associated with increased fracture risk because of reduced mass. It seems that moderate and balanced diets, and no excesses, are important to a quick recovery.

The comments of morgana are very relevant here. I am now willing to put up with slower bone healing because of the relief the NSAIDs give from the pains and discomfort around the knee. Without the pains and discomfort I feel more capable of doing the quad and VMO strengthening exercises, which are so important to an early and full recovery.

[mjeffrey]

Hi beefrank,

I wasn't suggesting avoiding NSAIDs, I took them myself in later stages even though I knew about the (possible) slower bone repair.

I was wondering if the ibuprofen was having an effect on the pain. Sometimes it works for me, sometimes not. So I stopped it for 6 hours. Bad idea. Much worse without the meds.
Also feel some internal ache as well.

And as morgana says you need to balance this against the benefits, plus the science is controversial.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259713

There is no robust clinical and/or scientific evidence to discard the use of NSAIDs in patients suffering from a fracture, but equal lack of evidence does not constitute proof of the absence of an effect.

I just wanted to let people know the issue so they can make up their own minds.
But it is interesting that I have seen a lot of people on this board are prescribed Hydrocodone in the US. Hydrocodone isn't used in Europe and I was prescribed paracetamol, neither of these are NSAIDs.
Also after 3 months I guess most of the bone repair has been done.

In this thread I wasn't suggesting people blindly follow what I do, everyone has a different diet and lifestyle. You need to understand the science and see how it applies to your situation.
When I was exercising I didn't take a multivitamin, I reasoned that my daily calorie intake was over 4000 calories and so I automatically get more nutrients, but I did need the Magnesium for cramps and the vitamin D.
I had a vitamin D test and it was quite low even though I was supplementing 5000 IU/week (but maybe the test wasn't reliable).

If you work in an office and don't see much sun like me then you probably need vitamin D (plus the other cofactors
https://www.vitamindcouncil.org/about-vitamin-d/vitamin-d-and-other-vitamins-and-minerals ).

Interestingly milk does not actually contain very much Vitamin D, except in the US where it is added as a supplement and also to orange juice! And the best sources are large fish which can have problems with heavy metal contamination.

For example, almost all of the U.S. milk supply is voluntarily fortified with 100 IU/cup

http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional
With sunshine, (fortified) milk and that much fish oil (some oils e.g. cod liver oil have a lot of vitamin D) you may actually be getting too much . 

For the protein bone mass density thing. There are contradictory studies but most support a positive correlation between protein intake and BMD. For long term BMD resistance exercise is important as well. Here is a fairly readable (quite opinionated ) summary http://anthonycolpo.com/do-high-protein-intakes-weaken-bones/

But I was really suggesting protein to retain muscle mass. It seemed to work for me, after 7 months my injured leg in only one cm smaller in circumference smaller than the other (it was always the weaker leg as well).
 
100% in agreement on not being extreme, just because something is good at one intake doesn't mean it is good with more.

[beefrank]

Hi Mark,

Many thanks for the information, explanations, and useful references.

My decision to stop the NSAID was because I had incorrectly concluded it was not aiding my recovery. The NSAID I was prescribed is Movalis 15 (also marketed as Mobic and Meloxicam) taken at 15 mg/day, 5 days per week. According to the information sheet for the drug, it has several possible adverse side-effects, which I understood was the reason the OS recommended taking a two day break from it every week. When I read that in addition it also might slow down the patella repair process, I decided to stop taking the drug. At my 3 month x-ray (I’m now about 5 ½ months post operation), my patella fracture was as visible (to me) as at it was at 6 weeks when the NSAID was first prescribed, so I felt that anything that hinders the repair process should be avoided. However, I'm now back on it after learning the hard way.

You make a good point on taking too much vitamin D. I started taking the fish oil on recommendation from my pharmacist because of its claimed anti-inflammatory properties. I hadn’t thought of it as providing an additional source of vitamin D. In my view, anything to control the pain and swelling was worth trying. I have always led a very active outdoor life (sports and now farming), and slow recovery from my patella fracture has been a major source of frustration. I now suspect that the anti-inflammatory benefits of fish oil are only minor in comparison with the NSAID.

On sizes, the thigh on my injured leg is also about one cm smaller in circumference than the good leg, but around the knee the circumference is about one cm bigger. Although not measured, I suspect the latter increases after exercise – it certainly feels like it.

In previous lives, I was a scientist and engineer. In my current life, I developed an insatiable appetite for information on what makes things (physical and biological) work. Your posts have triggered reading on a topic that I hadn’t considered before, and for that I’m very grateful.

Thanks,

Frank

[mjeffrey]

Interesting article on supplementing with protein for older patients undergoing TKA:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809795/

After 2 weeks patients receiving protein had 3% muscle atrophy versus 14% for the placebo group. At six weeks it was 6% versus 18%.

TKA patients receiving placebo exhibited greater quadriceps muscle atrophy, with a –14.3 ± 3.6% change from baseline to 2 weeks after surgery compared with –3.4 ± 3.1% for the EAA group and a –18.4 ± 2.3% change from baseline to 6 weeks after surgery for placebo versus –6.2 ± 2.2% for the EAA group

EAA = Essential Amino Acids (essentially protein, composition given in text)
Participants took the supplement after exercise.

Conclusion. EAA treatment attenuated muscle atrophy and accelerated the return of functional mobility in older adults following TKA.

I'd be interested to see a similar study for younger open knee surgery patients.

[beefrank]

Great find and interesting article. Anybody like me probably had to look up TKA, which means 'total knee arthroplasty', or in plain English 'total knee replacement'.

If only I had been told about the article, or at least its conclusions, 6 months ago I would have paid more attention to protein intake, but not increased it too much because of the reported higher risk of calcium leaching from bones.

Six months on, my quad strength and bulk continues to improve, but going down steep steps when the injured knee has to flex to 90 degrees or more while supporting my weight, the tendons where the quads join the top of knee still feel quite painful. I suspect that this is caused more by weak quads/tendons rather than tendon damage resulting from my accident. Do other fractured patella victims experience this type of pain? If so, has their physiotherapist or OS told them what its cause is?

[mjeffrey]

Hi Frank

Sorry about the TLAs (three letter acronyms) :-) I guess I've been thinking knees for way too long...
For your questions

Do other fractured patella victims experience this type of pain? If so, has their physiotherapist or OS told them what its cause is?

Yes I had exactly this! I could not extend my leg without pain: 5 kg ankle weight was the maximum I could (just barely) lift. And no, neither the PT nor the OS gave me any idea what could be causing it. Now I can lift 25 kg on the leg extension machine with the injured leg and 40kg with the good leg.
 
What changed? I had the hardware removed. See here:

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=64604.msg619159#msg619159

You might want to have a look here about how they put in a tension band. Seems to me that it would be surprising if it did not cause pain.

https://www2.aofoundation.org/wps/portal/!ut/p/a1/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAwCTYEKIvEocDQnTr8BDuBoQEi_l35Uek5-EtCp4c76UaoGhWmRbuUgUx3zkowt0vWjilLTUotSi_Qy8otL9CPKy8uN9BLz0_JL81LAftTLL0rXL8gNjajyLHYEAPQf-2c!/dl5/d5/L2dJQSEvUUt3QS80SmlFL1o2XzJPMDBHSVMwS09PVDEwQVNFMUdWRjAwMFE1/?showPage=redfix&bone=Knee&segment=Patella&classification=34-C1.1/2&treatment=&method=ORIF%20-%20Open%20reduction%20internal%20fixation&implantstype=Tension%20band%20wiring&approach=&redfix_url=1285238823367

I chose to get the hardware out of there as soon as possible and I certainly don't regret it.

cheers,
Mark

[beefrank]

The article was another great find Mark, and again one I wished I'd seen six months ago.

Just seeing diagrams of how a fractured patella is repaired provides a better understanding of why we experience long-term discomfort around the knee. I'd often wondered how it was possible to prevent irritation of flexing tendons by the fixed wire used in the repair. The answer is that it is probably impossible to isolate the two, and the wire will irritate tendons and be a source of pain and swelling as long as the hardware remains. If pain and swelling does not continue to reduce, but plateaus, then it seems entirely reasonable to conclude that a source of discomfort around the knee could be the wire and that your OS should be consulted about its removal. I now feel better informed about what is happening in the repair process and would not hesitate to consult my OS about hardware removal if I detected that improvement had stopped.

The advice from my OS (similar to advice given to many other fellow sufferers) was to not contemplate hardware removal unless symptoms dictated otherwise, because of the increased risk of a fracture along the old fracture line. However, I'd read somewhere that the body's response to physical stresses applied to weak structures (could this include fracture lines in patella?) is to strengthen them. It seems to me then that a combination of controlled physical exercise that stresses the patella, combined with appropriate nutrition, could strengthen the repair and hence reduce any re-fracture risk when hardware is removed. Does this sound reasonable?

Also, this website and others, including many of your posts and references, provide extremely helpful snippets of knowledge and experiences. Consolidated information in the form of, say, a "patella road-map to recovery" that  summarizes the types of surgical procedures and possible side-effects, suggested mobility and strengthening exercises at various stages during the recovery process, nutrition and reasons why some foods and supplements are important, stages in the repair process and what to expect, etc, I am sure would be invaluable for fellow sufferers and allay much of their angst and frustration. Have you seen anything like this?

I write again Mark, another great find, and I'm sure that it is something many fellow sufferers will find useful.

Cheers,

Frank