Effect of sodium hyaluronate combined with rehabilitation training on knee joint injury caused by golf

Abstract

BACKGROUND

In high-intensity sports like golf, knee joints are prone to injury, leading to pain, limited mobility, and decreased quality of life. Traditional treatment methods typically involve rehabilitation exercises, but their effectiveness may be limited. In recent years, sodium hyaluronate has emerged as a widely used biomedical material in the treatment of joint diseases.

AIM

To explore the effect of sodium hyaluronate combined with rehabilitation training on pain degree, flexion range of motion and motor function of knee joint injured by golf.

METHODS

Eighty patients with knee joint injury caused by golf were randomly divided into control (group B) and observation group (group A). The group B was treated with rehabilitation training, and the group A was treated with sodium hyaluronate combined with rehabilitation training. The clinical efficacy, range of motion and function of knee joint, quality of life and inflammatory factors were compared.

RESULTS

The excellent and good rate of rehabilitation in the group A was raised than group B. At 6 weeks and 3 months after treatment, the range of motion of the two groups was raised than that before treatment, and that of the group A was raised than group B. After treatment, the scores of Lysholm and International Knee Documentation Committee (IKDC) in the group A were raised, and those in the group A were raised than group B. The VAS score of the two groups was reduced than that of the group B, and the SF-36 score of the group A was reduced than group B. The interleukin (IL)-1 β, IL-8 and tumor necrosis factor-α in the two groups were reduced, and those in the group A were reduced than group B.

CONCLUSION

Sodium hyaluronate combined with rehabilitation training has a good clinical effect in the treatment of patients with knee joint injury caused by golf, which relieve pain, maintain knee joint function and improve patients' life quality.

Key Words: Sodium hyaluronate, Golf sport, Knee joint injury, Pain degree, Motor function

Core Tip: This study investigates the combined application of sodium hyaluronate and rehabilitation exercises in patients with golf-related knee injuries, providing insights into treatment strategies for sports-related injuries. The findings suggest that the combination of sodium hyaluronate with rehabilitation training helps improve knee flexion range of motion and quality of life, alleviates pain, and preserves knee joint function in patients with knee injuries.

INTRODUCTION

With the improvement of living standards, more and more people exercise fitness. Golf is especially loved by middle-aged and elderly men, but the injuries of muscles and joints are common because of inappropriate ways and methods in the composition of golf. Knee joint injury is the most common, affecting daily functional activities and quality of life[1]. Studies have shown that after conservative treatment, patients with knee joint injury caused by golf still have persistent pain, accompanied by loss of function and decline in quality of life, resulting in these patients eventually having to undergo surgery. a considerable number of these patients are not eligible for surgery because of complications or refusing to accept surgery. There is still an urgent need to further study the conservative treatment of patients with knee joint injury caused by golf[2,3]. Sodium hyaluronate is a glycosaminoglycan commonly found in human synovial fluid, synovium and cartilage. There is a great deal of evidence that sodium hyaluronate can improve the clinical symptoms of patients with arthritis[4]. Injection of sodium hyaluronate can potentially protect the surface of articular cartilage and soft tissue from joint function damage. Rehabilitation training can improve the key skeletal muscle strength and knee joint function of patients with knee joint injury caused by golf. It is an important training method to promote the rehabilitation of lower limb muscle strength and motor function[5].

In practical treatment, golf-related knee injuries can involve multiple structures such as ligaments, muscles, and cartilage. Therefore, it's essential to consider and address the different injured tissues comprehensively. Additionally, each patient's injury and physical condition are unique, and the rehabilitation process may be lengthy and slow, requiring patience and perseverance from both the doctor and the patient. In some cases, the treatment outcome may not meet expectations, necessitating consideration of alternative treatment options. Therefore, patient cooperation is crucial for rehabilitation training, including completing exercises on time and following medical advice. Non-compliance or lack of adherence from patients can indeed impact treatment outcomes[6]. This study aimed to explore the effects of sodium hyaluronate combined with rehabilitation training on the pain degree, flexion range of motion and motor function of the knee joint injured by golf, to provide reference for the selection of clinical treatment.

MATERIALS AND METHODS

General information

Eighty patients with knee joint injury caused by golf in our hospital from January 2022 to January 2023 were randomly divided into control group (group B) (n = 40) and observation group (n = 40) (group A). In the group B, there were 36 males and 4 females, aged from 18 years to 50 years, with an average of (36.85 ± 6.12) years, right knee (n = 15) and left knee (n = 25). In the group A, there were 37 males and 3 females, aged 19-51 years, with an average age of (35.54 ± 6.20) years, right knee (n = 16) and left knee (n = 24). This study was approved by the Ethics Committee of our hospital, and all the subjects voluntarily participated and signed the informed consent form. Inclusion criteria: (1) Knee joint injury caused by golf was diagnosed according to clinical symptoms, signs and X-ray imaging examination[7]; (2) Knee joint injury caused by golf; (3) Patients with complete medical records; and (4) American Association of Anesthesiologists anesthesia grade I-II, can tolerate general anesthesia. Exclusion criteria: (1) Ineffective conservative treatment, patients who need surgical treatment; (2) Patients with cognitive impairment; (3) Severe heart, liver and renal insufficiency; (4) Patients with joint fracture; (5) Patients with extensive osteoarthritis of patellofemoral joint; or (6) patients with deformity of the original affected limb.

Method

Control group: Patients receive rehabilitation training, specifically including the following steps: (1) Anti-inflammatory and analgesic treatment: Patients take the recommended dose of non-steroidal anti-inflammatory drugs (such as ibuprofen) daily to reduce inflammation and pain; (2) Local physiotherapy: 2-3 times a week, including massage, hot compress and cold compress therapy, each time for 20-30 minutes, to promote blood circulation and relieve pain; (3) Brace fixation: Patients wear ankle braces (such as orthoses) to provide support and stability and reduce the movement of the injured area; (4) Routine rehabilitation exercise: Carry out rehabilitation exercise every day, including stepping exercise, kicking and pedaling, lasting for 30-45 minutes each time, so as to improve muscle strength and joint flexibility; (5) Range of motion training: Conduct range of motion training every day, including passive and active joint activities, for 15-20 minutes each time, so as to restore joint range of motion; (6) proprioception recovery: Weekly balance and coordination training, including standing on one foot and closing eyes balance training, for 20-30 minutes each time to improve proprioception and stability; and (7) Gradually resume exercise: Gradually increase the amount and intensity of exercise every week, including walking, jogging and stretching for 20-30 minutes each time, so as to gradually restore normal life and exercise level.

Observation group: The patients were treated with sodium hyaluronate combined with rehabilitation training. The rehabilitation training treatment was the same as the group B. After injecting sodium hyaluronate into the knee joint, let the patient move the knee joint properly to promote the uniform distribution of sodium hyaluronate, and sodium hyaluronate is injected once a week. The patients were treated continuously for 4 weeks.

Observation index

Rehabilitation effect[8]: Lysholm score was used to evaluate the rehabilitation effect of knee joint function in the two groups. The score range was 0-100, 65-84, 85-94 and 95-100 respectively. Excellent and good rate = (excellent + good cases)/total cases × 100%.

Range of motion of joint: The range of motion of the two groups was measured before treatment and 6 weeks and 3 months after treatment.

Knee joint function[9]: For each group, the Lysholm score was used to assess daily knee function and motor function. The higher the score, the better the knee joint function and motor function was. The IKDC scores evaluate the knee joint function, stiffness and pain of patients. A higher score indicates better knee joint function and less pain and stiffness[9].

Quality of life[10]: The degree of wound pain was evaluated by VAS. From 0 to 10, the higher the score, the more severe the pain, 0 for no pain, 10 for the most pain[10]. A quality of life scale (SF-36) was used to evaluate the quality of life of the two groups, which included eight dimensions: Physical function, physical pain, total health status, vitality, social function, emotional function, and mental health. A higher score indicates a better quality of life for the patient[11].

Inflammatory factor: Before and after treatment, the venous blood 3 mL of the two groups were collected, and the levels of interleukin (IL)-8 (brand: Sai Hongrui, item number: SEA080Si03), IL-1β (brand: Sai Hongrui, item number: SEA057Hu02) and tumor necrosis factor (TNF)-α (brand: Shanghai enzyme-linked biology, item number: Ml077385) were detected by enzyme-linked immunosorbent assay in the two groups.

Statistical analysis

SPSS20.0 was used for statistical analysis, the counting data were compared by χ² test, the grade data were compared by rank sum test or χ² test, the measurement data were expressed by mean ± SD, and the comparison was made by t-test.

RESULTS

Comparison of rehabilitation effects

The excellent and good rate of rehabilitation in the group A was raised than group B (Table 1).

Table 1 The final criteria for diagnosing suspicious lesions.

No.	Criteria for diagnosing suspicious lesions
1	The results of two or more imaging techniques were consistent
2	The diagnosis was confirmed by pathological examination after operation or puncture
3	SPECT/CT follow-up review was combined with clinical history and other laboratory tests

SPECT/CT: Single-photon emission computed tomography/computed tomography.

Comparison of joint range of motion

At 6 weeks and 3 months after treatment, the range of motion of the two groups was raised than that before treatment, and that of the was raised than that of the group B (Table 2).

Table 2 Operations procedures of enzyme-linked immunosorbent assay.

No.	Operations procedures of ELISA
1	Coating: the antigen or antibody solution to be detected was coated on the microporous plate and adsorbed on the pore wall
2	Blocking: a certain concentration of protein (such as bovine serum albumin) was added to block unadsorbed pore walls to avoid non-specific binding
3	Addition of a certain concentration of detection antibody: the detection antibody labeled with enzyme was added to the well, and the antigen or antibody has been adsorbed
4	Wash: the unbound antibody in the hole was absorbed with a buffer solution
5	Addition of substrate: substrate was added to catalyze the reaction by the enzyme to produce a measurable signal
6	Reading plate: the signal is read by the enzyme marker to calculate the concentration of antigen or antibody

ELISA: Enzyme-linked immunosorbent assay.

Comparison of knee joint function

After treatment, the Lysholm score and IKDC score in the were raised than those before treatment, and those in the group A were raised than group B (Table 3).

Table 3 Comparison of knee joint function (mean ± SD).

Group	n	IKDC score		Lysholm score
		Before	After	Before	After
A	40	48.74 ± 5.85	87.24 ± 7.29a	47.11 ± 4.85	92.28 ± 6.29a
B	40	46.53 ± 5.64	70.42 ± 6.45a	46.62 ± 5.33	72.37 ± 5.57a
t		1.720	10.929	0.430	14.988
P value		0.089	0.000	0.668	0.000

^aP < 0.001. IKDC: International Knee Documentation Committee.

Comparison of VAS and SF-36 scores

After treatment, the score of VAS in the group A was reduced than that in the group B, and the SF-36 score in the group A was raised than that in the group B (Table 4).

Table 4 VAS and SF-36 scores.

Group	n	VAS score		SF-36 score
		Before	After	Before	After
A	40	6.53 ± 1.64	1.24 ± 0.29a	41.46 ± 10.50	68.28 ± 15.29b
B	40	6.94 ± 1.05	2.26 ± 0.56a	41.82 ± 10.44	58.48 ± 15.97b
t		-1.332	-10.230	-0.154	2.803
P value		0.187	0.000	0.878	0.006

^aP < 0.001;

^bP < 0.01.

The levels of inflammatory factors

After treatment, the levels of IL-1β, IL-8 and TNF-α in the group A were reduced than the group B (Table 5).

Table 5 The levels of inflammatory factors.

Group	n	IL-1β (pg/mL)		IL-8 (ng/L)		TNF-α (μg/L)
		Before	After	Before	After	Before	After
A	40	42.56 ± 8.23	23.42 ± 4.37a	58.34 ± 8.84	37.62 ± 6.38a	22.41 ± 3.58	11.38 ± 3.14a
B	40	43.21 ± 7.25	30.37 ± 5.42a	60.14 ± 10.52	48.26 ± 8.44a	21.82 ± 4.10	15.42 ± 2.85a
t		-0.345	-6.313	-0.829	-6.360	0.686	-6.026
P value		0.709	0.000	0.410	0.000	0.495	0.000

^aP < 0.001. IL: Interleukin; TNF-α: tumor necrosis factor alpha.

DISCUSSION

In the knee joint, the lower end of the femur and the upper end of the tibia contact a plane called the tibial plateau. Once the knee joint is injured by sports, it is very easy to cause uneven force on the internal and external platform, resulting in concomitant injuries to the blood vessels, meniscus, ligaments and nerves of the knee joint, thus seriously affecting the stability and range of motion of the knee joint[11].With the economic and social development of our country, there are more and more fitness people. as a sport widely loved by the middle-aged and elderly in China, the probability of muscle and joint injury in the process of golf is getting higher and higher. Studies have shown that after conservative treatment, patients with knee joint injury caused by golf still have persistent pain, accompanied by loss of function and decline in quality of life, which eventually have to be treated by surgery. however, a considerable number of patients are not eligible for surgery because of complications or refusing to undergo surgery. therefore, there is still an urgent need to further study the conservative treatment of knee joint patients with golf injury[12]. Although there are many treatments for knee joint injury caused by golf, most of these are symptomatic treatment options, including physiotherapy and rehabilitation assistance. According to the severity of the patient's condition, surgical intervention of joint replacement may be needed[13]. Here, patients with knee joint injury caused by golf were treated with sodium hyaluronate combined with rehabilitation training to explore the effects of sodium hyaluronate combined with rehabilitation training on pain degree, flexion range of motion and motor function of knee joint injured by golf. It is found that this treatment method has a good clinical effect.

It has been found that injection of sodium hyaluronate into the knee joint injured by golf can restore the viscoelasticity of the joint by replenishing synovial fluid[14]. Sodium hyaluronate is a glycosaminoglycan commonly found in human synovial fluid, synovium and cartilage. There is a great deal of evidence that sodium hyaluronate can help patients with osteoarthritis. Injections of sodium hyaluronate can potentially protect the surface of articular cartilage and soft tissues from damage associated with joint function[15]. Therefore, when sodium hyaluronate is injected into the joints of patients with knee joint injuries caused by golf to improve the viscoelasticity, it can help restore lubrication and damping properties in the joints, a process known as exogenous viscosity supplementation[16]. In addition, intra-articular injection of sodium hyaluronate can promote the synthesis of proteoglycan and glycosaminoglycan in cartilage (including endogenous sodium hyaluronate, etc.). According to Altman and other scholars, intraarticular injection of sodium hyaluronate can reduce cartilage catabolism activity, and then reduce chondrocyte apoptosis and increase chondrocyte proliferation, thus inhibit the role of pro-inflammatory mediators and pain mediators[17]. This study showed that the excellent and good rate of rehabilitation in the group A was raised than group B. 6 weeks and 3 months after treatment, the range of motion of the two groups was raised, and that of the group A was raised than group B at the same time. After treatment, the scores of Lysholm and IKDC in the group A were raised than before treatment, and those in the group A were raised than group B. After treatment, the VAS score of the two groups was reduced, and the SF-36 score of the group A was reduced than group B, and the SF-36 score of the two groups was raised the group B. It is suggested that sodium hyaluronate combined with rehabilitation training has a good clinical effect in the treatment of patients with knee joint injury caused by golf, which is helpful to relieve pain, maintain knee joint function and improve patients' quality of life.

Increasing evidence shows that long-term chronic inflammation in the joint, especially chondrocyte inflammation, plays a significant role in joint degeneration in the recent years as cell culture technology and molecular biology technology progress[18]. Sports injury leads to knee joint inflammation, which leads to chondrocyte inflammation, inflammatory factors, abnormal mechanical effects and other factors. and then lead to the inflammatory response of chondrocytes[19]. IL-6, TNF-α, and IL-1 are the main mediators of pathophysiological changes in osteoarthritis, which are caused by pro-inflammatory factors. Synoviocytes and chondrocytes are stimulated by a variety of intra-articular pathogens, autoimmune reaction products, post-traumatic host by-products, debris, and other inducements. Aggravate the biomechanical changes of the knee joint, resulting in an aggravation of knee joint sports injuries[20]. This study showed that after treatment, the IL-1β, IL-8 and TNF-α in the two groups were reduced, and those in the group A were reduced than group B. In the treatment of patients with knee joint injury caused by golf, sodium hyaluronate combined with rehabilitation training appears to have a good clinical effect.

To sum up, sodium hyaluronate combined with rehabilitation training has a good clinical effect in the treatment of patients with knee joint injury caused by golf, which is helpful to relieve pain, maintain knee joint function and improve patients' quality of life. the treatment effect is safe and reliable.

CONCLUSION

Sodium hyaluronate combined with rehabilitation training has a good clinical effect in the treatment of patients with knee joint injury caused by golf, which relieve pain, maintain knee joint function and improve patients' life quality.