KNEE ARTHRITIS - General principles of managing Osteoarthritis of the knee :
arthritis? - - Posted by NikkiE (NikkiE), 18 September 2004
Hi All,
This is my first time here and I was wondering if someone might be able to shed some light on my knee problem.
I was a jogger for about 10 yrs, and developed chondromalacia under my kneecap quite early on. It has flared up from time to time, but never really bothered me too much except for the awful noises.
18 months ago I started getting pain on the inside of my knee and went to a physiothreapist. She thought it was related to my mistracking patella, got me doing weights to build up a wasted vastus medialis, and stretches - and I spent 18 months doing all of this - but still the pain persisted (though reduced).
Finally I got an Xray done and the report said everything was fine. My dr said I could go back to jogging if I wanted (I didnt), but wrote me a referral to a specialist just find out what was going on in there.
When i went to the specialist he pulled my leg around and it was all fine. Then, he looked at the Xray and said i had some narrowing of the joint on the medial side. I asked if that meant arthritis and he said "it could be" and has told me to get an MRI scan.
From what I have read the only possible diagnosis could be arthritis. How could the Xray report-person get it so wrong??
I always thought I might get it one day, but I am 38 yrs old - not 68! Plus the chondromalacia isn't what is causing the problem(
).
Posted by hmaxwell (Heather M.), 19 September 2004
Chondromalacia is a softening of the articular cartilage that coats the back of the kneecap and the other bones in the knee joint. If you look at a chicken drumstick, at the skinny end you see the waxy-looking shiny stuff--that is articular cartilage.
The articular cartilage keeps you from having bone on bone contact in your knee. It also provides for a frictionless glide when you move your knee.
Chondromalacia is the first step of damage to the articular cartilage--it becomes soft and mushy. Then, if it progresses, the cartilage gets cracked. If left untreated or if the patient continues to abuse the joint with impact activity or bad mechanics/mal-tracking, then the softened articular cartilage begins to hang in shreds--looks like crab meat or frayed drapery. Once you have gone through all the articular cartilage (chondral layer on top of the bone), then you start getting into damage to the bone itself--called an osteochondral lesion. This is arthritis.
If you have medial joint space narrowing, that is a sign of arthritis. This will show up on an x-ray. However, you said you had chondromalacia on the back of your kneecap--this does not show up on the x-ray. It can show on the MRI, but not always. The only way to tell for sure is to do an arthroscopy.
As for the x-ray technician getting it wrong, I'm not sure what you mean. You can have evidence of joint space narrowing and not have it be arthritis yet--you just have less articular cartilage in that spot than the other side of the joint (the lateral compartment) or compared to your other knee. This may or may not be related at all to the pain you are feeling. If the doctor ordered an MRI, it is likely he thinks that the back of your kneecap is the issue, because an MRI will hopefully show the state of the cartilage there.
If you ran for over 10 years with diagnosed chondromalacia, that could easily explain your early onset problems with knee pain and potential arthritis. I had grade IV chondromalacia at age 31. I have grade II osteochondral lesions (it only goes to grade IV!!) and am only 34. So age isn't necessarily the main factor. As my OS loves to say, it's not the years, it's the mileage.
Read up on chondromalacia, patellar-mal-tracking and faulty knee mechanics, patello-femoral syndrome (PFS), chondral lesions, etc. in the patello-femoral joint section above. Also, click on the 'general info' tab at the top of this page and go to the steps to enlightenment--step 5 is all about kneecaps and chondromalacia.
Once you're done there, read this great web page which explains what you are facing in simple language:
http://www.steadman-hawkins.com/knee_chondral/overview.asp
http://www.steadman-hawkins.com/pate/overview.asp
Likely you will require physical therapy to retrain the muscles and get them to better support the knee joint. Also, patellar taping and a knee brace may be very beneficial, especially if your damage is limited to one area. Cox-2 inhibitors like Celebrex, Vioxx, Bextra, or Mobic may make all the difference in the world to your knee. A supplement with glucosamine, chondroitin, and MSM can help slow and even reverse (they think) the rate of cartilage destruction and degeneration. More advice is on the link I posted.
If a 6-12 month period of conservative treatment doesn't work, sometimes surgery is recommended. Be very careful, as the wrong or inappropriate surgery can leave you worse off than pre-op. This happened to me, and it's something I will have to deal with until I get my knee replaced.
Hope some of this information helps. You will definitely want to post in the above sections dealing with patello-femoral joint issues, rehab, and general questions, as there are a lot more people posting up there.
Heather
Posted by NikkiE (NikkiE), 19 September 2004
Wow thanks Heather for the very informative reply.
I have been taking glucosamine for a while now, but dont really stick to one brand - I just get what's on special at the time - some have chondroitin and MSM, some dont...
With the chondromalacia, the knee specialist felt all around my kneecap and didnt find any sore spots (although the xray shows the patella to still be mistracking).
The Xray report said: "The knee joint spaces are preserved. There is no evdidence of joint effusion. There is minimal calcification projected over the tibial bones but this is not a definfite abnormality. The bones are normal in appearance".
Woohoo! I thought when I read that, and fully expected the specialist to give me a big tick in the box to go back to jogging. I dont understand how the Xray technician could give an all clear on the joint spaces - even I can see there is a difference between the outside of the knee and the inside of the knee spaces.
Posted by hmaxwell (Heather M.), 19 September 2004
Joint space is totally different from patellar arthrosis (damage or degeneration to the articular cartilage on the back of your kneecap). Unless you did a really, really specific set of rarely ordered x-rays, it's unlikely anyone would be able to tell with any precision about the state of your patellar articular cartilage. And any damage to this cartilage can cause all sorts of pain.
Also, understand that reading x-rays is more of an art than a science. It may be that the knee specialist is seeing stuff that the radiologist didn't--that's why most surgeons like to read the x-rays themselves and not rely only on the report. It could be that the radiologist who wrote the report has a higher tolerance for narrowing--i.e. he calls your joint space normal, whereas for your OS it falls within the realm of narrowed. Medicine, especially knee joint mechanics, is much more of an art than a science!
If you have mal-tracking kneecaps, chondromalacia of the patella, and narrowed medial joint space, it would probably be a good idea to hang up the running shoes, at least until you find out what's going on. I gave up running at age 26, after years of whittling down my miles, surface tolerance, and days per week. It just wasn't worth the pain. I've asked several doctors why some people can run marathons and others like me couldn't walk after running 2.5 miles on a soft treadmill or springy grass with nice running shoes and orthotics. His reply was that running was the most impact you could put on your knees short of repeatedly jumping (like basketball). Some knees can take it, but others like mine have small mechanical deviations from the norm, and these magnify any damage or stress caused by running.
The good news is that you don't have any obvious bone spurs or anything. The MRI may tell more, or it may not. I've had five of them...only one was useful in any way. It's very hard to visualize the cartilage on the back of the kneecap through anything but arthroscopic surgery.
In the meantime, I would start finding other ways to stay in shape--eliptical trainers are low impact, as is a properly fitted bike. Running in deep water with a flotation belt might be fine, along with hiking or walking on relatively smooth surfaces. Unfortunately, your body starts getting even with you for youthful indiscretions once you get past thirty. It took me a long time to understand and accept that my knees look like those of a 75 year old. It's very frustrating, and I don't know 'why me,' but I have been forced to deal with it. The 'simple' surgery that I did to help me get back to hiking and working out every day turned out making me much worse. When you start messing around with patellar tracking, things get problematic. Plus I got a genetic double whammy, in that I form obscene amounts of scar tissue in response to very little trauma. The mal-tracking and scar tissue problem combined have put me on the total knee replacement express.
Knowing what I do now, if I could do it over again I'd give up the running at age 18 and take up something lower impact.
Good luck--and be sure to see a knee specialist! PFS is not something you want a generalist OS mucking around with, because that's like having a general surgeon do heart surgery...
Heather
Posted by NikkiE (NikkiE), 19 September 2004
Dear Heather,
I have to thank you once again for the detailed reply.
I havent really done much running at all over the last 18 months but was hoping to get back to it because I have put on lots of weight since I stopped, despite gym visits several times a week. I know, its that vicious cycle - my knee would probably feel better if I could lose some weight, but I cant lose the weight cos my knee is sore.
As an ex-runner I am sure you can also appreciate the great feeling it gives you and all other cardio (eliptical, ex bike and especially pool walking) all seem so booooorrrriiinngggg in comparison. But I agree its better to err on the side of caution, so will take yours and the good dr's advice.
Thanks again.
(The guy I am seeing is an orthapedic surgeon who specialises in knees).
Posted by Jules (Jules), 27 September 2004
Hi Nikki,
We could be identical twins, regarding our knees. You sound as if you have exactly what I have.
I have chondromalaica of the patella in both knees, or osteoarthritis grade 4. My cartilidge wear and tear is in the medial side too, which is more uncommon than laterally. I too am only 38 years old, but have not been active in sport or had any accidents, so I feel more cheated that this had progressed so far so quickly.
You need to have xrays with your knees slighty at an angle, I had xrays at three different angles and this showed the true picture of my condition.
I am due to have an MRI on Friday, but what I have read it is down to the interpreter of the results to what they turn out to be, two different interpreters will come up with different results. So I' not holding my breath on that one. Even though I will be in the machine for 2 solid hours.
I have been having pain in my knees since my early 20's, I've had numerous passive treatments and 3 bi-lateral arthroscopies, with lateral releases, microcopic drilling at the back of the patella and debriding, you name its been done, to no avail.
So now I'm refered to Oswestry in Shropshire UK, to have ACI, first op 19th Oct, with both knees being scoped and medial releases done, and harvest of right knee. Then on the 9th Nov, hopefully with have the second part for the implantation of the cells.
But my advice to you is to get the proper xrays done that will diagnose this condition more accurately, and make sure you see a specialist that knows about ACI, having had the 3 bi-lateral arthroscopies, I felt definately after the second one that they were just a waste of time for me and my condition, thats just my personal view in my case, yours may be different.
Any further information, please ask.
Best regards
Jules
Posted by NikkiE (NikkiE), 18 October 2004
Hi All.
I have just gotten back from meeting with my knee dr to get the reults of my MRI.
He looked at the MRI and said that I have worn away most of my cartilidge on the weight-bearing part of the medial side of the knee - arthritis. It will probably need surgery in 5 years time. I forget what he called it, but its to make me knock kneed, so I start using the good cartilidge on the other side of the joint. Then down the track, I will require a knee replacement.
I asked him if I would benefit from any more physio, but he said probably not, but to keep doing the weights etc., to keep my weight down and put a partial inner sole on the outside of the foot on the affected leg.
No more running, no more soccer, just swimming and cycling boring boring boring boring
How does one keep their weight down when they cant do any strenuous exercise?
Incidentally, the knee cap which my physio and I thought was the main culprit, only showed a small amount of wear and tear.
Not sure if I feel angry or sad.
I guess in the future I can sit around with my mother and discuss our knee replacements together - she's 64 and only just considering getting it done.
Posted by Cora (Cora), 20 October 2004
Hi Nikkie, welcome to the board 
. I gained 15 pounds since I quit running and playing soccor. But I lost 7 pounds swimming and biking, even though it is boring I must exercise. Another thing I love is lifting weights at the gym, particularly anything for the VMO's. Be careful though, know what you can and can't handle! I love it when my legs are sore from the gym! I'm broke but joined because I also have knee arthritis and a screwed up VMO, on both legs. But one leg it hardly fires at all. I tore some of the muscle years ago skiing.
I just turned 32 and know I have arthritis because I asked for the medical records to be faxed to my office. Here I was waiting for something to change, taking a prescription and all and it didn't change. I knew something was weird. I have moderate arthritis. I wish at my age it was at least in the beginning stages.
On the bright side you know what is wrong and can help yourself now with low impact stuff, good footwear and bulding up muscle where you need it. Don't be afraid to exercise it because it is good for the arthritis if it's low impact. I think it is hard to help arthritis, but you can certaibnly improve it. Best of luck!
Posted by NikkiE (NikkiE), 21 October 2004
Hi Cora,
Thanks for your answer. Have had my little dummy spit and am now trying to work out how best to manage it.I think I will go and see my physio (despite what the knee Dr said) and show her my results and have a chat. At least she will be able to advise me what exercises will aggravate it and make sure my technique is ok.
I am also trying to watch what I eat and hopefully start to shed some weight. I tend to turn to chocolate when depressed!
All this is complicated by another little medical problem I have at the moment called Labyrinthitis. It affects the inner ear and makes you have dizzy spells and feel unbalanced. This limits my ability to exercise, and i need to go to the gym with a 'buddy'. I would certainly not feel comfortable swimming!
Updated Sat Nov 21 2009
