The patello-femoral joint :
Any Trochlear Groove - friendly exercises? - - Posted by kevster (kevster), 27 October 2004
Hi all,
I'm looking for trochlear groove friendly cardio exercises. I'm a 36 year old male, had a LR 5 years ago, discovered much arthritis in the trochlear groove. Current OS said no procedure to fix that area yet, goal should be to "hold the line" on reducing damage and wait for future medical advances. Recently completed 5 months of VMO strengthening PT with minimal results.
My Dilema is that I have mild knee problems if I don't exercise, but major problems if I do. I just want to exercise without causing more damage.
In last 12 months, I can't do any Cardio activity without knee swelling and pain later in day. I've tried cycling upright and recumbant, elliptical, stair climber, nordic track, ergometer, rollerblading, even swimming. Bascially any exercise that requires my patella to track in it's groove will cause problems with as little as 5 minutes of activity.
So far, walking is least offensive, but it doesn't seem like exercise to me.
I know my problems are mild compared to so many I read about here. But if anyone is in a similar situation as me, and has ideas, I'd love to hear about them.
Thanks
-Kevin
Posted by mike_bknee (mike_bknee), 27 October 2004
Here is a website with good exercises;
http://www.ohsu.edu/orthopaedics/dc_knee.htm
Being in the same boat as you, I can only do the straight leg lifts and hamstring stretchs. I am also like you in that walking is about the only other thing I can do. However, I think walking really helps, and I wouldn't shortchange that exercise. I have had lateral releases in both knees in April, and am going to see an OS tomorrow to see if he can recommend an Avon Patella-femoral replacement. Since they took Vioxx off the market, I have been in agony.
Mike
MT
Posted by Leta_MT (Leta_MT), 27 October 2004
Hey Kevin!
It sounds like you've tried it all. I hear ya and I know how hard it is to find something that gives you the cardio you need. My groove had the "Mother of All Bone Spurs" straight up the middle. My LR made the pain worse, resulting in the discovery of the spur. I had an Avon PFR (as Mike already knows! 
) along with a TTT at the same time to correct the maltracking issues. Since then, I have been doing the aquatherapy thing and it has been good. It is MUCH different than swimming and there may be a PT group close to you that has such sessions in the pool. One of the mistakes commonly made with swimming rehab is that people flutter kick from the knee. NOT a good idea for kneegeeks! You should always kick from the hip and not the knee.
Before my injury, I was in excellent shape. I had a resting heart rate of 43 beats/minute. For the last two years, I have been trying to find the knee-friendly alternatives to kickboxing, aerobics and running. So far, the best thing I've found has been in the pool. Try to find a gym or PT group that offers aquatherapy and I really think you will be surprised at how great it can work!
Good luck and IM me if you have more questions. I jump around the board and may miss a question posted to this thread.
Leta
Posted by kevster (kevster), 29 October 2004
Thanks Mike and Leta for your thoughts. Mike, that link of exercises almost mirrors my most recent PT efforts with some tweaks and modifications. Unfortunately as I did see progress with the knee area strengthening, it did not change my proprensity for swelling with activity one bit.
Leta, great idea with the aquatics. Doesn't sound very convenient for a lunch hour work out, but I can't be pickey anymore.
This AVonPF replacement procedure sounds intriging, don't know why I've never read of it before. I'm not a surgery fan after my failed LR but I will follow those here with the PF replacement with great interest.
-Kevin
Posted by hmaxwell (Heather M.), 29 October 2004
Kevin,
I have kissing lesions--deep, focal lesions on the back of my patella that match lesions in my trochlear groove. I've also got bone on bone contact due to complications of my lateral release three years ago. I really can't do *anything* that requires moving the knee, as it causes swelling and sharp pain & aching afterwards. The kind of throbbing that keeps you up all night, despite the anti-inflams and painkillers.
One thing that really, really makes a difference is Celebrex. I took it for a long time, but was still having some pain, so I stopped--figured it wasn't doing any good. About three days after I stopped, my knee started aching more and more. Aching at rest, waking me up, making it impossible to sit with my legs bent. So after 10 days of increasing pain, to the point that I was limping again, my OS said to try the Celebrex again. I started taking it, and three to four days later, my pain levels started to recede again. At that time, I was actually relatively pain free much of the day after I had the Celebrex in my system for a week or so. Oh, those were the days.
So anyway, beyond Celebrex what helped me was patellar taping. I'm not sure if it's something that would help trochlear lesions, but I have to say that I find it difficult to believe you ONLY have lesions in the trochlear groove--I mean, something had to make the areas of damaged cartilage, right? Chances are it was your kneecap! Maybe the cartilage on the back of your kneecap is in better shape, but if you can get the patella tracking correctly again, maybe it would unload the trochlear groove? Just an idea.
Following on that principle, SYNVISC and/or an open patellar realignment (TTT like a Fulkerson or Maquet Procedure) might prove really helpful. It could be that your kneecap is still in a lousy position, despite the lateral release (chances are excellent that this is true, especially if you have only had an LR to realign, and if you have pain so bad that it inhibits developing your VMO). Was taping part of your intensive PT program? How about biofeedback, to be sure that your quads are both strong and balanced? Another trick I learned was to use a portable TENS/E-stim unit that strongly contracted my quads DURING the exercises that I did to target my VMO. Using this method, I was able to do stepdowns and even mini-squats, because my patella was forcibly held in the correct position by the e-stim contraction. Even after 2 years of constant therapy, I hadn't had that done before, so it was a real eye-opener. Just shows how helpful a creative and knee-knowledgable PT can be!
Hopefully this isn't all just repetitious stuff for you, but if you've been a knee patient for five years chances are it's old hat. If you have tried all of the above, and have tried 'living with it' (I hate that expression), then it might be time to talk to your doctor about a PFJR (patello-femoral joint replacement, or resurfacing of the back of the patella and the trochlear groove). Unfortunately, you have to get the tracking and mechanics fixed before doing the PFJR, or it will likely fail. Sometimes surgeons do the PFJR in conjunction with a TTT. On the other hand, if you just have a TTT that might resolve all of your problems....So that's something to think about. Get a really good doctor who specializes in PFS and put yourself in his/her hands.
Where do you live? Do you really trust your surgeon? How many second opinions have you sought? I'm on my seventh surgeon... I live to complicate people's lives, because #7 told me very nicely that he can't do much more for me, though he'd be very happy to try. He was really nice about it, but it was a very startling realization for me that my knee was that bad!
Hope you get some relief soon. I finally had to go on a pain management program. It has helped me do the 'trial of life,' but at this point my knee is unliveable. So within a few months I'll be looking for some answers. I'm also following the PFJR patients with great interest.
Heather
Posted by Leta_MT (Leta_MT), 30 October 2004
I am sure Heather has been here, but Kev, you may find it interesting: www.avonpatella.com (Heck, Heather probably WROTE the text!)
There are also a few more PFR types out there. I was really interested in the patient-matched prosthetics, but in the end, I opted for what my OS was comfortable with. (I practically held a gun to his head and made him do the PFR! The least I could do was let him pick the parts! )
So far, the outcome for me has been good. Although I am no where near the level I was before my accident, I am worlds better than before the surgery. It would be unrealistic to expect to be where I was before my terrible dislocation, so I'm happy with being able to WALK without pain! I'm still only 5 months post-op and am getting better every day. If I keep improving, it will all be worth the long hours of PT and at-home rehab!
Good luck to you guys and here's hoping you find an answer very soon!
Leta
Posted by hmaxwell (Heather M.), 30 October 2004
Thanks for the vote of confidence, Leta, but I can assure you I didn't write it 
And I'd be happy to trade my painfully acquired knee jargon and information for the chance to hike again. May have to seriously look at the PFJR, probably in the next few years, after having my kneecap pried out of the joint by a TTT.
And Kevin, that reminds me...have you been evaluated for patella baja or infrapatellar contracture syndrome? In the contracture syndrome, your kneecap gets scarred down--literally trapped in scar tissue--which forces it down and into the knee joint. That means instant bone on bone contact, and would ensure that your trochlear lesions were constantly being irritated, ground up, and rubbed by any movement of the patella. It's unfortunately one of the more common complications of lateral release. I had this within 5 months of my LR, and numerous attempts to fix it have left me worse off than ever.
Just an idea--have you had weight-bearing x-rays done to determine the space underneath your patella? And compare the position of the patella on your surgical leg to your other one? Do you have pain and severe grinding on terminal extension--those last 30-40 degrees before your leg is perfectly straight? And if you lock your leg in the straight position and then start to bend it again, to you get more pain and grinding, a big and juicy POP, or even visual confirmation that your kneecap is jumping?
Infrapatellar contracture and/or patella baja would explain why you are having so much pain with movements that load the patella and trochlear groove, or involve moving the patella in its groove in a normal way but which causes abnormal pain and crepitus.
Heather
Posted by kevster (kevster), 31 October 2004
Heather,
Thanks for both of your informative posts. I've tried both the taping and even bought a TENS unit last PT go around. Taping just plain felt good, even left it on for a few days after each PT session, but started developing a skin allergy to the tape glue. I too used the TENS during my PT, I can't invoke the VMO during a step up/step down movement, so having it fire the VMO was supposed to help retrain the muscle. Felt good, but I didn't see my VMO grow that much or swelling propensity decrease after 5 months.
You keep mentioning lesions, are those the areas of cartlidge that were chunked out (how's that for a description?) I had pics from my LR 5 years ago and you could see all this cartlidge with big chunks gone, and then the "crabmeat" stuff that the OS "smoothed" out during the LR.
My recent OS visit took more X-rays and said the cartlidge look good because there was space between the patella and femur on both sides, so he thought tracking was ok. But no one has seen inside my knee since my LR. I'm sure it cut up more because my threshold for swelling is almost just walking down the steps vs. 5 years ago it would only happen after a 30 minute workout.
What do you do with those syndromes you describe? My strategy is to stay away from surgery as long as possible, and sad to say, I think decreasing my cardio exercises to just walking for now. I'd rather preserve my knee function as long as possible even if it means I can't be the next Lance Armstrong. sigh.
Best of luck with your recovery. I've researched the TTT, it sounds like major surgery. I'll be optimistic and follow these AVON PFR's people. It sounds like the revision surgeries are much lower than those of TKR's, that's good. Celebrex is good, I took it for awhile for a herniated disk, it helped somewhat.
-Kevin
Updated Thu Apr 29 2010
