KNEEtalk

The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: highroller on June 28, 2010, 07:29:17 AM

Title: Sore knees, no diagnosis
Post by: highroller on June 28, 2010, 07:29:17 AM
Hi all,

I have a pair of very sore and irritated knees but no diagnosis despite a number of medical consultations and an arthroscopy. I am hoping that you may be able to offer some insights as I am at the point where my daily activities are significantly compromised.

A quick history:

May 2009: both knees frequently sore after weight training, consulted sports doctor, x-ray normal, prescribed anti-inflammatories and activity modification within comfort zone

June-Oct 2009: continued weight training with lower loads, still experiencing soreness but only severe for 1-3 days after training, took 2 courses of anti-inflammatory tablets without any noticeable effect

Nov 2009: knees deteriorated very rapidly over a period of 1-2 weeks, barely able to walk at worst, stopped gym training, MRI on left knee does not reveal any structural issues but possible fat pad impingement, rest and anti-inflammatories advised

Jan 2010: no improvement, consulted orthopaedic surgeon, examination revealed flexibility issues, suggested 2-3 months physio and stretching, continued to avoid weight training

Mar 2010: no improvement despite working on flexibility, scheduled arthroscopy on left knee (slightly worse than right) for early April

Apr 2010: arthroscopy on left knee, found to be in pristine condition, fat pad trimmed slightly as a precaution in case of impingement though no evidence of this within the joint,†surgeon has no idea what's wrong, states that fat pad trim 'works sometimes', raises flexibility / mobility again as a possible cause

Jun 2010: both knees were slightly better a couple of weeks post-op presumably due to the rest required to recover from the op and my walking range gradually improved over a few weeks (always some discomfort present though) but after a few minor setbacks, possibly due to overdoing it, a major setback sees me back to square one and limited to very short distance walking

Current status:

I will be talking to the surgeon again shortly but in the meantime I'd be grateful if anyone could offer any explanation as to what could be wrong with my knees and/or what I should be doing to treat the condition. There is a fairly constant ache with a sense that there is no cushioning/shock absorption when I walk. The discomfort gradually increases as I walk and there are occasional sharp pains. I can understand how I irritated my knees in the first place through high-intensity weight training but I have barely trained for 8 months and the condition of my knees is on a deteriorating trend.


Thanks for your time, it's much appreciated!
Title: Re: Sore knees, no diagnosis
Post by: Hopesmom on July 01, 2010, 10:37:30 PM
I as well experienced knee pain after some increased weight training.  This flared up what was a somewhat dormant fat pad impingement.  After trying every conservative method known for a 9-month period, I finally had the fat pad removed.  It had turned completely into scar tissue and was enlarged and impinging between the bones.  It was excruciatingly painful and had to come out. 

I have been trying to read up and customize my own postop protocol for preventing more scar tissue.  So that means rehab is gentle and slow.  My surgery was in January, so 5 months out.  Last week I tried doing some light knee extensions on the extension bench.  Bad idea.  I could hear popping under the kneecap, and also the fat pad in my relatively good leg became irritated.  So I do now believe that it was all the heavy leg extension work last year that started it up.  It's unfortunate as I love to do this weight-lifting exercise, but I no longer can.

I have corresponded with someone who also had a partial fat pad excision (mine was removed almost in entirety), and he said it took him a good year before his knee felt "normal" again. 

My knee is doing some really weird things.  Some days when I walk it feels like the patella tendon is "suctioning" in at the bottom of my kneecap.  It just is a different thing every day and I never know what it's going to be till I get out of bed and start walking.  The good thing is it changes so I can at least that the next day will be a better one.

These knees are such complicated joints.  It seems to me that you just have to be very gentle with rehab and try to be extremely patient and let time heal.  In the meantime, elevate and ice, ice, ice. 
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 02, 2010, 09:14:56 AM
Thanks for your reply. I can certainly empathise with your condition and experiences, especially the day to day variation in the way the joint feels and susceptibility to setbacks.

My MRI did reveal some fat pad irritation but nothing severe. The surgeon didn't see any evidence of the fat pad being problematic on inspection during the arthroscope but he trimmed off a section anyway as a precaution.

I've decided to try complete bedrest, or as close to that as I can manage, for a couple of weeks initially to see if that helps to calm down the irritation. That decision was partly inspired by a very good ebook on patellofemoral pain that I purchased from saveyourself.ca which draws on some work by Dr. Scott Dye (see The Pathophysiology of Patellofemoral Pain, 2005). The main idea is that the joint tissues can lose their 'homeostasis' from various forms of mechanical stress - this reduces the stress levels that they can withstand until balance is restored. The challenge then is to gradually expand your 'envelope of function' back to pre-injury levels while staying within this slowly expanding comfort zone. I'm thinking total rest initially followed by the sort of rehab protocols I've seen described in Doug Kelsey's excellent blog (http://sportscenteraustin.blogs.com/the_view/knee/).

I'm seeing a colleague of the surgeon that performed my arthoscopy next week to get his thoughts but the above is the best I can come up with from my own research. My surgeon didn't offer much hope at the post-op consultation - basically said that anterior knee pain is poorly understood and he has no idea what's wrong with me.

Hopefully some others can chime in if they had experience of knee pain with no clear structural cause...
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 05, 2010, 07:35:36 PM
Wow. I was searching on Google for information about the site saveyourself.ca, and your description of the nature of your pain has to be about the closest to mine that I've found. Here is how it started for me:

I never had any significant pain in my knees at any point in my life. Then, in September of last year, I sprained my ankle while running. I still do not know why it happened, but perhaps to compensate so that I didn't injure my foot further, my groin muscles tightened up (though at this point I didn't know this). I probably should have went to the doctor at this point, but for the next few months I slogged through it, and every time I tried to exercise for any significant period of time, this terrible pain would start to shoot through my knee. For at least the next week, I would have to limp around, and my knee felt inflamed. But after this, my knee felt perfectly fine again, and it wouldn't bother me unless I tried to exercise. Around November, not knowing what the problem was, I decided to wait a long while before trying to walk again, hoping that it would cleared up by then.

Around early February, I decided to try to exercise. Unfortunately, nothing changed and my knee was inflamed again. At this point I made an appointment to the doctor, and he diagnosed me with Patellofemoral Pain Syndrome. I tried doing the rehab exercises he gave me, and wearing a knee brace, and for a couple of weeks I was walking every day without a problem. I thought maybe I was cured. As it turned out, I just wasn't doing anything strenuous enough, and I was again in pain.

But this time, something changed. After limping for a couple of weeks, my knee wasn't getting better. I started getting more sharp pains well after the initial time of injury, and this had never happening before. Soon, it was getting much worse. I decided to go on crutches. Honestly, I had no idea what was wrong with me, and I ended up being on crutches for 11 days before seeing the doctor again. He acted like I was crazy for using the crutches, and told me to get off. I followed his advice, and very rapidly my knee got better. I didn't feel any more sharp pains. At this point, I purchased a book called Pain Free by Pete Egoscue, and tried doing the knee exercises in them. From his descriptions, I realized that my leg was rotating with every step and that this was putting unnatural rotational pressure on the knee, and so the misalignment was fixed. By mid-May, I felt perfect again. I wish this was the end of the story.

At this point, after walking without incident for a few days, I decided to run. Well, I guess the tissue was still sensitive, because it started hurting rather quickly. Interestingly, the pain was less severe than it ever was before, presumably as a result of my leg being in better alignment. But because I thought it was less sensitive to damage, I didn't lay off of it enough. I didn't try to run again, but after a few days, I did try to walk for a long period of time, and this was a huge mistake. It has since gotten progressively worse, and I am at the point now where I can't even walk for more than a few minutes without feeling sharp pains. The only days I didn't feel any such pain was when I came off of a few days on crutches. But I must have still been overdoing it, as I starting getting pains again the next day. So here I am, at rock bottom and I don't know where to go next.

I haven't had an arthroscope done, but it is reassuring that I may not have any underlying damage. Honest, your description of your pain almost perfectly matches mine. There is a feeling of "emptiness", like the padding is not there. There is constantly a feeling of inflammation, sometimes dull pains as well, and frequent sharp pains. I have noticed that more inflammation tends to follow the sharp pains, so I think recovery is mainly a function of avoid these sorts of pains. But I wonder: How is this accomplished, if I can hardly walk any distance at all without feeling this pain? In my case, you might say, go on crutches again, and when you get off, be EXTREMELY conservative. The only problem is, a couple of days ago, the OTHER knee started hurting from the strange contortions I had to put my body through on crutches. So now, I can't use crutches any longer.

The original reason I came to this thread was for information about saveyourself.ca. So you think that the information is useful? I wasn't sure, although the site does look professional, and the fellow who runs it seems like he knows what he is talking about. Maybe I'll give it a shot.

If you have any helpful tips as to what extent I have to reduce activity, I appreciate it. Honestly, I just can't imagine being completely bedridden though. But it may come to that. Thanks.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 06, 2010, 07:58:06 AM
Thanks for your post.

Your symptoms do indeed sound very similar to mine. It's very frustrating not having a diagnosis on which to base a treatment plan - so far it's been trial and error, with plenty of error, including in my case an athroscopy that may not have been necessary although I understood that at the time.

Regarding saveryourself.ca, in my opinion he's very much the real deal. He distills a huge volume of scientific research and practical experience into a set of very readable tutorials on various conditions. I bought the full set and I'm very impressed with what I've read so far. They're not just conventional advice regurgitated - there's† solid critical analysis and lateral thinking throughout which I found very refreshing after wading my way through countless websites promoting the same mainstream ideas many of which are well established but highly questionable e.g. strengthen the VMO muscle, etc. He's also comfortable critiquing practices from his own professional domain of remedial massage therapy where warranted.

I also just read an interesting book called Explain Pain that describes the neurological basis of pain and how pain can exist and persist independent of underlying physical problems. Kind of led me to a similar conclusion regarding trying to restore function incrementally but from a different angle.

Your point about how to attempt rehab protocols from a base of very limited function resonates strongly with me. That's basically the situation I've found myself in of late and why I've decided to try maximal rest for 1-4 weeks before slowly resuming activities again and when I do start progressively increasing the load on my knees it will be much more gradual than before. You should check out that blog my Doug Kelsey that I mentioned above - the posts go back a few years but it's well worth your while working through all the knee-related ones. Some good ideas in there. There's an emphasis on determining your comfort zone and operating well within that using very high repetition exercises that recondition your tissues over time as you slowly add resistance. The timescales are generally quite long though - of the order of many months for a full recovery though every case is different.

Finding competent doctors and allied health practitioners that can help with elusive conditions such as these is very difficult in my experience. I'm willing to scour the earth for the right folks if I don't make any progress in the next 2-3 months.

Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 06, 2010, 02:36:32 PM
I think this theory of "homeostasis disruption" as a result of mechanical stress makes perfect sense from the standpoint of evolutionary biology. Think about it. If you are putting stress on your joints that could potentially cause erosion of the soft tissues over time, it would be adaptive for your body to give a signal of pain so that you would back off that activity. If you continue to perform the same activities, the pain threshold changes to increase the warning signal. Unfortunately, like many things in life, a mechanism that is usually adaptive can in some circumstances become maladaptive. I think that is the case we find ourselves in here. Certainly in your case, where you are certain that there is no underlying damage to the articular cartilage, I think this explanation is the only sensible one.

Since I have already been in this downward spiral, and almost fully recovered from it (albeit it was far less severe last time), I may be able to give some helpful pointers. I want to emphasize that the "occasional sharp pains" that you mentioned that you are feeling when you walk is a sign that you are not making progress. I'm sure you notice that the aching and inflammation is increasing, sometimes hours after feeling the sharp pains. There are probably mornings, though, that you wake up and you are feeling a lot better. Then you start walking, you feel the sharp pains, and finally, you are back in the same situation again. Such is the endless cycle that patellofemoral pain syndrome can be.

The first time that I stopped using crutches, a couple of months ago, I noticed that even though it was quite uncomfortable to walk, I no longer got ANY sharp pains while walking. I was fortunate that I felt progressively better every day. I can report that, after getting off crutches more recently, with the far worse PFPS, I didn't get sharp pains the first day after walking. This includes one period of three days on crutches, and one for nine days. However, I was eager to be able to live my life in more of a state of normalcy, and so I was probably overdoing it. I was standing while taking a shower, I was preparing food, I was walking needlessly at times. I probably walked 5 times more than what I really needed to. I regret this now, because I can no longer use crutches.

I do think, though, that less activity is never a bad thing with this disorder. "Walking through it" is not really an option. However, to fully recover, you will need some activity. The question is, how do you judge the appropriate level of activity at any given time? I'm going to try a very low level of activity for the next few days. If I continue to get those blessed "sharp pains", though, I think that I'm going to have to go to non-weight bearing status for a few days. I just can't imagine crawling around like a creature of the bowels of the earth, a troglodyte, for any period of time, but given that I don't have access to a wheel chair, and that there may be no other feasible path to recovery, I'll have no choice but to consider it. I just can't imagine this dragging on for months to come. But I don't want to short-circuit the recovery, since it will only be a longer period of time before I feel "normal" again.

I only want to emphasize, again, that you will feel pain along the whole path of recovery. A lot of pain. But it's the sharp pain that you want to avoid. It feels like someone is taking a sharp implement and scraping the underside of your knee cap when you walk. It doesn't occur with every step, sometimes you only feel it a few times a day. This is what you have to avoid. This only occurs when walking, not lying down. If you feel a pain that has a little sharpness to it, but is mostly dull, then that is not what we are talking about. Dull pain is to be expected, and you will feel a lot of it before you fully recover. But if you are feeling any of the sharp pain, you doing something wrong, and it's time to change course.

I will mention one more thing: If you do go non-weight bearing for any length of time, your muscles will atrophy, the calf in particular. Of course, you can easily regain the strength by doing calf raises, but this is easier said than done when your knee is in such a bad state. Your quads will also lose some strength, and it will be much harder to retrain them, since you can't do squats. So if it is possible to recovery without going non-weight bearing, this is the better path. But as a last resort, non-weight bearing may help. Just make sure that you are ultra-conservative when you start walking again. You don't want to be in the same rut again, but with weaker muscles.

I think above all, if you do recover to the point of full normalcy, where you no longer have any pain, remember that you are likely still not at 100%. There are days when I've said to myself, "what if?". I was almost there, and I threw it all away. If you make what you think is a full recovery, but you start to feel ANY of the patellofemoral pain symptoms again, IMMEDIATELY stop what you are doing and rest. Even though I fixed the issue with the tightness in my groin muscles, if the tissues are at all sensitive, there is the possibility of a downward spiral. If I only knew.

Hopefully this is helpful to you.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 07, 2010, 06:29:30 AM
Thanks a lot for your detailed post - it's very much in line with the conclusions I have reached from personal experience of sabotaging my own recovery process on a number of occasions as well as consistent with the best advice I have read on the subject.

It's such a delicate balancing act trying to progressively nourish the joints and condition the soft tissues with movement while avoiding aggravating matters further. Looking back, even though my attempts at incremental resistance were minimally intensive compared to the demands of the workouts I used to perform, I can see now with hindsight that I was pushing the envelope too far too fast.

I hear you regarding the sharp pains. Almost certainly an indication of overdoing things as well as being very unpleasant in their own right - they have the power to change my mood dramatically in an instant - not so much because of the pain itself but more so as a stark reminder of the protracted reality and stubborn resilience of the condition.

I also managed a period of a few weeks at one point where I gradually extended my walking range up to a few km's without experiencing any sharp pains. The dull ache and sense of joint grinding was always there throughout though. I never at any point felt that I could break into a light jog without seriously compromising my knees.

I spent last week resting and confined to my apartment in the manner of the cave-dwelling creature that you mentioned :-)  This week more of the same but doing a very light (much less than bodyweight resistance) leg press type movement lying on an exercise ball for 10 mins a few times a day.  Next week I may try some light stationary bike work and try and limit walking as much as possible as that is still very problematic for me.

Anyway, thx again for the input, it's much appreciated. I'll keep this thread updated with my own progress (or lack thereof) in case others can benefit, would be great if you could do the same.


Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 07, 2010, 03:11:23 PM
I'll certainly post an update if I feel that I'm making any progress.

Isn't troglodyte perfectly apt, though? I don't care which definition you are using, be it the caveman, the hermit, the chimpanzee, or the Dungeons and Dragons monster, they all seem to apply. You just rely a lot more on your hands with this condition. Here's hoping that we can quit knuckle dragging and get back to the bipedal locomotion that should be our birthright.

I'm going to try integrating those Egoscue stretches that I mentioned into my daily routine. I did notice, when this condition was much less severe, that on days when I did the stretches in the morning, I was much less likely to get sharp pains. Unfortunately, I didn't realize the extent that I would have to limit my activity. The stretches helped, I'm pretty sure, but alone, they weren't enough. I'm just not sure that it will matter at this point, though. But I think it's worth a try. If it seems to help at all, I'll report back.

Hang in there. There is light at the end of our deep, dark, depressing troglodyte cave. (Or is the light at the beginning? Just make sure you're facing the right way!)
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 08, 2010, 03:15:39 AM
Indeed, the troglodyte is an apt symbol of our plight. It's a form of evolution in reverse as we regress from unassisted bipedal perambulation on the open savanas to stooped and faltering navigation of our rehabilitation caverns.

Regarding stretching, I spent quite a bit of time earlier in the year working on my flexibility/mobility with traditional stretches, yoga routines, foam rolling, joint mobility† exercises, etc. I made some modest improvements in my range of motion but it didn't make any appreciable difference to my knees. More recently, I read a few articles that suggested a tight rectus femoris muscle can often be a factor in knee pain - I tried some of the deep stretches recommended but only ended up aggravating my knees presumably from the compressive forces on the kneecap in the stretched position. I'm undecided on whether and how to resume flexibility/mobility work at the moment but I'll check out the Egoscue approach that you mentioned.

Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 08, 2010, 04:55:52 PM
I decided to purchase that E-book from saveyourself.ca, and I have to say, everything which I have surmised from personal experience was just reaffirmed in 35,000 glorious words. Let's sum it up in just a few:

1. Get rest. A lot of rest. If anything has ever irritated your knee at all, don't do it anymore. In fact, do even less than that as the maximum loading capacity of your knee is now diminished.

2. Slowly, and progressively, perhaps over a period of months, build up that capability of the tissues in the knee to withstand ever greater impacts over ever greater periods of time. If you have any setbacks, you must scale down your activity dramatically or risk losing all of the progress you have made.

3. This is my favorite part. There is essentially nothing else you can do about it. Either follow 1. and 2. with utter precision, while praying to whatever deity or deities you happen to subscribe to (or just hoping the laws of physics will provide an opening for your irritated nerve fibers to calm down), or be crippled for the rest of your life. Wow, you have to love modern medicine.

At least I know beyond any doubt what I have to do now. If anyone with PFPS stumbles upon this thread, that summary is about as good as any. At least you know you're going to be having a thrilling summer '10 (or winter '10 if you're an Aussie or Argentinian).

On another note, I changed 2 things yesterday. I did that Egoscue stretch, and started using a cane. I don't know which helped, but I was able to sleep for the first time in a while without icing before bed. It could just be a coincidence, or it could be that one or both of those things helped. I think I am walking towards the light, but this cave has many passageways and sometimes the light you see is just a crack in the ceiling, a thin shaft of light that ultimately leads nowhere.

Hopefully this will help somebody.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 09, 2010, 04:44:24 AM
Glad to hear you found the ebook useful. I was so relieved to find a plausible model to work with after sifting through conventional wisdom endlessly rehashed in other resources.

Unfortunately, the dreaded sharp pains paid me an unexpected visit yesterday. A rather excruciating encounter at that. I fear that my experimentation with light repetitive movements this week has backfired. I'm not sure I can go much lower on the intensity scale - I would be able to sustain the exercise ball leg press type movement almost indefinitely for 1000s of repetitions without stopping but only performed 5-10mins 2 or 3 times a day. I find myself once again weighing the relative merits of a trip to the bathroom to relieve my bladder against the discomfort of a 20 metre walk and the potential for further aggravation.

Thinking of starting to use some form of assistance to unload my knees a bit when shuffling around the apartment. A cane of some sort might be the way to go - I'd be interested to hear more of how that works out for you.

You mentioned icing in an earlier post. I have been doing that 2 or 3 times a day for 30mins at a time but I can't say whether it's of any use. Interestingly, the saveyourself.ca guy has written about this recently - he's pretty sceptical of the ability of icing to penetrate deeply and influence inflammation within the joint but thinks it might possibly provide some benefit via neurological disruption / change in stimulus to the area. He also mentioned that heat may be ever so slightly more effective than icing - I might try that as well.

Other than post-op, I've never experienced any clear signs of inflammation such as swelling, heat, redness, etc. in the knee area which further reinforces the credibility of the tissue homeostasis model to me.

Also thinking of going metaphysical and trying meditation and visualisation techniques. Not sure whether imagining myself gamboling gleefully through the meadows will make the return to reality more depressing but it might help with the neurological dimension of injury perception and the pain response.

Anyway, looks like it's back to as fully supine an existence as I can manage for the coming days...
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 09, 2010, 03:56:15 PM
The E-book was definitely useful. Can't say that I was overly enthusiastic about the message, though. But I won't shoot the messenger. My only regret is that I didn't purchase it sooner, as it might have saved me from months of suffering.

From reading your earlier posts, it wasn't entirely clear that it was that severe in your case. I'm sorry to hear that. But we are in the same boat. I feel that I have to deliberate over every move I make. There is a virtual Congress or Parliament in my brain. The liberal party is saying, "Move or you will die!" The conservative party is saying, "Don't move or you will wish you were dead!" How can you balance the body's essential need for stimulation against the PF pain's essential need for rest? I've been in the most exquisite pain over the last few weeks. And I'm not even talking about my knees. Literally, my foot, hips, back, neck, and shoulder have all been terribly antagonized since I've been immobilized. I know all of this pain would almost immediately subside if I could just walk around normally. There is a certain sway to your body when you are properly ambulatory. This is how your joints stay healthy. Standing and walking are the natural anatomical positions of the human body. When you sit or lie like a lump on a chair/sofa/bed all day, your body just falls apart.

I definitely ice, especially when my knee is bothering me enough that I can't concentrate on anything else, or I feel that I won't be able to sleep. I actually can't take anti-inflammatory medication, as it seems that is has caused a stomach ulcer. So this is the only prospect for any relief in my case. Do I suppose that the icing will actually help it recover, though? I can't say that there is no benefit, but I'm doubtful that anything other than a slow, progressive reintroduction to weight bearing loads will have much benefit. For pain relief, though, icing is the best thing around.

It's interesting that you mention that you haven't experienced inflammation. I haven't experienced swelling, heat, or redness either. You really can't tell from any external sign that anything is wrong. But some of the pain I've experienced is most accurately described as inflammation I think. It sort of felt like a burning sensation. What is strange is that the pain I've felt recently, I am at a loss to categorize at all. It doesn't seem like an ache, a pain, or inflammation. I guess the best description would be a constant dull ache, with a strong feeling of pressure at the location of the ache. If I bend my knee, the sensation gets stronger. Stranger still, the intensity of the feeling seems to variate inexplicably throughout the day. I really can't explain why it feels decent one moment, and not the next. At times, I barely even notice it, as if my knee is almost healthy again. At other times, it's as if my knee is the central focus and purpose of my life. Forget thinking about anything else.

Most steps I take now I feel a dull ache in my knee. I don't think this is necessarily a bad sign, though. I haven't really felt sharp pains over the last couple of days. Sometimes it is difficult to distinguish between the different genera of pain. It feels much the same every day, so at least for now, I don't know if I am making progress. If only there was some clear signal that it was ready for more activity.

I would recommend a cane, as it seems to target precisely the problem at hand. Because it reduces the load on the knee, it should allow you to walk for a longer period of time without pain. But I think you should only use it when you don't think there is any other path to rehab. And it occurs to me that if you overload your knee while using the cane, it could actually cause more problems. Think of it this way. You are now bearing less than 100% body weight. Let's just say 70%. Now, even with the cane, you still overstimulate the tissue. What do you suppose you'll be able to do after that? If you can't even handle 70%, how will you ever handle 100% again? If you're going to use the cane, it's because you've exhausted all other possibilities. Make sure every step you take is slow and deliberate, so as not to put undue stress on the joint. Remember, the moment of contact with the ground is the point of greatest load. You don't want to exceed 100% body weight if you can help it. And try not to bend the knee much with each step. Remember, the load increases proportionate with the angle of the leg.

If this approach fails, then as I've pointed out before, you've been demoted to slithering like a worm. There are definitely adverse consequences to non-weight bearing, but as I've said, in my experience your knee will be able to handle a greater load when you start walking again. Still, when the condition has degenerated to this extent, that is certainly not a cure. If you do elect to try this approach, I would suggest no more than 1 or 2 days the first time. Any more than that, and there will be a noticeable degradation of muscular strength. Perhaps try the cane first.

I honestly feel like I might be making some progress here. But each day is tenuous, and I'm afraid that when I take the next step, and try to increase my activity level, I'll tumble to the bottom of the cave again. Sometimes this condition just seems so hopeless. The most important thing for rehab, I think, is just to accept your station in life right now. Don't have a timeline in your head when you have to be "normal" again. Yes, we are going to miss the entire summer. Summer 2010 is forfeit. Perhaps more than that. This might be depressing, but it is a necessary precondition to fully recover. If you think you need to get back to something by a certain date, you are going to make mistakes. That's what I did. In mid-May, I was so exciting to finally feel "normal" again. I thought all my problems were resolved. And I especially gave my self a pat on the back for achieving it at just the right moment, right around the time when I most wanted to be active. That was just about the biggest mistake of my life. Psychologically, I would have been better off if I hadn't cared about the change of seasons. If I'd only said, "You know, wouldn't it be grand to be walking/running right about now? But I know I need at least another few weeks to be sure I'm all right. So I'll pay close attention to the signals my knee is giving me, and basing it on that, and that alone, irrespective of the weather outside, I'll get back to activity." If I had done that, I might be cured right now. I'll never know.

About the Pete Egoscue book, Pain Free, it is important to realize that once you fall into the PFP trap/hole/cave, it becomes a sui generis disorder, one which is not amenable to easy intervention. I know now that the Egoscue method is not a panacea. But, based on my experience with it, I still believe it has some merit. I'll delineate a few of its virtues here:

1. Our favorite joint, the knees. When I got off the crutches in early May, my knee was incredibly sore still. Fortunately, it was ready for recovery and I didn't experience any setbacks. About a week after starting to walk again, I got delivery in the mail of the book. I immediately tried to put it into action. There are two separate sets of exercises, one for internal rotation of the leg, and one for external rotation. I wasn't sure which was relevant to me, but I first tried the internal rotation. This includes exercises for glute strengthening, hip flexor strengthening, and a stretch (which requires a lot of time!). Honestly, the first time I finished the exercises, I felt a lot better. The ache in my knee seemed to quite rapidly subside as I was walking. Within perhaps 2 or 3 days, I was actually starting to run/sprint around the house. It was almost a miracle. Then, all of the sudden, I got this excruciating pain in the usual spot. I couldn't believe that something that seemed to help so much, didn't actually fix my problem. So I went back to the book again. I decided to give the method every chance to work. So the next day I tried doing the external rotation exercises. This includes groin muscle strengthening exercises, and another stretch that takes a really long time. After the stretch, I starting trying to walk around again. Again, almost miraculous results. Every other time I ever had that sort of pain after walking, I usually had to limp for about 2 weeks. Just two days later, it was as if nothing had happened. This of course, was because the cause of the pain in my case was that my leg was abducting with every step I was taking. By loosening groin muscles, I was finally walking in alignment again. Unfortunately, as is now clear, even though I solved muscle tightness issue, I still had PFPS. And that is something that is not easy to conquer. I can't blame Pete Egoscue, though. His approach, which is contrary to conventional wisdom, definitely helped me in a way that the doctor's physical therapy exercises did not. Usually, knee problems are attributed to foot pronation issues, knee tracking misalignment, quad/VMO weakness, or hamstring tightness. Egoscue says this is bunk. He claims that knee problems usually originate because of either tightness or weakness in the hip flexors or groin muscles. Based on my experience, it seems that he is correct. Again, this is another one of those things that would have been a lot more beneficial to me if I knew it sooner!

2. I also tried doing the exercises for the feet. I had never had foot pain before, but as a result of my body falling out of proper alignment because of inactivity and use of crutches, I did have some persistent pain in my feet wouldn't subside. After doing the exercises, which in this case only took about 20 minutes total, the results were amazing. It felt like I was using my whole foot, rather than just the outside edge. I guess I was always underpronating and didn't realize it. the foot pain quickly subsided During that short window of time when I was able to walk, I also noticed that I was no longer getting shin splint pain, which had always plagued me when I tried to walk fast for any period of time. Again, it definitely worked.

3. I was also about to try the exercises for the lower back, upper back, and neck before I started having knee trouble again. I had neck pain for a long time, usually triggered when I craned my neck to the side for any length of time. Honestly, after a few times of doing the exercises, this was gone. I had lower back pain and sciatica on and off over the years, and since the start of 2010, I had persistent mild sciatica which wouldn't resolve. Again, after a few times of doing the exercises, for the first time in months, my back was feeling normal. As for upper back pain, that wasn't usually a problem, but if I tried to sit with good posture for any length of time, I would have pain. After doing the exercises the first time, I noticed my shoulders became naturally less rounded, and it was easier to sit up straight in the chair. It wasn't perfect, and I unfortunately wasn't able to continue doing them as a result of my knee flaring up again.

Despite the fact that it can't cure PFPS, I would definitely recommend Pain Free to anyone. Just realize that it isn't a panacea. If I'm able to recover from this, I'll probably do all of the knee exercises in the book for about two weeks, just to make sure I'm in alignment. But I'll also continue to be careful, knowing that PFP does not ride easily into the sunset.

That was a pretty long post. But if it benefits someone else, it was worth the time.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 10, 2010, 10:23:16 AM
I've actually been taking a course of anti-inflammatories recently - I had one repeat left on a prescription from some time ago so I thought I'd give them a shot again but can't say I've noticed any difference. I was aware of the risk of stomach and intestinal complications and wary of oral NSAIDs but I've never noticed any discomfort so I do take them for short periods occasionally when injury dictates. I've also been taking fish oil and a powdered joint formula containing glucosamine, condroitin and MSM on the offchance that they are of some benefit.

I'm very conscious of the risk of leg muscle atrophy and deconditioning but as you mentioned it's difficult to counteract that when your envelope of function is so constrained. I'm trying now to at least perform some of the movements that were recommended post-surgery such as leg slides, leg raises, etc while lying on my back. Anything to keep the joint from seizing up and the surrounding soft tissues from losing their strength and balance. There's also a cartilage issue - the Doug Kelsey blog cites research suggesting that articular cartilage needs motion to condition its cellular matrix - without the right mechanical pressure the cells are not stimulated to maintain their bonds and the tissue softens and frays. This is the basis for his arthiritis rehab protocols whereby the right level of progressive load can improve the integrity of existing cartilage even if it can't encourage new cartilage development.

I hear you regarding accepting the situation and releasing attachments to activities, timelines, etc. I was actually planning some extended travel but that is obviously indefinitely on hold now. Fully appreciating and respecting the delicate nature of the recovery process and the fragility of progress is also so vital. I fully expect to have further setbacks but they should be much less severe and shorter lived with a more vigilant and conservative approach to managing my activities.

Regarding the relationship between joint pain and myofascial issues, they are so intertwined that it's difficult to identify linear causality. For example, is the joint sore because the muscle is tight or is the muscle tight because the joint hurts? With the interplay and feedback loops it's probably always a bit of both.

I can empathise with your smorgasbord of aches and pains throughout the body - I have quite a few of my own, including what might also be a fairly mild case of sciatica emanating from a tweak of the glute/hamstring area a couple of years ago. I latched onto the concept of trigger points and various self-treatment massage techniques a while back but haven't had great success ironing out the knots so far. The saveyourself.ca ebook on that subject disabused me of getting my hopes up for a quick cure on that front as well! I do believe the trigger point concept provides a crediblr model of he problem to work with though. I've also tried a number of joint mobility routines (e.g. IntuFlow, z-health, etc) which I believe have a lot of merit for general health but as you indicate for Egoscue not a panacea. I will check out Egoscue - looks worthy of investigation with your provisos well noted.

Anyway, thanks for the ongoing contributions, hopefully over time we will chronicle our full recoveries and help others overcome this frustrating and poorly understood affliction.

Anyone else that wishes to join the discussion, please do, would be great to get some more opinions and experiences.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 10, 2010, 04:56:56 PM
I'll certainly keep you posted on any progress, or if I should face such misfortune, any setbacks that occur along the bumpy road to recovery. I don't know that I'll be posting every day as I have been, because as you know, there are sometimes excruciatingly long stretches of undifferentiated aches and pains, where progress is minimal, hope falters, and you question whether you might be crippled for life. But I'd like to chronicle here any significant changes or progress, including after I make a "full" recovery, and any lingering issues such as going up and down stairs, and whether I'll ever be able to return to my previous level of activity. Prior to last September, I never had the slightest problem with my knees. I could do single legged squats, walk up and down stairs all day long, and run up and down hills without any joint difficulties. Sure, my muscles ached sometimes. But my knees were fine. My most solemn hope is that I'll be able to return to full normalcy someday. But, life being as it is, such a prospect will be uncertain for a long time to come. Whatever the outcome, I'll record it here so that others might be able to avoid some of the pitfalls that I've unfortunately succumbed to.

I hope you'll do the same. Indeed, anyone else with any input would be appreciated if you're currently going through the same struggle. If anyone has any questions feel free to ask and I'll certainly be willing to relate my experiences.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 11, 2010, 02:11:17 AM
I'll also be posting less frequently but I'll aim to update with any significant developments or useful information that I encounter in my research such as the following article which includes contributions from Dr. Scott Dye, the masochistic scientist that prodded his own knee tissues without anaesthetic to advance the understanding of knee pain and proponent of the tissue homeostasis theory.

http://www.runnersworld.com/article/0,7120,s6-241-285--11553-1-1X2X3X4-5,00.html

I have an appointment with my OS in 2 weeks. I'll be better prepared with a barrage of questions this time round but not sure he's going to be of much use in resolving the problem at this stage given that it does not appear to be an operable condition. I'm interested in getting a bone scan though - does sound like a useful diagnostic tool for PFPS.

You mentioned that you've never experienced knee pain in the past. I have had very mild knee pain on and off for years stemming from my early experiences with weight training back in my late teens / early 20s (pushing 40 now) when I was obsessed with the weight on the bar rather than the effectiveness of the training protocol. My training in recent years has been much more sensible and well-rounded - lighter weights but much more intense, metabolically demanding, multiplanar and varied employing loaded and bodyweight movements (such as the 1-legged squats you mentioned), etc. My knees were much better with this approach up until last year. Still, despite the more evolved approach, my knees were likely under just as much stress even if the program allowed for much more balanced muscular development and better conditioning of the energy systems. If only I had backed off at the initial signs of trouble. It's funny how your perspective changes with knowledge and experience - the notion of a month off at that stage was incomprehensible whereas now it's just a logical choice.†
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 13, 2010, 03:35:01 PM
I've had a major setback. I haven't been doing anything differently over the past few days, but my knee is still getting worse. I've even been getting help with virtually all everyday tasks. I'm only walking to the bathroom and back, perhaps transferring my position a few times during the day, and then going to sleep. It is about as minimal a level of walking as you can get. As I mentioned, I'm even using a cane. But still, I can't walk at all without triggering the pain/inflammatory response. I'm at rock bottom here and I don't know what to do next. Literally, this morning I crawled out of bed, used a stool to prop myself up to the toilet and do my business, then crawled down the stairs with the stool, crawled over to the computer, and pulled myself up here. And here I am now. How did I know it would come to this?

I don't know if this is going to work at all. I don't know how long I should try it for, and if it fails, I don't know what I should do next. I know from past experience, as I mentioned, that a period of non-weight bearing seems to increase the tolerance level of the joint. But to what extent? This seems to be about as severe as this can get. I'm really starting to think now, what if all else fails? Do I need a knee replacement? I certainly can't go on like this forever.

My birthday is next month. I'll be turning 26. A year ago I'd never even heard of PFPS, and thought the only way that something like this could ever happen would the passage of a lot of years (maybe when I'm 75), a catastrophic accident where my knee is shattered, or something really horrific like MS. This wasn't on the radar screen. I knew young people didn't get osteoarthritis, so that wasn't an issue. But then it happened. And here I am.

Yesterday, my sister came over to visit. She is a nurse, and I was explaining to her the situation that I'm in, and the path to recovery. She kept saying, "there has to be some treatment, or something else you can do." I just kept explaining that there isn't anything. I think everyone around me feels as helpless as I do. I used to walk all the time with my sister. I guess you could say that we were "walking partners". It was just really hard to explain to her that we might never do that again. Indeed, that I might never walk again at all. I'm sorry that I sound so melancholy here, but I'm truly at a loss. What do you do if any amount of walking is too much? What is the path to recovery? If, as Paul Ingraham writes, this path involves not "biting your cheek", then it seems like I'm going to have one very sore cheek for too long a time to contemplate. I've tried to chew, and I just can't anymore.

So that is the story now. Maybe I'll try to walk again tomorrow, I don't know. I know you've mentioned that it's been up and down for you as well. At one point you said you were able to walk a few kilometers. Were you ever at a low point like this prior to doing that? I'm just trying to keep my sanity here, but the prospects now are truly frightening to me. I feel alright as long as I have hope, but that was seriously deflated yesterday. I'll post when I start walking again, and I hope to have better news. But you just never know. If this doesn't work, then it seems like the end of the road for me. Like the poor souls in Plato's Allegory of the Cave, condemned to stare at crude shadows of a real human existence until the end of time, the real form being denied to me forever. I suppose in their case, they never knew otherwise. But when you know what you are denied, it is a far greater torment.

Maybe the Buddha is right. Maybe there is no abiding essence to anything, no "real form" which is being denied to me, just an endless round of sense impressions which arise and then fall away. Just an endless round of suffering, of stress. The arrow which has pierced me, is not in my knee but in my mind.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 14, 2010, 04:02:43 PM
Hello,

I was attempting to do some research this morning into PFPS and I came across a sports medicine site which mentions the "tissue homeostasis" theory. Here is the link: http://www.clinicalsportsmedicine.com/chapters/24b.htm

I noted that they actually gave this condition a name, peripatellar synovitis. I googled this condition, and what do you know? A link came up to a medical journal article written by our good friend, Dr. Scott Dye. In it he outlines the theory which has been expounded upon here over the last couple of weeks. But more interestingly, he describes a surgical procedure called a synovectomy that can actually remove the swollen and inflamed synovial tissues. I don't like the idea of surgery if it is unnecessary, but it may be coming to that. It seems utterly absurd to have a knee replacement if this far more conservative procedure could give me the results I'm looking for.

My question is this: Given that Dr. Dye's theory is on the cutting edge, how can I find a surgeon who would be familiar with this procedure, and willing to perform it on me if all else fails and it is in fact medically indicated? I don't want to waste my time consulting with a orthopedic surgeon who is only going to recommend a lateral release or some other such useless or counterproductive procedure. If I'm going to have surgery, it needs to be as close to certain as possible that it's actually going to work. Here is the link to that journal article:
http://docs.google.com/viewer?a=v&q=cache:sIxlKJaiqGYJ:rehabeducation.com/main/wp-content/uploads/Therapeutic%2520implications%2520of%2520tissue%2520homeostasis.pdf+peripatellar+synovitis&hl=en&gl=us&pid=bl&srcid=ADGEESgJblYrmnEPa2PN31zzj4W09zVDfFmScJ4ecwcRm37IhjMt7u90rdhitEmaDRGt_6-h9MycFKDYKguOWrMs3tz-AsjhPWb9m4uZGxNuHVkpyKKDMggbbajsQAcN1b8bYLTxaEi3&sig=AHIEtbQBlnP0zzXSVU7HZrcFbzOb2qldhQ

If you could, ask your OS about this procedure. I'd be willing to bet, though, that they've probably never even heard of it. I think this procedure should be a last resort, but at least there is potentially something that could help.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 15, 2010, 08:29:17 AM
I'm also starting to lose hope that complete rest will facilitate repair and expansion of the envelope of function. Like yourself, I literally couldn't be restricting my movements any more within the limits of practicality. I haven't left my apartment for nearly 3 weeks now and for the last week, after abandoning my experiments with light repetitive movements, I have spent almost the entire day lying in bed save for the occasional hobble to the toilet or kitchen. Despite this, I can't detect even the slightest improvement. If anything the pain is getting worse. My sleep is quite disrupted now which wasn't the case previously. It's possible that the healing process is underway internally and it will take a bit longer to manifest itself symptomatically but it's hard to believe that my condition would be static or regressing at this stage.

I will persevere until my OS appointment on July 26 and review the situation then. I will ask my OS about the synovectomy procedure. Apparently there were no signs of any synovium damage or inflammation from my arthroscopy but perhaps there are tests that can be conducted to diagnose issues that are not visually detectable. From reading Dr. Dye's papers, it does seem to be a tissue that is heavily implicated in PFPS. As I mentioned before, I am also keen to get a bone scan done as that can reveal markers of increased metabolic activity consistent with irritation of osseous tissue.

As for my low points prior to recovering enough to walk a few km's, looking back, it's basically been a series of lower highs and lower lows with my current state the overall nadir. Prior to surgery in April, I was at the point where I could walk maybe a block or two in considerable discomfort. After surgery, I had no option other than rest because of the post-operative swelling but I was weight-bearing after a few days and at the 2 week mark I could walk a few blocks with much less pain than immediately prior to surgery albeit with a certain amount of discomfort still present. After that, I gradually extended my walking range over a few weeks until the setbacks took hold. The period from Oct last year to April was a gradual oscillating decline in retrospect but the intermittent recoveries were enough to keep me optimistic. It's only now that I am really starting to confront the reality that this could be a long-term or permanent condition that may even deteriorate further. Not a pleasant prospect.

I too have been dwelling on matters philosophical and spiritual of late but my attachments to the world of form are winning the struggle for now. Perhaps this ordeal will spur my conscious growth to a place of enlightened contentment unruffled by the tribulations of my physical avatar. But probably not - most likely I will continue to feel sorry for myself and whinge up a storm!


Title: Re: Sore knees, no diagnosis
Post by: kscope09 on July 15, 2010, 11:17:53 AM
You really need the opiion of pt or surgeon.  I don't think complete rest is the answer, but no-one on here can say do this exercise or do that exercise because you need to be examined and have thwem given by an expert.  resting for weeks on end is very dangerous because your uslces will waste quicker than you will believe.  The muscles went right down on my left knee which hurt like hell but was still walking and doing stairs, and I wa still exercising them.  I think you need urgent advice from someone qualified very quickly before things turn really nasty.  Atrophy is muscle wasting that most commonly occours after surgery and it is very ahrd to get he muscles going again and this can happen while you are exercising.  If you don't exercises for weeks and you get true atrophy it will eprmenantly waste your muscles and however hard you try you will not get the strength back.  I don't want to frighten anyone but beware.  The more the muscle wastes, the more pressure is carried by the joint when you stand or walk and the more damage is done to the cartliage.  I know that pFS isn't as simple as some people make out but a good pt should be able to help in the maentime.

best of luck to both of you.
Title: Re: Sore knees, no diagnosis
Post by: Lottiefox on July 15, 2010, 11:32:02 AM
I have to say that I tend to agree with kscope - I have PFS (with confirmed grade3-4 cartilage lesions on the kneecaps thru MRI)  and whilst SOME rest from activity that aggravates the symptoms is sometimes essential, doing nothing simply isn't an option. PFS sets in for a HUGE variety of reasons and yes, inflammation inside the synovium is an issue but whether this is a cause or a symptom is not really known. What IS known that without strong and effective muscles around the knee it has no natural brace or support. Those braces with the cut out holes for the patella? They try and help the natural brace effect of the muscles. Even if you're avoiding activity you should be doing quad exercises, hip abduction and adduction, calf stretches, ITB stretches, hamstring work and stretches and making the muscles fire. Lying in bed is a recipe for less muscle activity, increased instability of the patella and probably depression to boot!

Just my two penneth worth! And I do know JUST how frustrating PFS is. Trust me!!  :D

Lottie
Title: Re: Sore knees, no diagnosis
Post by: kscope09 on July 15, 2010, 11:50:05 AM
You must go and see someone ASAp but for now you could try the straight leg raises as they can't realy cause you any damage, just start off with a few and increase gradually.  What kind of symptoms are you having?  Pain under the kneecap? with a large helping of rice crispies?  Do you have medial or lateral pain as well?  Do you ahve anterior pain that goes down the tibial tuberosity?

Don't think about srugeries just yet, see someone who can take a look at you and see what they say.  If it is PFS they might say they can get you back to normal in 3 months but the more you rest now the harder it will be.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 15, 2010, 02:47:47 PM
I'll mention that sometimes the pain feels worse when you are going non-weight bearing for a while. Still, it seems that the "envelope of function" will be improved upon resumption of activity. With this severity of the condition, not that much better, though. So take it as easy of you can when you resume walking. If you weren't getting any sharp pains, there should be some improvement.

If you are having trouble sleeping, I'd recommend an over the counter sleep aid. I've been taking a pill with 25 mg Diphenhydramine HCl, and I've gone from being fortunate for getting 4 hours of sleep a night to now regularly getting at least 7 or 8. If the pain is too much for you to fall asleep initially, ice it before bed.

I hear you when you speak of a new "overall nadir", with high lows and low lows. The state that I am now in was triggered when I brilliantly thought that I was perhaps better enough for some more extended walking and even some squats. Well I was in for a pleasant surprise that night. I felt some of the worse inflammation that night that I had ever experienced. Since then, my envelope of function is seemingly permanently altered. Of course, I haven't tried "everything" yet. My recommendation would be, to use what might be one of your last opportunities here to try things a little differently. Progress even more slowly than you have in the past. As much as you'll want to do more as quickly as possible, you know it is anathema to recovery. Remember, as saveyourself.ca points out, even if an activity is pain free, you might be bumping up again the outer limits of your envelope of function. This makes you quite vulnerable to relapse of symptoms. But the fact that you could increase the envelope at all should give you some hope.

Good luck with the bone scan, hopefully it will help you understand finally the location from which the pain is emanating. If it's not the fat pad or synovium, though, what else could it be? The actual bone tissue itself? How would that be treated?

To the other posters, thanks for your two cents. I fully understand the dangers of muscle atrophy, but am at the end of my rope. Both highroller and I are not able to do any level of activity without triggering a pain response. This means that we can't even walk to the toilet without risking worsening the condition. What I'm doing is a last ditch effort to open up a larger space of function so that rehabilitation is possible. What good is my quadriceps if I can't walk anyway? I'm completely disabled right now. I can't go anywhere or do anything. My life is at rock bottom. There seemed to be no prospect that what I was doing before would ever work. So this is what I'm doing. Perhaps I'll try to integrate those straight leg raises, though. If something could prevent atrophy, that would be a positive thing. But I don't see the alternative to what I'm doing. If you have a better suggestion, I'm open to it. But continuing to antagonize the irritated tissues doesn't seem like a good one.

My plan right now is to try to walk again tomorrow. I honestly have no expectations at this point, but if I could just get through a couple of days without pain, I might have a chance. We'll see.
Title: Re: Sore knees, no diagnosis
Post by: kscope09 on July 15, 2010, 03:09:25 PM
I'm really sorry about this, really!  I know what its like when people better off than me tell me what I should be doing and it feels terrible.  I like you have a real problem with depression and feel like tearing my hair out sometiems because my life isn't what it used to be and I'm trying to get back what I can but I know I'll never be the same.

I think you've really got to get to a doctor, a pt or a surgeon as soon as you can or at least speak to someone over the phone.  I don't think complete rest is the answer, maybe a couple of days but no more.  After my surgery I was told to try to walk as normally as I could and not to try to limp, which was impossible.  When you walk try to do it as slowly as you can and take small steps, don't try to march around as you might have when you are well.  The cane is a god idea though to help with balence and maybe a pair of crutches will help you get about for a week or two.  When my left knee flared up in May the pt told me to use crutches for a week and just get a bit of weight off it but still keep it moving and do exercises.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 15, 2010, 04:32:35 PM
kscope09,

Thank you for your comments. I certainly agree that too much rest could be counterproductive. Honestly, I don't think I'll be doing more than 2 or 3 days of rest at this point. That should do the trick, and if it doesn't I'm really out of options. I'll try this for a few more weeks I think, and then it's time to enter the medical system. I've just read so many horror stories of people whose condition was worsened by surgery, and I'm doubtful that PT could do much for me. I suppose they could pump me full of narcotics, but is that really a worthy life? I don't think that's something that could continue indefinitely, anyway. This is the most frightening thing I've ever faced in my young life. I know I have a long road ahead with no certain prospects. But for now, I have to keep my hopes up. I don't think I could live the rest of my life like this.
Title: Re: Sore knees, no diagnosis
Post by: kscope09 on July 15, 2010, 04:47:28 PM
To be honest I thnk from what you've said you seem ready for the medical system, by that I mean the physio because you certainly don't want to jump into surgery.  i think you shouldn't even contemplate surgery at the moment.  Just take things one step at a time and get a diagnosis.. Mris, x-rays, even just examination by the right people will  all be helpful.  With me I had the scans and the pts opinions and  they all said I was fine and to stop wining.  I saw a surgeon and he took a look inside and found all manner of nasties, just read my signiture.  Now when I go to doctor I get taken a bit more seriously.
Title: Re: Sore knees, no diagnosis
Post by: Snowy on July 16, 2010, 05:32:24 AM
As a fellow PFS sufferer, I have a huge amount of sympathy for what you're going through - I know that feeling all too well when the knees just feel like a giant pair of rotting teeth.

However, I have to echo the concerns that Lottie and Kscope09 have expressed about the total rest regime. While I'm no expert, nothing I've ever been advised over my years of treatment for PFS indicates that a total avoidance of all activities is a good idea for this condition. While avoiding certain activities will undoubtedly help with inflammation and pain, the muscle atrophy around the knee resulting from total rest is very likely to end up making things worse. I would seek medical advice ASAP, rather than continuing on this course of (in)action.

I did notice that earlier in the thread you discussed synovectomy, and were concerned that it was a cutting edge procedure that would not be widely available. The good news is that if this is the right route to help with your knee issues, it's not an uncommon procedure and there are quite a few folk here on the board who have been through it. If you browse through the post-op diaries and other sections of the forum, you'll find threads from people who have had (or are thinking about) the surgery which may be helpful for you.

I wish you both luck finding some relief from your symptoms. If it's any reassurance, I found PT to be effective when my symptoms became particularly severe - but it did take finding the right physiotherapist with the right approach.
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 16, 2010, 07:05:31 AM
A warm welcome and a big thank you to all the new contributors - your time and effort is very much appreciated as is the wealth of knowledge and experience you bring to the discussion. This forum is a wonderful virtual support system to be sure. I hope that over time I can also help some fellow sufferers here as you folks clearly have from your prolific post counts. I'm half way to shedding my MICROgeek status, maybe one day I will attain the prestigious rank of SuperGeek :-)

I very much share your concerns about the downsides of near total rest but as kneealwayshurts has explained, it really is a last resort in a situation where virtually all movement triggers a pain response and may be causing further deterioration. That being said, as well as performing the very low intensity exercises that were prescribed for me post-surgery, I am now endeavouring to experiment with movement patterns where the biomechanics and force vectors are more favourable. For example, I just found that I can tolerate some leg exercises a little better in an inverted position while performing a kind of shoulder stand. A little unorthodox but it could help. I'll play around with a few other configurations and see what works. It's only a preliminary step to allow some expansion of the envelope of function - sufficient hopefully to allow me to embark on a more traditional progressive mobility/resistance program.

I have been considering seeing a physio and almost made an appointment last week but I am going to wait until I've had the consultation with my OS on Monday week, partly because I'm really not comfortable going anywhere at the moment with my limited ability to support my own weight and also partly because I don't have a medically confirmed diagnosis on which to base a rehab process. I have also had poor to mediocre results with physios in the past and I am somewhat wary of the profession generally. I'm not dismissing the value of well applied physiotherapy and I don't doubt that there are competent and conscientious practitioners out there but in my experience they are the exception and difficult to find. I will do my best do find a well credentialled physio with a solid track record in knee rehab this time.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 16, 2010, 03:40:33 PM
Thanks for responding, Snowy. I'll admit, in everything that I've ever read concerning rehab of PFPS, both conventional and unconventional, I haven't seen total rest recommended. My fascination with this approach is solely because of personal experience. A couple of months ago, my condition took a sudden turn for the worse, and I found myself unable to walk without significant pain. I'd had PFPS for months prior to that, and I'd never experienced anything like that. Since it was going to take a while before I was able to get to the doctor, I decided to take matters into my own hands, and since I didn't really know what was wrong, I thought that it might be safest to use crutches until I could consult the doctor. When I finally got to the doctor, it was obvious that he had never heard of this approach either, because from the way he reacted, he obviously thought using crutches was inappropriate. He directed me to stop using them, and despite how badly I had felt before using the crutches, I made an almost miraculous recovery in about 2 weeks after walking again. There were no setbacks, either. Just smooth and steady progress. You can see, given this experience, why I was hoping to recreate these results again. Unfortunately, this time, for whatever reason, this is not working, and I find myself unable to do anything more than the most essential activities. Even that seems to irritate my knee.

I noted in an earlier post that non-activity does indeed result in muscle wasting and should be used as a last resort. I think this is the last time I'm going to try this approach, though. I've started walking again this morning, and if I begin to experience irritation and pain again, which I must glumly concede is the most probable result, it will finally be time to see a specialist. I suppose there are a number of options I haven't tried yet. I might be able to get a more sophisticated knee brace, and taping seems to be an option. I have my doubts about the efficacy of physio at this point, but it might be worth trying with someone with extensive experience dealing with this sort of condition. My biggest fear is that this advances to point of surgery. It's not even the thought of being cut open, even though honestly I have some anxieties about this as well. But the poor track record of surgery for PFPS lends itself to doubts with proceeding down that path. If, down the road, I am recommended for surgery, I'll certain inquire on this forum about the suggested procedure. I don't want to go through with a procedure that might be worthless or make my condition even worse. Hopefully input from members here, with their extensive knowledge and experience on matters of the knee, can help me make the right decision.

It's good to hear that the synovectomy procedure has given some people good results. From my preliminary searches, though, it seems that most references to this procedure are to people with rheumatoid arthritis. How often is it done for severe PFPS?

I am getting to the end of the road for "conservative" home treatment. This is my last attempt, and if it fails, I do believe I'll be making a appointment to see the doctor sometime in the next week. What questions should I ask seeing a specialist for the first time? Is there anything in particular that I should always mention, or a particular test that I should request, such as an MRI? What should I expect to get out of this? I know that this will be a long road forward, but I'm not sure how much longer I can withstand this level of pain and maintain my sanity. I suppose I don't have a choice.

Thank you for any helpful insights!
Title: Re: Sore knees, no diagnosis
Post by: Snowy on July 16, 2010, 05:55:17 PM
It's always tough working with a condition like this, where finding a viable long-term solution is so dependent on correctly identifying the underlying cause. That's one of the key things to keep in mind - that PFS is ultimately itself a symptom of something else in the knee that isn't working correctly, and while it's possible to address the PFS symptoms you probably won't ever get long-term relief until the underlying cause is identified and resolved.

As I said, I'm not an expert - but after many years of different treatments and all the background reading I've done, here are some thoughts from my experience that may be helpful.

I wouldn't write off PT, but you really do need to find the right physiotherapist and that isn't always easy. I spent a lot of time working with PTs in the UK who always took the same approach, which was a very straightforward approach to muscle strengthening. The problem was that a lot of the exercises they prescribed - squats, leg presses etc - only aggravated the knee further, leaving me in a vicious circle where as the muscle strength improved so did the knee pain.

I didn't really start to make significant progress until I moved to Canada and by default acquired a new set of doctors. My family doctor referred me to an OS after a particularly bad flareup left me barely able to walk. He sent me for MRIs, and was the first to identify the underlying cause - my kneecaps don't track correctly. This patellar malalignment was leading to the huge irritation and pain during certain activities. The surgical procedure for this would be a lateral release (cutting the ligaments around the patellar to realign it correctly); however, my OS felt that my malalignment wasn't severe enough to warrant surgical intervention (refreshing to hear from a surgeon!) and recommended trying bracing and PT first, and following up for a thorough review with a sports medicine doc if the PFS persisted.

Initially, the basic exercises provided by the OS and the braces provided substantial relief. The braces, put on correctly, realigned the patellar slightly so it wasn't causing the same irritation. I didn't even see a PT at this point because with the aid of the braces, I was able to resume most activities. I did drop running and kickboxing as high impact continued to be problematic, but I felt this was a fairly small price to pay. This was about 3 years ago.

Last summer the PFS flared up really badly again. (We moved house and I spent a solid month carrying boxes up and down stairs and on my knees laying hardwood floor, so my own fault.)  When it didn't settle down I got a referral to a sports medicine doctor, who gave me a thorough exam and then put me on a month of high-dose NSAIDs and recommended a PT with specific experience in dealing with knee issues. This PT took a totally different approach to all the others I'd worked with. In terms of exercise, he went right back to basics. For the first few weeks, all I did was hundreds of daily isometric exercises - things like static quad flexes. This strengthened my muscles while the NSAIDs settled the inflammation down. (I was allowed to continue with other exercise that didn't aggravate the pain - in my case, only swimming and cycling.)

The PT also had the benefit of knowing that the underlying cause was maltracking patellars, and we spent some time investigating this. It turned out that most of the maltracking wasn't down to the actual knee structure (hence the OS's reluctance to operate) but down to overpronation in my gait. He got me into some custom orthotics, and they were a real eyeopener - once I'd adjusted to them I was actually able to walk long distances without aggravating the knees.

This combination of really getting to the root cause of the PFS, combined with a PT who really knew his stuff when it came to knee problems, was really a turning point for me. I was seeing great progress in the PFS - it was so much better that I'd even stopped using the braces on which I'd relied for 3 years - and then unfortunately I took a tumble on the ski slopes this March, blew my left ACL, and am now recovering from a surgical ACL reconstruction! That of course is a whole other story. :)

Sorry that was a bit long-winded, but I hope my story gives you some reassurance about how effective PT can be - and the importance of figuring out what it is in your knee that's causing this aggravation. Synovectomy would only be a solution if the root cause of your problems is inflammation of the synovium, but again there's an underlying "Why?" there. For me the surgical route would have been some form of lateral release because my underlying cause was the maltracking patellars, but in fact my OS was spot on when he said that he thought conservative treatment would be sufficient for me. It just took finding the right people to work with.

I'm not sure whereabouts you are, but this site has some lists of recommended knee experts in various areas and this would be a good place to start. PFS is complicated and can result from a huge number of different things, so don't rely on a family doctor or someone who's not really grounded in knee issues to provide an accurate diagnosis. If you can, find an OS who actually specializes in patellar issues. Talk to their office about recommendations for a PT who really knows what they're doing with knee problems.

Good luck! It isn't an easy road, for sure. I'm sorry things have gotten so bad for you, but hope that you can find a solution that works. 
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 16, 2010, 07:12:17 PM
I need all the information I can get right now, so I really appreciate you taking the time to relate your experiences to me. For me, the amazing thing is that I know exactly what got me where I am, at every step of the way. I'm not sure if you reviewed any of the earlier posts, but I can quickly summarize:

Sep. '09: I injured some ligaments in my left foot while running. I don't know what the relation is between the two, but after my foot healed, and I tried to exercise, I started to get excruciating pains in my left knee after a period of activity. Inflammation followed, and after a week or two I felt fine again. This went on for several months.

Mar '10: I eventually went to the doctor and he recommended some basic strengthening exercises and to wear a knee brace. It actually seemed to work at first, but after about two weeks I started getting the pains again. This time, inexplicably, the condition begins to worsen. Instead of healing as it always did, the inflammation lingers, and I started getting sharp pains even when not exercising. After a few weeks like this, it took a further turn for the worse, and it was painful enough that I thought I shouldn't walk on it. I noted this in my previous post. The interesting thing is, between that last flare-up and this current one, there was a period of about a week when I felt completely recovered. And it was around that time that I discovered the origin of the problem. It turns out that it was an issue with how I was walking. Apparently, for a reason I still don't understand, my groin muscles tightened after I injured my foot, perhaps to help keep pressure of my foot so that it would heal. For reasons I also don't understand, the muscles never loosened up again, even long after my foot healed. When I really started paying attention, I could actually see my leg rotating with every step I was taking. When I lifted my heel off the floor, the leg would abduct. As you can imagine, this is not a good thing. The only joint in between the hips and the ankle is the knee. And my poor knee was being battered by all of the rotational force being exerted on it.

May '10: In mid-May I felt great again. I tried to exercise a few days before, and I had injured my knee yet again, but shortly after this was the point in which I discovered the issue with muscle tightness. Fortunately, I was able to perform some stretches which fully resolved the issue after a few days. I detail this above in an earlier post. In the shortest time ever after injuring my knee, I felt great! So, of course I thought my problem was over. Wrong. When I tried to run, I started to get pain after a few minutes. Interestingly, the pain was much less severe than usual, adding more weight to my belief that the main issue had been resolved. And yet, there was still pain. After this point, it was all down hill, because every step of the way I just didn't rest enough. And so here I find myself. That is the origin of my doubts about how much PT much actually help me. I have no doubt that after the past month, I've had some muscle wasting, and I have no doubt that I have some muscle tightness. But I really didn't when I was running in May. I felt like I was walking and running as straight as an arrow. And yet I still had pain. Why? And why did it just keep getting worse? I know I had an alignment issue, but I took care of it. It was resolved. That's what makes me lean towards the theory that the tissue which was being antagonized all along has now become hyper-sensitized. Highroller details this theory of "tissue homeostasis" in an earlier post. It's really the only thing which makes any sense. Do I know exactly what tissue is irritated? No. I probably need to get an MRI, or some other scan. It might be the synovium, or it could be a fat pad impingement, or it could be something else. But I have my doubts that PT alone is going to make this substantially improve at this point. I suppose, conceivably, that anything which can relieve some of the pressure on the joint could help. I probably am quite weak right now, and I doubt that's helping matters any. And as I mentioned, a better knee brace, or a taping technique, could help. But unless the sensitivity of whatever tissue in my knee is actually plaguing me right now decreases, I'm having a hard time seeing a path out of this.

Jul '10: So that is where I am right now. Thank you all of your input. I'm sure over the next few months I'll end up trying just about everything. There has to be something that can beat this darn knee into submission!
Title: Re: Sore knees, no diagnosis
Post by: Snowy on July 17, 2010, 01:38:09 AM
Wow - you really have been through the wringer. The only thing I can think of reading through your posts is that you may have returned to exercise too soon after the effective stretching regime. One thing my PT emphasized is that something like the malalignment I have isn't going to correct overnight, and that I would need to keep up the exercises and other measures (like the orthotics) long-term or even indefinately to ensure that the progress I made would last. A few days of stretching doesn't seem like it would be nearly enough to maintain an improvement, especially if you were working on something that had built up over the longer term.

It's tough when it feels like you've tried everything without getting any closer to a real answer. There will be a solution that works for you - just keep plugging away at it.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 18, 2010, 10:41:17 PM
Yeah, well thanks for the moral support. I know that my problem was mechanical in origin. I just honestly don't think it is anymore. Do I think that getting my body into better alignment might help the situation? I do think so. And after the last month, a lot of my musculature has atrophied. But my fear is that this inflamed tissue is so damaged, that what has happened might be irreversible. It's really that bad. I know that this is usually not the case, but I'm still looking for some kind of opening, where I can go a few days without irritating this tissue further. I'm not sure I've found that opening yet. I'm not sure that's possible. But I'm not going to give up without trying everything. In the end, I might never be the same, but there has to be something that can be done. If there is, I've resolved to find it.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 20, 2010, 04:26:17 PM
I just looked at the calendar, and it's amazing to think that it has been over a month now since I could last walk. Every day seems to pass at an excruciatingly slow pace, but the days have still flown by. It seems unreasonable to think that anything I might do now will have an impact.

My mind is constantly mulling over all of the possibilities concerning my knee, and I experience constant anxiety. This morning I woke up with my heart pounding out of my chest, and my head has just been spinning all day. At points when this has happened before, I would resolve myself to try something different, with the hope that this might produce different results. As long as there is hope, my anxiety can subside. I think I've reached the end of my road now. There is nothing further I can do for myself. The next step is to see a specialist, get some scans done, and proceed from there. I hope I can manage well enough until I can see the doctor, but I think the next few days aren't going to be great, to say the least.

I've been looking this morning at the blog that highroller mentioned in one of his earlier posts, and went all the way back to 2005 to find a post about fat pad impingement. From reading it, this seems like a real possibility in my case. One of the interesting things about developing PFPS in my other knee has been that I've been able to compare the two knees. It turns out that the pain has manifested completely differently. My better knee, which didn't have any problem until recently, seems to be a more classic example of PFPS. It is quite achy, the onset was insidious, and the pains are around most of knee cap. In my other knee, it does ache sometimes, but the pain is far more sharp. The onset was acute, and the first time I ever experienced pain it was quite excruciating. Prior to that, I never had any pain at all. In addition, the pain is very localized, to one very small corner of my knee. Despite that, it is agonizing enough at times to really put a damper on my spirit. It's bad enough that I really can't walk without serious suffering involved. I've tried palpating my knee today, and to be honest, pressing down on my kneecap itself didn't produce much pain. If anything, pressing on the tendon below the kneecap seemed to hurt more. It's definitely not the tendon itself though, but something beneath it. Whatever it is, it seems to extend to beneath the kneecap as well. Interestingly, when I first had these pains, I thought it was some sort of tendinitis, and never considered that it might be the knee cap itself. Ever since the doctor diagnosed it as PFPS, though, I've been caught in that paradigm. Now a new thought has come to mind, though.

When I slammed down on the side of my foot way back in September, I have to presume that a huge amount of energy was transferred up my leg as well, and not in the anatomically correct fashion. It makes sense that the corner of my knee which is painful, is the exact place that would have taken the brunt of the force. Isn't it possible, that at this moment, the fat pad was compressed against the bone? The strange thing is that I didn't really feel any pain until a few days later, when I walked for more than 30 minutes. What is also strange is where to place that leg rotation issue in all of this. It's possible that the rotation was a preexisting issue, that only became a problem because the fat pad was then vulnerable after my injury. It is relevant to note that my other leg was also rotating when I was walking, but it was adducting rather than abducting. Yet this never caused any pain at all. It seems far more within the realm of possibility that my foot injury also injured my knee, rather than some mysterious, unexplained muscle tightening. It would also explain why I was continuing to have pain, albeit substantially less, even after a few days of stretching. The rotation did stop, but not the pain.

I know that all of this is just idle speculation, and you folks might think that I'm completely nuts for engaging in it, and not even having made an appointment to the doctor. That's just my personality I guess, I like to work through problems myself. I love to think through things, and even when I think I might be finished with it, I start thinking some more. I don't know if any of you are familiar with the Myers-Briggs personality test. It's a little pseudo-scientific, but I like it anyway. I'm an INTP. So that explains that. At least I have some things to mention to the doctor when I finally get there. The only thing I am certain of, is that this is something I won't be able to resolve myself. That's a difficult place to be in, but I'll just have to go with the flow. As always, I'll keep you all updated if there is any news or progress.
Title: Re: Sore knees, no diagnosis
Post by: kscope09 on July 20, 2010, 04:35:27 PM
You've made the right decision in seeing a specialist.  Looking back at my knee hsitory I wish I'd just seen a specialist in the first palce instead of all those gps and physios who treat me like a timewaster.  Saying that I would ahve been pretty frightenned if a specialist had told me to have scope early on as I was afriad of surgery.  It was only when I was at my whitt's end that I decided to go for it.

Let the specialist have a good look at it and get the scans done if he thinks you need them and myabe you won't need surgery, just a intensive course of pt.  Alos, I bet once you get the ball rolling and you know things are being dealt with I bet you'll start to relax.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 20, 2010, 08:38:06 PM
I just finished making the appointment, and fortunately I don't have to wait too long, as it's at 11:15 on Monday.

That's exactly how I felt at the GP. He didn't really seem to understand what I was going through. And at that point, it wasn't nearly as bad as it is now. I'm glad I won't be going back.

I'm just wondering if you can relate your experiences getting that arthroscope. Did you need general anesthesia? And how large is the incision? I suppose as far as surgical procedures go, it is on the less radical side or things, seeing how surgeons regularly crack open people's rib cages to perform heart surgery. But I've never had surgery before, and the thought of them making even a small incision still gives me anxiety. I'm still hoping to get through this without surgery, but I recognize now that I may be out of luck. If I want to find out what the problem is, I might have no choice.
Title: Re: Sore knees, no diagnosis
Post by: Vickster on July 20, 2010, 08:46:21 PM
Scope portals are around 7-10mm each, teeny tiny :)  Usually done under general, but can be done with local, depends on the OS and anaesthetist.  Which country are you in?
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 21, 2010, 08:08:27 AM
Just catching up here after a few days absence wallowing in self-pity :-)

Glad to hear you've decided to seek medical advice - we actually have our appointments on the same day! I sincerely hope that you have found a good practitioner as a lot can depend on that. What type of specialist did you opt for by the way - sports doctor, orthopaedic surgeon, etc? I may well be seeking a second opinion in the near future but we'll see what my OS comes up with next week. Perhaps we could document a checklist of items to address in our consultations here in this thread - I'll start jotting down some notes tomorrow.

My MRI revealed quite a bit of fluid accumulation in the fat pad which led to the sports doctor identifying it as the likely culprit back in Oct/Nov last year. At the time he felt that 4-6 weeks rest might be sufficient but mentioned that the fat pad can take quite a bit longer to settle down in some cases. When I returned 6 weeks later with no improvement at all he felt that fat pad inflammation was much less likely to be the primary cause. He had previously suggested that a cortisone shot would be the next step if the initial period of rest was unsuccessful but no longer felt that was the right course of action. Instead, I was referred to an orthopaedic surgeon who eventually performed an arthroscopy on my left knee (slightly the worse of the two) and excised some fat pad tissue but this was only a precaution against impingement was was not indicated by inspection of the joint. I would be very interested to see a current MRI of my left knee in order to compare the patterns of fluid build up vs 8 months ago. I guess I could have ongoing fat pad inflammation without prior or current impingement.

The location of my pain does not feel like it is emanating from the fat pad, at least not directly. It feels more peripatellar as well as partly originating at the interface between the femur and tibia. Not at all localised to any specific points.

Regarding surgery, I totally understand your anxiety, especially as you haven't had the pleasure previously but I can tell you that the arthroscopy procedure was a fairly straightforward affair in my own experience. I had a general anaesthetic. The incisions and the resulting scars are very small and barely noticeable. There was considerable swelling for a few days after the op - my knee made the most unpleasant flatulent sound when I bent my leg for a week or more! I gradually returned to weight bearing status over a week and was even able to walk home a couple of km's from my follow up appointment 2 weeks after the op. In my case though very little was actually done - only a small chunk of fat pad was removed - so the experience will vary a bit depending on the repair work conducted. There is some minor residual numbness in a couple of small areas around the incisions - sensation seems to be slowly returning over time.

As for an update on my own recent activities, I have been performing a sequence of low intensity leg exercises 2/3 times a day. I find the inverted position (shoulder stand using elbows for support with hands at the back of hips) to be the least stressful for knee bending movements - I do a kind of inverted squat and a bicycle motion. I also do some leg raises, leg slides and a leg curl while lying on my stomach - for the latter I raise my knees off the ground slightly when fully extended. I'm not approaching any kind of muscular failure on any of these exercises but I'm aiming to increase the repetition count day by day. I'm also doing some basic mobility exercises such as arm circles, etc to try and counteract the ravages of the sedentary lifestyle on posture and range of motion.

I also went for a short walk on Monday and Tuesday. I wasn't sure that I would be able to do it or that it would be sensible to try but I was able to walk a couple of blocks and back by moving at an extremely slow pace with very short steps and sitting down periodically to rest. I managed to avoid the dreaded 'sharp pains' but the experience was quite uncomfortable throughout. I was quite anxious that I would collide with another pedestrian and lose my delicate equilibrium or be unable to continue walking but I eventually crossed the threshold of my rehab cave with great relief. This experiment has not triggered a flare up beyond the poor state my knees were already in but I'm not sure whether to call it progress or not. I'm still hobbling tentatively around my apt with grinding knees that always feel on the precipice of more excruciating pain.

I'm turning 40 on Friday - looks like I'll have to defer the full festivities to a later, and hopefully more pain-free, date but in the meantime I'll be prescribing myself a couple of bottles of anaesthetic from a good vineyard!
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 21, 2010, 04:54:39 PM
You know, I think we ought to throw a pity party! Extending all the way from your birthday to mine on the 7th of next month. There's no greater cause for celebration than self pity, don't you say? So my cave or yours?

Just promise that you'll go easy on that anesthetic! It needs to last a couple of weeks, and besides, while that eternal slumber which may follow too copious a quantity of said anesthetic might sound appealing at first thought, since in sleep of any sort knees don't hurt, you just might have some good years ahead of you.

What strikes me in your case is that the OS seems to have been unable to pinpoint the cause of your anguish. What if conservative measures fail? How can they even perform a surgery, if they don't know where the pain is emanating from? Really, that's why I've been holding off seeing the doctor for so long. I just have my doubts about whether they'll be able to do anything for me. My expectation is a recommendation from the doctor to use a specialized brace, and he'll probably want me to see a physical therapist. What's the likelihood that this will improve my circumstance to any measurable degree? As long as the PT doesn't suggest squats as a means of quad strengthening, I suppose it can't much hurt.

You've mentioned in various posts that you've been implementing various light exercises for your knees. Do you feel that this has made a real difference? I've only been doing basic stretches and strengthening exercises, but more to just maintain my ability to attain an upright posture, rather than anything specific for the knees. My problem is that I seem to have trouble simply doing basic day to day functions without triggering those dreaded sharp pains. Though, on some days I don't have much of an inflammatory response, which gives cause for hope. I'm just afraid that doing more activity might just irritate the tissues more. But in your experience, do you feel that doing those exercises "conditions" the knees so that they can bear a greater load for the rest of the day? If not, I'm doubtful that they would help at this point. I know that doing exercises within the envelope of function should in theory increase that envelope over time. But if I just end up irritating my knee by walking anyway, then what's the point?

If you've able to do any unessential activities and come out of it feeling alright, then I'd call that progress. Just don't get too excited and suddenly increase the distance you've been walking. Keep at that safe distance for a while.

My specialist actually did a residency for Sports Medicine, and Orthopedic Surgery. I'll have to be careful that he doesn't try to push me into the operating room before a good attempt at other measures.

At least we have the pity party to look forward to in the days ahead. Nothing like a good wallowing in the mud of self pity to cool down all of those feelings of depression and anxiety!

Title: Re: Sore knees, no diagnosis
Post by: Lottiefox on July 21, 2010, 07:07:37 PM
Hi,

Good news on the appointment. At least its a forwards move to fidning out what may be wrong.

Don't dismiss suggestions such as a brace or PT, especially the latter. A good PT won't just get you doing pointless exercises that aggravate the knee. They will begin by doing a full assessment of your alignment, posture, biomechanics, and strength in your existing muscles. Then they should start with the basics and see what you can achieve. Can exercises work? Yes - quite often, if they are focused for you, done as prescribed (and that means FREQUENTLY) and assessed along the way. A good personal trainer can often take the same approach if they are appriately qualified in corrective exercise and biomechanical assessment. (eg NASM trainers with corrective experience qualification). I have seen people with pretty significant knee issues improve their function ten fold through the right functional approach.

Might you stress the knee or cause irritation? Possibly, but this should be a minimal risk with the right supervision. But without taking a risk what is the alternative? Staying laying down for the rest of your life and wondering what might have been?

Your doctor should NOT push you into surgery - that is the last thing a good knee specialist should focus on. I can't recall if you've had scans or X-rays but these can be a starting point. You mention sharp pains - they may indicate something structural, may be cartilage damage, may even be an underlying fracture of some kind that has gone undiagnosed. But, yes, there may be nothing as such that is seen. BUT that doesn't mean you can't get improvement, lengthy as this may be.

I know how frustrating this whole experience is but you must enter any form of treatment with the mind set that it will help. Otherwise - no point even trying it in my opinion. I was similarly dismissive of a lot of things - til I tried them.  :)

Good luck

Lottie  8)
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 22, 2010, 12:52:26 AM
Hehe, pity party sounds good, we'll have a 'joint' celebration then :-) If you are in the vicinity of Melbourne, Australia, feel free to drop by my convalescence cave at 7pm tomorrow evening. I will kick off proceedings with a lengthy speech bemoaning my predicament after which everyone will hit up the liquor stash. Once the alcohol numbs our aching knees, perhaps we can take advantage of our expanded envelope of function with some cossack dancing.

As for the exercises that I'm doing, I really can't say that I've noticed any benefit so far in terms of pain relief or expanded function. The cogs move slowly in the recovery process though and it hasn't been long since I started so I'll keep at it for now. Even if it's not helping to resolve the underlying problem at least it will help to counter muscle atrophy and deconditioning to some extent. There's a small gym for residents in my apartment building so I might also try some stationary cycling on the lowest resistance level over the next few days.

Lottie, that is encouraging regarding PT. I'm sure my OS will be pushing that again as the best course of action but I'd feel a lot more comfortable if I had some semblance of a diagnosis beforehand. Finding a competent PT will be a challenge as the industry seems rife with mediocrity. Certainly the PT I used earlier this year did not perform anything approaching the assessment that you described. Neither did my OS for that matter.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 23, 2010, 04:21:10 AM
Hey highroller,

I just want to wish you a very happy, pain free birthday, which I am in no doubt you will attain with judicious consumption of that heretofore mentioned grape beverage. Just remember, much like the envelope of activity for our knees, to get the right amount. Too little, and there will be no subsiding of pain; too much, and you'll be tumbling down onto that most sensitive place on your body (not being the usual place in your case), writhing in pain despite the analgesic effect. Get it just right, and the salutary benefit is achieved.  I hope I'm not putting a damper on the festivities, but I regret to inform you that I won't be able to attend this blithesome event, as I'm now comfortably (or uncomfortably, as I think of it, darn knee!) ensconced at my home in the suburbs of Boston, Massachusetts. If I wasn't nearly at the antipodes of your location, though, I think a bit of spirits, or some fine Australian wine, as the case may be, would hit just the right spot. My incorporeal presence will be with you, hoping that you will have many more, pain free birthdays, perhaps being achieved without resort to a quaffing of the vintner's finest Liquoreux. Rather, in the future may you enjoy it for its own sake. :-)
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 25, 2010, 05:02:40 PM
Well, tomorrow is the big day at the doctor for me! I just want to thank everyone for their posts of encouragement, and all of the helpful information that has been conveyed over the past few weeks. This has been one amazing, sorrowful, rocky, roller coaster ride for me and it has been great to talk to others who are going through much the same thing.

I'm still not quite sure what I'll be asking the doctor tomorrow. I think first, and most importantly, is explaining how the nature of this disease has changed, transmogrified really, over time. There was a sharp break in symptoms in March, and it has never been the same. At first, it followed a normal pain response pattern. It wasn't surprising that a knee which was rotating severely with every step might hurt, even severely, after walking for a long period. Also not surprising, it recovered completely after a few days. Such was my condition for over six months. Then the sudden break. I think I must have irritated it while it still in its antagonized state. I'll never know for sure, but I think it was actually because of an exercise the doctor recommended. I was doing leg extensions, and it must have been too soon. Ever since, I've never been the same. It is an absurdity, I think, to call the conditions by the same name. There is barely any commonality between the two, with the obvious exception that they are both in precisely the same location. What was once clearly a bio-mechanical abnormality, is now a condition of highly sensitized tissues, perhaps a neurological disorder. And the doctor I'll be going to is a sports medicine specialist and orthopedic surgeon. What is the chance that he'll be able to deal with my condition? I think my only hope here is that tests come back with something clearly abnormal; perhaps something floating around in there that doesn't belong.

I've more or less tried it all. Right now I've been doing hip girdle stretches and strengthening, quad work, hamstring and calf stretches, all really to no avail. I feel like I'm walking alright, but it just doesn't seem to matter. Sure, my quads are still in a pretty weak state, but I should note that this was not the case when my condition worsened to its current state, but rather has been a byproduct of my sedentary existence since then. If the doctor recommends physical therapy, I'll give it a go. But this is only attacking the problem at the very periphery of what the problem is, while missing the core. Something is very wrong with the tissues inside of my knee. What exactly, I do not know. But I suspect that this is not something that will be amenable to simple physical therapy or bracing. I've tried a month of rest, and I don't intend to give up on this any time soon, but what's going to suddenly change?

I truly do wish that I wasn't so glum about my prospects at the doctor. But I really don't have much cause for optimism. Whatever happens, I'll post an update tomorrow telling you all how it went.
Title: Re: Sore knees, no diagnosis
Post by: Lottiefox on July 25, 2010, 06:07:29 PM
Good luck tomorrow - seeing a sports medicine/orthpod is definitely the right way forwards. Be open to suggestions, but push for some proper investigations and evaluation of what might be going on with the knees. Leg extensions KILL my kneecaps, I have just started to progress to short arc extensions over a towel or foam roller which works the final bit of extension without too much stress on the kneecap. Leg extension machines in the gym however are just OUT fir good for me, they shear the kneecap way too much.

Let us know how you get on

Lottie  :)
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 26, 2010, 08:51:47 AM
Thanks for the birthday felicitations. I restrained my inner dypsomaniac and imbibed an admirably moderate quantity of Merlot from my personal wine cellar (actually a cardboard box under the sink) but 'twas a pleasant distraction to focus on the palette rather than the patella for a change.

Anyway, thought I'd provide a quick update on my OS appointment as it may be of some limited use to you in advance of your own consultation.

In a nutshell, my OS feels he's not in a position to help me any further and has referred me to a rheumatologist as the next logical step. He feels that a clear structural cause has been ruled out and that the 'inflammatory' category of disorders, of which there are many, now need to be investigated properly. In my case, the problem is clearly not an overt externally observable form of inflammation as there is no sign of swelling but is a more subtle irritation of the joint tissues as per our discussions above. He also feels that fat pad inflammation is not indicated by the history and current state of my condition despite the oedema detected in my MRI.

I raised the tissue homeostasis model of PFPS and its chamption Dr. Dye. He's actually met the guy and is very familiar with his work. He regards Dr. Dye as a very intelligent individual but somewhat at the fringes of the profession in terms of his comparatively extreme views, practices, conservative treatment/rehab protocols and reluctance to operate (e.g. he might recommend avoiding sport for 5 years after an ACL tear if it takes that long for a bone scan to return to normal). That said, he doesn't dispute the explanatory power of the tissue homeostasis model although it leaves you with rather limited options in terms of addressing the condition.

I didn't specifically discuss a number of other items that I had on my checklist (e.g. synovitis, etc.) - they are now best deferred to the rheumatologist consultation which is scheduled for Aug 26. Frustrating to have to wait so long, especially as the initial appointment will likely trigger further tests and follow up consultations, but these folks are clearly in demand from our fellow hobblers.

I also got my knees x-ray'd as an input to the rheumatologist consult. I took the images home but the report will be issued directly to my OS. From what I can see the images look very similar to the ones that were taken over a year ago. There is a decent gap between the femur and tibia which is consistent with the lack of any† osteoarthritis evidence from my arthroscope. My OS detected some very mild softening of the patellar cartilage when probing it during the op and characterised its state as somewhere between grade 0 and grade 1 on the common 4 stage (I think) model of osteoarthritis degeneration. So not even chondromalacia patellae which would be level 1.

I am going to make a PT appointment asap as well. I'll be bringing a healthy dose of inquisitive scepticism to the consult but at the same time I'm open to any rational rehab protocols that mesh with my evolving model of the underlying tissue dynamics. Crucial to this is a conservative approach that respects the fragility of my condition and its susceptibility to setbacks and ongoing deterioration.

Anyway, I wish you the very best of luck in your own consult later today and look forward to hearing about the outcome and any further insights that you glean.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 26, 2010, 08:50:45 PM
It's good to hear about the birthday and the new appointment, highroller. Hopefully a rheumatologist will have better insight into your condition.

I have to say my own appointment is about what I expected. I could have written the script, really. I described my condition to the doctor, and he then palpated and also flexed and extended my knee. He said he thought that I had chondromalacia and perhaps that was irritating the tissues. He had me contract my quads and mentioned that there appeared to be some muscle wasting. He didn't order any other tests but suggested that I do a few weeks of PT with a follow up visit to his office in a couple of months. I suppose there isn't much else he could do for me, anyway, as I am obviously reluctant to have an arthroscope done that might not even be necessary. Truthfully, I was hardly able to get a word in edgewise, so I certainly didn't mention anything about Dr. Dye or any other theories for that matter. I'll just go with the flow.

The good news is that there are some signs that my condition has been improving the last few days. There was once a point when I couldn't even flex my knee at all without a sensation of a tremendous amount of pressure, as if I was lifting hundreds of pounds. I now have a full range of motion in my knee. Yesterday I walked for 15 minutes, though I was doing my best impersonation of how I'll be walking when I'm 95, and it didn't trigger any inflammatory response. I was also experimenting with advice on that saveyourself.ca E-book which suggested that some people actually fare better sitting with their knee bent. As it turns out, this seems to be the case for me. Of course, it's just my luck that my other knee seems to be irritated when bent. But I'm more concerned about my worse knee, so that takes precedence. When I can, I'll sit with the bad knee bent, and the far less bad knee extended.

So the only real change here will be going to PT. Let's see if I get the Lottiefox white glove treatment with fancy bio-mechanical analysis, or if they have me doing single legged squats while balancing on a unicycle and holding a 500 pound boulder. Perhaps after imbibing a bit of highroller's Merlot, just to add to the challenge. Got to strengthen those quads! I'll be in the strongman competition in no time!
Title: Re: Sore knees, no diagnosis
Post by: highroller on July 27, 2010, 12:31:38 AM
The outcome of your OS appointment was a bit predictable all right but hopefully the conventional approach will yield some results. Great to hear of improvements in your condition though - it could just be a turning point that you can capitalise on fully this time with a more conservative progression. Fingers crossed.

My condition is fairly static now. I ended up spending a bit of time on my feet yesterday with travel to and from the appointment. I couldn't really walk any slower without going into reverse and each step is very tentative but I managed to avoid sharp pains and it hasn't flared up today. I will try and walk as best I can for a short distance every day from now on.

I did try a few other activities in recent days but was disappointed in my limitations. Stationary cycling is just not possible as the bent knee position puts too much pressure on my kneecap. Swimming is only possible with virtually no leg movement. Sitting in the pool's jacuzzi was quite pleasant though and I was able to perform a kind of cycling motion with my legs in front of me. I'm continuing to perform the other floor-based exercises I mentioned in an earlier post and increasing the frequency and repetition count.



Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on July 30, 2010, 04:26:33 PM
I went to my first PT appointment on Wednesday, and I must concede, it was far closer to the "white glove" treatment than I was expecting. My PT's approach was very professional, and regardless of the general effectiveness of the techniques employed, it's comforting to have a experienced eye observe my progress. The good thing about this is that any progress I make will be measurable. I'll just describe a bit of what happened.

First, I was asking to fill out some paperwork. The most relevant to the assessment, I think, was a questionnaire asking me to rate the difficulty of performing various activities. For example, I put "Extremely difficult or impossible" for running any length of time, and walking more than a mile. I put down "Very difficult" for walking a couple of blocks and climbing stairs, "moderately difficult" for getting into the tub, "slightly difficult" for getting into a car, and "not at all difficult" for rolling over in bed. This establishes a good baseline of what I felt I was capable of doing on the first day of PT.

The PT then observed my posture and gait while walking, to establish a baseline for that. After that, was the only moment that was really at all painful in this process. I was expecting, and certainly wasn't disappointed in this regard, for a squat test to see how deep I could go. That was probably the first time I had attempted to squat at all in at least six weeks, and so I interested to see was I was capable of doing. It ended up being around 2/3 or so of the way to parallel before I felt a bit of sharp pain course through my knee. The PT made the point that you can't establish a baseline without risking a little bit of irritation, and I really can't argue with this. Fortunately, he was satisfied with that and there was no more squatting after that. A little bit later he had me attempt to stand on one leg. I was a bit surprised that I was able to do this for about 30 seconds without much trouble. A few weeks ago, even standing on both legs for any length of time seemed to provoke a crushing sensation in my knee.

He then did a complete assessment of the range of motion, flexibility, and strength of my knee joint, hips, and legs. As I had observed myself, I do now have complete range of motion in my knees. He actually measured it with some sort of device to ascertain the angle of the knee flexion, and it was about the same in both knees. For muscular strength, he would place me into a certain position, and I would attempt to resist movement as he applied pressure in the opposite direction. There are probably some muscular imbalances, but nothing too serious as I was generally able to hold fast. For flexibility, the PT did notice tightness in some areas, and said that would be something we would work on over time. I was a little concerned during this process that the pressures being applied might irritate my knee, but there was no other moment like the squat test, happily.

When this was complete, he demonstrated how to do various stretches that should help to restore a normal gait. I've expressed skepticism in the past about the efficacy of these measures, but on the other hand, I've certainly seen the benefits of stretching with the Egoscue method as I described above. I have no doubt that flexibility plays some role in rehabilitation, but given the severity of the condition, a protocol of rest with a slow progression of activities is clearly still the most important factor in recovery. Even here, though, I think having a PT involved will prove beneficial. He has undoubtedly treated and seen to full recovery a good number of people, and will hopefully help me to determine when I might be capable of increasing my activity levels.

Since June 13th (which was the day that I had my first major flare up of inflammation), this is probably the longest period of time that I've gone without a major flare up. The last time I had a bout of inflammation even approaching that level was on July 12th, and a more minor flare up on the 19th. I decided this morning to attempt to walk at a more normal, but still slow, pace, and I went for about five minutes without any major pain, but I won't know until later in the day if there will be a negative reaction to it. If there isn't any adverse reaction to it, I'll probably do the same tomorrow. My greatest fear is that all of this "progress" may simply be a result of the tissues calming down concomitant with the lower level of activity, and that as soon I start upping the level to something resembling a normal walking gait, I'll be right back where I started. I'll know in the next couple of weeks.
Title: Re: Sore knees, no diagnosis
Post by: highroller on August 01, 2010, 09:28:14 AM
Sounds like you've found a decent PT there. The chap I tried back in Jan was a charlatan by comparison. I have an appointment with a new guy next Friday - he comes highly recommended and specialises in knee rehab so hopefully he'll live up to the hype.

I'd rate your current capabilities slightly ahead of my own. The mere thought of a 2/3 squat is sufficient to trigger a sharp pain in my kneecaps! I have near complete range of motion in the knee joint, albeit with some discomfort, as long as no additional pressure is applied but, for example, a quad stretch, kneeling back on my heels or even the point of maximum knee flexion on a stationary bike are beyond my limitations right now. I did walk for a few blocks today at a slow pace but experienced a couple of sharp pains about a block from my apartment on the return journey which made for a rather uncomfortable and nerve-wracking home straight. I need to be very careful about the time I remain fully weight-bearing for any single contiguous period. Hopefully today's unpleasant episode won't result in a setback but that won't be apparent until I gingerly alight from my bed tomorrow morning.

I have established an exercise circuit that I perform at home once a day now with a gradual progression in the number of circuits and repetitions:

Shoulder stand position: inverted knee extensions, bicycle movement, squat
Lying single leg raises
Lying leg curls
Lying glute/hip raises
Walking (on the spot or moving slowly) raising thighs to 45-90 degrees *
Walking on the spot leg curl *
Calf raise
A few upper body movements such as chins and push-ups

* I hold on to the backs of 2 chairs initially and later transition to unassisted

I repeat some of the exercises at other times during the day for lower rep counts to keep the joint lubricated and maybe build some neurological acceptance of the movement pattern if that makes any sense.   

I managed to secure an earlier date with the rheumatologist (Aug 12) plus I've also scheduled a consult immediately prior to my PT session next Fri with the sports doctor I originally saw at the onset of my troubles last year. So it's a shock and awe barrage of consultations over the next 2 weeks.

One treatment I may pursue with both the sports doctor and the rheumatologist is a more potent cocktail of anti-inflammatory agents than I tried previously, possibly even a cortisone injection. The difficulty with the latter is what tissue to target as well as the risk of tissue damage. I don't have any visible swelling but my instinctive sense of the underlying problem, which accords with the tissue homeostasis model, is a more subtle inflammation of the synovium or other delicate structure.

Anyway, great to hear you're making some progress and under competent supervision now. Just be sure to take it easy, one step at a time so to speak...
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on August 01, 2010, 04:19:54 PM
Such is the intractable nature of this condition, that it has now descended to a state not much elevated above its worst. It's interesting that you mentioned specifically that a quad stretch is beyond your envelope of function. That was also the case for me, and I demeritoriously failed to recognize this before it was too late. My knee has become a veritable Potemkin village which, when it reaches its most tranquil state, elicits a sense of complacent ease, and I have often misconstrued this as a sign of recovery beyond what is warranted. The facade of recovery, unfortunately, belied the true, delicate state of my knee. The pressure was just too great, and my knee succumbed.

On Thursday, I did a standing quad stretch, and afterwards felt that I might have antagonized my knee. I decided that the next time I did this stretch, I would try it lying down, thinking that the one legged stand was the main culprit. It turns out that it was the stretch itself that was bothering it, but by the moment of this realization, it was already too late. Most of the progress, if it was ever genuinely progress at all, is now lost and I find myself once again limited in my range of knee flexion. It is perhaps not as bad a few weeks ago, but it is nonetheless a blow to my psyche to regress, as the Evolution of Man in reverse, to a state more resembling that of the troglodyte.

It's really too bad, as everything else went without a hitch. I couldn't have felt much better on Friday morning, and not much worse the whole of Saturday. My knee just ached throughout the day. I think the best thing to do now is to rest a few days before going back to PT, and report the negative response to that stretch. Hopefully by the end of the week I'll regain most of the lost range of motion.

I'm sorry to hear about those sharp pains during your walk. Just remember, even if you can't notice the difference, you probably will have a lower envelope of function for a couple of days as a result of that. I agree that you do need to regulate the amount of walking that you do. Any increase should be introduced as gradually as possible.

If those exercises aren't bothering you, I think that is probably a good thing. I had integrated some bicycle movements and knee extensions as you had mentioned, and I do feel that it may have played a role in increasing the degree of flexion in my knee prior to Friday's unfortunate events.

As far as those cortisone shots are concerned, even if you do get some relief, how do you know that it is actually therapeutic and not simply, as I put it above, a Potemkin village? You might feel better for a while, but when the effect wears off, you'll be right back where you started or worse. If the pain relief is a mirage, you might not realize that you are further irritating your knee. And of course the always present danger of tissue damage that goes along with steroids. Structurally, your knee is fine. You don't want to change that.

As far as the PT is concerned, all I can say is, while it is a benefit to have professional advice, don't let that override your own good judgment. I should have stopped doing the quad stretch immediately after it first bothered me, and not tried to rig up my own alternative version. I do think that you need to always be your own best advocate, though. And if the PT wants you to do something that you're pretty sure is going to elicit a "Yowie!" (And by this I simply mean a pain response, and not that mythical creature lurking in your own outback. Although, as we know, after a Yowie!, you'll more resemble a Yowie!), you need to suggest a more conservative approach. As far as the quad stretch is concerned, I'd suggest passing on that for a while.



Title: Re: Sore knees, no diagnosis
Post by: highroller on August 02, 2010, 07:28:45 AM
Sorry to hear about your setback. Looks like we've managed to coordinate flare-ups in anguished synchronicity! Despite feeling a bit tender yesterday evening, I managed to get through my exercise routine this morning without noticing any significant adverse effects from yesterday's ill-fated excursion but not long after I felt the onset of aggravation to my left knee.

Regarding anti-inflammatory treatment, at this stage it's just a topic for discussion with my doctor. My concern is that I am not able to sufficiently diminish whatever tissue inflammation may be at work through rest and conservative activity management alone. Perhaps some external assistance could give me the functional space I need to progress. Snowy mentioned a one month protocol of  high dosage NSAIDs and low intensity exercises in an earlier post that yielded some results. I'm certainly mindful of the risks and issues - just something to consider. Having tolerated oral NSAIDs in the past, I would try a more potent tablet before considering an injection. I'll report back on my doctor's opinion after my consult on Friday.
Title: Re: Sore knees, no diagnosis
Post by: Lottiefox on August 02, 2010, 06:26:43 PM
A conventional quad stretch tends to annoy my kneecaps too - it places tremendous pressure on them when you bend like that to stretch the quad.

It might be worth discussing foam rolling with your PT. I am a convert.

http://sportsmedicine.about.com/od/flexibilityandstretching/ss/FoamRoller.htm

It allows you to target specific areas that are tight, acts as a form of warming up of the muscles and used regularly (at least once a day) loosens the knee and the structures around it. Not saying it is right for you, but the NASM training principles advocate it prior to any training session and afterwards in combination with stretching. It is relatively quick, cheap and can really help with kneecap general aches and pains.

As regards higher dose NSAIDs - I had a month of Naproxen last year when I had my worst flare. They did bring down the swelling but I can't say they made a massive difference to pain. I sometimes use topical NSAID gel if the knee is especially sore - Voltarol is good for me and reduces the nastiness of bunging NSAIDs into your gut.

Lottie  :)
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on August 03, 2010, 04:45:24 PM
That flare up I had on Friday now appears to have been rather minor, and I'm now back on track again. I had my second PT session yesterday, and I'm quite surprised at what I was about to do! He first had me on a stationary bike for about 8 minutes, of course at the lowest resistance setting, and I made it a point to cycle as slowly as possible. Then, and this is where I started to sweat a little bit, he had me doing leg presses at 40 pounds (about 18 kg) of resistance. I did 2 sets of 10 reps, and I'm happy to report that there were none of the dreaded sharp pains. Finally, I did 3 sets of 10 step-ups onto a 4 inch (about 10 cm) platform. Again, a sense of relief that there were no sharp pains. At the end of session, there was a bit of soreness, but nothing major. I was a little concerned that I might have a flare up a few hours later, but fortunately, just a little soreness. Right now I'm sitting here and feeling pretty decent. My next PT session is on Friday.

I asked if I should be doing any exercises other than the ones prescribed. He said that I should just take it easy so that he can monitor my progress. I think he'll probably up the ante at the next session. Maybe 50 pounds for the leg press, or a 5 inch step up. As long as I'm making progress and not in pain from the exercises, I'll keep slowing increasing the loads week by week. Just the fact that I'm capable of doing these exercises at all gives me some hope!

I did mention foam rolling to the PT, and he is familiar with it. He said he actually uses it himself at home. He did suggest, however, that it would probably be more relevant for me when I've progressed a bit more.

Concerning NSAIDs, what has always confounded me is whether the benefits are merely analgesic, or are actually therapeutic. NSAIDs operate by inhibiting COX enzymes which are catalysts in the production of prostaglandins, which is a eicosanoid (signaling molecule) in the process of inflammation. Interestingly, eicosanoids are also messengers in the nervous system. Certainly, it seems that the process of pain response and inflammation are tightly intertwined. But, what I don't know is exactly how they are interrelated. Severe inflammation can damage surrounding tissues, and it seems that whenever I have an inflammatory response, thereafter I have a heightened sensitivity to pain. But in a case of more subtle inflammation, are the NSAIDS merely reducing the inflammatory response, but not actually affecting the sensitivity of the nerves to pain, or are the two processes more deeply intertwined, and COX inhibition will actually intervene in the "pain response cascade" and perhaps provide enough headroom (kneeroom?) to break the vicious circle, and begin a virtuous circle of recovery? I want to also mention that I thought that I tolerated NSAIDS reasonably well, but I did have some stomach upset recently when upping the dose to deal with the severe inflammation last month. Any treatment with NSAIDs taken with the intention of therapeutic benefit would presumably involve rather large doses. If your doctor does suggest that as a possible line of treatment, it might be wise to request a prescription for PPIs (Proton-Pump Inhibitors) or other stomach acid reducer to decrease the risk of ulcer formation. NSAIDs are powerful drugs and shouldn't be trifled with. You're already in more than enough pain, and don't need any augmentation to the pleasures of PFPS.
Title: Re: Sore knees, no diagnosis
Post by: Lottiefox on August 03, 2010, 07:07:51 PM
Good news that you're tolerating the PT exercises. I tend to find that a dose of ice after things like that also helps with controlling any possible flare ups, but each knee is of course different!

Has your PT said anything about working on your hips and glutes? Clearly the step ups involve all of the lower leg muscles (I trust he is checking you for proper form and that you're stepping up rather than pulling the leg up, and that your knees are not caving inwards etc as you shift your weight....) but a focus on the hips and glutes can also REALLY help with PFS. In fact they are the things I had to start with before I was even allowed to sniff the leg press! I now find that single leg work on the leg press is also more useful than dual leg, but being very careful with the range of extension and not locking the knee out at all. Do you have homework from your PT? I agree you don't want to overdo things but it is good to maintain things at home to allow progression in your sessions. Funny how opinions differ on foam rolling too - some PTs/Trainers get people using it first thing as the principle that the looser and less knotty a muscle is, the more it can be worked effectively. Others want to see what you can do "raw" I guess. No right way - which is what makes rehab so frustrating at times!!

Glad things are improving though.  ;D

Lottie
Title: Re: Sore knees, no diagnosis
Post by: highroller on August 06, 2010, 11:00:17 AM
Indeed, great to hear of your continued progress. We need all the good news we can get around here!

Re: foam rolling, I have experimented with it extensively in the past. I even own my own roller as well as a few other medieval instruments of soft tissue torture! I can't say that I've ever noticed any improvements in tissue quality or†function from performing the various exercises, even the exquisitely unpleasant IT band roll, but it does feel right on an instinctive level. I have my fair share of trigger points - unfortunately they are incredibly resistant to treatment and any progress in tenderising the knots is usually short-lived.

As for the last few days, I've been pretty much immobilised by the latest setback. On this occasion I've been trying to reduce the time I spend weight-bearing to an absolute minimum while still performing the unloaded movements in my exercise routine. I've resorted to wheeling myself around my apartment on an office chair, sitting in the shower and even scooting around on my butt in a fashion that even a troglodyte would find demeaning, such is the discomfort I have been experiencing merely from standing. With my consults approaching earlier today, I was somewhat desperate to diminish the irritation as best I could to facilitate travel and the assessment process.

Which brings me to the consults themselves.

First up, the highlights from my appointment with the sports physician I approached† with the nascent stages of my affliction back in May 2009 and then subsequently a couple of times toward the end of last† year.

- His assessment of my knees through a variety of manual tests revealed a reasonable level of function that is very much at odds with my hobbling gait, weight-bearing discomfort and other limitations
- He feels that the condition may be perpetuated and worsened in a vicious circle by pain itself i.e. pain (and possibly an exaggerated perception of injury through faulty neural feedback) -> biomechanical compensations and faulty muscle recruitment (e.g. hobbling) -> pain
- Suggested pain medication such as Panadol and anti-inflammatories coupled with PT aimed at restoring healthy recruitment patterns
- Whereas I was concerned that masking the pain response could leave my knees vulnerable to further aggravation, he felt that†I need to disrupt the pain response to provide space for the development of function and neural rewiring
- Also need to rule out a number of inflammatory conditions that can be detected via a blood test. This will also be useful for my rheumatologist appointment next week.
- I may also get another MRI on one or both knees. He felt that this could wait until I have tried 2/3 weeks of PT but I was keen to pursue multiple lines of investigation in parallel to accelerate the diagnostic process so he left that decision with me.

Notes from my PT appointment:

- He had a chat with my sports physician so was well briefed on the history of my condition and working theories of diagnosis
- Prescribed a series of exercises mainly aimed at reestablishing proper recruitment of the quads when I walk:
† †- Mini walking lunges *
† †- High knee walk with bent supporting leg *
† †- Single leg balance with bent supporting leg *
† †- Lying (supine) hip/lower back rotations
† †- Massage knee area
† †* very shallow knee bend, maybe 15 degrees
- May work more on the neural dimension of the problem through soft tissue work in the lower back and spinal area during our next session. He mentioned that the nervous system can amplify the intensity of the pain signal disproportionately leading to overcompensation responses.
- I should stop doing my own exercise routine. He felt that the inverted movements, while ok for lubricating the joint, are reinforcing recruitment patterns that do not translate well to functional movement such as walking.

Next steps then are:

- PT exercises daily
- Panadol and Naprosyn daily
- Blood test asap
- Rheumatologist appointment on Aug 12
- Next PT appointment on Aug 16
- Next sports physician appointment on Aug 27, possible MRI prior to this


Title: Re: Sore knees, no diagnosis
Post by: highroller on August 06, 2010, 11:17:27 AM
I felt that a separate post was warranted to mark tomorrow's auspicious occasion.

Happy Birthday to 'knee always hurts'!

Consider this virtual greeting card to be delivered in an expanded envelope of function addressed to your re-emerging alter-ego 'knee never hurts'!!
Title: Re: Sore knees, no diagnosis
Post by: highroller on August 07, 2010, 11:47:02 PM
I started taking Panadeine yesterday but didn't notice any reduction in pain. I even experienced a few sharp pains while walking around my apartment. It's going to be difficult to find the right balance of activity in order to incorporate my new exercise program (which only takes 5-10 mins in total) while containing the latest flare-up. I'll probably have to do each exercise separately over the course of the day and minimise or eliminate all other weight-bearing activity until the additional irritation abates.

On an optimistic note, I forgot to mention that my PT has had success with a few similar cases in the past and is reasonably confident that I will recover over a period of a few weeks to a few months. In his experience, progress tends to be non-linear with slow improvement initially and more rapid gains later in the process. Time will tell...
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on August 09, 2010, 04:06:45 PM
Hey all,

My birthday was on the 7th, and it turns out it was a bit auspicious. I'll get to that in a bit. I thought I would just be sitting around doing nothing on my birthday, but my brother-in-law, being the gentleman and scholar that he is, invited me over for a few beers. You know, I really had wine in my mind, but how can you turn this down. I'm not sure if my consumption was particularly admirable, or moderate, but it did actually relieve a bit of the ache in my knee. Truth is, I don't drink too frequently, so I'm not that familiar with my tolerance level for the wicked brew. Anyway, I did stagger a bit to the side at one moment, but happily I can report that my knee survived the day intact.

The happenings of the last few days have been quite auspicious, as I've mentioned above. I went to PT on Friday, and quite significantly upped the load levels. I did 40 lbs on a single leg with the leg press, 6 inch step ups (though I did almost get a twinge of pain on a few of the step downs), and did 8 minutes on the exercise bike at a significantly increased speed. My PT also did this massage on my quads, and Good Lord, I guess he found a myofascial knot, because I was in so much pain I was actually laughing. He also introduced me to the foam roller, which was actually less painful than those wretched hands of his. The good news is that none of this seemed to trigger the dreaded inflammatory response.

Now, the good news of the last few days. The PT suggested that I start trying to walk with a heel-to-toe gait, and this of course necessitates bending the knee a fair bit when walking. I was a bit skeptical, but of course, I gave it a go. I've been walking like this since Friday afternoon, and at a decent clip I might add, and no sharp pains! Perhaps my knee is finally crossing the threshold back to good health! It still aches quite a bit, but this seems even this may be diminishing. I'm just hoping that this isn't the quiet before the storm. But if a few days has gone by, which is the case here, and I'm not seeing any setbacks, I'm think that I've progressed to a new stage. Now I just have to keep from regressing to the deeper bowels of the cave.

Keep hanging in there highroller. That's really terrible news about your knee. It was just July 13th when I was last in a similar situation. I think your PT is right about the non-linear progress. It's really at the point when you're able to walk normally that the progress starts to pick up. Perhaps you still can't squat, or have trouble with stairs, but if you can walk for any length of time you can "condition" your knees back to health. Back in May I went from being on crutches to thinking I could run in about 2 1/2 weeks. You need to be able to walk with proper gait and at a normal speed, though. I think what you need to do now is just rest it until you can at least stand without pain. Then, start slowly increasing your walking speed again. One thing I've found is that you can actually handle more weight than you think earlier than you think. The PT had me doing very low rep moderate weight exercises with a full range of extension right from the start. I was quite nervous about it, but it turned out that it may have actually helped. I don't think what you're facing is really all that unusual. You just have to have the right approach to recovery. With time, you'll no doubt improve.
Title: Re: Sore knees, no diagnosis
Post by: highroller on August 14, 2010, 03:27:43 AM
Glad to hear you celebrated in the time honoured fashion and avoided any calamities. The grain is as worthy as the grape for marking these chronological milestones although that being said in your condition you should be wary of anything involving hops.

Also great to hear of your continuing rehabilitation progress. Your feats of strength and athleticism would merit a world ranking in the patello-femoral pain pentathlon!

I have had rather a mixed week since my PT session on Fri Aug 6. The aggravation I experienced just prior to that appointment did settle down and I was able to start the new exercise program. I was actually starting to make some progress and even managed to walk at almost normal speed for short distances.

Encouraged by this, I set off for my rheumatologist appointment on Thurs and planned to walk a few blocks to take care of some errands on the return journey.

The rheumatologist had already received the results of a comprehesive set of blood tests and pronounced all readings as normal. He also found no evidence of any inflammatory condition from a physical exam or from reviewing my x-rays and MRIs.

I did manage to walk those few blocks on the way back without triggering any sharp pains but I experienced the usual gradual build-up of a sense of pressure / fullness in my knees over the course of journey and felt that I was very much at my limit by the time I got home. Unfortunately, by Fri morning it was clear I had triggered another flare-up and was forced to avoid weight-bearing again. The situation may be slightly improved today but I'm erring on the side of caution and resting. Hopefully I can resume the exercises in time for my next PT appointment on Mon.

I have only been taking the pain killers and anti-inflammatories sporadically, partly due to stomach discomfort which may be unrelated but in the interests of not adding an ulcer to my list of concerns I decided to back off the medication. As noted in an earlier post, I detected very little analgesic effect from the Panadeine anyway.†

In the interest of accentuating the positive, I do feel the PT's exercise program has some merit, particularly the idea of reengaging my quads through shallow knee bending movements. I clearly need to be more vigilant about limiting the duration of any individual period I spend weight bearing to a few mins at most for the time being.

The heel to toe gait sounds interesting - does that mean making initial contact with the ground using the heel and pushing off with the toe?
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on August 15, 2010, 12:19:25 AM
Cue the music to The Good, the Bad, and the Ugly, as that about sums up my past week in the land of pain.

The Good:

Now, before we begin with The Good, let's keep in mind that there is a Bad and an Ugly to follow. With those caveats, there were some hopeful signs this past week.

I almost thought I caught a glimpse of the cave entrance earlier in the week. Like any well behaved troglodyte, I was in no rush to climb out of the cave of course, but had intended to wriggle on my belly until reaching the opening. This would take a few more weeks perhaps, but I was on my way to freedom. If level of knee function = walking speed X amount of time walking X degree of knee flexion, it wouldn't be too immodest to claim a 100 fold increase in function from last week to the present. It's has been well established that there would be a tipping point wherein a certain threshold is reached, and you can truly feel a change, as if a burden has finally been lifted off of my disconsolate knee. The change was not entirely unexpected, but it was sudden. In a moment, I had realized my knee had changed. It still didn't feel completely "normal", but it was certainly the best place I had been in since late May. However, as you'll see in "The Bad", I'm not going to be winning the PFP pentathlon any time soon. However, to while away the time, I have been playing a nifty little strategy game called Defense Grid. It turns out that this afternoon I got in second place on one of the maps. That's second place as in second in the entire world. Not quite as impressive as it sounds since there are only around 3600 entries for that map. But a nice distraction from the pain (and it turns out I'm in quite a lot, look out for The Ugly). At least I have something to be proud of. But nothing regarding my knee, as it turns out.

The Bad:

I have warned myself and others about being overzealous when you think you're making progress, but I guess I couldn't help myself. On Thursday I ended up walking just a wee bit too much. It was in the late evening, but that unmistakable "pressure or fullness" returned suddenly. On Friday, I dialed down what I was doing quite a bit. Yet, I was again feeling sharp pains. Today, I'm not quite sure what I'm capable of doing since I've decided to hobble around at the slowest possible pace. I've so far avoided sharp pains today. It is quite excruciating to have a setback when you can almost taste recovery. But I've resolved that I will avoid the condition ever descending to its previous low. However long this takes, I'm confident now that at least I'm pretty close to the threshold of recovery. I noticed that highroller triggered another little episode on Thursday. You're not joking about our "anguished synchronicity", are you?

The Ugly:

No, I'm not referring to my slimy, scaly troglodyte body. I must confess, a rather unlovely pain has stricken my back! This is nothing new for me, sadly, as I have been dealing with sciatic pain since the ripe, old age of 19. But what an inopportune time to resurface! I must count my blessings, however, as this condition can be amongst the most painful known to man (or woman). A couple of years ago, I was bending over and I somehow tweaked the nerve in my lower spine. Crushed may be more appropriate here, as the pain was ineffable. It sent some sort of shock wave up to my brain, and my vision went blurry, and I heard a sort of whooshing tinnitus in my ears. Not a moment that one cherishes, but I'm happy to at least report that this time it's far less severe. Of course, only relatively. I get a most pleasant (if I was a masochist, anyway) reminder every time I bend over or try to lift myself off a chair. And I know that at any time, I could be completely immobilized.† Maybe I should check if there is a back geeks forum?

I suppose this is a little belated birthday gift from my body. Aww, you shouldn't have, spine! If I am truly fortunate, perhaps for my next birthday my neck, hips, and wrists will also deign to present me with such an exquisite ceremonial dagger. I am rather offended that they forgot this year! (I shouldn't say any more, as they might not think that a week is too late to present me with a gift!)

I've had that music in my head for a couple of days now. Much like a microcosm of life itself, my past week has had a little of The Good, the Bad, and the Ugly.
Title: Re: Sore knees, no diagnosis
Post by: highroller on August 22, 2010, 09:50:26 AM
I do hope things have improved since your last update a week ago. That recurrence of sciatica is truly a cruel twist of fate. It was however encouraging to hear of your proximity to the cave mouth - I look forward to hearing motivating accounts of the lush sun-kissed meadows beyond as you traverse their expanses with the agility of a gazelle in due course.

A quick update on developments in the dank recesses of my own cave over the last week or so.

I did recover from the last setback, at least back to the rather debilitated state I found myself in prior to the flare-up. These episodes have lasted 2-3 days recently which is an improvement of sorts I suppose given that prior setbacks have lasted quite a bit longer.

I had my second PT appointment last Monday. Two exercises were added:

- Step-up onto a platform about the height of a telephone book for 2 sets of 6 reps per leg.
- Seated thoracic rotations with a 5 second hold for 5 reps each side

I was able to perform the step-ups initially but their once unintimidating form has now morphed into the imposing aspect of a sheer Himalayan mountain face after I was greeted with a few sharp pains at the summit of a left leg ascent. I've dropped them for now.

Thankfully I have managed to perform the remaining exercises most days and with highly questionable enthusiasm I have also added walking at at near normal pace for a very short distance as well as a brief stint of 50-100 revolutions on the stationary bike, both just once per day. This seems to be right at the perimeter of or just beyond my comfort zone as I have found my left knee aching quite a bit for the remainder of the day but more or less back to its usual state by the following morning. There seems to be a fairly static limit to the duration of time/distance I can remain weight-bearing, particularly in motion but also when standing still. After this brief experiment, I think I will switch to more frequent sessions of shorter individual but hopefully cumulatively longer duration over the course of the day.

I've been peforming quite a bit of foam-rolling and other forms of self-massage and myofascial release prior to and during each exercise session. I have located a couple of trigger points that reproduce similar referred pain in my knees but kneading them into submission has not yielded any noticeable benefit thus far.

As for the painkillers and anti-inflammatories, they have been jettisoned from my regimen following further bouts of stomach pain and heartburn. This is a concern as my doctor was keen to investigate the effect of suppressing the pain response on the movement pattern compensations that I have developed.

So perhaps a little progress but the pace is glacial and always teetering on the precipice of reversal.
Title: Re: Sore knees, no diagnosis
Post by: highroller on August 24, 2010, 02:43:31 AM
Looks like I'm in the throes of another setback. I can just about tolerate weight-bearing for about 60 seconds before the discomfort forces me to sit down again for quite some time until I am in a position to attempt to walk again. Admittedly I pushed the pace a little in recent days but only ever so slightly. Such a frustrating, nay infuriating, condition. Hopefully I'll be able to resume the original exercise program in a few days and start over.

I have a doctor's consult on Fri - unfortunately there will be no progress to report since our last session 3 weeks ago.

My worry is that every setback, even the minor ones, chip away at my functional limits and establish a new ceiling for recovery. That seems to be the case looking back over many months. Frightening to extrapolate that trend.

I'll forgo any disingenuous optimism today in the interests of fully indulging my misery!






Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on August 30, 2010, 12:44:21 AM
I was fortunate that I was able to get back to my previous state after about 9 or 10 days. Unfortunately, I had another setback this morning.

I actually was making significant progress. In the last couple of weeks, I've been doing squats almost to parallel at PT, and I was OKed to climb and descend stairs normally on Friday. I think it was the combo of the stairs and the fact that I've walking more and at faster speeds that pushed me over the limit this time. Setbacks are inevitable, as I've learned by this point. I have to be pleased with the progress that I've made though, and hope that more is to follow. I do feel that the worst of this is over, and that it is highly unlikely that I'll ever be going back. Irritating the knee is still a setback, but as long as I rest it enough, it won't go back to where it was again. That is a bit liberating, but sadly, I'm still not able to do much, as the setback today testifies to. Oddly, I felt like I've been at this point before. My knee has felt similarly, and the amount of activity that I did, was acceptable at that point (probably in early May). But it is a truism with PFPS that the longer you've had it, and the more severe it has been, the more difficult it will be to resolve. My experience does corroborate that these setbacks seem to accumulate, even changing the level of sensitivity permanently (or semi-permanently). This doesn't mean that recovery is impossible, I don't think, but that at each step of the way, it is more likely that we will overestimate our capabilities. After my last setback, I had established with my PT that I would really limit activity out of the sessions, and I regret deviating from this. He has generally made the right calls, since I haven't ever had a setback during a session.

This is the first time that I've really got to test out the other knee, though, and I have to say that the plot thickens here. The odd thing is that it really doesn't seem bothered by walking at all, or at least not much, even at faster speeds or for greater lengths of time. However, there does seem to be a correlation between doing things that involve the knee being bent, and the level of soreness in the knee afterwards. So for example, squatting, or even just sitting for any length of time with the knee bent, seems to bother it. The strange thing is that there is really never the sort of sharp pains that I've experienced in the other knee, or the inflammatory response, either. Just a general soreness, or ache in the knee that sometimes seems to subside but rarely for long. The only time I really experienced any pain in this knee was when I forgot that I was having issues with it and walked up two stairs at once. There was a sort of crushing sensation in the knee at that point, but it didn't really hurt much more afterwards and there wasn't an inflammatory response.

I am a little concerned that even if I'm able to resolve the issue with my left knee, the issues with my right knee might persist for longer. I just have that sense. We'll see I suppose. I do regret ever using crutches, though, as it seems like my right knee would be perfectly healthy if I hadn't. It is just strange how the symptoms are so different. I hope I didn't tear the meniscus or damage something else. It seems unlikely, but perhaps PFPS just manifests itself in different ways. The most hopeful thing is that if anything it seemed like it was improving slightly even as I was beginning to do squats and climb stairs. So perhaps if I can keep giving it moderate inputs, it will eventually resolve.

The only thing I know for certain here is that I don't know much about the path this recovery will take. While that is not very comforting, the path out of this wretched cave is long and twisting, and we can hope it leads to pain free knees in the end!

Good luck with surmounting your Mount Everest by the way! I don't suspect either of us will be climbing the real thing any time soon!
Title: Re: Sore knees, no diagnosis
Post by: SqshPlr8 on August 30, 2010, 10:44:14 PM
*I posted this under "To scooter or not to scooter," but just read your posts and was amazed how similar our conditions appear to be. I might give total rest a shot, rather than fiddling with a scooter...† Best of luck!

I have had bilateral knee pain for ~ 4 months.† I stopped playing squash and running in mid-May after twisting my left knee.† † Had x-rays, MRI of my left knee (only x-rays of my right), which revealed nothing.† I was diagnosed with fat pad impingement and CP, for which I had a six-week stint at physical therapy and then a three-week protocol of Voltaren (10 days) and simple stretches, both of which didnít help. Iíve been swimming which, at first, helped a tremendous amount with pain.† Now, though, even swimming Ė both breaststroke and flutter kick Ė can be bothersome.†

The most annoying thing, however, is everyday activities.† Walking anymore than 100 m aggravates my knees.† I can characterize the pain as a din of discomfort punctuated by specific, spear-like pains behind and below my patellae. Sitting for long periods of time sucks, too.

I was just tested for rheumatoid arthritis and Lyme disease, which, thankfully, came back negative.† †I see the doctor again in two weeks, but my biggest concern at the moment is simply trying to deal with physical reality of everyday life.†

Iíve tried tracking braces and tape, along with orthotics, but they havenít really helped.† Iíve also tried crutches to no avail. The pain is not debilitating Ė though it is verging on intolerableóbut I seem to be aggravating it by everyday movements.† As an interim measure, I have thought of renting a scooter to get to, from, and around work, at least until the pain comes down and I can see the doctor.† †

Few questions: 1) Has anyone here had PFS, CP, fat pad impingement symptoms that affected their everyday movements? If so, what did you do to cope?

2) Is the scooter a good idea? I donít want my quads to waste away, but I donít know what I should do.† My PT and doctor said that walking is fine, but the pain just seems to be getting incrementally worse day by day.†

3) Has anyone here with PFS etc. used a scooter/wheelchair for any period of time to let the symptoms die down before going back to rehab?† If so, could you elaborate on the success/failure of your experience.

Thank you so much!

26 y, M
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on September 03, 2010, 12:21:46 AM
I've noticed that this thread has grown to quite a substantial size! I'm telling you, when all is said and done, this is going to be one of the largest threads this forum has ever seen! I bet you were never expecting that, were you highroller?† ;D

I went to another PT session yesterday, and out of some sort of miscommunication, I ended up doing a routine scarcely different from last week, despite my setback. There was a moment there when I thought I was descending Everest. Somehow I made it through. My knees were sore afterwards (which could actually be referred pain from my trigger points), but I'm pretty sure they weren't irritated. This thing is finally coming along, I think. I hope you've made some progress in calming down those knees since your last post. I'm telling you, once you past a certain point, it's much smoother sailing from there! There was once a time when I would have been happy to stumble into a billabong and have a saltwater croc chew me to bits, such was my distraught state of mind. Fortunately, wrong country. Anyway, I wouldn't have walked far enough to "stumble" upon it. But I might have liked to! My knees are still petulant, whiny little expletives, but no saltwater croc is getting them now! You'll have to pry them from my cold, dead, corpse, vile croc!† :P
Title: Re: Sore knees, no diagnosis
Post by: highroller on September 07, 2010, 03:30:33 AM
The thread has indeed grown way beyond my expectations but I may have had some naive notions of a swifter resolution back in the day when I penned the inaugural post. I've been disabused of any such delusions since but it's great to have some virtual company to share the protracted and undulating road to recovery.

Perhaps if we maintain the momentum we might attract the attention of the entertainment industry looking for a moving storyline. Surely no audience could fail to be stirred by the emotional rollercoaster that is the life of a PFPS sufferer. I think we could stretch dramatic license to incorporate your croc attack scene as well - in 3D - that should broaden the demographic and make it a blockbuster!

But returning to the more poignant dimensions of the plot, I've been maintaining a bit of radio silence here of late as I try to dig myself out of this latest rut within ruts. I did see my sports doctor again on Aug 27 and he proposed that I give the painkillers / anti-inflammatory combo another shot in conjunction with the physiotherapy program. He switched the anti-inflammatories to Voltaren as I had not tolerated Naprosyn and also prescribed medication to protect my stomach. His working diagnosis remains nerve irritation and he also suggested a recovery timeframe of 6-9 months.

I seem to be tolerating the latest cocktail of pharmaceuticals but I can't detect any analgesic benefits. Unfortunately, I'm struggling to perform the same exercise program which I could complete pain-free over a month ago. I do what I can but at this point it's not much. I spend 99+% of the day off my feet.

I'm not sure if it's related but I seem to have aggravated my hands and fingers from the self-massage I was performing on my legs. They have been very stiff and painful for about a week now. I'm wondering if I may have a more generalised hyper sensitivity to nerve irritation.

I'm seriously considering getting a wheelchair for mobility as I am confined to my apartment and totally dependent on my girlfriend for shopping, etc. Cabin fever may be imminent if I don't escape the confines of my cave but then again, a psychological disorder might be just the antidote for my faulty neurological wiring - radical, but I'll try anything at this stage!
Title: Re: Sore knees, no diagnosis
Post by: highroller on September 15, 2010, 05:37:18 AM
Quick update:

I had another consultation with my doctor yesterday. He is confident that I am suffering from neuropathic pain which he tells me is very difficult to treat. He prescribed Amitriptyline and has also referred me to a pain management specialist - the lady in question is a doctor, anaesthetist and medical acupuncturist. I'll be seeing her in 2 weeks.

I'd be interested to hear any thoughts, advice, experiences, etc. regarding neuropathic knee pain and medication/treatment protocols.

Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on September 15, 2010, 04:48:25 PM
Let's see, who should be the director? How about James Cameron! Though the audience would probably be bored to death with our daily routines. But when we get our avatars...

It's quite saddening that you've come to the point of considering a wheelchair. The thought certainly crossed my mind more than once when my condition was at its worse. I know most other members of this forum would advise against it. But you have to live your life. You're been essentially confined to your apartment for months. I think you need to do whatever is necessary to improve your quality of life. You're sitting 99% of the day anyhow. I'm not sure that everyone understands how psychologically distressing it is not to be able to move around under your own volition. I think just being able to move without anxiety about your knee or having to ask for help with every little thing will be cathartic.

I wouldn't be so quick to assume that the hand pain is from hypersensitivity. I've had aches and pains all over my body during the past few months. In fact, right now, on my right side, my neck, shoulder, elbow, and wrist is quite uncomfortable and stiff. And this isn't the first time I've had such issues. Even back in March-May, I had severe pain in wrists (around where the thumbs attach), which I now think was carpal tunnel syndrome. I had so much pain in so many joints that I has the doctor test me for rheumatoid arthritis and Lyme disease (both came back negative). It resolved almost immediately when I was able to move around again. Unfortunately, after my condition worsened again, the pain has returned with a vengeance.

Isn't it just stating the obvious though, that PFPS, especially when severe, is a form of neuropathic pain? I suppose he is suggesting that it might originate with the central nervous system rather than the localized tissues. It's worth a shot, but if it started as PFPS, I'd say it is probably still PFPS. But it may be that those who tend to suffer from this condition do have more sensitive nervous systems. I know mine is quite wonky. A few years ago, while working on a construction site, I started to get ringing in my ears. At first it stopped, but then a few days later it started up again. It's never stopped again. There's nothing in my ears producing a sound signal. I understand that I damaged some fibers in the inner ear, but why the sound? I expect it will be with me for the rest of my life. Another strange thing happened a few months ago. When my knee was at its worse, in June, I was really "nuking" it with ice. I think I might have damaged a nerve, because my foot started to turn almost purple. I of course immediately stopped icing, but it was already too late. Afterwards, my foot just felt "wrong". In fact, the description of neuropathic pain fits it perfectly. Burning and cold sensations, pins and needles, numbness and itching. After a few weeks, it started to spread to my other foot and to a much lesser extent my hands and face. I think I may have triggered a case of complex regional pain syndrome, which is a form of neuropathic pain. It used to be called causalgia, which many veterans of the Civil War in the United States were stricken with. Of course, with them, they probably sustained serious battle injuries. In my case, it started icing my knee. Lovely, isn't it. The only good fortune is that it isn't too severe. From what I've read, CRPS can be absolutely debilitating. In my case, it's more of a minor irritant. But I'm fearful that it could get worse, naturally.

Having what is certainly a case of some sort of neuropathic pain (I'm not sure if it's actually CRPS, though), and two difference sorts of PFPS (Inflammatory in the left knee, aching in the right), I can say definitively that PFPS doesn't feel much like neuropathic pain. I don't want to contradict your doctor, not knowing all the details that he must be familiar with. But unless you have pain symptoms consistent with what I've described above, I'd be skeptical.

As for my knees, they are a mixed bag. My left knee continues to make progress. In fact, my PT has reduced the number of sessions to one per week. I can now go up and down stairs and do most everyday things around the house without much difficulty. I don't know if it will ever be "normal" again. But even if I can't exercise much, my life may be returning to relative normalcy soon. I'm hopeful. The other knee is a different story. I can't really say it's getting worse, but I don't think it's getting better, either. I've referred back to our venerable old guide, the saveyourself.ca e-book again, and it's really describing what I'm going through to perfection. I think it's even more relevant than it was to my left knee. What's interesting is that virtually nothing I do really causes me any significant amount of pain, or at least sharp pain. Some things are mildly uncomfortable, but nothing that prevents me from doing anything non-athletic. The problem is that it triggers pretty significant aching in my knee at a later time. It's really exactly as described in the e-book. I think the most frustrating thing is that you can be at rest and still trigger pain. At least with my left knee, when I was at rest I knew I was fine. That was true even at its worse. With the right knee, even though it is quite mild, I can't even sit with it bent. I can't complain because it could be so much worse. But it will still be a protracted period before I can exercise again, and it is rather disheartening. If I ever want to have a chance at full recovery, I'm going to have to scrupulously follow the advice laid out in the e-book.† If I'm fortunate, it might take just a couple of weeks. But I'm not counting on it. I've experience enough to banish "naive notions of a swifter resolution" from my mind for all eternity.

Whatever happens ultimately, this whole experience has permanently reshaped my view of life, in ways that I can't even comprehend yet. We are all so fragile, and I'll never doubt that again.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on September 22, 2010, 02:22:01 AM
Today is likely my last PT session in a while, as I've had a bit of a flareup with my right knee, and as a precaution I want the doctor to look at it before I continue. After the session last week, which was the most strenuous yet, my knees ached severely that night. The next few days, it was actually a bit painful to walk, which it hadn't been before. I've slowed down considerably as a precaution.

In addition, I've noticed a new issue with my left knee. A few weeks ago, when I was doing step-ups and step-downs at PT, I noticed some sharp pains in my knee. Having pain in my knee is, of course, nothing unusual at this point. But what was strange is that it didn't seem to trigger an inflammatory episode. Over time, the level of tolerance seemed to build, and stairs didn't hurt so much. But then doing squats hurt. I realized the reason this week. The part of my knee that always had the inflammation was the lower lateral quadrant. This pain is in the upper lateral quadrant, an area that had never hurt before. So something else is going on there. Honestly, it might be chondromalacia. I suppose I can only hope that it is not too severe and can be rehabbed over time. For now, I'm not going to worry much about it but it just shows how much farther I have to go for full recovery, and the diminished chances of that ever truly happening.

I'm taking every relevant precaution to prevent my knees from getting worse and to hopefully prepare them for more PT in the next few weeks. I'm still committed to making any sacrifice necessary to achieve a non-surgical recovery. Even if it takes another 6-8 months, that would certainly be worth it to me. The alternative of surgical procedures with uncertain results, or consultations with the pain management doctor for the rest of my life is not too appealing.

The setback this week shows just how precarious this condition is. A Sword of Damocles dangles by a thread over the knees of Patellofemoral Pain sufferers, threatening loss of mobility at any time. The only solution seems to be complete recovery, but what are the prospects of that?
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on October 02, 2010, 09:39:14 PM
I should have never given you the idea. Sometimes you'll see with longterm PFPS sufferers, they'll just get sick of immobility and start wandering. Just at random. And then you stumbled across one of those crocs you've got down under, and you just decided to feed yourself to him, didn't you? I should have never given you the idea!

For my part, I'm just about ready to give a croc some knees. He can have 'em. They don't do me much good.

I was recently inspired by a story on these forums by a poster who was told by the doctor that he would never recover. He implemented an approach not too dissimilar from the one suggested by saveyourself.ca, and has experienced a total recovery. I figure it's worth a shot. But if this fails, then I think it's time for acceptance. The most difficult thing is going to be that, while I'm no longer disabled in a strict sense, it still feels quite horrid to walk much of the time. I imagine if I was doing more of it then it would be even worse.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=53006.0

How does somebody live like this over the long term? It's one thing if I'm able to just relax and take it easy. But to actually live every day life? It seems like a heroic feat. Except I'm no hero.

I haven't even left the house since the last PT session. I've been resting, and trying to integrate very modest activity into my routine. But I can't say I've seen much in the way of results. I'm committed to rehab for at least while, perhaps a few more months. But if I'm not making clear progress by the end of this upcoming winter, then I think it will have to be the end of the road. Perhaps there isn't a route out of the cave. I'm starting to think that now.

How did you do at the pain management specialist? This has been your longest interlude, and I pray that this is not indicative of a reptilian induced requiescence.
Title: Re: Sore knees, no diagnosis
Post by: highroller on October 03, 2010, 03:04:52 AM
Indeed, it's been nigh on a 3 week hiatus since my last communiquť from the Antipodean cavern of despair. Let's rejoin the action right after the doctor consultation scene in mid Sep.

I started on Amitriptyline at 25mg per day. I actually took it from April to July last year for a long-term headache condition. I felt that it was of some benefit but I was experiencing heart palpitations and decided to discontinue taking it for the good of my ticker which was diagnosed with a very mild arrhythmia. I was training quite intensely in those days and was less concerned about resuming it now due to my current lifestyle which would make a tree sloth look hyperactive by comparison. It does take a few weeks to work its magic - the jury is currently out and will reconvene with a verdict around the 4 week mark.

The pins and needles, aching and sensitivity in my hands is better than it was at its worst (when even typing was barely tolerable) but I fear that this latest gremlin in my dysfunctional nervous system has settled in for a long-term residency. I haven't acquired a wheelchair yet but I'm not sure that I could even operate a manual one with the state my hands are in currently.

As for my knees, I can report a slight improvement with qualifications.

I did discover that I was able to perform a slow squat to near parallel about 2 weeks ago. It doesn't feel too good but it also doesn't trigger sharp pains if performed in a slow and controlled manner. I am only able for one at a time and a few per day. I haven't been attending PT but I was inspired to try some isometric holds by another ebook I recently purchased from www.thekneepainguru.com. One of the 5 pillars of the rehab protocol described therein is strengthening the tendons and ligaments around the knee joint via extended set techniques to ensure that the connective tissues are sufficiently stressed to stimulate an adaptive response. The other dimensions of the method are relaxation of tension in the nervous system through breathing, stretching, a healthy diet and adequate water intake. I've only dabbled with the least stressful exercises so far and have quite a few questions on execution and the underlying concepts so I have scheduled a chat with the author next week - he offers a free 25min initial consultation as part of his 'coaching program'. No harm listening to what he has to say.

I've been able to tolerate standing for longer periods over the last couple of weeks. My limit now appears to be 5-10 mins on a good day vs 1 min at the recent trough of my knee condition curve. Over the last few days I have emerged from my cave twice and managed to walk a block and back each time at relatively normal speed and gait although each time I felt the dreaded fullness/pressure sensation gradually returning on the home leg of the journey coupled with some discomfort at home as the day progressed. Nonetheless I was encouraged. Unfortunately this morning I experienced a most excruciating sharp pain in my right knee while walking back to bed from the bathroom. Both knees feel a bit aggravated now and I fear another setback has occurred.

I did see the pain management specialist last week. She suggested I increase the Amitriptyline dosage to 37.5mg per day and has proposed a series of 6 acupuncture sessions aimed at restoring balance and facilitating the body's healing processes. So a fairly holistic type of approach. She did perform a short acupuncture session during the initial consultation and I'm due to have a chat with her on the phone tomorrow before deciding on whether to proceed. My doctor indicated about a 50% success rate with the patients that he has referred to her. I'm highly sceptical but somewhat desperate and willing to try almost anything at this stage so I'll probably proceed with the treatment.

As ever, I'm sorry to hear of your own ongoing struggles with this accursed affliction but the boulder hasn't rolled over the cave mouth and extinguished the fading rays of daylight yet. I do however sometimes feel like the boulder is pursuing me to the furthest recesses of the cave Raiders of the Lost Ark style. There's another action scene for the movie - Inkneeagony Jones and the Cave of Doom as a working title perhaps?
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on October 04, 2010, 01:10:00 AM
I seem to demonstrate an almost preternatural knowledge when it comes to what you're up to. How did I know you were up and walking around? Thanks for allaying my fears! Though had I simply perused any old atlas I would have known that salties aren't distributed anywhere close to your location. That would be the equivalent to you thinking that alligators inhabited my backyard.† :-[

It sounds as if you were making the most substantial progress since Kevin Rudd inhabited The Lodge. At least you know you can make progress. For a while there you were afraid that you were descending into the depths of an abyss from which you could never extricate yourself, but it is still unfortunate to hear of the setback. I can't tell you how many times the pressure has subsided from my knees, but it has ever been a siren song, luring me to complacency, and the pressure never ceases to return.

Now this is going to be a bizarre tale. Feel free to laugh and cackle if you'd like, I can't hear you. I had a little accident massaging. But it wasn't my hands that hurt, but rather what I was massaging. I think I may have made medical history by being the first case of Illiotibial Band Syndrome inflicted by the hand. I've come to realize recently that a lot of my aches and pains are actually myofascial pain, so I've been regularly massaging. The side of my knee was a bit sore last night, so I decided to rub it, nothing too rough. In my brilliance, and just for good measure, I decided to massage the other side as well, even though it didn't hurt at all. I don't know how it happened, but it hurt like heck afterwards. I am now left with a most pleasant sensation on the sides of my knees, especially when bending them. I guess you're not the only one with gremlins in your nervous system. Now I don't know if it's actually ITBS, but I'll have to see what happens in the next few days.

I have tried to maintain a positive demeanor through all of this, if not for only for my own sanity then for that of those around me. But so often I've found myself plumbing the depths of despondency, searching for a flicker or a fragment or a shred or an atom of hope in all of this, only to come out empty handed most of the time. I've mostly found comfort in the fact that this condition is so variable. If it only ever stayed the same, then that would be cause for desperation. But it does change, and I have to believe that it changes primarily based on what I've done over the previous 24-48 hours. There have been times when I've been able to sit with my knee bent for 30 minutes or an hour without trouble. But then, of course, any longer triggers the dreaded return of pressure to the knee, and eventually aching and burning. Sometimes I've been able to walk for a significant period of time as well, but later that day I'll feel it. And don't get me going on squats. Even if they don't hurt while you're doing them, you're going to wish the evening never came. Having experienced all of this more than once, I've tried to be a lot more consistent in restraining myself to only those activities that don't trigger a response. But even so, my knee still cycles between all of the different states. I do think it may be in a generally better state than when I was doing squats in PT. But there must be something I'm doing to irritate my knees, and my poor brain can't figure out what it might be.

But I think you've just figured out your primary stumbling block. Dodging all of those rolling boulders doesn't make for the ideal convalescence cave, now does it?

As I mentioned, I'm going to be attempting rbcyclist's approach for next few weeks. It certainly won't hurt to try. I'll let you know if I'm experiencing any progress at all, or if I'm not. And I hope you'll keep me updated on how it goes with your guru. If you haven't looked at the link, the rehab protocol focuses on:

1. Adequate rest, and finding positions which allow for this, and
2. Short bursts of light activity, followed by a longer period of rest, and repeated many times throughout the day.

It actually makes quite a bit of sense when placed in the framework of my personal experience and everything else I've read. But it will be the implementation that will be most challenging. Call me Inkneeagony Jones.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on October 12, 2010, 05:41:31 PM
Hey,

I was thinking about the original intention of this thread, one part of which was to perhaps attain a definitive diagnosis of your condition to replace that nondefinitive PFPS diagnosis. I was searching the interwebs again and came across an old staple of ours, that old Dr. Dye piece, Therapeutic Implications of a Tissue Homeostasis Approach to Patellofemoral Pain. I'll just quote a specific part which caught my eye:

"In addition, magnetic resonance imaging is poor at identifying which of the patellofemoral tissues are producing pain. As has been shown, even identified structural damage of articular cartilage may not necessarily play a role in the genesis of anterior knee symptoms. A careful examination of magnetic resonance imaging of the patellofemoral joint often manifests low-grade effusions associated with symptomatic peripatellar synovitis. This finding frequently goes unreported by radiologists because of their focus on the structural characteristics of joints. Thus, it is important for the treating orthopedic surgeon to look at the images directly. I believe peripatellar synovitis to be one of the most common, underdiagnosed conditions of clinical significance about the knee. Technetium bone scans, which manifest loss of osseous homeostasis, often correlate well with patellar pain and its resolution."

I was thinking recently, if the conservative approach that I've been trying to follow doesn't produce results, of the questions I might ask the OS, and the tests that might prove fruitful. Did your surgeon ever take a look at the MRI you had done to check for "low-grade effusions". And have you ever requested a bone scan? The strangest thing is that the surgeon didn't find anything unusual during the arthroscope. Is it possible that they missed possible symptoms of synovitis? I imagine that if a surgeon is looking for, say damage to the cartilage, and are not particularly concerned about the synovium, that they could possibly miss signs of problems with it.

I was also looking at a couple of other articles which might be of interest:

http://www.orthosupersite.com/view.aspx?rid=26361 This site also suggests synovial irritating as an underdiagnosed cause of peripatellar knee pain.
http://gait.aidi.udel.edu/educate/syncon.htm

That last one there is just to put out another crazy possibility to consider. Particularly this: "Evidence on imaging studies depends on the stage of disease. Until the loose bodies are ossified or calcified they may be radiographically invisible. This often leads to an unfortunate delay in treatment."

Again, wouldn't a surgeon spot this during an arthroscope? I suppose one has to recognize that surgeons are human, and prone to err. It never hurts to seek a second opinion.

I've come to the conclusion that I've got precisely the same thing as you in my right knee, but probably a good deal less severe. It's just that general soreness, and if I pay close attention, there are subtle sharp pains in there as well. Fortunately they aren't excruciating, but they're there. And the more I experiment, the more I realize that they're triggered by a very minimal level of activity. I've purchased a little floor bike from Amazon.com. It cost about $23. Yeah, I'm cheap. But I'm interested in seeing if cycling might allow for some level of motion that would be within my "envelope of function". But if it ends in failure, I'd like to think that something other than painkillers or Buddhist/Stoic acceptance of the situation could help.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on October 13, 2010, 11:06:40 PM
I attempted a little experiment this morning, which involved a return to the "95 year old" gait pattern which had worked so well to rid me of that dreaded inflammatory condition that I had been afflicted with over the summer. Unfortunately, a pretty severe sharp pain coursed through my knee after not too many steps. Every day my condition is more resembling yours. I sure hope this isn't a sign of what's to come.

That this pain was actually worse than most of that which I have experienced walking more normally, got me to thinking. Why would that approach have worked with the other condition, but not this one? I think the answer lies in the specific tissues affected.

I'm now convinced that the other condition was a pretty severe impingement. Of what I don't know. From extensive reading over the last few months, the most logical conclusion is the Hoffa's fat pad, but since it wasn't diagnosed, I'll never know for sure. But what is relevant, is the circumstances that actually provoked the pain response. In that case, it was not so much pressure that caused a problem. I didn't have the movie goers sign, and standing wasn't a problem except when it was at its absolute worse. But friction definitely did. That's why walking without flexing the knee, and doing so slowly, ultimately proved to be the solution. The inflamed, and probably enlarged tissue, was getting impinged when I was walking.

This more recent condition, I think, is likely a form a synovitis, but could have an osseous component as well. In contrast to the first condition, which was highly localized, this one is peripatellar, with pain experienced around all parts of the knee cap, though it is more intense in the superior lateral part of the patella. I think the key difference here is the sensitivity to pressure. The unfortunate fact is that when the knee is fully extended, which it is when standing, there is still a significant pull on the patella from the quadriceps, which undoubtedly increases the pressure in the patellofemoral joint. It seems that in some cases, the tissue is just so sensitive, that even this force is too great for it. This might be the situation that you and I find ourselves in. The synovial tissues slosh around to some degree, which may be why the symptoms are not completely consistent. You falsely sense improvement, but then the tissues shift around, and suddenly there's that sharp pain again.

I want to consider the possibility that there may not be any amount walking that will not irritate it, but that some level of motion may be acceptable (I can hope, anyway!). Since that floor bike is coming in next week, I might finally have an opportunity to test this theory out. The only thing that is pretty certain to me right now is that when I wake up in the morning I feel pretty decent most of the time. It's only when I start moving that things tend to go south pretty fast. I'm sure that the joint must be capable of some level of motion and pressure. Even standing exerts quite a lot force on the joint. There is a whole lot of space between that and 0. I'll quote Dr. Dye here:

"By suggesting that a patient decrease loading to within his or her jointís current diminished envelope of function, I am not advocating a sedentary existence or treatment approach. On the contrary, it is desirable that the patient remain as active as possible within the upper threshold limits of their jointís envelope (ie, that which is painless). Even joints that are substantially compromised functionally may safely withstand activities such as swimming or light bicycling, which can effectively maintain muscle strength, tone, joint range of motion, and even endorphin production without supraphysiologic overload of the system as a whole."

There are certainly some conditions where patients are instructed to go non-weight bearing for a time. And while that is not appropriate to our situation, it may be that we need a load level that is significantly below body weight, as nearly any amount of body weight loading will overload the tissues. In practice, this would entail finding a method to not walk at all (assuming any amount of walking provokes a pain response. Of course, if you've found a low level that doesn't then this wouldn't be necessary.), but also finding a loading activity that can be performed for some length of time that doesn't overload the joint. One would hope that this stage would not last more than 2-3 weeks and that some walking could then be integrated into the program. But it is becoming an inescapable conclusion that almost any, and perhaps all, walking is a problem for me. Given the persistence of the condition, which has hardly changed at all in 3 1/2 months, and may be getting worse in some respects, I have to conclude that a different approach to recovery may be necessary.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on October 17, 2010, 11:42:49 PM
I've come across a couple of other articles that may be relevant to your situation. The first one suggests saphenous neuritis as a possible cause of anterior knee pain. In most cases there would be more of a medial localization to the pain, but I remember that you mentioned some discomfort in the region of the tibial-femoral compartment as well. It seems unlikely to be the full cause of your symptoms, but it could be a component. Unfortunately, I couldn't find a link to the full article, but here is a summary:

http://www.curehunter.com/m/pubmed11929207.do

The second article might actually be relevant for my own condition. This article posits that hyperinnervation of the lateral retinaculum, which can be caused by recurrent ischemia events and may be possibly be triggered by repetitive microtraumas to the tissue, are an underdiagnosed cause of PFP. The study also suggests that as the severity of pain increases, there is an even greater proliferation of abnormal vascular and neural structures. At the end of the article, they also mention several possible treatment modalities. This would be consistent with the lack of visible swelling or deterioration of tissues in your MRI and arthroscope results. Access the PDF linked on this site:

http://informahealthcare.com/doi/abs/10.1080/00016470310018225

My exercise bike came in, but I'm afraid that even using it with no resistance, it may be like trying to surmount Everest with a mountain bike. It's just difficult to separate out the causes of the pain. By the time I get on the bike, it's already too late. I've noticed two different pain responses. The most obvious, of course, are those sharp, lancinating pains that seem to randomly emerge from time to time. I've gone days without any, and some days I've had more than one. But I'm convinced now that those pains are not the only or even most relevant indication of trouble. Even if I wake up in the morning and my knee feels fine, almost as soon as I start moving there is a soreness or aching feeling quickly worsens as I continue to walk. Standing is even worse, and makes those sharp pains all the more likely. This unfortunately precludes slow walking as a strategy.

I've been experimenting with using crutches to lower the load on my knee, but without success thus far. I'm not convinced that this is a neurological condition, and is simply "all in my head." I still think there is a tissue or tissues that is causing the pain, and I just need to find out what that is and then treat it accordingly. It was definitely triggered by mechanical irritation. My hopes of recovering utilizing a conservative approach continue to slip away, though I haven't given up yet. If it does prove impossible, identifying the involved tissues will likely be the only hope of recovery. It seems that the worst case scenario would be that the sub-chondral bone is implicated in the pain, as this would necessitate a PFJR as the only likely solution. I think many of the other tissues would be amenable to a more cautious surgical approach or possibly even pharmacological intervention.

I've barely even begun the process of pursuing the medical route, so it's a long road ahead if that proves necessary. But when I first entered the cave, I wasn't promised a speedy evacuation if I decided I'd had enough. Nobody promised that the route out wouldn't be long and undulating and sickly damp and slippery, or that there wouldn't be an occasional large boulder Indiana Jones style. Keep me updated, and perhaps you can mention some of this to your rheumatologist.
Title: Re: Sore knees, no diagnosis
Post by: tumba on December 06, 2012, 07:44:21 PM
Guys, how did things end up for you?
Title: Re: Sore knees, no diagnosis
Post by: SuspectDevice on March 18, 2013, 05:18:48 AM
Guys, how did things end up for you?

I'd love to know also.

Their stories are very similar to mine (though their pain sounds worse)- i.e. no real reason why their knees suddenly became so sore & sensitive.

I can't PM anyone, but if anyone else can get in touch with the two main posters in this thread (knee always hurts and highroller) & get them to respond, it would be be fantastic.
Title: Re: Sore knees, no diagnosis
Post by: SuspectDevice on March 18, 2013, 07:01:37 AM
I'd like to re-activate this thread, as the experiences are so similar to mine.

Briefly, I was a keen triathlete.

Tore left medial meniscus April 2012, had 1/3rd removed May 2012 (age 48).  Rest of knee looked really good when he went in.  MRIs in the past for right knee pain have shown some 'high grade' chondromalacia, but it never caused me too much trouble.

Was back on my bike within 6 days of surgery (but did not attempt to run for 8 weeks), but over the next few weeks, both knees developed PFS within a month. Aching, burning, stiffness, pain anterior & medially both knees. 

Really weird that it should start after a massive decrease in my training load????

Have seen physio, GP, OS & 2 Sports Drs.  Lateral release was mentioned, platelette injections.  Latest advice from Sports Dr seems to be a cessation of aggravating activities, hip & glute strengthening exercises and conservative activity. 

Reading the posts of High Roller and Knee Always Hurt, I realise I'm pretty lucky - despite constant pain of varying levels, I can walk without the stabbing pain they had & am not house-bound, can still do most daily activities, though have to take them easy (e.g. lawn mowing in 20-30min bursts, not the 2hrs I used to do).  And I can't imagine how bad it must be to go thru this at just age 26 like one of the posters - just terrible, at my age you can understand it, especially given the work my knees have done, but at 26 !!!

I tried 15mins easy riding on my bike today after taking it pretty easy for 6 weeks, but forget it, I can tell it's going to send me backwards.

Had dinner with my OS last week - he very sensibly said forget more surgery, it is unlikely to help.  He also said they know sweet FA about PFS, and agreed that the conservative approach recommended in the Richard Bedard & Paul Ingraham Ebooks was a good way to go.

But damn it is frustrating to go from such a high level of athletic ability to this.  Gotta hang onto the positives though.  I can still swim (but can't kick too much so use a pull-buoy), can do upper body weights and walk 30-40mins.  I can also use the hamstring, adductor and abductor machines in the gym without aggravating (I think) but anything that works the quads (leg extensions, squats, lunges) is out.

I'll use this thread to inform others of how I go and hopefully it might help them.
Title: Re: Sore knees, no diagnosis
Post by: highroller on March 28, 2013, 11:39:19 AM
Just checked my old thread on a whim and note the recent posts - welcome to the new arrivals! I'm a bit pressed for time right now but will provide an update in the next week or so and fill you all in on my trials and tribulations over the 2.5 years since I last posted. I'm still struggling and can't offer any silver bullet insights but hopefully my experiences will be of some use. Later folks...
Title: Re: Sore knees, no diagnosis
Post by: SuspectDevice on April 08, 2013, 09:03:18 AM
Just checked my old thread on a whim and note the recent posts - welcome to the new arrivals! I'm a bit pressed for time right now but will provide an update in the next week or so and fill you all in on my trials and tribulations over the 2.5 years since I last posted. I'm still struggling and can't offer any silver bullet insights but hopefully my experiences will be of some use. Later folks...

Looking forward to your response, let us know anything you can.

cheers
Title: Re: Sore knees, no diagnosis
Post by: SuspectDevice on April 21, 2013, 05:30:51 AM
An update - my knees seem to be heading in the right direction, less regular pain/burning/stiffness.  But not out of the wood yet. Was able to cycle for 30mins y'day without any major setback in pain levels.  But can't get too excited, still need to be very careful not to overdo it.

But my back is killing me!  Tweaked it with a slight twist after a long 1hr swim last weekend & can't get it to settle.

Aging is crap!
Title: Re: Sore knees, no diagnosis
Post by: BTSF on April 27, 2013, 05:12:55 PM
Hey everyone,

Echoing the sentiment of other recent posts, I'd love to hear from the two original posters.  I just came across this thread, and have been reaching my own low point of sorts of late. 

Without getting into details, I am seeing a very very reputable doctor in this field (let's just say he gets this injury), and a PT recommended by him for the last 6 weeks.  I've also been using crutches to get around, and trying to stay well within my envelope of function.  Under my PTs guidance, I've been doing extremely light muscle strengthening (quad sets, heel slides, leg raises).  However, my knee still swells with inflammation at the end of each day.  Ice, rest, and elevation does seem to help, but each day is a recurring pattern.

I'd love to know if either of the two original posters found success along the way.  Like the original poster, I'm 25 going on 26 years old, and have been dealing with my own PFPS journey for over a year now.  I'm finally with medical professionals who know what they're doing, but it would help to hear about the story from the patient side of things to help brighten my outlook.
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on May 08, 2013, 05:55:10 AM
I've noticed that several people have requested an update on my condition over the last few months. I haven't logged into my account for probably a year or so, but I'll use this opportunity to break the good news. My knees have made something like a full recovery. They seem to be a lot creakier now, for some reason, but no more pain!

Truthfully, I'm not fully sure how or why the recovery happened. But I'm convinced that there was never anything structurally wrong in the knee, hence surgery would have been pure folly! I am grateful that the doctors I went to always told me the truth, even though I didn't want to hear it at the time. I'll never know for sure why it even happened, but I suspect a muscular imbalance developed, probably because of some of the exercises I was doing. Maybe the quadriceps were overpowering the hamstrings, or something along those lines. And so the joint wasn't tracking properly, and then inflammation developed. At that point the problem became one primarily of inflammation. So fixing any muscular imbalances didn't matter much once the inflammatory process was activated, which is why PT failed for me.

The only thing that worked was rest. I realize now that I always made the mistake of not resting enough, for months on end. In retrospect, I think my knee may have been fine sooner than I realized. But I become anxious at the most marginal pain, always suspecting it was a harbinger for the full return of the by then intractable problem. I slowly built up my strength, and then worked up the courage to being walking more and more. I did feel some slight pains in my leg at the time, but I convinced myself that it was something else, maybe trigger points. Within a few months I found that I didn't have any limitations at all.

I have a few pieces of advice. One is to always do less than you think will be necessary for recovery. That sounds strange, because our natural inclination is to think we have to do something to recover. But at least for me, rest was key. If you have a problem with exercise, cut out all exercise. If you have a problem walking at all, you probably need 3 months or so of complete rest. Generally that's a bad thing, but if you've tried less than that and it didn't work, then that's your only alternative. I'm assuming that there isn't some other structural problem, which only a doctor can identify. I had advanced MRI imaging done which found no structural issues whatsoever. If there is no identifiable pathology within the knee, then I think inflammation is the likely issue, in most cases. Remember that the compressive forces within the knee are extremely intense. Only rest will allow the irritation to subside once it has begun. Strengthening alone won't allow irritated tissue to recover.

I'll conclude for now by saying that at its worst, it couldn't have been any worse. But I had never had any problem like that before, so it didn't make any sense that I couldn't achieve a full recovery.  Even a really severe case can recover. If anyone has any questions, I'd be happy to try and answer.
Title: Re: Sore knees, no diagnosis
Post by: SuspectDevice on May 08, 2013, 06:31:14 AM
I've noticed that several people have requested an update on my condition over the last few months. I haven't logged into my account for probably a year or so, but I'll use this opportunity to break the good news. My knees have made something like a full recovery. They seem to be a lot creakier now, for some reason, but no more pain!

Truthfully, I'm not fully sure how or why the recovery happened. But I'm convinced that there was never anything structurally wrong in the knee, hence surgery would have been pure folly! I am grateful that the doctors I went to always told me the truth, even though I didn't want to hear it at the time. I'll never know for sure why it even happened, but I suspect a muscular imbalance developed, probably because of some of the exercises I was doing. Maybe the quadriceps were overpowering the hamstrings, or something along those lines. And so the joint wasn't tracking properly, and then inflammation developed. At that point the problem became one primarily of inflammation. So fixing any muscular imbalances didn't matter much once the inflammatory process was activated, which is why PT failed for me.

The only thing that worked was rest. I realize now that I always made the mistake of not resting enough, for months on end. In retrospect, I think my knee may have been fine sooner than I realized. But I become anxious at the most marginal pain, always suspecting it was a harbinger for the full return of the by then intractable problem. I slowly built up my strength, and then worked up the courage to being walking more and more. I did feel some slight pains in my leg at the time, but I convinced myself that it was something else, maybe trigger points. Within a few months I found that I didn't have any limitations at all.

I have a few pieces of advice. One is to always do less than you think will be necessary for recovery. That sounds strange, because our natural inclination is to think we have to do something to recover. But at least for me, rest was key. If you have a problem with exercise, cut out all exercise. If you have a problem walking at all, you probably need 3 months or so of complete rest. Generally that's a bad thing, but if you've tried less than that and it didn't work, then that's your only alternative. I'm assuming that there isn't some other structural problem, which only a doctor can identify. I had advanced MRI imaging done which found no structural issues whatsoever. If there is no identifiable pathology within the knee, then I think inflammation is the likely issue, in most cases. Remember that the compressive forces within the knee are extremely intense. Only rest will allow the irritation to subside once it has begun. Strengthening alone won't allow irritated tissue to recover.

I'll conclude for now by saying that at its worst, it couldn't have been any worse. But I had never had any problem like that before, so it didn't make any sense that I couldn't achieve a full recovery.  Even a really severe case can recover. If anyone has any questions, I'd be happy to try and answer.

Thanks so much for replying, and your story gives me a lot more hope.

Your story also matches exactly what the 2 Ebooks I've read on this problem say - the key is rest.

One question - apart from limiting your exercise, did you have to limit any normal day to day activities?
Title: Re: Sore knees, no diagnosis
Post by: knee always hurts on May 09, 2013, 02:21:12 AM
Quote
One question - apart from limiting your exercise, did you have to limit any normal day to day activities?

Well, on account of the stabbing pain, I wasn't able to do much. Crutches were the order of the day. And crutches = no hands. If you mean during the recovery phase, well then my limitations were more of a precaution. Though I suspect at that point that the problem was gone. But it was better being safe than sorry.

As I've looked at your story, at first I thought it might have had something to do with the surgery you had last year. But it was only on one knee, correct? And the pain is bilateral. It may be that the recovery from the surgery caused some muscle and tissue degeneration, which then led to vulnerability when you resumed exercise. I don't think the chondromalacia, which you've likely had for years anyway, is the cause. And if I recall the evidence that I examined at the time, chondromalacia is not typically associated with any pain at all.

Based on what I can glean of your case from what you've posted, I think it would be best to abstain from all unnecessary activity for a while, perhaps a month or two. I don't think that you have to stop normal activities such as grocery shopping and the like, but if possible you should delegate lawn mowing to someone else or hire someone to do it if necessary. I'd definitely suggest that you stop going to the gym. You're probably aggravating the tissues in your knee even if you don't realize it.

After the period of rest, I'd recommend slowly building your strength back and then slowing reintroducing physical activity. I'm not sure if you're currently in PT, but if it isn't working for you, don't hesitate to stop it. Don't sacrifice your future for the sake of medical orthodoxy. It might be worth a try if nothing else works, but it isn't the only option. Perhaps it would be more sensible to enroll in PT after you've given your knees a good, honest rest.

Is any of this guaranteed to work? No, but unless you have a better answer, it's probably worth a shot. Keep me updated on your results!
Title: Re: Sore knees, no diagnosis
Post by: SuspectDevice on May 10, 2013, 10:21:18 AM
Quote
One question - apart from limiting your exercise, did you have to limit any normal day to day activities?

Well, on account of the stabbing pain, I wasn't able to do much. Crutches were the order of the day. And crutches = no hands. If you mean during the recovery phase, well then my limitations were more of a precaution. Though I suspect at that point that the problem was gone. But it was better being safe than sorry.

As I've looked at your story, at first I thought it might have had something to do with the surgery you had last year. But it was only on one knee, correct? And the pain is bilateral. It may be that the recovery from the surgery caused some muscle and tissue degeneration, which then led to vulnerability when you resumed exercise. I don't think the chondromalacia, which you've likely had for years anyway, is the cause. And if I recall the evidence that I examined at the time, chondromalacia is not typically associated with any pain at all.

Based on what I can glean of your case from what you've posted, I think it would be best to abstain from all unnecessary activity for a while, perhaps a month or two. I don't think that you have to stop normal activities such as grocery shopping and the like, but if possible you should delegate lawn mowing to someone else or hire someone to do it if necessary. I'd definitely suggest that you stop going to the gym. You're probably aggravating the tissues in your knee even if you don't realize it.

After the period of rest, I'd recommend slowly building your strength back and then slowing reintroducing physical activity. I'm not sure if you're currently in PT, but if it isn't working for you, don't hesitate to stop it. Don't sacrifice your future for the sake of medical orthodoxy. It might be worth a try if nothing else works, but it isn't the only option. Perhaps it would be more sensible to enroll in PT after you've given your knees a good, honest rest.

Is any of this guaranteed to work? No, but unless you have a better answer, it's probably worth a shot. Keep me updated on your results!

Yes, your suggestions are in line with where my thinking has got to.

Unfortunately, I'm rather exercise addicted, so am experimenting with ways to keep some form of fitness (e.g. swimming without kicking using a pull buoy, and gym work which does not stress my knees, easy walking).  But I don't think I've cracked it yet & so complete abstinence from exercise may well be needed  :'(

We are currently moving house which means packing = extra stress on knees, but in a few weeks, I'll have more opportunity to really rest up more.

I agree with you - somehow the surgery triggered problems in both knees unrelated to the actual surgery spot in the left knee.  Could be muscle changes, could be I changed the way i use my legs as a response to surgery pain, could be some sort of chemical imbalance.  Don't know, but it is bizzare that my knees would get bad with less exercise post surgery - pre-surgery, I was running/cycling/swimming around 6-13hrs/week, smashing my legs to pieces.

I don't do PT - my experience has been our local ones (I live in rural Australia, so not much choice of PTs) are clueless on this stuff.  And I'm certainly wary of medical orthodoxy.

Anyway, thanks for your thoughts & ideas.  It is really good to get some input from someone who has been thru this sh*t.

BTW, I've come across several other triathletes who have had this problem.  One is about to get bilateral lateral releases (which I'm betting won't be a solution).  The other basically rested for 5 years (no running, cycling), then got back into it gradually including barefoot running & minimalist shoes & is good now.
Title: Re: Sore knees, no diagnosis
Post by: BTSF on May 26, 2013, 07:27:51 PM
'knees always hurt' - thank you for your encouraging story. I've been on crutches coming up on three months now, and I've found the hardest part to be the mental aspect. So hearing from someone who's successfully come out the other side definitely helps.

Here's my question - how long did it take you to transition from crutches to walking again, and when did you feel "ready" to take that step? 

I recently saw my doctor and PT again (reminder - this doc knows his stuff, and is a research pioneer when it comes to this injury), and they both advised me to begin walking a little bit, standing on two feet, and using one crutch in the mornings. The theory is - "you've healed tremendously, now we need you to re-build your muscle memory and make sure you don't atrophy further." While they both admit that I need to listen to my body and be careful, they essentially want me to start testing my boundaries.

After following their advice for a day or two, my knees still became symptomatic - swollen and inflamed at the end each day, which leads to throbbing then sharper pains if I put weight on it. So I've since decided it's too early to do what they're saying, and I still probably need a few weeks more of rest. I'll still keep water walking in the pool (which I picked up a few weeks ago), but other than that it will be rest, ice, and very very basic PT (light quad sets, drakes, and the like).

Any advice from someone who's made the transition?
Title: Re: Sore knees, no diagnosis
Post by: Chicagodude on May 31, 2013, 05:30:37 AM
knee always hurts, I'm glad your knee is doing better and you're able to do stuff without pain.

A few questions for you:

1) You said you think inflammation was the main cause of what you were experiencing.  Do you think ice would've helped reduce the inflammation faster?  I also want to ask specifically about ice massage, which in my experience is much more effective than standard icing with an ice pack.

2) As you believe inflammation was the problem, do you think a pro-inflammatory treatment such as prolotherapy with PRP would've helped?
Title: Re: Sore knees, no diagnosis
Post by: BTSF on November 12, 2013, 07:05:16 PM
Hi all,

This thread was one of the first I saw when I was desperate to recover from my patellofemoral knee pain. I often refreshed the page hoping others would post details of their stories, but that rarely happened.

In any event, I've been crutch-free for two weeks now, and am on an upward trajectory. I've distilled my story into two blog posts I want to share with you:

Part 1: Injury and Recovery - http://themindfulcaveman.com/my-knee-story-part-1-injury-and-recovery/

Part 2: Reflections - http://themindfulcaveman.com/my-knee-story-part-2-reflections/

I hope you find something insightful and useful from the experience I went through. Please reach out via the comments section of either post if you'd like to chat with me about anything in further detail.

Bryan