KNEEtalk

DIARIES => Post-op diaries (<50 posts) => Topic started by: RyanC on January 13, 2021, 11:25:56 AM

Title: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 13, 2021, 11:25:56 AM
Introduction

Hi,

My name is Ryan, I am 29 years old and I am from Adelaide, South Australia. I am a former tour guide/bar tender but now work as a web developer here in Adelaide. I have done heaps of travelling through South America and Europe and have always been a really active person, playing Basketball, Cricket, Football, Hockey and Netball through my teenage years and into my 20's (not all at the same time).

I am currently 7 weeks post operation for a fat pad impingement so I am a little late to be starting post op diaries but better late than never. I plan on firstly recounting the last 7 weeks week by week, and then continuing to update on my progress every week or so.

I am writing this to both track my recovery progress but also to help others who also have had similar surgeries.

TL;DR: Ryan, 29 from Adelaide, South Australia. Web developer and was active all through teens and 20's. Had a fat pad impingement trim surgery 7 weeks ago and now will recount last 7 weeks and continue to report how it's going.

Attached is a photo of me, pre operation but post injury, just to put a face to a name and story.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 13, 2021, 11:36:17 AM
The Injury

In March 2020, I decided to go and try out for a new field hockey club. I had sprained my ankle badly in June 2019 playing social netball and had not done much running/exercise since. Everything was going fine during the training session until about 2/3rds of the way through when I landed, with my leg at full extension where I felt a sharp pinching sensation below my knee cap. I had no idea what it was but I went off. I did come back on the last 5 minutes of the training session where it started to hurt again.

I didn't know what I had done. I tried running on my knee 3 days later and it felt terrible. I left it for a few weeks to see if it got better but it did not. I later saw a physiotherapist where I saw him for about 10 weeks. He gave me a whole bunch of exercises to do but nothing was helping my knee. I was then referred onto a podiatrist who got me orthotics. This also didn't help so I decided to do 3 months of yoga. When this didn't help I got really frustrated and got an MRI scan. The scan came back saying there was nothing wrong so the doctor referred me to another physiotherapist. When I saw the physio, he thought that I potentially had some meniscus damage and that I should go see a surgeon. I saw the surgeon once, where he said there was some abnormalities around my lateral meniscus and he recommended surgery.

TL;DR: Hockey training. Landed while running in full extension and felt a pinch under my right kneecap. Did 10 weeks of physio, got orthotics and did 3 months of yoga, nothing helped. Saw a surgeon, recommended surgery - potential abnormality with lateral menuscus.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 13, 2021, 11:44:37 AM
The Surgery

The surgery was an arthroscopy. It took place on the 23rd of November, 2020. Initially it was cancelled because my state went into a COVID-19 lockdown but it was later put back on. I didn't know that I had a fat pad impingement prior to surgery, I thought that I was having my meniscus repaired.

The surgery took about 30 minutes. After it was done, the surgeon told me it was a fat pad impingement and that I should be all good in 2-3 weeks, I now know that is a ridiculous timeline for a recovery from a surgery like this, especially on a fat pad. I stayed overnight in the hospital.

TL;DR: Right knee arthroscopy with a fat pad impingement trim. Surgeon told me after it was a 2-3 week revovery.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 13, 2021, 12:02:49 PM
Week One

I could walk on my leg only hours after my surgery, although it was just me hobbling to the toilet and back. The hospital staff gave me regular pain medication and about 12 hours after the surgery they gave me an ice pack. I had three incisions, all of which had bandages on them and they put a waterproof film over the top. I stayed in hospital overnight and was sent home in the morning with a script for some pain meds and some basic physio exercises. The exercises included:

The first three days I did not do much at all. I followed the doctors advice just to take it as easy as possible and kept my leg elevated. My knee was just achy and sore and I couldn't do much at all.

On day four, I decided to give driving a go. Even though my knee was sore, I felt as if I could perform the emergency brake if I needed to. I jumped in my car and drove around the block and it was fine. I also starting working again from home on day 5 of recovery.

I spent most of this week just on the couch. After driving and walking a little bit on day 5 my knee was so sore, just really achy. Basically after week 1, the swelling in my knee did start to subside a little but it was still very much in the early stages and was still very sore. I changed the dressing on my incisions multiple times and was performing the physio exercises multiple times a day, even they were quite painful to do.

TL;DR: Could walk straight after surgery. Had basic physio exercises to do. Lots of icing and put on pain meds. Most of week resting with leg elevated. Started driving again day 4. Working from home day 5. Knee was getting achy and sore after being on it too much.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 14, 2021, 09:04:40 AM
Week Two

I did quite a bit more walking this week. Not so much because I went for walks around the block, just because I started to get back on my feet more. I moved back into my house after staying with my parents for the first week. This meant that I had to be on my feet to cook, clean etc. I have a supermarket only about 50 metres away from my house, I started walking there and back to get supplies. Looking back on my fitbit, I was doing an average of 6000 steps per day. My knee did get sore though, not the pain I used to get from the impingement, just like an inflamed and achy pain, especially if I had been on my feet for an hour or so.

I do remember one of those days later during week two that my knee was feeling quite good. I walked around the block and couldn't believe that it felt so good so soon after surgery. I got pretty confident and asked my friend if he wanted to go for a short beach walk and get dinner that night. That was a really bad idea, about 1 minutes into walking along the beach I knew I should be resting my knee, it didnt feel as good as it did earlier in the day. I remember that night it felt really achy and painful and knew I still very much had to take it easy. I was a little disappointed as the surgeon told me 2-3 weeks and I'd be fine.

TL;DR: More walking - average 6k steps/day. Knee still getting sore and achy after an hour or so on feet. Later in the week I had a good walk with minimal pain around the block, but then pushed it too far and it got sore. Bit disappointed that knee wasn't recovering as quickly as I wanted it.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 14, 2021, 09:39:30 AM
Side Note - Recovery Time

I really wish my surgeon told me realistic expectations for the recovery period. When I first came out of the surgery, the surgeon told me that I should be good to go in 2-3 weeks. I now know that that is an absolutely ridiculous timeline. When I saw him for the 2 week post op appointment, he told me to give it another 4 weeks to settle. At the 6 week post op appointment, he told me that these things take 3-5 months. I didn't really know what to believe so I started doing some research online. From what I can see, fat pads can be a pain, and many people go through 'cycles' where the knee starts to feel better, they start using it more and then it flares up, which can go on for months. From what it looks like, a fat pad surgery generally takes 6 months to full recovery, where the first 2-3 month being the worst. I have seen cases where it took 18 months to recover but none where it was 6 weeks or less. But yes I am sure the surgeon knew that recovery could take this long and I wish I knew the realistic expectations going into the recovery so I wasn't so devastated every time a milestone came around where I thought I should be better and running again.

TL;DR: Surgeon told me 2-3 weeks for recovery, that is ridiculous. After a lot of research, looks like fat pad clean up surgery takes around 6 months to recover, many times longer, with first 2-3 months them being pretty irritable. Wish the surgeon gave me realistic timeframes.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 15, 2021, 09:02:53 AM
Week Three

Two and a bit weeks after the surgery, I saw my surgeon for the routine 2 week post op appointment. There he removed my bandages and checked up on how I was going. I told him things were going OK but things were very much still inflamed. At this point, I was expecting to feel close to 100% better as he told me I should be good to go in 2-3 weeks. At this point, he told me to give it another 4 weeks and check back in.

That week I saw a lot of improvements. I started to walk more, mainly around the block a few times a day and early in the week I was doing about 8k steps per day. I had a Christmas work function where I dressed up and put my no so cushiony boots on. I did limp around a little that day, and it didn't help that I had to go up and down a few times. I woke up the next morning and my knee felt fine to my surprise. I then got a bit more confident and had a day where I did 14k steps and the knee felt fine. I couldn't believe it, maybe the surgeon was right about the 2-3 week timeline. I even rang my parents, almost in tears, telling them that my knee was going to be fine! The following day I did another 12k steps. I woke up the next day and my knee was a bit sore. I didn't think too much of it and had another big day on my feet. It was becoming obvious throughout that day and the day after that I had pushed my knee way too hard. At the time of writing this (7.5 weeks post op), my knee hasn't felt as good as it did at the 3 weeks post op mark. At 3 weeks, I actually got to the point where I was thinking, 'well if this is as good as my knee gets then I am satisfied with it'. I could just live my day to day without pain. I felt like I wouldn't be able to run but I was in no pain (and taking no painkillers at the time).

So yeah, I had pushed it too hard and I had my first flare up of the knee. I'll leave the 'trying to get the flare up under control' part for next week as most of that happened in week 4.

Added note: I also saw the physio for the first time post op (my physio and not the physio that comes and sees you after the surgery). He said he had seen many fat pat impingement surgeries and we needed to have a focus on building quad strength (and other muscles). The exercises he gave me were:

TL;DR: Saw my surgeon, he told me to give it 4 more weeks to settle and check back in. Saw many improvements this week. Doing 8k steps a day. Got more confident later in the week - was doing 14k steps a day and was feeling great - not 100% but could walk without pain. Then had my first flare up, started to limp again and knee felt hot, agitated and inflamed. As of now (7.5 weeks post op), my knee hasn't felt as good as at 3 weeks. Also saw the physio, he wants me to work on my quad strength.
Title: Re: Fat Pad Impingement Surgery and Recovery
Post by: RyanC on January 15, 2021, 09:08:32 AM
Week Four

So as mentioned I had flared up my knee. My knee was visually more swollen, it was hot and just really agitated. I got to a point where I had to limp around a bit which I hadn't done for weeks. I knew that I just had to take it easy so thats what I did. I spent most of the week on the couch watching TV, icing it as much as possible and just generally resting. There isn't much more to report for this week other than I just rested. It took a solid week for it to begin to start to settle. By the end of this week, it was still nowhere near what it was at 3.5 weeks and I was starting to get pretty down about it, especially as 1 week prior I thought my knee was a couple of weeks away from starting to run again.

Note: I am trying to recount what happened as best as possible, but I am writing this as of 7.5 weeks post op. Some of the end of week three actually happened in week 4 I think. I believe it was about 3.5 weeks, so in week 4, that my knee started to feel really good and I had my first flare up.

TL;DR: Was trying to get my flare up under control. Lots of rest and icing. After this week, it has settled somewhat, but no where near as good as it was the week prior.
Title: Re: Fat Pad Impingement Surgery and Recovery
Post by: RyanC on January 15, 2021, 09:33:45 AM
Week Five

At the start of this week my knee was still a bit agitated but getting better. I think it really started to feel significantly better about half way through this week, but still nowhere near as good as 3.5 weeks post op. I started walking around the block again and things were feeling OK. Again I started to get quite confident on my knee again. I actually went to a party one night and ended up doing 17k steps in one night, at one stage I was dancing on the dance floor. My knee was feeling OK but by the end of the night it was really sore, just achy and swollen. I woke up the next day and it didn't feel too bad but not quite right. That week I had also started going for bike rides. My physio had advised me that I should only do rides for 30 or so minutes but I was going for hour and a half rides. Basically this is when my second flare up happened! I have only got myself to blame as I was going so hard. On New Years Eve I had already planned a bike ride with a friend and then was having some people over my house for some drinks and celebrations. I basically planned to just try and get through that night and rest my knee in the new year.

The weirdest thing happened though, after going for a big bike ride and being on my feet all night my knee felt really good.. I woke up on New Years Day and my knee felt great. I couldn't really work this out as I had pushed it so hard. This is the end of this week but Ill continue for week 6!

TL;DR: Knee started feeling better, but not as good as 3.5 weeks post op. Went to a party and did 17k steps in one day - achy and swollen afterwards, regretted it. Started bike riding as suggested by the physio. Went for a ride on new years eve and was on my feet all night, actually felt better after that? Very strange. Plan on resting knee in the new year.
Title: Re: Fat Pad Impingement Surgery and Recovery
Post by: RyanC on January 15, 2021, 10:07:16 AM
Week Six

I still can't really work out why my knee felt so good after new year, I have a feeling I might have 'loosened' the scar tissue up a bit and warmed it up so it felt OK. I did end up taking it easy for the next couple of days and thats when it became obvious I was going through another flare up. Again, my knee was agitated, hot and achy. I was seeing both my physio and surgeon on the same day early this week. I saw the physio first, he could sense my frustration. He said that the surgeon might opt for a cortisone injection to help calm things down. He gave me a few extra exercises to do this time he gave me:

I asked my physio about fat pad taping and fat pad massage. He seemed to be against both but said we could give the massage a go next time.

I also saw the surgeon. I went in and explained to him what had gone on. He seemed a bit disinterested and didn't have any answers or suggestions for me. I asked about the cortisone injection but he said he didn't recommend it and that it wouldn't shorten the recovery time at all. He then told me that these things take 3 to 5 months to recover and that most people see a 50% improvement in their original symptoms and that I just had an 'irritable' knee that I would have to live with. He ended up giving me some anti inflammatories (Celecoxib - I have a sensitive stomach) and told me to take them 'when required'. I was starting to get pretty annoyed in the appointment, especially as he told me that I should be good to go in 2-3 weeks. I asked him what happens if my knee is still no good in 5 months time? Do I just have to live with a crappy knee for my entire life? He responded by saying that if my knee was not good in 6 months time, that he could do the surgery again, but he would 'alter the healing process' basically by using cortisone injections during the recovery period. I was not happy to hear this.

I left the surgeons office pretty upset. I ended up calling my mum and just broke down crying saying that my knee was no good and I would essentially be disabled for life. Everywhere that I read, arthroscopies take 6 weeks to recover from. I felt like I just just left with a knee that was worst that before the operation.

That is when I started to go down a bit of a rabbit hole on the internet about fat pad impingements. From what I could see, the surgeries were rarely successful and that many people ended up with worse knees post op and wished they'd never got the surgery. After I read Clarkeys post op discussion, I felt kind of depressed. He said it took about 18 months to get back into running. At this point I was 1.5 months post op... so did that mean I had another 16.5 months of recovery to go? I felt super down and depressed for a couple of days.

After doing some more research I found this article. Its from a medical journal and it tracked the recover of 34 patients that had a resection of their fat pad.

https://www.arthroscopyjournal.org/article/S0749-8063(07)00590-7/fulltext#back-bib4

It said that 30 out of 34 people recovered to their pre-injury status. I couldn't believe it as I felt like this surgery almost always failed. I then started finding a bit more information on realistic timelines. It looks recovery periods for fat pad impingements are around 6 months, where the first 3 or so months they are pretty irritable. This gave me some relief that all that money I spent and pain I am going through might be worth it!

TL;DR: Was clear I was having a second flare up and was getting agitated that my knee wasn't healing. Saw the physio and surgeon on the same day. Got some new exercises from the physio. Saw the surgeon, thought I might be getting a cortisone injection, he recommended against it. Was getting pretty annoyed at the surgeon as knee was not healing. Said I just had an irritable knee. Started feeling down about it and went down a rabbit hole on the internet, seemed like fat pad impingement surgery never worked, sometimes made things worse. Finally found the right info about realistic expectations for a surgery like this.
Title: Re: Fat Pad Impingement Surgery and Recovery
Post by: RyanC on January 17, 2021, 08:50:49 AM
Week Seven

After I saw the surgeon the previous week, I had been taking the anti-inflammatories every day (1-2 times a day) and was icing my knee religiously. I was sometimes icing my knee up to 15 times a day. If I was just sitting on the couch I would ice my knee for 20 minutes. If I was working from home and had a moment, I'd grab the icepack and ice my knee. I also tried ice massaging. This is basically where you have an ice cube, and massage the ice cube into the fat pad area. I felt this agitated the fat pad slightly, but was also good for it, so I would do it and then do regular icing afterwards. I stopped walking around the block, or doing any unnecessary walking at the start of this week and also stopped bike riding to try and settle my knee. Things did seem to get better but I was wary of pushing to too hard again and having another flare up.

A strange thing happened at the start of this week as well. On Saturday Night, when I at a friend's party, I felt the part below my knee get caught and then it almost popped back into place. It continued to do that and was causing some pain on the medial side of my knee. Also, I was starting to get pain below my knee cap when I did the leg extension exercises I was given by my physio. I had a chat with my physio and he didn't diagnose me with anything but he said this is really common, especially when the quads start to get weaker after surgery. I told him I had been working on my quads but they just didn't seemed to be getting any stronger, if anything, they were getting weaker! He gave me a few suggestions on what I should try to strengthen my quads:


The last exercise is really good and I feel like I am getting a good full leg workout from it. That's all for this week, and I have now completely caught up. Check back in in a week's time for the week 8 update.

TL;DR: Lots of icing, up to 15 times a day and taking anti-inflammatories, seems to be helping settle the knee. Now getting catching and popping, that wasn't there pre or post surgery but physio isn't too concerned about it but says probably due to weak quads. He has given my more quad exercises to do which seem to be helping. Now caught up so next post will be in 1 week.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 19, 2021, 04:59:58 AM
Side Note - My Irritable Knee

As I mentioned in previous posts, I have been icing my knee religiously and taking anti-inflammatories twice a day. I had such a great day yesterday on my knee. I woke up and was getting ready for work and the knee felt great. I felt the outside of my knee and it wasn't hot and didn't feel inflamed. I work a desk job but I did go for a few walks around the building as I usually do to keep myself sane. I also went for a very short walk around the block and ended up with 8000 steps for the day. My knee felt like it felt 3.5 weeks after surgery (it was feeling great then). I did my rehab exercises as usual and iced my knee probably 5 times last night. I woke up this morning and my knee was just feeling pretty crappy. I played golf with my parents today (they walked the course and I hired a golf cart). It just felt inflamed and achy and sore. It was really disappointing as yesterday was really good. I feel overall my knee is starting to improve, I just feel the threshold for it flaming up is really low. I guess it's just super frustrating!

I feel like sometimes I do the same amount of activity as yesterday and my knee doesn't flare up and then sometimes it does. Hopefully it starts to settle quickly!

TL;DR: Knee was feeling as good if not better than 3.5 weeks post surgery. Did 8k steps, which is quite normal for me and now feels inflamed. Cannot work this knee out!
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 27, 2021, 07:17:32 AM
Week Eight

This week has been up and down. I think 3 out of the 7 days of this week my knee has been feeling really good, at times almost feeling 100%, but then, after doing a little too much walking or pushing myself a little too hard with the rehab, it will flare up and feel bad. It is so frustrating really, I sort of get these glimmers of hope, and then it just knocks me down when my knee is feeling irritated again.

Warning: Emotional Rant
This knee injury is just really holding my life back. I spend quite a lot of time at home on the couch, icing my knee and watching TV. There are so many things that I want to do but just cannot. I have been able to bike ride but I can run or play any sports. I really want to get back into the dating scene after a break up mid last year but I am kind of thinking what is the point. Normally when relationships start, you are just going for hikes, beach walks, exploring etc, I just cannot do anything. There has been an opportunity at work for me to join the innovation team for 3 months but I had to turn this down as they are constantly out of office, meeting with people, even sometimes travelling around Australia, my knee would simply not be able to handle this. I feel really disabled and just overall frustrated that things aren't getting better.

As mentioned, it was feeling good, then flares up. It doesn't seem to take much to flare it up and sometimes it is quite random. One day it might be feeling great, and then I do 8k steps on it (out of necessity - going to the shops, going to work etc), and this won't flare it up, and then the next day I'll do 4k steps, a little rehab and it will flare it up. I have been trying to take it easy and ice it as much as possible which seems to help but I just don't know if things are getting better... this waiting game to see if it might get better in 2, 3, 4, 5 months is just killing me!!

On another note, I feel like my overall health is deteriorating as a result of my knee problems. I just feel weaker overall and have less energy. I think this is because I am not exercising much. Post injury but pre op I used to be able to go rock climbing and do yoga, I just cant do those things anymore either..


TL;DR:
Knee has been up and down. Three days this week it has felt good, almost 100% but have had another flare up. Seems like minimal time on feet will flare up my knee. Had an emotional rant you can read :-[ and just generally feeling down about my knee and whether it will recover.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 27, 2021, 07:44:12 AM
Side Note - My Symptoms

The surgeon says I have atypical symptoms for a fat pad impingement. When I injured it originally, I felt a 'pinch' below my kneecap on the right side. This pain then seems to move across to the lateral side of the knee, where the femur meets the tibia, just above that boney 'notch' on the outside of the leg - I think thats the fibula? The pain, pre operation was a sharpish but also dull pain which seemed to be quite localised.

From the arthroscopy, there was nothing wrong except for a fat pad impingement on the lateral side. As the hospital physio kept saying 'you have a perfect knee'.. Things have settled from the arthroscopy, as in my incisions don't hurt anymore, general surgery swelling has gone down, but I am left with this irritable fat pad. When the fat pad does get inflamed, the outer side, below my kneecap gets quite hot. The weird thing is, I get almost all of my pain in that same area on the lateral side. Sometimes the pain shoots down that tendon that is on the outside of the lower leg. The pain is now more 'spread out' and not localised as it was pre operation.

The symptoms are so weird and are really not consistent with those online. It kind of makes me question my diagnosis, but the reality is I have not responded to conservative treatments, and the only thing the surgeon could find was a fat pad impingement, other than that, I have a 'perfect knee'

I am adding an image. The RED area is where it gets hot when the fat pad gets irritated. The BLUE circle is the area where I get the pain and the arrow is where it shoots down.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on January 27, 2021, 08:33:27 AM
Have you considered that you might be icing the knee too much and causing irritation to the tissues and nerves?
Usually the advice at least post injury or post op is 2-3 times a day and never more than 20 minutes at a time (with ice pack wrapped in a cloth to protect the skin). You say you have no more swelling, maybe give the icing a rest for a few weeks?

Have you sorted your footwear out yet?

Not sure which tendon you mean on the outside of the leg, perhaps you mean the ITB? Has the physio checked for irritation/tightness?

Exercise wide, have you tried swimming, excellent cardio and full body workout with no impact on knees.  And do some hydrotherapy exercises like pool walking while in there

What physio type rehab exercises do you do? Stretching? If youíre lying or worse sitting around all day, perhaps your back is grumbling which can also impact your legs.

Maybe the discomfort is nothing to do with your fat pad but referred from another structure?
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 28, 2021, 10:17:43 AM
Hi Vickster,

I have not considered that and that is a very good point. Yeah I will stop icing for a bit and see how it goes. If I do continue, I will do it for no more than 20 minutes at a time.

I haven't bought any new footwear but I am back in the office 4-5 days a week now, and wear my work shoes with orthotics. My work boots have a bit of a heel, which I heard helps take pressure off the fat pad.

No not the ITB, its the one the runs down the lower part of the leg. I don't even know if it's a tendon, maybe it's just a muscle. It's basically the muscle/tendon that runs down that blue arrow in the photo.

I don't do any stretching but maybe I should start? Yeah I work as a web developer, so I literally sit all day. I try to get up every hour and go for a 5 minute walk but still have to do a lot of sitting. I have a sit/stand desk at work but I feel like a lot of time on my feet might flare up my knee.

Ryan

Edit: Attached are shoes, left are ones I wear to work, right are ones I try and wear casually
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on January 28, 2021, 01:34:27 PM
Iím not sure why standing would aggravate a knee that has kneecap issues...itís better for posture and body not to sit too much!  If youíve to sit, you should try to keep your leg up and straight, especially as you have kneecap soreness.

Sitting also tightens and shortens calf muscles, which why stretching is helpful as well as strengthening. Can you go back to your physio to get some tips about general conditioning and not just the knee. The muscle you say is sore is I think tibialis anterior

https://www.torbayandsouthdevon.nhs.uk/uploads/25345.pdf

Youíll also need to work on the rear calf muscles (gastroc and soleus) and also hamstrings, glutes. Maybe get back into Yoga or Pilates?

Perhaps go get a good deep tissue massage of lower back and legs...a good sports massage therapist can tell you how to stretch effectively and safely too

You do have rather slender and even slightly bowed legs, although could be the photo. Perhaps some strengthening and stretching may help...speak to physio (maybe find a new one for a fresh pair of eyes)
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on January 30, 2021, 11:36:20 AM
Hmmm I think you're right, and I know work has some of those mats people stand on which makes it easier on the knees for standing. There are some people that just don't sit down at work at all. Maybe I'll try and stand for 1-2 hours a day and sit the rest and see how that goes. I normally spend the first hour at work checking emails, getting back to people etc, might be a good time to do it.

I really want to get back into yoga, but I don't feel like my knees could handle it at the moment. Quite a few of the poses require me to be in a lunge position, and my knee gets pretty aggravated when bent and load bearing. I have started to stretch a bit more every day as I have been told by many people that my calf muscles are extremely tight.

I am going to get a deep tissue massage, that is a great idea. They're not cheap though, looks like its about AUD $60, which is about £35 for half an hour. I think I'll do it anyway.

Yes I have very bowed legs (I'll add a photo) and my knees don't touch when I put my feet together. When I got orthotics, I was treated for my foot rolling out, not in which the podiatrist said was uncommon. I think my bowed legs used to be worse when I was a kid but have gotten better as I grew up. They never used to cause me any trouble and am not sure if they bow made me more susceptible to this kind of injury.

In terms of strength and flexibility, I just found out there is a public pool near my house, and on the way to work for me. They do Yoga on Wednesday mornings and Aquarobics a few days a week. I think I'll hold off from the Yoga at this stage but the Aquarobics sounds interesting. I have been looking for something to get my heart rate up but easy on the knees. I have hurt my ribs (trying to jump over a fence - dont ask!) so I am nursing that back to recovery at the moment, but will get into it soon!
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on January 30, 2021, 11:49:43 AM
If you want a proper cardio workout, assuming you can, why not try swimming? Do the exercises yourself before, after and during. While the pools were open here, I was doing the exercises hydrotherapy physios had showed me and swimming as much as my ankle would take.
Hoping the pools open again soon (currently under full lockdown) so I can get back in for fitness, ankle rehab and knee prefab before my scope (assuming okayed by surgeon and physio)

I pay £35 for a sports massage, I think itís good value, youíre paying a trained professional. Have an hour for the first one, as they may have quite a lot of work to do on both legs, glutes and your lower back

Maybe look at Pilates rather than yoga
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on February 08, 2021, 10:26:03 AM
Hey Vickster,

I have been thinking about doing some swimming. I was going to go on Saturday but I saw my physio on Friday and he recommended I sign up for a gym and start using some of the machines with light weights as part of my rehab. I also like the idea of the gym as this gym does yoga and pilates classes which I am going to attend.

Cheers
Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on February 08, 2021, 10:43:48 AM
Week Nine

Week nine was slightly better in some ways but worse in others. The first 4 days of the week went well but then I had another flare up of my knee but this time no as bad as previous flare ups. It was quite bad for about 1.5 days but started to settle. I was going to go to a gig on the Friday night with a couple of friends but I had to cancel to rest my knee. I did manage to get out on a couple of bike rides which was nice and good for the knee, but other than that, especially on the weekend I did not do much.

I have been continuing to take the anti-inflammatories that the surgeon gave me, though I am taking them more 'as required' rather than twice per day.

I don't have much more to add for this week, I am writing this a week late and have just started full time work so really exhausted/can't remember much of this week. I will add more information to week 10 which I will write now.

TL;DR:
Slightly better than the previous week. Had 4 good days but flared up over the weekend. Continuing to take anti-inflammatories.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on February 08, 2021, 11:05:51 AM
Week Ten

I started full time work this week. I was a little bit worried as I had to go into the office everyday which meant I would have to do 6-7k steps just during the day (a bit of a walk to and from the car park, then going to meetings, everyday activities at home etc.) Things did seem to be fine and as the week went on, my knee was feeling better and better

Even though the knee was feeling stronger, I could see that I was losing a bit of weight. I have been a little lazy with rehab the last week or so and I think my right quad got a little smaller. It was noticeably smaller than my left (good knee leg). I saw my physio on Thursday (I think I said Friday in a previous post) and he recommended that I join a gym so I can start using some of the leg exercise machines. He also recommended getting on the cross trainer and maybe even doing some yoga/pilates if the gym offered it.

On Friday, I went to a local gym and did a trial. I jumped on the cross trainer for 15 minutes (which was the first time I had broken a sweat exercising in a long time), and did some of the leg extension exercises and the seated squat things (ones where your sitting down with your legs almost in the air and push up on a board with weights). The exercises didn't feel great, I just felt this pain in my right knee on the lateral side when my knee was bent at about 45 degrees. I was convinced that I would wake up the next day and the knee would feel terrible but it didn't. It felted a little unstable but nothing too bad. Two days later I did a trial at another gym, this time for a week. I did a similar thing, cross trainer for 15 minutes, extensions and seated squats. I also just did some arm exercises and a few chin ups while I was there. Again didn't feel great with the leg exercises and pulled up a little more sore the following day. My knee did feel a little inflamed the following day, and I did go to a BBQ where it hurt a little to stand up for a long period but it was OK. The following day (today) my knee felt pretty good back at work. I went back to the same gym and did the same exercises plus some stretching at the end of the session.

This is the first time in quite a number of weeks that I feel my knee is starting to improve. I feel like my knee is less irritable and I am able to push through some exercises that would have flared up my knee for a week or two if I did them 1.5 months ago. It is definitely not anywhere near perfect but it is looking kind of promising. At the same time I don't want to get my hopes up as I have felt like this before and then just come crashing down when my knee has a big flare up.


TL;DR:
Started full time work in the office so I am up and about a bit more. Saw the physio who recommended joining a gym and doing some leg exercises as well as going on thee cross trainer and doing some Yoga/Pilates. Knee has handled the gym quite well so I will continue. First time in a while that I feel like my knee is starting to improve, but don't want to get my hopes up too much
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on February 08, 2021, 11:28:33 AM
With any new resistance programme, low weight, high reps is much better and continue to fatigue not pain. And donít forget to stretch after your workout (and light icing if inflamed) :)
Leg extensions can be unfriendly to the PFJ, did the physio specifically mention doing those?
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on February 28, 2021, 08:34:54 AM
Week Eleven, Twelve & Thirteen

Hi all, apologies, I have been quite lazy with the posting. I will write for week eleven, twelve and thirteen all in one post.

I think part of the reason why I haven't been posting is because my knee was getting better, so I was starting to get on with my life. That is until I had another major flare up.

Last post I mentioned that I felt like my knee was really improving and I think it really was. I believe one of the reasons why it was improving was because I was starting to use it more, but not too much. I was doing about 6k steps per day when I went into the office, which was 5 days a week. I was also bike riding quite a bit and have joined a gym where I get on the cross trainer. One of the reasons why I go to the gym is because the physio recommended it. This is because there are leg machines that I could do as he is concerned with the strength of my quads. The first couple of times I went to the gym, I did the leg extension exercises and the seated squat things. It didn't make my knee feel great but it didn't really flare it up. My knee got to the point where I felt like I could return to rock climbing and felt like I could probably go on a beach walk with some friends. Last Saturday, so about 8 days ago, I went to the gym and did 20 minutes on the gross trainer and was feeling good. I then jumped on the leg extension machine on the lowest possible weight. I did one set of leg extensions and again, they were not feeling great but I continued to a second set. On the second set, I had done about 6 reps already, and on the seventh, as I was lifting my leg up, I felt a sharp pain under my knee cap on the right hand side, exactly where I get all my pain. I knew instantly that I had hurt myself and stopped the exercise. I didn't know that I had flared my knee up quite badly until that night. I was meeting some friends in the city for a drink at a pub and then planned on going into the fringe festival that is currently on in my city. My knee was feeling pretty average walking to the pub, and when it was time to go to the festival, I knew that I just needed to go home. The next day it was obvious I had hurt it quite badly. I don't think it has been this flared up for months. I am so disappointed and I am pretty down about it. It has been 8 days since the flare up and it still feels pretty bad. It has improved slightly but its still pretty painful and just generally unstable/sore.

I don't really know what to think right now. Part of me thinks my knee is just buggered and it will never get better. The other part of me knows that it has only been 3 months since the surgery and that it generally takes about 6-9 months to recover. There is also another part of me that doubts whether this is actually a fat pad injury or something else is going on. In saying that I do have pretty typical symptoms of fat pad impingement, the only weird thing is that my symptoms are on the lateral side of my right knee.

Anyway, I plan on just resting again. I have to go into work but I will be spending a lot of time at home.


TL;DR:
Knee was feeling pretty good and I thought things were getting better and I was starting to move on with my life. I then flared my knee up quite badly at the gym doing a leg extension. Now feels like it felt 1 month post operation. Super frustrated with it but what can I do..

Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on February 28, 2021, 08:36:57 PM
Ryan,

Thanks for the update. I re-read your The Injury post. You had a traumatic accident. While it's possible this could lead to fat pad impingement, there could well be something more than that. I am skeptical the sharp pain you felt at the time of the accident is a suddenly sprung up fat pad impingement. I had impingement in the very same spot but it developed gradually through overuse (running).

I realize you had an MRI and your knee was scoped and nothing more was found. That's of course good but like you I wonder if something was missed. Good scoping can go beyond the MRI so not sure what to recommend. Any scope can cause tissue damage so I am reluctant to call for a second exploratory scope. Maybe a second, more powerful, MRI with a different radiologist. There are various advanced MRI techniques, including quantitative MRI, use of contrast agents, etc. We need to rule out ligament or lateral meniscus tear.

Age is on your side. For many of us here this knee club is like Hotel California. Hope you'll be one of the few who can check out.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on March 02, 2021, 08:35:42 AM
Gday silver_maple,

Thanks for taking the time to reply.

From what my surgeon has told me, there seems to be multiple ways to irritate/pinch your fat pad. I think many people have an overuse type injury but I have also read online hyperextension/direct blows are really common ways to pinch your fat pad. I am also skeptical that there is something else going on but the surgeon has gone in there with the scope, looked all around, has pictures of my perfect meniscus etc.

I am 99% sure that there is nothing wrong with my meniscus but skeptical about the ligaments. However, when I did pinch my fat pad, I did feel it on the right hand side under the kneecap and then the pain sort of gradually moved to the outer lateral side.

How are you going with your fat pad impingement? When did you injury yours and what type of treatment have you had?
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on March 03, 2021, 12:45:19 AM
Ryan,

There are three fat pads. I developed a supra-patellar fat pad impingement in the right knee only due to overuse (running and long walking). The fat pads are quite innervated and can be a source of sharp pain if impinged/inflamed. When the pain hit me I tried rest, ice and activity modification (stopped running). That worked to reduce the pain dramatically. Eventually saw a doc after even walking more than 8-10 km inflamed the area. By the time I had the MRI, as I had reduced walking to ~ 6 km a day max, the impingement had eased and was diagnosed as "mild". But if I were to increase the walking distance it would flair up.

Inflammation is not good for the knee as it sets degenerative processes in motion, mostly re cartilage.

In your case, I wonder if the doc recommended more conservative treatments before surgery. Yes, surgery can be indicated for impingement but only after less aggressive modalities have failed. As some fat pad appears to have been removed, you may experience some kinetic changes in the knee, like you describe in Week Seven.

Another poster, kneegeek2020, was so upset part of his fat pad was removed that he tried fat injections in order to restore it.

The default solution is to wait the six months post op and see if you heal. The good thing is you appear to have no other structural issues and only an "irritable knee". Please keep us posted from time to time. Best.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on March 07, 2021, 12:42:31 AM
Hey silver_maple,

I did try a number of conservative treatments pre operation but had little to no success with these. These included seeing two physiotherapists, doing all the strengthening exercises, getting orthotics, rest and doing yoga for about 3 months. I found that my symptoms were just getting worse and that is when I decided to see the surgeon, as recommended by my second physio.

Yeah I am basically just going to wait until 6-9 months post operation and see how things are going. That seems to be the general timeline for these things to settle. I do have faith as my knee has settled a bit before but then I have aggravated it, so I think I just need to take it easy, which is really hard for me to do as I am 29 and just want to get back into life!

Ill keep you updated.

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on March 07, 2021, 01:25:05 AM
Week Fourteen

My knee has started to settle after the flare up that I had 2 weeks ago and I am starting to see a bit of a pattern. When I flare my knee up, it generally STARTS to settle about 1.5 weeks after the flare up. So there are some positive signs but it is still certainly inflamed. I am back to the point where I can walk on flat surfaces with good shoes on without much trouble if I take it easy, in other situations, like walking flat footed, or on uneven surfaces, my knee doesn't feel great. I have been taking ant-inflammatories, celecoxib, twice a day, morning and night and I think that is helping a bit.

I saw my physio on Wednesday. There was not much he could do but recommended that I pull back from the rehab exercises for the next couple of weeks but continue bike riding as much as I could. This seems to be the only exercise that never flares my knee up. I think I have just been so concerned about my quads and how much weaker my right is from my left. I think I have wanted to get my right quad back to what my left is like too quickly. I think the reality is that my right quad is going to be a lot weaker than my left for a long time, and that it is not realistic that in 3 months time my right left will be as strong as my left. I think I need to just continue to do what I can on my right, i.e. bike riding, the cross trainer at the gym etc until my knee completely settles. I also think that when my knee does settle again, I just need to take it easy and continue doing the exercises that I know don't irritate my knee and avoid that ones that do.

This all sounds like the logical thing to do but I guess when my knee is starting to feel good and strong again, I just want to get back into my normal life again and start pushing it harder because I think I can.

Maybe this is too much information for an online forum but whatever. My now ex girlfriend and I broke up in June last year. I feel like I have not only been trying to deal with a knee injury/surgery but also a break up which has been incredibly difficult. The first 6 months of break ups are always pretty hard, and it is still hard, but the last couple of months I have been keen to try and move on and meet someone else. I have just been desperate to just get back into life, start meeting people, do different things etc but I feel like this knee injury/surgery is just holding me back. Realistically, I would have done the typical get back into shape thing that a lot of people do post break up. I would have been running, playing hockey, netball, and just generally going out more and doing different things. Instead I haven't been able to play any sport, no running, many times I have had to turn down social events/going out, it just sucks!!!!! I have been talking to a girl recently that I met that didn't eventuate to anything in the end but I think part of the reason why it didn't is because I wasn't able to do some things that she wanted to do. She is really into hiking, camping, running and wanted to do some of those things with me but I just couldn't, and am unsure when I will be able to do those things again, if ever!

Anyway that's enough for this week, I'll try and check back in for week fifteen.

Ryan.



TL;DR:
Knee starting to settle after the flare up 2 weeks ago. Seems to take 1.5 weeks to start to settle after a flare up. Really need to accept that its going to take a long time for my right leg to be as strong as my left and when my knee does settle, I need to continue doing exercises that definitely don't aggravate my knee and leave the more intense knee strengthening exercises until much later in the recovery.

There is also a bit of an emotional rant in there about wanting to get back into life, especially post break up.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on March 15, 2021, 10:05:14 AM
Week Fifteen

Hi All,

I haven't seen much improvement in my knee this week but it hasn't gotten any worse. It is still no where near as good as it was 3 weeks ago before I flared it up. It's getting closer to four months post op now, and it has been a significant time since the surgery. I am really sceptical as to whether this knee is going to get better and whether the surgery has done anything, or whether it has made it worse. Right now, my knee is significantly worse than what it was pre operation. I am just playing this waiting game and I don't know how long post operation it has to be to determine that the surgery has failed and this is how my knee is now. My surgeon says sometimes it takes 3-5 months, others on the internet say 6 months. I think 6 months is about when I'll know but I guess its just not really looking promising.

One thing that does seem to help is wearing shoes with a bit of a heel. I think it takes the load off the fat pad a bit. About 6 months ago, I bought a pair of RM williams boots which have a fair heel on them. I wear them to the office and my knee seems to feel the best when I am at work. I recently bought some adidas sports shoes to wear on the weekend and casually as I got a bit sick of wearing these big hiking boots everywhere. I was wearing them on the weekend and they just don't feel great on the knee which is annoying. I have bought an old but in good condition second hand pair of RM williams boots off ebay. They cost $600 a pair but I got this second hand pair for $200. I got them from a shoe repair shop who has repaired them etc. I am going to try and wear my good pair to work and this second hand pair on the weekends. I like wearing shorts so they will look a little funny but oh well, if it helps my knee then its all good.

That's all for this week, not much has changed since last week. I'll check back in next week.

TL;DR:

Not much has changed, not worse but knee still not as good as 3 weeks ago before I flared it up. Kind of losing hope that this knee will get better. Ordered a pair of boots that have a heel as that seems to help.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on March 28, 2021, 08:33:57 AM
Week Sixteen & Seventeen

During the past 2 weeks I have seen some improvements in my knee. I don't feel like it is quite as good as what it was about a month ago before it flared up but it certainly isn't as bad as the week after it flared up. I really haven't been doing much rehab and am noticing that my legs are getting really quite weak which is a bit concerning.

I got a sports massage a couple of weeks back. I was feeling like the muscles down the side of my leg, both above and below the knee were quite tight and getting sore. I paid AUD $60 for the 30 minute massage. It wasn't too bad, probably won't get another one for a while but this guy was also a physio and was giving me some exercises I could try. I told him it was hard for me to do any kind of quad exercise but he said that I should be trying to focus on any muscle in the legs/glutes that I could work out without it putting pressure on the knee. He got me to do some 'hip thrusts' with about 20kg on my stomach and it felt good. Since then, I have been going to my gym and just trying to work out most if not all my leg muscles. At the moment I can do:


There seems to be quite a few exercises I can do without flaring the knee up so hopefully a month or two of this and my legs will start to get a lot stronger and help with the injury. Thats all for these two weeks!

TL;DR:
Knee feeling a bit better. Got a sports massage and was pretty good. Guy was also a physio and gave me some exercises to do. I have been in the gym working out every leg muscle I can without flaring up my knee.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on April 19, 2021, 02:25:36 PM
Week Eighteen, Nineteen and Twenty

I haven't posted in a while so I'll give an update for the last 3 weeks. The last three weeks have been up and down. My knee is just so irritable. One day it feels quite good, I am walking around the office with little to no pain; sometimes it stays like this for a few days, and then it just seems to flare up a bit and is sore/achy, the muscles around it are sore etc. I haven't really been able to figure out a pattern or what exactly flares it up, but I just seem to go in these cycles. It is about 5 months post operation now, which seems to be a long time. I don't know at what point I can say, 'the surgery didn't work' and now I have a really irritable knee, or whether its still recovering.

A few weeks ago, my left knee (my good knee) was starting to hurt in the exact same spot as my right knee. Obviously this made me pretty concerned as this was my good knee. I had been neglecting my left knee as all rehab etc was done on my right. I haven't been running obviously so my left has gotten quite weak. I have been continuing my rehab at the gym and have been making sure I work out my left knee as well. At the time of writing this, the pain in my left knee has gone away. This has got me thinking though, maybe a lot of my knee pain is caused by very weak muscles rather than irritation of the fat pad, or the weak muscles make it easier for my knee to flare up. So I have been getting into the gym quite a bit over the last three weeks and been doing rehab on both legs, doing the exercises I listed in my previous post. I am definitely getting stronger and am able to left more and more weight. I am still trying to take it easy though. Any sign of knee pain, especially on the leg extension machine or the squat machine I will stop.

So I guess the plan for the next couple of months is to try and build as much strength in my legs as possible without flaring it up too much. I am not convinced that my knee is completely settled since the surgery and I am reluctant to even consider a second surgery any time soon. I think even if I flare up my knee a little bit doing rehab, the benefits from the strengthening might be worth it!

TL;DR:
Knee up and down still. Left knee (good knee) starting to hurt in the same spot. Getting back into rehab and working out might left at the same time. Left knee not hurting anymore. Still taking it easy with the gym leg exercises and plan to continue over the next couple of months
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on May 02, 2021, 07:05:31 PM
Ryan, there is one California-based knee doc who has quite a following on this board. His name is Scott Dye. On the question of post surgery recovery he states the following:

[...] it can often take up to 18 months or more to achieve full joint homeostasis/healing following even minimal surgery. All concerned need to respect this principle.

As previously stated, healing is a ďrate-limitedĒ biological phenomenon analogous to the maturation of a fine French Bordeaux such as a Ch‚teau Lafite Rothschild. Eight to ten years are required to create a drinkable vintage from the initial grape juice. The vintners understand the chemistry (to a degree) but they donít control it. They cannot make a palatable wine in a week, month, or a year. Similarly, we cannot ďaccelerateĒ restoration of joint homeostasis/healing.
Each knee must take its own unique time. Therefore, patience is a virtue in this clinical setting.


Ref: Dye SF, Dye CC. An overview of patellofemoral painófrom a tissue homeostasis perspective. Ann Joint 2018;3:61.

Please keep updating us. I for one read each installment of your progress with great interest.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 05, 2021, 08:59:51 AM
Twenty-one & Twenty-two

Hi All,

I went to the surgeon about a week ago for my five month post op check up. I explained to him that I am still getting a lot of pain in my knee and that I don't really feel like it is getting better and that it is worse than pre-operation. He basically explained to me that if it is not better now, then this is how my knee will be... which was obviously pretty hard to hear. I do tend to read different things online i.e. many people say 6-9 months to heal, others say 18 months so I am trying to stay optimistic. He has gotten my to do another MRI and we are going to go from there. I am very very reluctant to have another surgery. He said he can basically do the same surgery but give cortisone injections at 2 and 4 weeks to change the healing process. This is something to consider, but as I said, I am very reluctant to do this and will most likely be looking to wait at least 12 months after surgery to consider another.

In terms of symptoms/how the knee is going, these past two weeks have not been too bad and I have seen some very slight improvements in my knee. Long story short but I was at a friends birthday party and got chatting to a girl who is a physio. We immediately had plenty to talk about and she was keen to listen and give me some advice. I briefly explained all of my symptoms (including a new one - both of my knees seem to get sore, below the kneecap, when I sit for too long) to her. She told me that I should stretch out my quads and also really focus on trying to strengthen my glutes. So that is what I have been pretty much doing. I have noticed that when I stretch my quads, its quite tight in my knee when I get my foot very close to my glute muscles. I get a bit of a sharpish pain above my kneecap on the right side when I do it. I have also been doing that stretch, on the ground on my side and pushing down on my right leg that I am stretching to really stretch out my ITB. That sharpish pain about my kneecap is more pronounced when I do that. It is a bit painful, and is sore after I come out of the stretch, but it seems to free up my knee a bit. I have also been doing the glute 'hip thrusts' at the gym which have been pretty good.

As I mentioned my knee has felt slightly better. I even went down to the beach on sunday morning, after knee rehab and went for a bit of a walk (on the concrete) and it was the first time in a very long time that I was just walking a long completely pain free. I also feel like I have slightly more stability in my legs and have put on about 2-3kg in the past month or so. This weight definitely has to be leg muscles as my diet has not changed and I have not been doing any upper-body weights. As I am writing this though, which is about 3 days after this week has finished, I feel like my knee has gotten a bit worse but I will update that in the next post.

On another more positive note, I have been absolutely desperate to play sport for the past year but just haven't been able to. I have started to get back into indoor bouldering and have been doing yoga and my usual bike riding, but I also enquired about a local wheelchair basketball league. There are casual games on Tuesday nights at 6:30 and 7:20pm with a skills session beforehand. I ended up giving it a go two weeks ago and absolutely loved it!! I had no idea what I was doing but kind of got the hang of it after a bit. I have now played 3 games for my team 'The Demons'. It's a great feeling walking into a sports centre on a chilly autumn night and playing some sport. It has really helped with my overall mental health around the situation as I can sometimes get quite sad about my knee issues.

Finally, I plan on continuing with rehab. At the moment, I am getting down to the gym about twice, sometimes three times a week and doing a pretty intense leg workout. I am starting to be able to lift heavier and heavier weights. In saying that, my legs are still pretty weak, and over a year of minimal activity/injury cannot be made up in a month or so, so I have to stick at it. I am very curious to see how my knee is after 2-3 more months of rehab.


TL;DR:
Saw the surgeon, told me that my knee probably wont get any better as it has been 5 months. Having another MRI to see if he can see anything. Very reluctant to get another surgery. Knee going OK, some improvements. Been stretching quads/ITB and focusing on glutes at the gym which I think is helping a bit. Have put on 2-3kg from doing rehab in the last month or so. Started playing wheelchair basketball and absolutely loving it, great feeling to be playing some sport again. Will continue with rehab as usual
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 07, 2021, 09:06:08 AM
Hey silver_maple,

Thanks for checking in and thank you for that information. That paper is reassuring to my situation! I feel like I have always been a slow healer. It's almost like it is quite hard for me to get injured i.e. I played years and years of sports without even a pulled muscle (well up until I was 28), but when I do get injured, it takes me a while to get better. I think back to when I rolled my ankle, it took me a good 6 or so months to stop feeling any pain where I rolled it, which I think is longer than usual.

I'll try and keep posting here, I myself like to look back when I feel like I am making no progress and see where I was. If anyone else is reading in say hi as well!

Regards
Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 09, 2021, 08:08:28 AM
Week twenty-three

Hi everyone,

This week has been up and down but overall positive. I had quite a good week the week before this one, but at the start of this week, my knee was feeling quite achy and sore, which was disappointing. Then it seemed to turn and it was feeling OK for the rest of the week. I have been continuing with rehab, I think I have got down to the gym about 3 times this week and I am definitely getting stronger. I will put up a picture of my right leg compared to it about 3-4 months ago, my quads are certainly getting bigger! Realistically, my legs are still quite small to what they were back in my mid 20's. I've always had really quite chunky strong legs so I think there is still a long way to go. Also, I am sitting at about 80kg at the moment. My baseline weight when I don't work out is about 82-83kg. I think this means that there is still a lot more muscle for my legs to gain.

I also saw my surgeon on Thursday regarding my MRI results. There hasn't been any new injuries/damage since the surgery. He said that it looked like there was still a level of inflammation inside of my knee from the surgery. I will add some images from the MRI. The first one is what my surgeon showed me when he said there was still some inflammation. He also mentioned that I had a bit of an abnormality with the the protective coating (cant remember the technical name) on the under side of my patella. He said that the coating is missing on the bottom part of my patella which might be causing some of the pain in my knee, especially when my knee is at 30% flexion and under load. He was saying that there is a surgery that he can do that can shorten the patella tendon so that the part of the patella. He wasn't really suggesting doing that surgery, I think he more meant if in a year or so things aren't getting better or have gotten worse then that could be something to look into. As I mentioned in previous posts, I am very reluctant to have another surgery and am certainly looking to wait at least 6 months if not 12 to rethink what I can do. It is a bit promising that there is still some inflammation in my knee as my knee is yet to recover fully from the surgery. I am still remaining optimistic that with more time and rehab, I can get my knee back to a point where I can live pain free throughout the day and get back into running. I am not too concerned if I can never play sports again that involve running, but being able to go for a jog would be awesome!

Not much else for this week, I will try and check back in about a week.

Ryan


TL;DR:
Up and down. Little achy and sore at the start of the week but got better. Continuing with normal rehab. Have put muscle on my right leg but still a way to go. I am still about 3 kgs of my baseline weight. Saw the surgeon for my MRI results. Showed nothing major, just that there is still inflammation in the knee and is yet to recover fully from surgery.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 09, 2021, 08:15:54 AM
MRI photo 1
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 09, 2021, 08:16:34 AM
MRI photo 2
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 15, 2021, 03:39:49 PM
Week twenty-four

Hi All,

I am writing this week's update a day early because I feel pretty frustrated and feel like I need to get some thoughts/feelings off my chest. Essentially, I feel like over the last 3 weeks, my knee has been improving. I  was just starting to do more with my knee and I was having less and less pain. I was also starting to lift heavier and heavier weight at the gym and my legs are definitely getting stronger. On Wednesday last week, I had my first day completely pain free. I just got up in the morning, went to work etc and even went for a walk in the afternoon. Its starting to get cold where I am and I like the nighttime walks in the dark in winter listening to some music. I have started going to the gym with a friend where we work out for a bit but then I go onto the leg machines to do rehab. On Thursday night, we decided to work out shoulders and legs. We did a couple of exercises on shoulders but did lots of exercises on legs. Long story short I flared up my knee quite badly again.. I am not sure what exercise did it as there was not a point where I got a sharp pain in my knee, but it has certainly flared up. I normally leave the gym feeling quite good on my legs but this time I felt really bad. I am so disappointed, I felt like I was making so much progress and it was taking so long to actually make progress and I have just stuffed it up. I feel like I was at the exact same point as I was at the 3 month mark when my knee was feeling better and I flared it up.

Gah, so I guess I am back to resting, icing and just sitting around at home doing nothing.

Somehow I am staying optimistic. I feel like I am still in the window where it could get better. I am very much taking the information from Claire Patella (Claire Robertson) who seems to be an actual knee guru, focusing on infra-patella knee pain. She says that it takes 6-9 months generally for fat pads to settle and they are particularly irritable in the first 2-3 months. I guess my knee was pretty irritable in the first 3 months, then started to settle and then I flared it up. Also, I guess it took a big leg workout for my knee to flare up this time. Three weeks after surgery, it took just walking around the block to flare it up, three months it took very low weight simple gym exercises to do it and this time it was heavy weight full leg workouts that did it. I hope this doesnt take another 2.5 months to settle like the last flare up did but I guess I just have to go through it. The sad part is that I was starting to plan what sports I was going to get back into and I what I was going to do with my knee that was better. I guess that is just on hold now...

TL;DR:
Knee was starting to feel a lot better, but have completely flared it up again. Really disappointed with the set back
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 22, 2021, 05:39:51 AM
Week twenty-five

Hey all,

Writing my blog entry early again as I have quite a bit to say! Basically, I was pretty bummed a week ago as I had flared my knee up quite badly. I thought I had essentially set my self back months and was pretty down about it. I started to do a lot more research and was just reading more and more (and listening) to Claire Robertson and how she recommends managing irritable fat pads. Perviously, I had just been taking all of my advice from my physio and surgeon. Claire recommends the following things when trying to calm a fat pad: Getting good footwear, ideally something with a heel and try to avoid being flat footed. Secondly she recommends using an ice-massage and thirdly, she recommends taping the patella off the fat pad to provide some relief. I already had the footwear more or less sorted, but I hadn't really tried taping or ice massage. I have been taping it a bit bit the main thing I have been doing is giving it an ice massage once a day for about 5 minutes. The improvements that I have seen the last week have been quite incredible. It took about 3 days for the ice massaging to kick in but by Wednesday (it's now Saturday), my knee was feeling very good. I felt like it was improving about 10% per day whereas this would normally take about 2 weeks to happen. On Thursday night I went for a night walk and was feeling confident enough to go for a 20 meter jog, something I have not done in over a year, and my knee felt quite good. Since then, my knee seems to improve every day. I am going on more and more walks and even went on a 100 meter jog today and was feeling very confident on it. I really cannot believe that it is improving so rapidly but I think what is happening is that ice massage is really penetrating into the fat pad and reducing the inflammation. I used to also get pain shooting up and down my legs which I think originated in the fat pad. This pain has also gone away.

So I guess the plan is now just continue with the fat pad ice massage and try to get back into the rehab stuff at the gym. I'll keep everyone updated!

TL;DR:
Seen massive improvements in my knee, I think mainly to do with ice massaging my fat pad. Went for my first (very short) jog and my knee felt pretty good. Went on a slightly longer one (100m) and it also felt very good.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: jgardner on May 23, 2021, 08:44:56 PM
Thanks for sharing the great news about your improvement (and more generally for sharing your story here)! This is very helpful. I have a bit of a fat pad issue and will add that 5-minute ice message to my recovery "toolkit".
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 24, 2021, 05:47:01 AM
Hey jgardner,

Awesome, please let me know how it goes for you!

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on May 31, 2021, 12:29:08 PM
Week twenty-six

Hi all,

I pushed my knee a bit too much the previous week with the jogs and the walks and after a really positive week, my knee was beginning to ache and become quite sore. I was upping the icing but really needed to pull back on the walking. I was a little disappointed as my knee was almost feeling 100% but I am still remaining positive. It was pretty up and down through out the week but at the time of writing this, my knee is feeling pretty good. I went for a bike ride down the beach a couple of days ago and that was probably what made my knee feel the worst. It just was not feeling right and was quite achy afterwards.

I also saw a different physiotherapist a few days ago. This was mainly because I wanted to try dry needling but also to get a second opinion and my other physio basically was like "keep doing the exercises and see how you go and come back every 2 months". My new physio really took the time to listen to me and was quite surprised that I had actually had an operation for a fat pad impingement. She did a whole bunch of tests and found that I had a really tight ITB and that my hip adductor (I think) was quite weak and mentioned that could be contributing. She also did the dry needling. I was expecting her to put the needles in my ITB and the muscles but she put about 4-5 needles directly into the fat pad. I don't know if I liked it! It was a bit sore afterwards for a couple of days but subsided. I think I will try it again as I have read many people have had success with it. Also, she showed me how to tape my knee to pull my patella up and away from my fat pad which I have been doing each day with rocktape. Also, she was able to access my latest MRI results. This is the conclusion from the scan:

Small near full thickness chondral defect with subchondral oedema inferolateral patellar facet. Mild proximal tibiofibular joint effusion without significant underlying degenerative change. No meniscal tear. No features of Hoffa's fat pad impingement. Scarring is evident involving the superolateral aspect of Hoffa's fat pad in keeping with debridement.

I cant really figure out what that first bit means with the patellar facet, if anyone knows, please let me know!

Overall, my knee is feeling OK. I have been doing quite a bit more walking and certainly have less pain. I am consistently doing 9-10k steps per day quite easily which is a significant improvement from a couple of months ago. It is still far from perfect and don't really feel confident to run on it again. Hopefully just a bit more time (maybe a couple of months) and my knee will really start to become good.

Until next time,
Ryan

TL;DR:
After a near perfect week the week before, my knee has started to become quite achy after the funning/lots of walking. Had to pull back a bit. Saw another physio to do some dry needling, she noticed my hip adductor is quite weak and gave me some exercises for that.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on June 05, 2021, 04:03:08 AM
Ryan,

I am bit surprised by this (second) MRI report as the first MRI report (per your initial post) said that there were no structural issues with the knee. And you have been taking it easy since. I have to assume the first radiologist missed things or the MRI imagery was not of high quality.

The near full thickness chondral fissure in the patella is potentially a concern. There is likely a teeny layer of intact calcified cartilage (bottom layer) to guard against pain but there is also subchondral oedema - so in all likelihood this is where the source of the pain is - the near full fissure. This chondral defect, on the lower and outer side of the patella, has been described as "small". It would be good to ask how small.

There have been claims on this board that some people can spontaneously fill in such fissures with fibrocartilage (not the best). I think Vickster made a claim of that nature c. 2014. Mainstream docs view focal chondral defects as potentially repairable with transplant procedures - ACI, MACI and the like. Not saying that's the route you should take. Knees are finicky and sometimes surgical intervention causes more trouble than what it purports to fix. You are lucky there is no meniscal tear. Noteworthy the doc who scoped your knee did not notice the chondral defect. I still find it hard to believe the defect appeared post scope given how careful you have been.

The MRI also states there is no (Hoffa) fat pad impingement. So your conjecture that the pain is coming from the fat pad may not be right. No loss reading Claire Robertson re fat pads, it's good to know that stuff.

Which doc ordered the second MRI? Why did a physiotherapist have to tell you about the MRI results, presumably for the first time? I would have expected the doc who ordered the MRI to interpret the findings for you and recommend treatment.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 05, 2021, 10:10:31 AM
G'day silver_maple,

Thanks for commenting.

I guess ever since the surgery, I have just assumed that the impingement had been removed but the actual fat pad was just inflamed and irritable and that was the source of my pain, now I am not too sure. I haven't written my weekly update yet but my knee has been OK. I have done about 70,000 steps for the week and it was feeling good for 6 out of the 7 days but today it is just really sore, which is so disappointing. Then again though, when I say 'OK', its not like I am anywhere near full function and don't have the confidence to run on it. So 'OK' means it feels about 60% right.

I agree, I can't imagine this chondral defect has popped up post surgery as I have been taking it so easy. The only time I could think of is about 3 months post surgery when I was doing leg extensions at the gym with very low weight (1 plate). My knee was at about a 30 degree angle lifting the weight and I just got this really really sharp pain just below the kneecap on the lateral side. It did feel like something 'tore' but I just thought some of the scar tissue on the fat pad got ripped off and aggravated.

So if this was there post surgery, I also find it hard to believe that the surgeon missed it during the scope.

In terms of the second MRI, the surgeon who operated on my knee ordered that one at the 5 month post op appointment. This is because I was not seeing much improvement. From what I can remember him saying, it was something along the lines of:

"There seems to be some inflammation in your knee still. Everything else looks fine, you are missing some of your cartilage at the bottom of your knee cap which could be genetic, there is an operation that I can do that shortens the patella tendon which could help for this but it is a 3 month recovery." And that was about it. He didn't give me a copy of the MRI and basically was like "that's all I can do fo you, you don't need to make another appointment".  It wasn't until I went to the new physio that she gave me the results of the MRI and mentioned what had actually been found.

Hmmm so I don't really know what to do. I am seeing my GP on Monday for something unrelated to my knee. I will get the results of my first MRI result and see what it says as I have lost that one.

Also I think it is also worth mentioning that my knee still gets quite warm and sometimes quite hot. I also have this 'snapping' sound that comes from the lateral side of the knee. It is not painful, but happens about 30-40 times a day

Ryan

Edit: I have found my MRI results for my first one, posted them in the next post along with the full results of the second MRI
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 05, 2021, 11:08:46 AM
Hi silver_maple,

I have actually found my first MRI that I had on the 13/07/2020. This one was done at with the same company that did my second one. I have also posted the full results of the second MRI as well.

This is the report for the first MRI:

Coronal and sagittal alignment of the knee joint is normal. There is a small joint effusion present decompressed into the suprapatellar fossa. There is a minimal amount of synovitis here and in the intercondylar region. There is no large intra-articular body visualised. There is no infiltrative marrow lesion demonstrated. There is no Baker's cyst.

Patellofemoral Compartment: The Insall-Salvati ratio measures 0.96 which is within normal limits. Femoral trochlear morphology is normal. The medial and lateral retinacula are intact. There is some minimal chondral oedema about the medial patellar facet articular cartilage but no full thickness chondral defect is seen here. There is no subchondral change. There is some chronic fibrocartilaginous repair with some minimal subchondral oedematous change at the troclear groove articular cartilage with no other chondral defect or subchondral change seen about the femoral throchlea. The quadriceps and patellar tendons are intact. The quadriceps, prefemoral and Hoffa's fat pad appear unremarkable. Small amount of fluid in the deep infrapatellar bursa. No evidence of prepatellar buritis.

Intercondylar Region: Both cruciate ligaments are intact. Some minimal subcortical oedema is seen at the posterior tibial spine which may be possibly traction related to the posterior cruciate ligament.

Medial compartment: No tear of the medial meniscus is demonstrated. The medial collateral ligament is intact and unremarkable. The meniscofemoral and meniscotibial ligaments are normal. There is no chondral abnormality or subchondral change visualised.

Lateral compartment: The lateral meniscus is intact. The lateral collateral ligament is intact and unremarkable. The popliteus tendon and other posterolatereal corner structures appear unremarkable. There is no chondral defect or subchondral change seen throughout.

Conclusion: There is no acute internal deragement. No high grade chondral abnormality seen.






For reference, here is the full copy of the MRI results from the one I had on the 24/04/2021:

Intercondylar Region: ACL and PCL intact.

Medial compartment: MCL intact. No meniscus tear identified. Articular cartilage is intact. No subchondral oedema.

Lateral compartment: LCL complex is intact. No features to suggest ITB friction syndrome. Popliteus is intact. No meniscal tear identified. Articular cartilage is intact. No subchondral oedema. Small effusion is noted arising from the posterior aspect of the proximal tibiofibular joint with mild associated synovitis however no underlying degenerative change. Normal apperance to the fibular origin of the soleus.

Patellofemoral compartment: Small knee joint effusion is noted. Patellar retinacula are intact. Quadriceps and patellar tendons are intact. There is a small near full thickness chondral defect involving the inferolateral patella with subtle subchondral oedema. remaining patellar cartilage well preserved. Single full thickness dark chondral fissure troclear groove with subchondral cyst formation however this is a stable funding. Remaining trochlear cartilage well preserved. Scarring is evident involving the supereolateral aspect of Hoffa's fat pad in keeping with debridement. No features of Hoffa's fat pad impingement.

Other findings: No Baker's cyst. No features of pes anserine bursitis.

Conclusion: Small near full thickness chondral defect with sub chondral oedema inferolateral patellar facet. Mild proximal tibiofibular effusion without significant underlying degenerative change. No meniscal tear.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on June 05, 2021, 03:47:31 PM
Ryan,

Thanks for posting the full MRI reports. The first one looks reasonably benign. To operate on the basis of such report simply on the suspicion of a fat pad impingement looks like an aggressive modality to me. No use crying over spilled milk. You have no alignment issues. That your doc would suggest patellar tendon shortening is beyond me. Frankly I have no confidence in this doc.

While the second MRI is fresh I'd recommend seeking a 2nd opinion from a different doc. The question is what to do with the cartilage defects, you've got one in the troclear groove as well. Your body has managed some fibro repair already (per the 1st MRI report). Maybe you can manage that again but fibrocartilage is less durable. Why our body would not attempt genuine repair with hyaline cartilage I don't know. This fact is behind the proliferation of various chrondroplasty techniques. The snapping you get could be the plica - if you can replicate it in front of your GP, he/she may confirm that. It could go away after a few weeks.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 06, 2021, 01:47:51 AM
Hi silver_maple,

Yeah I couldn't believe when the doc recommended patellar tendon shortening, seemed a bit ridiculous. This particular surgeon has seemed pretty disinterested every time I go in.

In terms of the original surgery, I guess I was pretty desperate. My knee symptoms seemed to be getting worse and I had not responded to physio, yoga or orthotics. When I went into this original surgeon, he said something like 'you seem to have an abnormality around your meniscus, the only way to know what's going on in there to do an arthroscopy and see what is going on'. That's when I had the surgery and he found the fat pad impingement that he trimmed back. I'll add a photo to this post of the image of the impingement and what it looked like after trimming.

I think I will make an appointment to see another doctor and work out my options. From what it sounds like, these chondral defects can be the source of a lot of pain and might be what is causing it and the fat pad is fine.

It's just hard to know what to do right now. I am 6.5 months post operation which seems to be a long time but I also read some places that sometimes the knee needs longer than that to settle after any surgery. I have this chondral defect on my patellar which has seemed to pop out of no where and have no idea whether that is causing my pain or the fat pad is still trying to settle after the surgery. It is also hard as the inferolateral patellar chondral defect is almost in the same spot as the fat pad impingement surgery and that is always where I get my pain, I never get pain on the medial side of my knee.

Also, my knee does seem to give me these snippets of hope, where it is feeling really good and feeling like I can run, then it just throws me back down. It's hard to say if my knee is better than before surgery. I never used to have a couple of days where my knee was feeling good pre-surgery, there was always an ache or pain in there whenever I walked. I am sometimes now able to walk pain free but my knee seems to 'flare up' much easier than before. Anyway enough of that rant!

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 06, 2021, 08:16:50 AM
Week twenty-seven

Hi all,

There has been a bit of discussion back and forth since last week. Basically I now know that I have a small amount of cartilage damage on the under side of my kneecap on the bottom on the outside. There is also some damage in my trochlea groove. I was a bit disappointed as my surgeon failed to mention this to me a month back when I got my MRI results. I have been freaking out a bit the last couple of days, I've had some really positive days but the last two my knee has been really achy. I guess I just think that I am almost 7 months post operation and things have not gotten back to normal. I also went down a bit of a rabbit hole as to how chondral defects are treated and that really freaked me out i.e. the process and recovery with treatments like microfractures and ACI, MACI etc. I even watched a video of a MACI operation and just burst into tears.

In terms of the week, I have had some pretty good days, especially the first 5 days. I clocked up about 70,000 steps this week as I was out walking around the block, climbing etc. On day 6 of this week though, my knee was just getting a bit sore. I played golf (and hired a cart) yesterday and things were OK but it was pushing it. I was meant to go out yesterday for some karaoke and just couldn't as my knee was just sore and I didn't think I could handle it.

I don't know why but when my knee started to hurt later in the week, I really started to get a bit depressed about it. I think this is because it has been over 6 months since the surgery and I feel like I am still so far off running properly/living a normal life. I seem to get glimmers of hope, then I just get thrown back down. I have had some time to think about what my next plan of attack with this is as I refuse to believe that this is just how my knee is and this is how I have to live from now on.

I have been doing some reading on chondral defects and a lot of people do respond to physio and strengthening the muscles around the knee. My muscles in my legs have certainly gotten stronger since doing rehab but I think they are still way weaker than they normally are. I haven't been super super consistent with the rehab either. I was doing the really light at home ones for about 3 months post op. I did have weeks where I did not do the exercises, and at one stage, I didn't do any for about 3-4 weeks. I then was pretty consistent with the gym rehab for about 2 months but for some reason, about 1 month ago, I started working out my upper body a lot more and the leg exercises only at the end if I had time. I recently posted a photo of my legs and how I have put on some muscle, I think I have actually lost some of that since posting. I also think that my job is really not helping with the rehab. I just sit all day and that is making my legs (and just body in general) weaker. I think if I do two rehab sessions a week, that only counteracts the sitting all day and doesn't have a positive gain on my muscles.

Side note: My dad has was diagnosed with chondromalacia in both knees under the knee cap when he was about my age (maybe a bit younger). He has never had surgery and the pain went away when he stopped playing football (aussie rules). He hasn't had any pain since.

Basically what I am getting to is my next plan of attack for this knee. I know there is no way I am having another surgery until at least 1 year after this one. Also, I know that the muscles in my legs are just weaker than what they usually are. I think I need to start getting really serious about this knee rehab and try to build the muscles in my legs as much as I can without flaring my knee up. If I can spend the next 2-3 months doing that, I think I will be in a better position to come up with a plan from there, knowing that my legs are strong but I am still getting/not getting pain.

Thats all for this week, I will check back in next week!

Ryan


TL;DR:

Now know that I had cartilage damage on the inside of my patellar, which my surgeon seemed to fail to mention to me. Overall knee has been good but sore at the end of the week, has gotten me a bit down. Basically know that I will not have another surgery until at least 1 year post op, so only option is to strengthen the muscles around the knee and see what happens with that. Will then be in a better position to make a decision about what action to take next
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on June 06, 2021, 10:08:42 AM
Perhaps you are overdoing it and not having rest days or days where you stick to only gentle non weight bearing type exercise, a gentle flat cycle just to get the knees moving or a gentle swim, some pool walking perhaps. Followed by ice and heat and feet up :) Avoid deep squatting lunging, weights for a bit, give the knee a rest. You want to avoid inflammation as that causes damage to cartilage.

Itís very easy to overthink what might be going on especially when receiving a detailed MRI report. As my surgeons various have explained many times, radiologists are expected to report any and all findings, however many might be on little or no clinical consequence. Itís down to the expert specialist to correlate with history, clinical examination and discussion of symptoms with patient.

I would doubt a tiny defect without painful crepitus, swelling, loss of ROM is the cause of your knee soreness, and certainly not in need of major surgery :)

I went down the whole MACI thing in 2010, big traumatic weight bearing defect on lateral femur (which as noted had filled with fibro), even had the harvest scope after a long fight with private insurer but being mildly knock kneed and having some other wear, the surgeon (an expert in cartilage repair) wouldnít do it (without straightening the joint first).
Iím very glad actually, yes my knee is a bit of a mess now (Iíve just had a scope and 3 patches of micro fracture to grade 4 bits). Notably that WB defect fibro seems to be holding up ok, but one of the micro fractures was to the same bone, but a different bit (other were WB medial femur, trochlea and chondroplasty to patella)

Stick with physio, the gym, pool, but donít overdo it, walking 10k steps every day is probably too much for your knee, you need to find the right balance between weight bearing activity, non impact and most importantly rest (a couple of days a week). Perhaps give yoga or Pilates a go on the rest days, make sure your core is good and all the leg muscles firing properly (plus hips, glutes, lower back) and everything supple.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 07, 2021, 09:36:54 AM
Hi Vickster,

I probably am overdoing it a bit. 10k steps per day is probably too much, I am just really keen to get back to my normal self and when the knee is feeling good, I just start using it. I have/am pulling it back and will see how it goes. I think I need to stop the icing for a bit, I think my skin is starting to burn a bit! I also don't think the taping is doing anything, so I might stop that also.

Also I agree with you with the radiologist thing. I think most of the stuff on the MRI is just because they have to report everything. Also thanks for the info about your MACI, that sounds like an absolute last resort for me and something to think about in 6 months to a year when all else has failed.

I have also been considering having a cortisone injection. I seem to have problems with inflammation and my knee getting a bit angry so maybe I am a good candidate for it?  I feel like there is no harm in trying??

And yep that is the plan, sticking with the physio, gym etc. I haven't yet tried the pool but it is winter where I am and most are closed. There are some indoor ones but its a bit of a hassle to get down there. I've been indoor bouldering quite often which is surprisingly OK for the knee, especially if I do certain types of climbs and take it easy.

Cheers,

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on June 07, 2021, 10:47:08 AM
Cortisone (or any injected steroid) can damage cartilage so unless your knee is very inflamed (swollen, hot) and nothing else helps (eg anti inflammatory gels, or oral medication), best not to go there if it just feels a bit sore (especially if itís transient following activity, better to moderate activity and have proper rest days). You could ask your specialist about hyaluronic acid injections (like Synvisc or other brand) or Platelet rich plasma (PRP), they are natural and can help lubricate the joint and reduce inflammation.  Although again theyíre more for moderate to severe symptoms really (not least due to the cost).

In terms of icing, you should never apply ice directly to skin, wrap in a cloth (or if doing massage to fat pad, put olive oil on the skin and keep the icecube moving always). Have you tried heat on the joint too, especially to warm it up before exercise?

It is possible your knee will never feel exactly as it did as youíve had surgery. All surgery will cause changes in the joint, as scar tissue is unavoidable, so it may just be a matter of accepting that and moving forwards with your different knee.

MACI and other cartilage repair modalities are often a poor option for defects in the patella/trochlea due to the forces with bending and straightening so again youíd really only want to consider if severe pain and functional impairment :)

Have you considered mindfulness or CBT as a way of managing the psychological impact (rather than looking for invasive treatments?) Might be worth looking into
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 09, 2021, 09:35:45 AM
Hi Vickster,

OK I will avoid steroid injections for now. I have actually booked in to see a new surgeon. As mentioned before, I am not looking to get another surgery done any time soon, well at least not for the next 6-12 months, but it would be interesting to see his interpretation of the MRI results and just get some advice from him. I will discuss my options around those injections you mentioned with him.

Regarding icing, I always put olive oil on my skin before applying ice. I have not tried heat to the joint before exercise, I mainly use ice before exercise. I could give this a go and see if it makes any difference.

I understand that my knee will never be the same, and am happy to accept that I will never play competitive sport again. To be honest, I think I would also be able to get past the fact that I couldn't run again, I just don't seem to be able to live a life where I can live normally and go on one walk a day without it flaring up after a couple of days. I also get into situations where I can just hang out with friends because my knee is hurting so much.

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on June 09, 2021, 10:47:53 AM
If using a static ice pack, you should wrap it in a cloth not just oil the skin (the oil is for ice massage where you are using an ice cube on a small area eg the fatpad)

What pain relief have you tried when itís sore? What sort of pain is it?
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 09, 2021, 12:04:29 PM
Hi Vickster,

I haven't been using ice packs, only the ice massage for a couple of minutes a couple of times a day. I always put olive oil on my skin before hand.

In terms of pain relief, I still have some celebobix. I haven't actually taken any for this recent flare up as I have recently started taking some medication for something unrelated and read that it slightly increases your chances of developing GI tract bleeding if taken together. I might take some ibuprofen as apparently it is slightly better for this. I might also start taking some paracetamol as well to see if it helps.

In terms of the pain, I seem to get the exact same symptoms every 'flare up'. There isn't a specific spot where it hurts, it just aches and is 'angry' on the lateral side, right where the fat pad is, under the patella. But I also seem to get pain that kind of shoots up and down my leg. So my IBT will be sore, like an achy swollen pain, as well as the tendon that runs below the knee on the lateral side. Even reecetly I have this achyish pain in my glutes. Even the muscles behind my knee kind of ache. I feel like it all originates from my knee. Last night, I was getting these 'shooting' pains on and off coming from the bottom right (of my right knee) part of my knee cap.

The pain I got pre surgery was so much more 'localised', but now when it flares up, I get the symptoms of above.

Cheers,
Ryan

Edit: I also seem to get more 'popping' and 'clicking' in my knee when it is flared up, and that seems to settle when my knee is OK.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on June 09, 2021, 12:25:13 PM
If itís more muscular ache or tightness that doesnít relieve with focused stretching and rest, have you tried sports massage? Of glutes, hamstrings, quads, calves, even lower back? Anything awry can cause stiffness and knee pain. Do you use a foam roller, tennis ball etc as part of your gym workout ?
Presumably a physio has done a thorough assessment of all your muscles and gait?
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 13, 2021, 09:11:52 AM
Nah its not muscle tightness, I definitely know that feeling. The achy pains in my legs are most pronounced closest to my knee, and only come up when my knee is really irritable and achy, so its definitely to do with that. I do use a foam roller and tennis ball quite regularly as part of my workout.

The physio hasnt done a gait analysis but I went to a podiatrist and got one done and wear orthotics, so I think that is all good. Also, I have tried getting a sports massage. It was OK but it was $60 and can't really afford to get one too often!

Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 13, 2021, 10:25:07 AM
Week twenty-eight

Hi All,

This week has been the worst week in a while. As mentioned in week twenty-seven, I pushed my knee too much with 70k steps for the week. At the beginning of this week, I tried to push through it a bit, thinking it was just some general soreness. I had pulled back on the walking but I was still doing the gym exercises (leg extensions, hamstrings etc). It got to a point where it was just soo painful, even to the point where I was limping around the house. It wasn't really that painful when I was doing the exercises at the gym, but when I got home and everything settled and I later tried walking on it, I was in a lot of pain. The pain is just this achy inflamed feeling, not in one particular spot, but more just in general on the lateral side under the patella. It also seems to shoot up and down my leg on the lateral side and I even get the achy pain behind my leg. This has been the hardest week psychologically since I had my knee surgery and had a bit of a breakdown on Thursday night because of it. Previously, I was able to stay optimistic as I could just say 'Oh I am only 3 month post operation, I am still in the window of common recovery time'. Now that it is approaching 7 months post operation, I am really having doubts to whether my knee will ever completely settle and that the operation actually made me knee considerably worse that pre op. I am tryinggggggg my best to stay positive, but it is hard. I am able to play my wheelchair basketball, go bouldering, go to the gym so that is a positive. The only thing is, I get these snippets of what life can be life with a good knee. And I start doing things I love, like going for walks, starting to jog, just being outside and using my body, especially as I spend a lot of time inside on a computer for my work, and then it all comes crashing down!

For the last 3 days, I have taken it really really easy. I haven't been going for walks, or been doing any gym workouts for my legs. I've just been mainly sitting around not doing a lot except playing chess online (add JuannyPubs23 on chess.com if you want a game!), but I have been going to the gym and doing some upper body workouts, to keep myself sane. I have also just been taking two celecobix every day to try and help. I have pulled right back on the icing, as I am a bit concerned about how much I am icing it and I think my knee needs a bit of a break - my knee has been pretty cold in general lately, but this might be because it is getting really cold where I am and I wear shorts all of the time (yes I am one of those). My knee has improved since and it was feeling OK today. I did some gardening and took my dog down to the park and went for a very very small walk today without much trouble. I am pleased that it has started to settle after the flare up but am still upset that it flared up in the first place. I clearly have to be more careful, and not start walking around the block three times a day the moment it starts to feel OK.

I have had a chance to do a lot of thinking over the past couple of days and have just been trying to figure out what is going on with my knee. I know its not great to dwell on it and look up different surgeries but I just can't help it. This is what I have come up with what could possibly be wrong with my knee:


Other than that, I can't really think of what could be causing all this pain in my knee!

As I mentioned in a previous post, I am going to see a different surgeon to get some advice. Also as mentioned previously, I wont be getting another surgery for at least another 6 months but I am interested to get a second opinion. I am even thinking about seeing a third surgeon just to get a couple of opinions about what is going on (something I probably should have done before my first surgery).

Anyway that is all fo this week,

Ryan


TL;DR:
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on June 13, 2021, 05:27:05 PM
Ryan,

I salute your intention to get a second opinion. And a third, if possible. I'd also recommend consulting with a physician who does injective therapy before you do any further surgery.

I've been seeing two knee docs (Cleveland Clc) and while I put neither on a pedestal, to their credit, when I presented with a fat pad impingement, degenerate meniscus tear, and generalized plus focal cartilage wear, neither even mentioned surgery. In fact the initial recommendation was to do absolutely nothing beyond rest and quad strengthening. I actually had to push to get PRP shots.

I remain skeptical you needed the first surgery. Within the paradigm of Dr. Dye your envelope of function is reduced. If you stay within the EoF (and you have tested the boundaries) you may be ok but the objective is to improve and at 29 you have a chance of doing that. Do look at the injective side of things (other than steroids).
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 14, 2021, 09:30:39 AM
Hi silver_maple,

Thanks, yes it will be interesting to see what they have to say. Regarding the injections, that is what I am thinking I will try before another surgery. I am pretty keen to stay away from the cortisone injections but understand there are other options. I'll chat to the surgeons about this in depth about these.

Sounds like you have some good knee doctors. My doc just went straight in there, without trying other types of treatment. I had no idea injections were a thing before my surgery and would have liked my health professional to take me through those options.

I agree, I am also skeptical that I needed surgery. To be honest, when I decided to have surgery, I hadn't done any physio for about 5 months. I did it for about 3 months after the initial injury but was not seeing any improvements so I stopped. I think the physio was quite inexperienced (he was about 25 - younger than me) and went quite aggressive with the physio and was trying to get me back into running as soon as I could. There was no recommendation of icing, taping, rest etc. I also spent a lot of time sitting last year. I was finishing off my computer science degree and was working three days a week as a web developer. I basically spend 60 hours a week at a computer and didn't do much exercise. Basically what I am saying is that I think I got really weak and unfit which did not help my knee at all. I am still struggling to get that strength back.

Thanks again for replying, I'll keep you posted.

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 18, 2021, 10:20:16 AM
Hi all,

Thought Iíd give a quick update before my weekly update as I saw a different surgeon today for a second opinion. This guy seemed pretty good, he certainly seemed a lot more interested than my other surgeon. I explained everything and he had a look at my MRIs. Before reading the summary of the MRI reports, he could see that I had damage to the cartilage on my patella. He was stepping through the MRI and showed me that on the left side, the cartilage was intact but on the right on the bottom side, it was missing/damaged. He then had a look at the MRI pre surgery and could see the same thing. He then did a physical exam and was pushing down on the spot where the chondral defect is and it was really sore. I showed him the picture of the fat pad impingement that the previous surgeon removed and he said ĎI wouldnít call that a fat pad impingementí and called it something else, I think he said plica?? He basically concluded that the pain I am getting in my knee is probably due to that cartilage damage on my patella and not the fat pad. He said that this issue is really hard to treat and recommended continuing to see how itís goes over the next 3-6 months. He did say a way to treat this is to do a microfracture operation but there is no guarantee that it will work. He said there are two ways to do it, one is through arthroscopy and the other is somehow he flips the patella and adds something else which is sometimes more effective. He said in the meantime I can try a hyaluronic acid injection to see if that helps which I think I am going to try in a couple of weeks.

So I donít really know how I feel about this new diagnosis. It sounds like my first surgeon just mis-diagnosed me and I had a surgery that I probably didnít need.

Regards
Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on June 19, 2021, 04:37:29 AM
Ryan,

This second doc appears to be closer to the mark. The fact that he is going through the MRI slices and not just the radiologist's report is a good sign. Not to mention the first doc didn't even comment on the MRI report, it was your physiotherapist who shared that. You would recall that a few messages back (June 4-5th) when you wrote you are getting 40-50 snapping sounds a day I ventured a guess it could be the plica. The second doc appears to confirm that. I had a snapping plica which went away on its own after 3-4 months.

More serious is the cartilage damage. Likely that's the source of the pain since the fissure is deep and there is subchondral edema. If it were not as deep you likely would not have pain that shoots up all the way to the glutes as well as downward because cartilage itself is aneural. But once the damage gets close to the bone - watch out. The mild synovitis that you also have should be symptomatically contained to the knee and not shoot up and down very far. With the icing you were generally taking care of the synovitis.

I have to unfortunately concur this cartilage damage is difficult to treat. Microfracture (MFX) will fill the gap but with inferior fibrocartilage. Could be acceptable for someone 65+ who is not too active but for someone like you, not yet 30, if you want to return to active sport, the fibrocartilage will not last.

Dr. Saw in Kuala Lumpur attempts to solve this problem by combining MFX with stem cells, reportedly resulting in close to hyaline cartilage. But he focuses on larger cartilage lesions and yours is small. You'd need to spend weeks in KL, it's a multi-stage fairly involved process, and there is no telling whether he'd take you on. This forum has lots of info on Dr. Saw.

You should've gotten a better grasp of what the other alternative proposed by the doc is. Maybe call and ask. It could be an allograft procedure like DeNovo, by the sound of it. I don't know much about its success rates in the patella.

The HA would do you no harm, so feel free to try it. It is highly unlikely to resolve the issue in the long-term even if you were to feel some short-term relief.

Bottom line is, the second doc is right in being hesitant to operate. Your damage is not that significant and the cost/benefit (not in terms of money) equation of surgical intervention is unclear. I am not keen on MFX but get the second alternative right and read up on it. And discuss with your parents.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on June 19, 2021, 11:25:18 AM
Hereís a Uk site that gives info about different cartilage repair options (itís a few years old, so maybe there are some other newer techniques), but de Novo for example isnít available here and I think itís being phased out in the US esp for the patella (where cartilage repair is much less successful due to shearing forces).
http://www.kneeclinic.info/problems_articular_cartilage.php
Thereís also a fair amount of info in the learning portfolio about articular cartilage issues and treatment options.

https://www.kneeguru.co.uk/KNEEnotes/learning-portfolio

The issue at least here with some of these techniques is either a lack of approval as deemed experimental and costs which can run easily to 15k plus if not available on the NHS (which many arenít outside trials).  The technique suggested above with Dr Saw is also expensive, USD 30k or more? and thatís a while ago, plus travel, accommodation, physio etc

Definitely try the HA, ease back on anything that puts lots of load on the kneecap like squats and lunges, ride your well set up bike, go swimming, walking. When working have your foot raised and your knee as straight as possible
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 19, 2021, 11:42:42 AM
Hi silver_maple,

Yeah for sure, I am much more content with that diagnosis. I am certainly giving the first doc the flick.

I have heard this about micro fracture surgery and that the fibrocartilage is not as strong as normal cartilage. That is definitely something to take into consideration. But if I am not going to be able to run/play sport anyway with a chondral defect, then itís worth considering if it will improve my quality of life. I donít think going to Kuala Lumpur is an option for me at this stage, especially in the days of COVID.

Itís all things to think about in 6 months time but yeah, if I am really not seeing any improvements in my knee, and the surgery will potentially enable me to go on beach walks, live with less pain, maybe go on the occasional run, have the ability to travel etc. then Iíll definitely consider it. I am more than happy to give up competitive sport/sport in general and lots of running if that is the only option.

In terms of the injection, yes I am going to get it in a couple of weeks time, they sound quite safe. It costs $500 AUD because it isnít covered by Medicare (Our universal health care - and annoyingly cortisone injections are and only cost about $40) but I will just pay and get it done - Iíll call up on Monday. I understand that it will not fix my problem, but I am hoping it will give me some relief so that I can keep focussing on strengthening the muscles in my legs. My right quads are still significantly smaller than my left and feel like that might make some difference if I can strengthen them up.

Iíll find out that second operative option that he mentioned and get back to you. It was something like a micro fracture, but then he covers it with something to hold everything in. I donít think it is done through arthroscopy either so I imagine the recovery is a bit longer.

Iíll keep you updated

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on June 19, 2021, 11:52:03 AM
Hi vickster,

Thanks for those links, Iíll have a sus. Also thanks for the info about the costs, I certainly wonít be able to afford $30k USD unless I took out a big loan so that seems a bit out of reach at this stage.

Just randomly, itís interesting reading about patella microfracture recovery and it mentions that some weight bearing exercises should be kept within the 0 to 20 degree range. I am assuming that below this, there is a lot of load on the patella. If I try squats, I get to about the 20-30 degree range and get pain in my knee and when on the leg extension machine, I can do them from 0 to 20 degrees flexion but after that, this is when my knee really starts to hurt. Just kind of confirms that this cartilage damage has been the issue all along.

Cheers,
Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on June 19, 2021, 11:57:41 AM
Regarding HA injections, my surgeon and I over the years have found the course of 3 injections better, longer lasting (and less painful than the single injection options). Ask the surgeon about this (and the costs). Iíve had maybe 5 rounds over the years (a couple of the singles, and the rest course of 3).

Iíve not had microfracture on the patella, but Iíve now had it twice on the trochlea (and on each condyle recently)
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on August 21, 2021, 10:23:58 AM
Hello All,

It's been a while since I last posted so I am going to give a bit of an update on how I am travelling.

I have stopped updating on how my recovery is going because I am now sure that the original surgeon did not treat me for what was wrong with my knee. I am now pretty sure that I have damage to the cartilage under my kneecap and I need to get that sorted.

About 2 months ago now I had a hyaluronic acid injection in my knee. It did seem to give me some relief but I feel like the benefits have all but gone. I am now left with the same knee pain I have had all this time. It has now been 9 months since the surgery and its safe to say it did absolutely nothing and was a complete waste of time and money and I am pretty disappointed in the surgeon. If anything it just weakened my muscles and made my knee worse. I certainly don't recommend Dr Roger Patterson out of SportsMed in Adelaide, SA.

As mentioned in previous posts, I saw another surgeon and he recommended microfracture on the defect. He said there is two types he can do, one is keyhole and the other is where he'll have to flip my knee cap, do thee microfracture and cover it with a gel that holds everything in.

I have booked myself in with a third surgeon to get another opinion as I certainly don't want to go under the knife again for the wrong thing. That appointment is on the 21st of September 2021. After that, I will make a decision on what I will do. My concerns with the microfracture is that it can potentially only last a few years and then needs to be done again, which I certainly don't want to do. I want to get something done that will give me some lasting results.

Anyway, I will update on how the appointment with the third surgeon goes and will go from there.

Ryan
 
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on September 22, 2021, 08:42:57 AM
Hi all,

I am not reporting on how my recovery is going anymore but I will update on what has happened as I have seen a new surgeon now for some second opinion (of the second opinion).

As mentioned in the previous post, I saw a surgeon and he recommended microfracture on the defect on my patella. I had an appointment with a third surgeon yesterday just to get another opinion before I went under the knife again. Basically this third surgeon agreed that the damage was on the lower right hand side of my right leg's patella and he essentially said there was nothing he could do and that damage to the patella can rarely be fixed and that I am stuck with it. I kept asking him questions and he finally said what he could do, which didn't have a high chance of working is a lateral release. I'll attach another photo of my MRI but he said it is tilting a bit to the side where it is getting irritated. He said I could try the microfracture plus the lateral release but has was basically saying that it has a low chance of working.

I am not really sure what I am going to do now. My knee has been OK recently but it still flares up and then takes 2-3 weeks to settle. I still cant jog and just live a pretty sedentary life.

What I am leaning towards is having another hyaluronic acid injection, as I did see some relief after that and to really spend this summer going hard (but not overdoing) the rehab, really trying to strengthen my hips, glutes and quads - I have been doing this but I also get lazy and just don't do it sometimes.

Then, in about 4-5 months, if its really something that I feel like is worth the risk of another surgery, I will go ahead with it. I am still not really sure and still thinking about it. If anyone has any input, please let me know :)

Ryan
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on September 22, 2021, 02:39:57 PM
Ryan, frankly I am leery of microfracture plus lateral release. The doc himself says there is a low chance of working. Not sure if he mentioned there is a good chance of you actually being worse post-op. Further, traditional microfracture, like the one proposed, results in a fibrocartilagenous fill (lower quality, lower durability) and in that place you need hyaline.

Please look into stem cell mixes, esp. adipose-based. You are young and bone marrow could also has some effect. No guarantee of a fill but at least there is no downside risk (other than money spent) and the procedure is repeatable, if needed. The patellar defect does not appear to be big enough to look at grafting although that could come under consideration down the line (years) if nothing else has worked.

Now, if you have pronounced patellar maltracking that needs lateral release to get fixed that's another matter. I haven't re-read your entire thread but from memory you did not have severe maltracking. So a lateral release could well over-correct any minor maltracking that might exist.

You could inject HA or PRP over the next few months as you continue to research. Try to find some physical activity that minimizes flares - being sedentary is not good for systemic health. I have found swimming to be quite nice for my creaky knees.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: Chris H on September 25, 2021, 03:05:44 AM
Hi Ryan.
My name's Chris, I also live in Adelaide and had the same surgery as you back in July 2020. Currently I'm frantically searching the web for fat pad solutions and came across your story. I'm going through exactly what you are. I'm finding no success with anything and I believe my surgery has made things worse. I would love to grab your information so we can keep in touch to chat privately and discuss. Maybe work together to try and find a solution?
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RGB on September 25, 2021, 11:10:04 AM
Hi guys. I have no medical training and I'm much older than either of you. So you should take what follows with several grains of salt. What I do have is experience with a similar problem starting 12/13 years ago at the age of 47. I started with a focal lesion on the trochlea and later developed a matching lesion on the patella. Believe me - I understand how debilitating patellofemoral cartilage defects are. One flight of stairs a day was the max without pain and swelling. No cycling. So all I could do with my legs was walk on the flat. I went through the full range of treatments - normal microfracture, debridement, PRP injections, adipose derived stem cell injections and, finally, Dr Saw's microfracture + lateral release + blood derived stem cell injections, staying a few months in Malaysia and then returning for injections every 6 months for 2 years. None of it worked and the operations all made things worse. My only way out in the end was a PFJR - with which I am very happy. However, at your age I'm not sure that's a good option. I understand the argument that treatments may have moved on since I underwent them but I do keep up my reading and I don't think they really have. Or I may have just been unlucky, or too old. However, what I would now tell my 30 year old self with those problems is:

"Find a way to conquer your psychological demons and find a way to live with the problem. Find a form of exercise you can tolerate and use that as your physical outlet - there are a few - swimming, sea kayaking, etc. If there's a quantum leap in treatment then by all means check it out but don't go searching for the rare doctor who'll promise he can make your condition better when most of the others say there's nothing they can do. If it really was that certain, everyone would be doing it. Once you get old enough, you can get a joint replacement."

I'm not saying all this applies to you both (especially the 'psychological demons'!) but there may be bits of it that are helpful. There are other threads that discuss my journey in more detail.

Good luck to you both.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: silver_maple on September 25, 2021, 03:06:18 PM
I second what RGB is saying. For Ryan in particular the option of doing nothing should probably be #1. Occasional HA or PRP can control inflammation if it gets out of hand. Neither will solve the underlying issue. I'd be really careful with lateral release for minor maltracking. I think it is next to impossible to do the release in such a way or to such an extent that the maltracking is perfectly offset and the knee functions like that of a newborn. Some of the more heart wrenching stories on this board have been from people who desperately want a lateral release reversed and for that the options are severely limited.
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: vickster on September 25, 2021, 05:21:04 PM
You can read about LR from an expert here
https://www.kneeguru.co.uk/KNEEnotes/articles/expert-views/2019/lateral-release-why-bad-reputation
Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on September 26, 2021, 11:12:04 AM
Hi all,

Thank you for all your replies, it has given me a lot to think about.

I tend to agree, I think going in for another surgery really is not a good idea at this stage, especially for the lateral release. Also, I really haven't regained my strength I had pre surgery, and I think if I have another surgery, I will end up with a very very weak right leg. In saying that, I have been in contact with a number of people on Reddit who have had microfracture on their patella and have had good (but not perfect) results.

I think what I am going to do now is really try and strengthen up my bad leg (plus my good one). I have signed up for a program online called 'Knees over toes'. It seems a bit 'cult-y' but does have good reviews. Basically a program with heaps of stretching and strengthening exercises, all of which help the knee. I am going to combine this with my strengthening of my hips, glutes and quads. I am also going to get another hyaluronic injection (will try and get my doctor to do a series of them), and I am also looking into PRP and stem cell treatmets. There seems to be a good place in Adelaide that does PRP and stem cell treatment at the same place. The side effects and risks of these seem to be low, the only thing is they are very expensive. HA injections are $500AUD a pop and PRP are $350. I am not too sure how much stem cell treatment is but I am sure it is expensive. And yeah that is pretty much my plan for the next 6 months. I am still not ruling out microfracture surgery, but I agree it is not the time to do it and I would like to gain more strength in my legs before doing so.

Ill keep everyone updated!

Ryan

Title: Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
Post by: RyanC on November 25, 2021, 09:18:36 AM
Hi all,

Thought I'd give a quick update of what is going on with my knee.

Things have been going pretty average since my last update. I think the HA injection has more or less worn off and I get a lot of achy pain. I have tried to keep up with the rehab but that does not seem to be helping that much.

About 3 weeks ago I had some x-rays and a CT scan with my new surgeon. He wanted to check how my patella was tracking. It looks like I have some patella tracking issues. When my quads are contracted, my kneecap goes out laterally. So I think I have finally gotten to the bottom of what is going on in my knee. I think about 2 years ago, I landed with my knee flexed, and as my patella wasn't tracking right, it chipped off some cartilage under my knee cap. And as I have the tracking issues, it continues to get inflamed. Getting that surgery was one of the worst things I could do as it just weakened my muscles even more. When speaking to the surgeon, he mentioned that with chronic cases of this, a tibial tubercle transfer is possible to try and re alight the patella. This procedure seems very invasive and would be a last resort.

I also had my first PRP injection when I got my scan results a couple of days ago. It was very uncomfortable and my knee still feels sore but sounds like that is normal. It will be interesting to see how my knee feels over the next few weeks/months.

So for now, I'll keep up with rehab, see how this PRP injection goes and keep that surgery in mind. Realistically I wont be going under the knife for at least another 6 months to a year, but will definitely be something to think about if my quality of life is really being affected.

Ryan