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Offline Jakem

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Over Icing?
« on: December 30, 2005, 01:31:36 PM »
As many of you know I am still struggling with heat.  I am 6 months post LOA and I have full ROM but I still have lots of heat.  The heat has been going on for 1.5 years.  My knee gets red and hot if I don't ice and the skin is sensitive to the touch.

I have been icing with the cryo cuff about 5-6 times a day for 1.5 years.  I always wait at least an hour between icings and never ice for longer than 20 minutes at a time as the literature recommends. 

I am wondering if icing for so long has caused a skin problem that is causing the heat and redness?  What can over icing do?  Is there any literature out there about over icing.

I was thinking of stopping all icing for a few days to see what happens.  Any opinions on that?

Offline Heather M.

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Re: Over Icing?
« Reply #1 on: December 30, 2005, 09:32:06 PM »
The times you are indicating wouldn't seem to point to over-icing, but some of the symptoms you have could certainly fall in that category.  I never discount someone's body being far off the bell curve, especially a knee with arthrofibrosis!!

So the timing on the ice sounds right...but you may have some other nerve damage going on, in which case ice could be really irritating things.  One thing to consider is something my PM&R doctor just brought up to me--peroneal nerve irritation.  I seem him once a month for scripts, PT advice, and follow-up.  I've been getting A LOT of pain between the IT band insertion (Gerdy's Tubercle for you anatomy buffs) and the fibular head.  The pain is quite severe at times, but responds fairly well to massage and myo-fascial release.  Ice is not so good for it, though heat seems to relax things.  My PM&R doctor had this idea that I may be dealing with peroneal nerve irritation, especially since I had an open IT band release requiring a three inch incision in the general vicinity of the nerve.  Basically, this is from the tibial tubercle over laterally about two inches--that whole area, almost around the side of the calf, and also shooting all the way down to my ankle on the outside of the shinbone.  He wanted to do a cortisone shot right then, but I had to go Christmas shopping and do cooking, and really didn't want to walk on it after a shot.  So we're doing it in mid January.  The shot won't be inside the capsule, it will be in/around the nerve to try to 'cool it off' in the doctor's words.  He's had good luck with this therapy on his TKR patients who have severe scar tissue problems--seems like the adhesions wrap around pieces of the nerve and really irritate it.

Another thought:  I don't have physical heat or redness unless I really overdo it in terms of walking or being on my feet.  Like every day of the last week, which I have spent chasing around a 2 and 5 year old.  Jeez, my knee was flaming hot last night, so much so that even an hour of icing didn't cool it off.  So I would also look at whether you are doing too much in the way of weight-bearing exercise.  Logically, it might not seem like too much to you, but if your knee is reacting, then obviously it feels something is going on.  Your rehab regimen was pretty aggressive, even if limited in weight-bearing for the first few weeks.

The other possibility would be chondral lesions/damage that get heated up when you do any kind of bending and weight-bearing activity.  It's fairly common to begin to experience articular cartilage damage after a few months with arthrofibrosis.  The worse the adhesions and patellar mobility, the more quickly it seems like severe damage sets in.  Depending on where these lesions might be, bending the leg to say 30-50 degrees while weight-bearing might be exactly the motion that loads the damaged area.  Doing this repeatedly can cause chronic, intermittent, or even constant heat and swelling.  It's really no different in my knee than the scar tissue heat--they both are related to swelling and the presence of inflammatory enzymes.

The heat could also mean that there is a problematic chunk of scar tissue in there somewhere.  Even if it's not impeding ROM or patellar mobility, it can still be generating heat and inflammation.  It becomes its own little combustion engine in some cases.....

Just some ideas.  I'd go back to the doctor for an evaluation/opinion.

Heather

PS Sheesh, I think I'm getting senile.  Sorry about the typos!
« Last Edit: December 30, 2005, 11:39:05 PM by Heather M. »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline Jakem

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Re: Over Icing?
« Reply #2 on: December 30, 2005, 10:09:59 PM »
Heather, those are all interesting possibilities.   I notice you didn't list infection as a possibility and that gives me some ease.  Why don't you think it might be infection?

I won't rule out over icing either as the red part encompances the exact area the the cryocuff covers which seem too coincidental.

I don't think it is chrondal damage as I have no pain in that area.

What is most anoying is that the heat is time based not activity based.  I can sit and do nothing with my leg elevated for days and the heat will start to creep in after 3-4 hours of icing no matter what.  Also interesting is where it starts.  It always starts in the quad believe it or not.  It starts in the quad about 2-3 inches about the knee joint/the top of the patella.  Sometimes it starts on the medial side of the quad, sometime on the lateral side.  Then it creeps towards the knee joint which is still cool.  About a half hour later it engulfs the whole knee.  Occasionally it starts about 5 inches about the knee cap in the center of the quad well above the quad tendon.  Try to figure that one out?!!


I am wondering if it is a nerve problem?  That sounds possible too.

Another interesting thing, is that after 20 minutes of icing all the heat is totally gone and will remain gone for 3-4 hours.  So the heat can come in fast and go out fast.  So fast that there is a freaky thing about it.   When my knee is really hot and red, veins are actually visible going over the surface of my knee cap.  I have never seen anything like that.


 

Offline Heather M.

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Re: Over Icing?
« Reply #3 on: December 30, 2005, 11:46:16 PM »
Hmmm.  That does sound suspicious.  One of the kneegeeks from the old board actually irritated her nerve incredibly with her cryo-cuff--she eventually developed red dots!

It could be that your body is responding to the perceived cold in the joint by rushing circulation to the area, like when your cheeks turn red in cold weather.  So given your additional information, I certainly would consider laying off the ice for a week or even longer and seeing where that leads you.  Give the body a few days at least to find its new equilibrium....the fact that the redness is in the shape of the cryo-cuff is telling.  You may also be having a skin reaction to the materials in the cuff.  Also, sometimes cryo-cuff pads and even knee braces can get fungus and other nasties in them--try washing it according to the manufacturer's instructions.  Buy some very soft cotton dish towels (Sur la Table or Cost Plus has them online) and make sure to put these towels between your skin and the cuff.  And switch them every day, washing them in HOT water with bleach.  If the cryo-cuff material is microwaveable, that might help eliminate any freeloaders or fungus in there, though this is usually a problem in the summer, not winter.

Regarding infection, it never even crossed my mind because you are so far out in the post-op process.  I suppose you could have a low-grade infection lingering in there that your body has fought to a standstill.  But based on my experience, when you have an infection there is no doubt!!  It's always been very obvious, from constant burning heat and redness to fever and night sweats to flu-like feelings.  Just no doubt, at least with my knee.

Heather
« Last Edit: January 03, 2006, 07:32:56 AM by Heather M. »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline mee

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Re: Over Icing?
« Reply #4 on: December 31, 2005, 03:51:51 PM »
Jake,

You definitely have a puzzle on your hands – or rather, your knee.    Heather has some good ideas about possible causes.  I also agree that infection isn't likely because you've done a couple of rounds of antibiotic, yes?  Plus, I would think that the cortisone shots would unleash it if it were there.  That said, I did a round of antibiotics about three weeks post-up because a portal was leaking a little - no other symptoms at all - and two days later, my knee looked like a balloon had deflated.  All the swelling was gone!  Go figure.

You’d said in one previous post that the heat felt as though it was superficial – not deep like the kind of heat you had before surgery.  It seems plausible that you are dealing with a nerve problem – from your description of where the heat starts, I guess it would be your femoral nerve.  Or, I wonder if it is some sort of vascular problem.  Could you be inflaming your blood vessels in the area with the icing? I know that you are icing within standard guidelines, but maybe your body is now rebounding in response to the frequent icing.  Since you note that it continues to heat up despite inactivity (I am presuming you are still icing during these rest periods), then it does seem to point to something other that the joint itself.

Under a previous post, though, you did mention that it flares up if you have to stand for 3-4 hours.  That sounds like a weight-bearing problem.  Remember that you’ve just started strength work.  When you stand and walk beyond the realm of your knee’s present strength, you are bound to irritate it.  When I asked about walking as an element of my rehab (as opposed to activities of daily living), I was told that the impact of walking on my deconditioned knee could inflame it.  I am restricted to cardio activity that keeps my feet on the pedals – be it bike, elliptical, or stepper.  If I end up walking a lot as part of my daily activity, my knee gets pissed off.  I am sure that I will not be allowed to jog - even for two minutes - until I can do single-leg squats comfortably, given that jogging is a single-leg stance activity.

Your knee heat sounds, at this point, like a conditioned response.  The question is: to what?  Since you are an engineer, you can approach this methodically and start removing each suspected stimuli.  Quit icing.  See what happens.  No go?  Gp back to ROM only activities with ice.  Then rest and no ice, etc.  The key, as Heather pointed out, is to allow enough time for your body to reach equilibrium.  I know you’ve rested, but for how long?  Four days?  Maybe it will take seven.  Clearly, you will have to make the call at some point, but given the amount of time you’ve been dealing with this, equilibrium may take a while.

If that doesn’t work, maybe seek out the assistance of a physiatrist, neurologist, or even, a rheumatologist.  I know that you don’t think it’s arthritis, but maybe this is some wacky immunological response. 

And finally, what does your gut tell you?   I remember after my ACL recon, I could not wait to get home from work to ice my knee.  It felt so good.  There came a point though, that it didn’t feel good, but I kept icing anyway, because I still had swelling and that’s what I was “supposed” to do.  This time, when I reached the point that it no longer felt good, I stopped icing.  Every time I complain about my knee irritation, my PT says, “Are you icing?”  So, I try icing, but my knee does NOT like it.  One day, I’d been swimming and saw a whirlpool next to the lap pool.  My brain said no, but my knee said yes.  I sat in the whirlpool for about ten heavenly minutes and my knee felt great for the next 8 hours.  I’ve done that a couple of times and my knee loves it.  My point is not that you should use heat on your knee.  It is that your brain may be overriding your knee’s message about what it needs.  I have found it difficult in the past to trust my knee – after all, it got me into this mess. But in reality, it was ignoring my knee and my gut instincts that got me into this mess.  I’ve decided to cooperate this time. :-)

I feel your frustration, Jake.  Believe, though, that you will figure this out.

Mary



Dec 1999  RKnee - ACL tear while running on treadmill-weird, I know!
Jan. 2000  RK ACL Recon
July 2000   RAnkle peroneal tendon repair (decade-old injury)
April 2001  RK scar debride
Sept 2005 RKnee debride & fat pad removal
July 2006 RKnee - full ROM, rehabbing sloooowly

Offline jim mac

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Re: Over Icing?
« Reply #5 on: December 31, 2005, 04:04:45 PM »
I was just reading this thread with some curiosity.  It's funny how we are all so different.  I can't ice enough!  My knee can go from feeling totally sh*tty and hot and swollen and stiff to almost immediately better with the addition of my Cryo-cuff and some ice cold water.  Icing is my little slice of heaven . . . almost like a little "reset" button for my knee discomfort.  Anyhow, good luck Jake.

Jim
2005 - 3/4 arthroscopy meniscus repair + plica removal, 3/9 staph infection 2nd scope (lavage), 3/12 open incision (lavage), 3/13 cauterize vein + lavage, 3/17 lavage and incision closure, -  Arthrofibrosis -  6/24 debridement, LR, MUA - 10/12 LOA + synovectomy 2006 . . .

Offline Jakem

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Re: Over Icing?
« Reply #6 on: January 01, 2006, 03:43:56 PM »
Thank you Heather and Mary for you thorough and thoughtful responses as I greatly appreciate them.  I have learned far more from people like you and other than I have from doctors about dealing with this dreadful arthrofibrosis desease.

As far as infection goes, I agree that it is highly unlikely.  I got antiboitics during my LOA surgery, got a cycle of Keflex after the surgery, took another cycle on my own, got another cycle when they thought I had cellulitis which it turned out I didn't and then was put on IV antibiotics for 35 days.  What a horrible waste that was all for nothing.  Never once did I have an elevated temp or even slight lousy feeling and repeated blood tests found nothing.  Also the cortisone shots have helped reduce the heat.

Arthritis can be definitely ruled out.  No signs of it on x-rays and no almost no pain.

My knee is extremely vascular at this point.  The heat starts up in the quad then slowly creeps towards the knee.  It takes about a half hour to reach the knee.  But when it reaches there, it then explodes and completely engulfs the whole knee in a matter of minutes and the knee becomes blazing hot and bright red and very sensitive to the touch.   Veins then appear on the surface of the knee cap.  It goes just as quickly, as soon as I apply the ice, within 5 minutes all heat is gone and will stay gone for 3-4 hours.  Most of the redness goes, but not all of it.  The veins dissappear too.  When it is gone it feels great and I can kneel on my knee pain free which you knee Geeks know is quite remarkable.  I will also note all the hair in that region has fallen out and does not grow back.


Yes in a previous post I did say that standing for 3-4 hours causes the heat to come in.  Since then I realized it has nothing to do with activity, the heat will return even if I am lying flat on my back.

Of course overall activity can be adding to this heat also, but I am positive that even if I went to zero activity, the heat would still be there.  That is why I added a tiny bit of jogging and tiny bit of strength training and that fact I am now more than 6 months post op.  These additions neither have increased nor reduced the heat in any way.  Therefore I have rationalized I might as well continue doing them.

It really seems like a conditioned response with the icing.  The bad news is I already tried to break the icing cycle and failed.  I tried to stop icing and the heat and sensitivity to the touch was completely unbearable.  I cannot stop icing for now.  I will try to gradually stop icing, but there is no way I can go cold turkey right now.  I also noticed when I tried to stop icing, that there was negligible swelling in the joint, just heat which is interesting and provides another clue but no answers.

The fungus theory is also possible.  I cleaned the Cryo Cuff as you recommended.

One of the problems it that there may be multiple things going on at once which is hard to figure out.  I may still be getting the typical arthrofibritic heat reaction that is exacerbated by a problem with the skin from excessive icing, fungus, rash or general irritation from all it has been through the past 1.5 years.

My gut tells me that I need to keep icing but try to slowly wean myself off it and that it is just going to take more time, mabye several more months and more cortisone shots.


Offline mee

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Re: Over Icing?
« Reply #7 on: January 02, 2006, 08:48:37 PM »
Jake,

Your further description does sound like a skin/nerve/blood vessel problem rather than your joint.  I know that you don't have pain, but maybe it's some weird relative of RSDS.  The lack of hair is an interesting symptom.

I lean toward the blood vessels, though.  I did a quick google on cryotherapy and rebound vasodilation.  There isn't a heck of a lot out there, but I'm sure you knew that!  Here's an article I came across that discusses cold-induced vasodilaiton.

http://www.gecdsb.on.ca/sub/projects/psl/senior/10/vaso.htm

It would be a giant leap from this experiment to your condition.  BUT, the most interesting thing is the reference to a "thermal physiologist." I'd never heard of that profession.   Maybe you could email this guy or another one for an opinion.

Another thought is that instead of trying to decondition the response with frequency, could you do it with temperature?  As in, use water that's not as cold?  Or, don't compress it with the cryo-cuff some of the time? 

OK, I'll let it go now.  But it was fun concentrating on your knee instead of mine.:-)

Mary
Dec 1999  RKnee - ACL tear while running on treadmill-weird, I know!
Jan. 2000  RK ACL Recon
July 2000   RAnkle peroneal tendon repair (decade-old injury)
April 2001  RK scar debride
Sept 2005 RKnee debride & fat pad removal
July 2006 RKnee - full ROM, rehabbing sloooowly

Offline favouritesearcher

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Re: Over Icing?
« Reply #8 on: January 03, 2006, 02:59:35 AM »
Hi Jake,

If it helps put another piece in your puzzle, I have also lost all hair on part of my knee, a small circular patch 1" in diameter, lateral side, just above kneecap.  After the initial surgery (ORIF) it grew back, since the second one (LOA) 16 months ago it hasn't.  Not related in any way to heat or swelling, for me anyway, but whole front of knee is over-sensitive.

Compression isn't always good for the knee; could be that the blood coming back into the area after the compression is taken away is causing it.  Have you tried cooling without compression?

John
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline Laurie

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Re: Over Icing?
« Reply #9 on: January 04, 2006, 05:02:41 AM »
Here is my 2 cents.

If you have the money, and I think you do, try some accupuncture. 

While in the midst of my knee debacle I did 10 appointments of accupuncture.  She (my accupuncturist) felt my knee and told me how hot it was and was astounded.  She also did Raaki on me.  She would put needles in my ears, legs - front and back, feet, etc....  The ears release the heat.  The legs and feet get your "chi" going.  She felt that toxins were stopping for some reason in my knee.  My flow or "chi" was bad.   I originally went to her for a peroneal nerve problem ( which she fixed on the 4th visit) but we still worked on heat and general flow for 6 more visits.

I cannot explain why or how it worked.  But for me it did.  It doesn't hurt and it's non invasive.  But, it is typically $60 bucks a visit which insurance doesn't cover.  You have to commit to several visits before you would notice anything.  In addition, finding a accupuncturist that you like and trust may take a bit of time.

I'd like to add that my accupuncturist stressed the importance of a good diet.  No preservatives. No sugar.  Nothing processed.  That left me with fruits, veggies and anything that at one point was alive.  I did this for several months.  I don't know if that had anything to do with it.

Good luck and don't get bummed out.  It is a long process and you have done fantastic so far.

Laurie  :)
Laurie :)