Scar Tissue? Meniscus? ((BACK FROM OS!))

[Mandy]

Hi everyone,

I wasn't exactly sure where to post this so I placed in the general section.    I'm going to my OS next week on Tuesday, June 27th.  I haven't seen my OS since my one week post op visit at the beginning of April.  Seems as though alot has been happening with my darn knees since then.  After surgery I was feeling great, able to get back to somewhat normal things (OS put me on some restrictions).  However, pain started happening in full force again around the end of april/beginning of may. 

I've been having extremely sharp medial joint line pain all throughout the day and night.  It's mainly my left knee, and not so much my right.  It has been bugging me not knowing what this pain is!!  My mother is completely set on it just being scar tissue.  She's also very set on that massage therapy is going to cure everything. (I went to a massage therapist once and hated it, but am trying a new therapist right after my OS appt.).  I somehow have a hard time believing that it is just scar tissue, since I had scar tissue before.  

I've read around here, as well as on other sites about the joint line pain i've been experiencing.  The thing i come up with the most is mensicus tears.     I don't really fit all the symptoms of a meniscus tear though.  Yes i have the stabbing joint line pain, but I don't have any locking of the knee whatsoever.  I do have troubles fully extending my leg, and cannot squat if my life depended on it.    I've also had my patella click and sometimes sublux a few times.

Does anyone have any idea what this could be?  My pain with this is going to be one of the first things I bring up at my appt for sure.  I'm just looking to anyone that may have a clue, so I can perhaps be a little more educated for my appointment.

Thank you all.
~Mandy

[Heather M.]

Scar tissue could easily explain each and every problem you've been having--not just recently, but over the years.  It's a very tough thing to treat, and if the patient isn't rehabbed in a certain way (and sometimes even if they are) the scar tissue can come back with a vengeance. 

Scarring or adhesions can cause all kinds of pain, at all levels and in various places around the knee.  Inside the joint and outside.  The symptoms and pain levels you suffer depend completely on how much scar tissue you have and where it is and how much there is, and how much it is impacting proper knee mechanics.

Check out Dr. Noyes' series of articles (four so far) on scar tissue for a better understanding.  And keep in mind that you can still have serious problems with adhesions even if you have full range of motion.  Again, it all depends on where the scarring is and how much there is and what way it is impacting the joint.

http://www.kneeguru.co.uk/KNEEtutor/doku.php

You should probably have your mom read up on scar tissue as well, so she can have a better understanding of how it is treated.  Proper deep tissue work can be an integral part of treating scar tissue problems, but it alone is not going to 'fix' a severe case of arthrofibrosis with adhesions deep in the joint.  That doesn't mean it can't help you--I'm only walking around today, I'm convinced, because i have deep tissue work done twice a week.  Otherwise, the soft tissues and muscles around my knee would have contracted so much I'd essentially be crippled.

I think what is really going to help you is seeing  an OS who has a lot of experience treating tough, recurring scar tissue or arthrofibrosis cases.  Because a lot of the things your doctor has had you do--go out and skate, even when it caused severe pain and swelling--are things that can actually lead to your body producing more scar tissue.  While aggressive 'functional' PT (like going out and playing hockey post op, starting with gentle skating and working up to drills and then games)  is highly recommended in sports medicine circles, when dealing with arthrofibrosis or recurring scar tissue problems it can actually lead to very bad outcomes--inflamed knee, constant swelling and pain, and the body laying down sheets of new scar tissue within months or even weeks of surgery to clean the joint out.

Another possibility would be damage to your articular cartilage as a result of either scar tissue or the years of poor patella tracking/dislocations/subluxations.  General PFS, in other words.

It could also be a torn meniscus, you never know.  That is one of those issues that can often accompany other knee issues, so you could even have meniscal problems along with larger alignment or scar tissue problems. 

Since your problems have been there for awhile, lingering and waning, flaring up and calming down, it seems pretty clear that you need a totally new approach to treatment and rehab.  That's just my opinion, having read your posts for over a year now and seeing you struggle to get back to hockey and sports despite multiple painful knee procedures.  Perhaps your body is just at the point where it won't tolerate this treatment anymore and is demanding that you try a new treatment methodology....?  Or get another opinion; no matter how great your OS is, it is always a very good idea to get a new set of eyes on a problem that has continued as long as yours.  And most OS's are actually glad to get another point of view, even if only to reinforce what they already know.

I understand completely how hard it is to be a young athlete and have your knee get in the way.  I was on swim team in high school and was counting on swimming to get me a scholarship to the Ivy League school I wanted to attend (because I certainly couldn't pay the tuition!).  But by age 13-14, I was already down for a few months with serious knee problems--dislcations, subluxations, pain, etc.  And I tried really hard to just push through the pain and swim anyway; it worked for awhile, but I would usually just lie awake at night while my knee throbbed and ached and hurt.  It wasn't until I began to modify my activities--gave up swimming the Individual Medley and doing breast stroke and freestyle, basically--that I was able to get some relief.  I also gave up running on everything but grass or packed earth.

So anyway, I just wanted to say that I've been in your shoes before.  I went the non-surgical route for 18 or so years because the OS I saw at age 13 told me that the surgeries to deal with my problem weren't very well-studied yet.  And that was in the days when arthroscopy was not widely used yet, so surgery was a major deal.  So Anyway, I know what it's like to have to do special PT, sit out certain drills the rest of the team is doing, tape the knee or wear a big brace, and in general feel like your body is falling apart in your early teenage years.  It's very frustrating.  You've been handling things very well and dealing with this for such a long time, I'm sure you just want RELIEF.  I hope you are able to get that, even if it means getting another opinion from someone who only works on knees....

Take care and hang in there.

Heather

[emphatic]

The thing i come up with the most is mensicus tears.     I don't really fit all the symptoms of a meniscus tear though.  Yes i have the stabbing joint line pain, but I don't have any locking of the knee whatsoever.  I do have troubles fully extending my leg, and cannot squat if my life depended on it.    I've also had my patella click and sometimes sublux a few times.

For what it's worth, not everyone locks with a meniscus tear. In fact, it's not a common symptom at all. The limited extension and location of the pain, along with the unwillingness to perform a squat are very clear meniscus tear symptoms.

However, everything you mentioned could also indicate some articular cartilage damage, or, as Heather noted, arthrofibrosis. (I'm not seeing a clear-cut case of arthrofibrosis in what you described, but she has vastly most experience with it than I do.)

Heck, you could have all three. I'd vote for just making a simple, clear, written list of your symptoms and talk to your doctor. Hopefully, he can point you in the right direction after that.

Once it all shakes out, though, I do agree that it would be a great idea to re-evaluate your rehab process. Something, somewhere , isn't working well for you.

Good luck with the app't!

Meg

[Mandy]

Hello everyone~

Heather, you never cease to amaze me!!  The information you have provided to this board is just incredible.  I read the articles by Dr. Noyes and I really learned alot, and made me think about a few things.  These articles will surely reach my mother so she can get some things straight.     I am wondering if you could possibly send me in the right direction by PMing me with a few arorthrofibrosis specialists in the Minnesota/North Dakota area (if there are any?)?? I know that Dr. Robert LaPrade is listed on the KneeGuru site.  Believe he's down at the U of M.  Is there anyone else to maybe look at ? I don't personally want to leave my OS but if it comes to it, I'd like at least a little time to go over my options for OSes. 

Also, what did you have in mind by completely changing my treatment methodology?  Is there something else I should perhaps be trying that I'm not aware of?

Meg--thanks to you too for the reply.  i've already got my list started with all of my symptoms and questions that i have for my OS on tuesday.  hopefully there will be some answers and i'll be sure to keep you informed!

thanks again so much!!
~Mandy

[Mandy]

i was searching for some info on the joint line pain and i came across a good article.  thought i'd maybe post it here in case someone else out there is going thru the same thing as i am!

http://www.sportsdoc.umn.edu/Patients_Folder/Patient%20Information%20Main/joint%20line%20knee%20pain/joint_line_knee_pain.htm

~Mandy

[Mandy]

well i'm back from the OS.  all i can say is wow, what a LONG day.  i checked in at 12:30 and did not leave the parking lot until around 4:30 pm!!!    its just been a long and frustrating day. 

i told my OS all of my issues that i've been having with the medial joint line pain, and the grinding i tend to get every once in awhile in the joint.  he listened to what i have to say, although i'm not really sure he actually understood where i was coming from.  while he knew where the pain was and whatnot, i felt that he couldn't believe what i was going through just because "the bone scan earlier didn't indicate any problems there"     so he ordered xrays to make sure i wasn't bone on bone, which i knew i wasn't even w/o the xrays.    the films indicated that my left kneecap rides higher than my right, indicating that my tendon is also shorter along with something to do with my quads.   all in all of  he basically tells me that he can't understand that i'm having this pain just becauase the bone scan back in march didn't indicate any problems there.  he told me to really stretch my quads (which i do anyways, typically in the morning and before i go to bed) and find some anti-inflammatory that'll work.  i've been thru couple rounds of antiinflamms with not really much success....but i'm taking celebrex for now.  i guess what the oddest part of the whole appointment is when i asked when i should come back, he didnt give me a time.  it was a "well lets see how the celebrex works and then i guess we will figure it out"  to me, it felt like the done deal that he was out of ideas to help.  i talked with my parents after the appointment because i was upset.  i told them that i'm sticking this stuff out for awhile and if its just not cutting it, i'm not going to just sit around in pain.  i've researched another possible OS around here that i think may be of some help.  parents thought it was maybe a good idea, even just to get another set of eyes on the problem.

besides that, after the OS appointment, i had a massage therapy session with a new therapist.  she is such a sweetheart and is a wonderful lady.  she was so comforting and really really down to earth which i love!!    she taught me some stuff i can do at home on the days that i don't go to her which will help i'm sure.  i have another session with her on thursday and i'm hoping that she can give me some relief!!

after the massage, my OS had me talk to the person who fitted and built my orthotics and all that jazz.  i told him about the ankle and heel problems i've been having lately and how it's affecting my day to day life.  he had me walk and checked everything out.  we found that my orthotics need to be repaired, as well as have the arch built up a little more to give more support.  he also diagnosed me with Plantar Fasciitis, as well as Achilles Tendonitis.  so with building up my orthotics he think that should help me, along with icing and taking things easy for a bit.  he also stronly recommended a functional ankle brace to wear while i'm working just because my ankles roll super bad and are all over the place.  he feels that this should help with some stability. 

so i guess all in all, two of the three things went well today.  i'm still digesting all of this, and wondering what i should do.  i shouldn't say i'm in a hurry, but i'd like to be as healthy as possible by the time i move to college this fall.  am i right to hold out with this anti-inflamm stuff for now??  i really don't want more surgery, but i at least need a straight answer from an OS about where i stand.

ugh sorry for the horrid long vent.  thank you for reading all of this if you did!!


Take Care,
~Mandy

[emphatic]

Mandy,

I know it's hard to see it at this point, but sleep on it a bit and I think you might not be as disappointed.

While it may seem like the appointment didn't go very well, I think you still got some information from it... just not a quick, packaged answer you could grab onto. It sounds like he's not seeing any new clinical reason for your pain, which can mean a couple things: either he's become defensive and isn't willing to look any further, or he's really not seeing anything new going on and thinks you're still in the healing phase and need to give the knee more time.

If you've got an inflammatory process hindering your healing, that can really be disruptive. It's also elusive to treat, unless you happen to be one of the lucky people who respond to the first NSAID they try. Celebrex, for all its knocks, is really an effective drug. All NSAIDs, however, need time. They also need the correct therapeutic dose. Americans are used to quick fix treatments and tend to take NSAIDs in a "here and there" fashion. But, to treat an inflammatory process, the blood level of the NSAID needs to be steady. That means you have to take the right dose every day for about 2 weeks before you can really evaluate how effective it is for you. Obviously, you'll know rather quickly if you have stomach problems with a particular NSAID (unless it's a silent GI bleed, but that's another nightmare...), but if you're doing OK, stay on it for a couple weeks before you decide it's not working.

I didn't realize you had a lot of orthotics in the mix. That adds another dimension to the problem.... which is that your knee biomechanics have changed rather dramatically in all your surgeries. It takes a long time for the knee to adjust to significant changes in the biomechanics, especially for athletes! Your leg learned all kinds of compensatory and assistive ways of moving while you were having problems. Now that the problems are fixed, your leg has to learn how to do it right. That's quite an intensive and involved process by itself. When you add other issues in the mix, such as those addressed by your other orthotics, it can get to be very complex.

Now, I see absolutely nothing wrong with seeking out another opinion. It definately can't hurt. You really could have something new going on and it needs to be looked at.

However, you're also still healing and that takes time. The hardest thing to learn is that the knee has its own timetable and doesn't give a rat's ass about yours. 

So, I suggest the following:

1) Find and make an appointment with a new doc (you can always cancel if you're magically better later)
2) Stick with one NSAID and give it enough time to work (make sure you take the correct dose)
3) Work with this new massage therapist and see if that helps (and review your new problems with her, she might have some ideas)
4) Go back to your basic rehab exercises and make a renewed committment to keep up with the basics to get (and stay!) as strong as possible
5) Do the stretching he recommended, and be extra vigilant in keeping an eye on how your muscles are doing -- try different stretches and be religious about stretching thoroughly every day for a few weeks and see if that helps
6) Follow up with your orthotics issues -- get the fixes done and see if that has an impact on the knee
7) Keep your chin up and hang in there

Just my thoughts... for what it's worth.

I really, really hope you can find the right track for you, and start feeling better soon! You're right, you definately don't need this heading into college.

Meg

[Linds]

Hey Mandy, i'm sorry that your OS isn't Harry Potter either!    So frustrating I am sure. I am SO happy that the Massage therapy lady was able to help you out though, and the orthotic guy is going to adjust your orthotics for you.. hopefully that will help. Plantar fascitis... Eww.. sucks.. I have on again , off again issues with that, and my achiles tendon from back in my days of being a long distance runner.

I think that maybe a "sober" second opinion might be a good idea.  It can never hurt to have a new set of eyes look at the problem!!! It doesn't mean you have to leave your OS, just getting another opinion.

I wish this had worked out better for you... hang in there, great big hugs that you'll figure this out soon

Linds

[Mandy]

Thank you very much for the responses Meg and Linds. 

Well the day after my OS appointment I talked to my parents about possibly getting another opinion on things.  They we're alright with things although I don't think that they are exactly sure what to think.  Like I was talking to another friend, through looking at the boards and doing my own research, I've become more educated on what could possibly wrong, as well as when it's time to get another opinion.  My parents probably don't fully understand why I want to get another opinion, but I've vocalized it as best as I could and they seem fine with my decision.    All in all, I managed to get an appointment for July 21st.  Not a bad wait at all.  I was planning on waiting until the end of the summer, or early fall!

I'm still taking my celebrex as directed.  Haven't noticed any relief from it, but I"m planning on sticking with it until I see this new OS.  It could maybe just need some more time to help me, who knows.  The massage therapist is still doing her work.  She worked on alot of trigger spots the last appointment, so hopefully that helps.  Orthotics are fixed and feel great.  I have soooo much less pain in my feet.  Granted they are still sore, but not as bad as they were.  Stretching is also another daily ritual.  I stretch when I get up in the morning, as well as anytime I have during the day, and then another stretch before bed. 

So for now, it's just a wait for this appointment.  Going to keep doing all the stuff above until I've been told otherwise!!  I'm extremely nervous for this appointment.  I started another post about this appointment.  http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=27844.0   

Thanks all, you're wonderful!
~Mandy

[Linds]

Hey Mandy,
Goodluck with your Second Opinion.. I hope it goes well, even if it just sets some things straight or puts your mind at ease.. or whatever.

I just wanted to say Hang in there with the Celebrex... it can take a few weeks to reach it's effectiveness.  My OS told me to take it for a month before deciding if it helped or not.

Keeping my fingers crossed for you.

linney