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Author Topic: plica or muscle imbalance? Seeking advice.  (Read 1387 times)

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Offline agatha

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plica or muscle imbalance? Seeking advice.
« on: September 04, 2006, 05:18:37 PM »
     Iím new to this site and Iím grateful for all the insights that Iíve gotten from your knee experiences. Iím especially concerned and sympathetic for the people who have ended up with more pain after surgery than before.   Iím finding out that the diagnosis of knee pain and disability is not an exact science as one might expect it to be.
    I hope someone out there can answer my main question which is ----Could a muscle imbalance alone result in not being able to walk at all without serious pain and limping?Ē     Somehow I feel as though the people on this site might know more than my doctors about some of this.
                My knee history is bizarre and I apologize for the length of this but here goes.  Iím 56 and have always been a healthy super-active person.  I partially tore my ACL in 1997 skiing but after 3 months returned to running, biking, rollerblading, swimming, etc. with absolutely no pain or problems.  Only things I couldnít do were squat-like movements which would make my knee stiff.  Then in 2003, I started getting a medial pain in that knee and finally had to stop running for the first time in 25 years.  Ortho couldnít find anything.  After several months of PT with no change, he gave me a Cortisone shot, that I felt, had no effect.   Six months later I had arthroscopy and OS found no damage in the knee except a slight indentation in the articular cartilage confirmed later by MRI to be osteonecrosis in the medial femoral condyle.  I was put on crutches to eliminate weightbearing on that knee but was allowed to swim and bike.  After 7 months on crutches, MRI confirmed that osteonecrosis had healed and I was Sooooooo happy that I wouldnít have to have my knee replaced (which is what osteo usually leads to). 
   That was Aug of 2005.  It has been over a year of rehab and a year of not being able to take 5 steps forward without major pain and a terrible limp.  I have seen 3 orthopedic doctors, 2 PTs , 2 gait analysts, and one neurologist.  No one has any idea what is wrong.  My MRIs show nothing wrong.  Bone Scans show the knee completely lit up which I guess registers activity.  I can swim, bike, do stair climber, elliptical, floor exercises and walk backwards --all without pain but when I try to go forward, I get a sharp-lights-out kind of pain at a specific point which causes my knee to collapse and I canít get it to straighten for the next step without really suffering.   After about 5 steps, my knee is so sore, I can barely get my foot to step down.  I look like Iím trying to prance because my knee comes up really high to avoid stepping.  I have a very loud click with pain in that knee when I go from flexion to full extension. My doctor tells me that it could be just from walking so strangely for a year. I believe itís the other way around.     
     At first I hoped  it was a weak/atrophied muscle but all the medical people have told me that my muscles are strong enough. So I have been working on the idea of a muscle imbalance because thatís the only thing left since the doctors have told me nothing is wrong with my knee.    But is this possible?  Or are these exercises just exacerbating an injured joint? 
   Iím now scheduled for exploratory arthroscopic surgery in 4 months(HMO).  My doctor thinks that it may be a plica (my idea since he didnít see a plica in the first arthroscopy) or articular cartilage damage that isnít showing up on the MRI (which will require PKR).  Unfortunately, my symptoms donít match either one completely.  I have absolutely no pain except when walking forward and no swelling or tenderness. When I read about the experiences of other people on this site with plica surgery outcomes, Iím afraid to have the surgery.  I know now that surgery is not always full of positive outcomes. But I canít live like this.
   I hope this could be a muscle imbalance even though my doctor doesnít think so.  Iíve been on strengthening/stretching programs with every muscle involved in walking since this started including a program of doing nothing.    I just canít understand how I can do so many other things without pain but I canít do the most essential thing, which is to walk forward. Itís as though something catches  in my knee. Is that what plica feels like? I didn't have this before the surgery in 2004.   Iím back on crutches whenever I have to go anywhere.  I hope someone can tell me if it could be a muscle imbalance Ė I want  this nightmare over but I donít want a surgery that doesnít do that and possibly makes it worse.  Iím thankful that I donít have constant pain but I hate seeing people  wince when they see me walk with this terrible limp.  Plus I had a very active job that I had to leave last Oct.
    Thanks in advance for any advice you can give me. 

Offline emphatic

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Re: plica or muscle imbalance? Seeking advice.
« Reply #1 on: September 04, 2006, 06:21:14 PM »

Yup, that's pretty bizarre. There's no way I can tell you what's wrong -- no one can, over the internet -- but maybe I can give you some ideas to try. Hopefully, other folks will wander by and offer their ideas, as well.

First, a plica typically acts like a meniscus tear in many ways. It has an inflammatory "feel" to it, as well. And that's what it is -- a piece of vestigial tissue which is inflamed and imposing itself in joint mechanics where it doesn't belong. So, things like catching, locking, swelling, other signs of inflammation, point tenderness, etc., can be seen with a plica.

On the other hand, a plica is sort of the wildcard of the knee -- if you can't find anything else, think plica. Lots of surgeons take out a plica just because they see it. Quite a lot of ills get blamed on the poor little plica.

On to muscle imbalance. For a muscle imbalance to matter, it must be altering your knee mechanics in a significant way. The most common muscle imbalance is a weak VMO (vastus medialus oblique - the medial part of the quad) and a strong vastus lateralis (the big part of the quad on the outside of the thigh). This pulls the patella out of its track when flexing the knee. Another example of an imbalance which matters is a very weak hamstring and overly strong quads in an ACL-deficient knee.

Muscle imbalances can be hard to track down. Some people have a more sensitive "threshold" than others. Typically, if you can perform functional testing satisfactorily and your knee mechanics look clean, it would be hard to call it a muscle imbalance.

The rest of your symptoms/problems make it hard to come up with something clear cut. Forward and backward walking are different enough to figure out a problem, but then you can perform forward walking substitutes without pain. So, the only thing that comes to mind is to look for heel-strike problems (have you ever had your feet checked? use orthotics?), lower leg problems (a bad shin splint or stress fracture maybe referring up to the knee? any point tenderness along the front of the shin?), or something else which only occurs with the leg at full extension and full weightbearing on a heel-strike. (The elliptical, stair climber, etc. don't require full extension with a heel-strike.)

Lastly, the bone scan with a history of osteonecrosis seems, to me, to be the biggest red flag. I'm not up on all the indications of bone activity, but I do know that high uptake only happens for a reason -- the bone is busily trying to repair itself. MRIs are not foolproof in showing articular cartilage defects. Also, with a history of an ACL reconstruction (around age 47?), you bounce right up to the top of the list for predisposition to articular cartilage problems.

That alone would make me want to find a really good articular cartilage specialist. It really is a sub-speciality now, and there is such a fast pace of change and new information in the field that it takes someone really on top of it to know what they're doing.

The scope seems like a good next step. However, the surgeon doing the scope is going to be the critical point for you. Anyone can do a scope -- you really need someone who knows what they're looking at.

That's all I can think of at the moment. I'll come back if anything else pops into my head.

Hang in there -- keep looking, keep educating yourself and don't give up!


Offline agatha

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Re: plica or muscle imbalance? Seeking advice.
« Reply #2 on: September 04, 2006, 09:16:18 PM »
       Thanks for your great advice.  Your comment on the bone scan is very interesting because although I thought the increased uptake meant something,  both Drs  said that bone scans really can't tell us much.  So why do them, I wondered at the time?  I requested one because I wanted to rule out hip problems since my hip was dropping/collapsing  when I hit the sore spot in the knee and I wanted to make sure there wasn't anything wrong with my hip.  I never had surgery for the partial ACL tear because "I have less play (2.5mm?) in my knee than they ever hope to get from surgery."
         You've made me wonder about hamstrings strength.  I've really focused on VMO and quads because so many knee people talk about knee pain associated with weak quads.  Plus my doctor told me that backward walking doesn't really task quads at all so I thought that my hamstrings were possibly too strong.  But when I think about it, the only knee exercise I cannot do is a hamstring exercise which produces the same click and triggerpain as my walk.  I've never pushed it because I was afraid that it was rubbing something the wrong way inside my knee and would make it worse.  It hurts that much.  But maybe I should try it anyway.         
    Just so you know - I can handle pain. I've had a lot of sports injuries over the years (which is probably why I'm here where I am today  -- should I have been a couch potato perhaps instead?) I broke my foot once and didn't even go to the doctor for 3 days.  Ended up with removable cast for 2 months.  But that pain doesn't compare to this. That's what's so strange.
     Thanks again.  I need to make sure my doctor knows what he's doing.  How to tell?