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Offline Sore knee

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Had tests today - can anyone enlighten me
« on: October 04, 2007, 02:31:38 PM »
I having had a LR in May had continued swelling etc and no progression. Then in Aug they scoped my knee again and had a chondroplasty and wash out. The swelling was down for about a week - 2 weeks and as time progressed the swelling is back up. So after months of physio I had to go for bio feedback testing today.

They put electrodes on the muscles and you have to contract and they measure how much the muscles are working.

Well basically they are not. My good leg was great, working well, ability to hold and sustain contraction etc.On my bad leg  you could see the flicker in my leg and my knee pulling slightly and movement in the thigh, they could see it but the measurements are minimal. They said the muscle fibres are fatiguing so easy and there is virtually minimal activity. The knee cap at times catches, its something that happens inside but I can't say where or when it will happen. I said even after all these months of physio and they said they now had hard evidence to show the OS. I think they maybe thought I wasn't trying hard enough or something and he said some people say they are in pain and doing exercises and aren;t but you have no reason to do that and equally you can't trick that machine so its not subjective anymore, I have something to show him. I now have hard eveidence to take back to the OS and say we have tried as much as we can think of, where do we go from here and hopefully he will come up with something to get this knee moving forward. There were 2 PT there doing it and they both said perhaps I have always had an inherent problem with the quads and my knee. (My earliest memories are of knee pain and they used to strap my leg often to try and make the muscles work and help the knee)

So here is my question, has anyone else had muscles not working. I think its the VMO and how do you overcome it. They now have measured this on the machine and the PTs have said they don't know where to go with it now so they are going to have a meeting with the OS. They said maybe he will suggest a stimulation machine and I said as long as it isn't more surgery and they said well no comment.

So sorry about long story, but anyone have any idea of what my options are now ?
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed

Offline tanyap

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Re: Had tests today - can anyone enlighten me
« Reply #1 on: October 04, 2007, 03:15:27 PM »
Hi Joanne,
Ive much the same situation going on - to a less severe extent - but instead of severity Ive got all the dislocations going on.

Here is the situation regarding muscles working or not working as explained to me by my OS:

A muscle has a certain amount of mass of muscle tissue and nerve fibres. There is a neuromuscular pathway from the brain to a muscle and the brain sends electrochemical messages to the muscle telling it to fire and how hard to contract etc...
Damage to a joint can cause the brain to 'switch off' the muscle. This is actually a self preservation mechanism that generally works quite well to prevent further injury. This is the brain thinking 'if I fire this muscle while there is damage I might cause more damage' - by damage I mean perhaps a trauma or in my case a dislocation. Pain causes 'muscle guarding' - this is the brain thinking 'oh i better not use this muscle cos it hurts' - this is a mechanism to prevent you from using a muscle until the area is healed enough to use it - its a sensible reaction of the brain in ordinary circumstances but in the case of a chronic problem with a joint it leads to atrophy of the muscle. If the muscle has not been getting used properly for a long period of time and there has been significant atrophy then the muscle bulk itself reduces, the muscle becomes weaker and the nerve fibres die off. If enough nerve fibres die off the muscle becomes 'dead' - it cannot fire - it moves into a state of being permanently switched off.

Can you switch it back on? According to my OS the answer is YES but its hard work. You get an e-stim machine and you use that to electrically stimulate the muscle. This causes a contraction that sends a message backwards from the muscle to the brain and causes the brain to go 'oh Ive got this muscle contracting I better grow some nerve fibres'. This, combined with voluntary exercise that stretches the muscle out, loads it in a controlled environment and sort of 'forces' it to do its job causes muscle bulk to grow and continued use of the e-stim causes more nerve fibres to grow.

Then - and this is the magical bit - the growth of nerve fibres reach a critical mass and suddenly you wake up one morning with a working muscle!! At least - thats what my OS tells me - I am still awaiting the miracle day and Im now 3 months in using e-stim and doing VMO specific exercises - mind you my VMO has been switched off for a long time - yours has probably only been switched off since your first surgery.

Now - the other thing is that surgery introduces muscle dysfunction - the kind of stuff I described above - but that dysfunction can be overcome with e-stim and exercise.

In your particular case you probably had old knee problems that had allowed you to have a weak VMO over the years, then your first surgery switched it off, and unbeknownst to you it wasnt firing at all, and your next surgery caused it more muscle dysfuntion and since then you have been breaking your heart with the physio with a muscle that quite simply isnt working swithced ON. With VMO its so easy for it to do nothing and not be detected because the lateral quads take over - so for example you can extend your leg or put weight through it - but because VMO stabilises your kneecap you can end up with tracking problems or in my case - recurrent dislocations.

SOOOOO - its highly unlikely any OS is going to suggest more surgery while you have a switched off muscle problem.
He will probably recommend an e-stim to get it going.

If you want to know more about e-stim have a look at www.kneehab.ie - thats the one I use. It doesnt hurt or anything - its fine and it definitely gets the muscle firing.

Another trick (this is an old one the physios used to use in the days before e-stim) is to poke and prod at your VMO with your fingertips, and massage it hard, get the blood flow going to it - muscles need blood to exist, if you get the blood flowing to it and exercise it and prod at it you'll help it wake up.

Ask me any more questions you have about it - I had a long and detailed discsussion with my OS on this very subject last time I saw him - he went into teacher mode and drew diagrams and showed me models of knees and muscles etc...

The theory sounds great but my VMO is still tiny :( 
But it was invisible to start with so tiny is better than nothing!!
1986 - recurrent dislocations of right patella began
1988 - Modified Hauser Procedure
1991 - dislocations started again
2005 to 2007 - 150 dislocations in 2 years - OUCH!!!
June 2007 - new OS, new physio
Oct 2007 - VMO woke up
Mar 2008 - big quads, still dislocating
Apr 2008 - next OS app

Offline Sore knee

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Re: Had tests today - can anyone enlighten me
« Reply #2 on: October 04, 2007, 03:35:14 PM »
THANKS  ;D


I think they worry  that this catching is causing the swelling which in turn is causing the inhibition etc. They then worry that this whole situation has been since childhood and given they have taped my leg, done all sorts of machines etc on it when younger and now been in PT for 6 months then what next.

My entire life has been plagued with knee pain, so I don't know what they will do next but am reassured you think no surgery. Thats GOOD news :)

How are you getting on ??????
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed

Offline tanyap

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Re: Had tests today - can anyone enlighten me
« Reply #3 on: October 04, 2007, 04:11:10 PM »
Hi Joanne - thats probably exactly whats causing the inhibition - although I do think that your surgeries have probably switched off the muscle - if you were inhibited enough your muscle might have required very little encouragement to switch off - it could already have been weakened and a lot of nerve fibres might have died.

Well to encourage you a bit further when I first saw my current OS (in June) Id no VMO whatsoever and it wouldnt fire no matter how much I scrunched up my face and contracted. He sent me to physio for 2 months and got me using an e-stim.

Then I saw him in August - this time I scrunched up and contracted as hard as I could and he was able to find my VMO. It was pea sized. The minute he felt the pea size of it he shouted 'SUPERB! - now that youve got it responding it will start growing and strengthening'.
He said it would take me 6 months to a year to rehab it fully.

Since then you dont have to go looking for it - you can just feel it with your hand when I contract. But its still very very small. Maybe sardine sized. But if its gone from zero to a pea in 2 months and from a pea to a sardine in another 2 then hopefully Im on the right track. I dont know yet if its firing automatically at all - but I can definitely fire it manually and Im just hanging in there hoping itll get bigger and start doing its job.

Im alright - i had a dislocation on tuesday so ive been pretty unstable since - not too sore though and Ive been able to do all my physio with no problems.

Ive another physio appointment on Oct 15th - Im hoping I do better on the isokinetic test machine - like you I sometimes feel like they dont 'believe' im doing my exercises - but the machine shows that I am.

When are you seeing your OS again to talk about an e-stim or other options? Ill be extremely interested to hear what he tells you.
1986 - recurrent dislocations of right patella began
1988 - Modified Hauser Procedure
1991 - dislocations started again
2005 to 2007 - 150 dislocations in 2 years - OUCH!!!
June 2007 - new OS, new physio
Oct 2007 - VMO woke up
Mar 2008 - big quads, still dislocating
Apr 2008 - next OS app

Offline TwoBadKneesUSA

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Re: Had tests today - can anyone enlighten me
« Reply #4 on: October 04, 2007, 06:04:28 PM »
Hi Joanne - Tanyap has some good stuff there.  I also have a, what I call a lazy VMO too.  I've always had it too.  I can get catching in my knee too, especially when the muscles are tired.  I think the catching is because of swelling myself not the other way around.  For me anyway it usually happens when I've over done things and the knee swells, then it starts to catch.  The VMO issue is a tough one.  I don't think in normal activity we use it as much as the others so it likes to get lazy, then throw in some pain and it takes a vacation.  I think its one of those things you need to keep doing exercizes for.  I hope you can get something out of this.

Milly
'83 lt knee scope
'88 lt knee LR
'89 rt knee LR (6 mos. after left)
'05 rt knee scope (clean up)
7/5/07 - scope, LR left, right clean
3/19/08 - LR failed, Supartz failed
http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=47974.0
8/21/08 - new OS apt
8/5/09 - TTT, LR, PFJR sched.

Offline Sore knee

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Re: Had tests today - can anyone enlighten me
« Reply #5 on: October 04, 2007, 07:54:25 PM »
I just wondered what if it doesn't work. They seem to think they don;t know if stimulating it more will, that was the impression they gave today. They just kind of looked at each other and I worry if there is a bigger picture here. I would always rather know what my options are, is there anything other than the e-stim ? I so hope I am going to prove them wrong and want my PT to see how much I am gonna try. Although I do feel vindicated that the machine today showed that everything I have been saying to him is true. They can see the flicker of the muscle and the effort but its just not doing enough  - something to do with the muscle bulk and mass, didn't quite follow what they were saying. They kept talking to each other and my PT was just amazed at how little strength it had.

Is an e-stim machine where they put wee electrodes on your leg and your muscles kind of jump and you get a pinks and needles sort of sensation through your leg ? They done that a few years ago, but nothing much progressed at that time and so they kept strapping my leg up.

Thanks so much for all input, I so hope to make some progress and will be interested to hear what is suggested. I go on holiday next wednesday - I'm taking my kids to Disney and am worried how the knee will cope with this, but none the less we cancelled it in summer and re-scheduled for now thinking I would be better and we lose it now if we don;t go. SO I will phone from the USA a week on Monday to hear what the OS has suggested.

I took in photos of my knees to show the PT, my husband has been taking photos every few nights as by night time its huge. He was blown away as during the day it gradually builds and he asked if he could keep the photos to show the OS as well.

Anyhow hoping for even a pea sized VMO very soon Tanya  ;D and thanks so much Milly. Good to know I am not alone.
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed

Offline Janet

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Re: Had tests today - can anyone enlighten me
« Reply #6 on: October 04, 2007, 09:46:14 PM »
Joanne:

I'm going to give you a different take on this from my own situation. I had an open surgery to repair a ruptured quadriceps tendon, then developed scar tissue which required two more surgeries. After my third surgery and months of PT, my patella was still catching, I still had pain, and my quads were still weak. My PT figured I was at about 50% function. My OS, PT and I had tried everything, including the stim you talked about. My OS (a knee specialist) was completely baffled, said she had never seen anything like it, etc. I know she thought I must have been slacking off or not trying hard enough. Fortunately, she referred me to see an OS who has special knowledge of problems dealing with scar tissue.

He determined that I still had or had regrown scar tissue in the area of the patella tendon. I also had damage behind the patella which he thought was causing some of pain and the catching. But the scar tissue was causing the quad muscles to shut down. He explained that no matter how much I exercised the quads, my body would shut down the muscle due to pain. (Ah, vindication that it wasn't my fault!) This was following four years with weak quads! Would they ever recover? He said that once the biomechanics were corrected by removing the scar tissue mass, the quads would eventually work again because they were not damaged, just shut down.

I had the surgery and had another long, long course of rehab. My quads did strengthen over time, but it was a very, very slow process to build the muscle. Remember, it had been years of weak quads. The surgery was a great success as I gained much function. However, in my case, the damage behind the patella continued to cause pain and prevented me from making a "full" recovery. I still walked with a limp. Last November I had a knee replacement, and am doing very well now. I no longer limp and my quads are getting stronger every day. I worried that my body wouldn't remember how to walk correctly, but as the muscles grew stronger, my brain "remembered" the correct way and the body responded.

I just wanted to let you know that there may be another underlying problem that is causing the quad to refuse to strengthen. Don't give up on this. If you can't get good answers from your OS, perhaps a second opinion would be in order.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline Sore knee

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Re: Had tests today - can anyone enlighten me
« Reply #7 on: October 05, 2007, 08:24:14 AM »
Wow I am glad you are doing so much better now Janet. When they scoped the knee in Aug would they look at the quads tendon as part of the scope ? AT that time they were more interested in the patella than muscle function ?

Its always useful to have a list of possibilities. I will phone when away on holiday to see what the OS has suggested for my return and we will see what happens.

Thanks so much for your input, I am just eager to hear of any suggestions on what could work.
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed

Offline tanyap

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Re: Had tests today - can anyone enlighten me
« Reply #8 on: October 05, 2007, 09:38:31 AM »
Excellent stuff from Janet there - sounds like we are all saying the same thing - if there is an underlying problem that causes the muscles to shut down then you can try as much as you like but they will stay shut down from pain.
MY OS said pretty much the same thing to me - in my case 2 years ago there was a 5/6 month period where I dislocated every couple of days due to atrophy, which obviously led to pain, which led to shut down. Now Ive been noticing that I get along fine with my physio exercises but each time I dislocate I just cannot do certain exercises for around 3 days afterwards cos my VMO is gone back to sleep - but the e-stim, and forcing the exercise wakes it up again, I noticed it only this morning that it felt like it was firing again compared to the past couple of days.
Janet - Im also much encouraged by what you have said regarding the body 'remembering' how to use the muscles and do its thing - I was kinda wondering had too much time passed for my own muscles to remember how to work.
Milly - I assume my own lazy VMO has come about from my 20 years of dislocations - I used to only dislocate if I tried to run or something hit me hard in the leg - but over the course of years it meant my VMO was shutting down every so often for a period of days or weeks. So it gradually wasted away.... I have had many physio sessions over the years but 2 years ago I hadnt done any physio in around 8 years - so I betcha my VMO has been quietly disappearing for 8 years - its also around the time I stopped cyclying to work so it wasnt getting any exercise forced on it and unbeknownst to me I wasnt using my leg properly in ordinary activities like walking or dancing socially - it was compensation all the way!!

My OS says that Im in a bit of a catch 22 but Ive got to ignore my dislocations while I build the muscles - the dislocations wont stop til the muscles are bigger and stronger but because each time I dislocate i shut them down its a constant struggle to get them bigger and stronger........
He also told me that no surgery in the world was gonna help me with them so weak cos Id just start dislocating again afterwards if theres no muscle to support the joint. However - he DID say if I get them as strong as they can go and I still dislocate easily that he would consider surgery.
I know they are getting stronger - but it seems like a huge struggle.

Joanne - about the e-stim - the people who sold me my one said that youve gotta be using it twice a day for at least 3 or 4 months to see a difference. From what Ive read elsewhere and on this site e-stim is not really growing muscle bulk - VMO needs to be exercised under load to bulk up - but it stimulates the bulk that is there and helps new nerve fibres grow and basically wakes up the muscle.

Try and enjoy your holiday - just take it easy on the knee, and plenty of rest and RICE for it.

1986 - recurrent dislocations of right patella began
1988 - Modified Hauser Procedure
1991 - dislocations started again
2005 to 2007 - 150 dislocations in 2 years - OUCH!!!
June 2007 - new OS, new physio
Oct 2007 - VMO woke up
Mar 2008 - big quads, still dislocating
Apr 2008 - next OS app

Offline Sore knee

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Re: Had tests today - can anyone enlighten me
« Reply #9 on: October 06, 2007, 04:07:54 PM »
I will thanks Tanya, kind of nervous to see what the OS says and where we go from here as this has been 6 months (just over now) of really intensive physio compared to others around me in the clinic. So I don't know what else there is for me to do at PT. I just hope they can think of something as the thought of just living like this would be frustrating.........so I won't settle myself properly until I hear what they think I should do, maybe more bio feedback to measure any changes. I don't know, nothing I can do about it. I just feel very frustrated at all the hard work I have put in over all these months to be no better, not even that worse than when it started. My kneecap yesterday for the first time jumped right out as I turned made a huge click and then slid sharply back in. That freaked me out !

I am just wondering now if they would have looked at the muscles etc during a scope, would that be a standard part of the investigation ??? Ohhh for answers to knees eh :)

How are you doing ?
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed

Offline tanyap

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Re: Had tests today - can anyone enlighten me
« Reply #10 on: October 07, 2007, 03:38:05 PM »
Hi Joanne,
During your scope they would probably assumed that your muscles were weak due to the knee problems that you were having, there would be no way for them to know at that point if the brain was shutting the muscles down. Itd be normal after surgery for muscles to shut down to some extent - thats how the body knows not to use a joint thats healing.

The trick with e-stim is to continue the physio AND the e-stim at the same time. The e-stim is re-building the neuromuscular connections, the phsyio is using the muscles and engaging those connections. So Im afraid you probably have a lot of physio in front of you - but you should start making progress if the muscles get switched on again. I am, and thats the same problem I had. I can only feel my VMO contracting during my exercises for the past few weeks now - prior to that there was no contraction that I could feel - it was only contracting during e-stim, never during exercises. Now of course its tired all the time - but before it never got to be tired cos it did nothing!!!

Youre getting jumps and clicks cos your muscles arent working properly. I sound like a barrage of gunshot when I move sometimes.

Im doing ok, have just increased the weights Im using for my straight leg raises so my legs been pretty tired and sore the past few days. but that usually settles within a week and then itll just be ordinarily sore :)

I havent been wearing my knee support the past couple of days, i havent felt any more wobbly so thats good!!

im rattling round on my own at the moment, my boyfriend is gone to berlin for a few days for an art exhibition, so im home alone. in some ways its lovely having the place to myself, in other ways its a bit lonely. but i must admit - id a great nights sleep with no one bumping into me!!!
1986 - recurrent dislocations of right patella began
1988 - Modified Hauser Procedure
1991 - dislocations started again
2005 to 2007 - 150 dislocations in 2 years - OUCH!!!
June 2007 - new OS, new physio
Oct 2007 - VMO woke up
Mar 2008 - big quads, still dislocating
Apr 2008 - next OS app

Offline Sore knee

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Re: Had tests today - can anyone enlighten me
« Reply #11 on: October 07, 2007, 04:54:03 PM »
well a good nights sleep goes a long way and when he comes home you will enjoy his company ;) ;)

SOunds like you have a way to go with PT too, oh the joys. How do you manage to fit in work or anything with your knee so vulnerable to dislocation , that must be a constant worry :-\

Anyhow, you always sound so upbeat and cheerful so whatever you are doing its obviously working for you and thats great !!!!!!
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed

Offline tanyap

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Re: Had tests today - can anyone enlighten me
« Reply #12 on: October 07, 2007, 05:13:27 PM »
Oh I do have a long way to go!!

yeah - its a bit like walking a tightrope every day :) Actually I can minimize the risk by walking slowly and being very careful with every step - its second nature now. But Im missing my social life, Im too unstable to do a lot of things I used to do so I miss going to art galleries, country walks etc...
Im just hanging in there praying that the next 6 months bring changes.

I fond this site a great help, I talk to people who are going through the same thing as me (or similiar), and I can help out other people if Im past where they are (like after surgery).

You get a good insight into how the body works and also its nice to hear other peoples OS's have said similiar things to my own - makes me believe in him a bit more - I must admit I was a bit wary of the whole muscles not being fired story before I found other people with the same issue!!
1986 - recurrent dislocations of right patella began
1988 - Modified Hauser Procedure
1991 - dislocations started again
2005 to 2007 - 150 dislocations in 2 years - OUCH!!!
June 2007 - new OS, new physio
Oct 2007 - VMO woke up
Mar 2008 - big quads, still dislocating
Apr 2008 - next OS app

Offline Janet

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Re: Had tests today - can anyone enlighten me
« Reply #13 on: October 07, 2007, 08:22:55 PM »
Joanne:

No, they cannot check the quad tendon during scope. It is outside the knee capsule. My quad tendon repair was done during an open repair. MRIs and an ultrasound were used over the years to see that the tendon was still intact, and a EMG showed the the nerves were firing correctly. That's why I was told the muscles weren't damaged, just shut down.

I thought I might always walk with a limp, but I don't! My leg is still weak, and my calf/behind the knee gets especially tired when I walk more than 20 minutes. My husband thinks that's because I didn't push off with my toes for so many years, I would just swing my leg around so I didn't have to bend it very much. But I keep walking and biking, building muscle and functional strength. I'll tell you, I didn't think it would take this long to recover from my TKR. I thought by this point I wouldn't even be thinking about my knee. Well, my knee doesn't hurt much anymore, but I still have a ways to go to get to normal function. I'm glad I have had the motivation to work so hard at this through the years, because it really takes dedication to rehab/recover from all these knee problems!

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline Sore knee

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Re: Had tests today - can anyone enlighten me
« Reply #14 on: October 08, 2007, 08:25:53 AM »
Janet

You are an example to us all. Guts determination and focus  - it will pay off. Its amazing how you revolve your life over a knee and yet before all this you don;t think twice about them.

You keep going and thanks for the insight, I am throwing lots of questions in the pot right now before the OS and PT have their meeting. Figure its worth a shot, they might consider something they hadn't thought of before.
11/5/07 LR right knee and cartilage tidied up
6/8/07 Knee aspiration, steroid injection- more physio
22/8/07 Knee to be scoped for answers
16/5/08 Patella stabilisation for  subluxations
24/6/08 Infection -hospitalised for a week. Debridement surgery
21/11/08 Repeat patella stabilisation performed















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