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Offline highroller

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Sore knees, no diagnosis
« on: June 28, 2010, 07:29:17 AM »
Hi all,

I have a pair of very sore and irritated knees but no diagnosis despite a number of medical consultations and an arthroscopy. I am hoping that you may be able to offer some insights as I am at the point where my daily activities are significantly compromised.

A quick history:

May 2009: both knees frequently sore after weight training, consulted sports doctor, x-ray normal, prescribed anti-inflammatories and activity modification within comfort zone

June-Oct 2009: continued weight training with lower loads, still experiencing soreness but only severe for 1-3 days after training, took 2 courses of anti-inflammatory tablets without any noticeable effect

Nov 2009: knees deteriorated very rapidly over a period of 1-2 weeks, barely able to walk at worst, stopped gym training, MRI on left knee does not reveal any structural issues but possible fat pad impingement, rest and anti-inflammatories advised

Jan 2010: no improvement, consulted orthopaedic surgeon, examination revealed flexibility issues, suggested 2-3 months physio and stretching, continued to avoid weight training

Mar 2010: no improvement despite working on flexibility, scheduled arthroscopy on left knee (slightly worse than right) for early April

Apr 2010: arthroscopy on left knee, found to be in pristine condition, fat pad trimmed slightly as a precaution in case of impingement though no evidence of this within the joint, surgeon has no idea what's wrong, states that fat pad trim 'works sometimes', raises flexibility / mobility again as a possible cause

Jun 2010: both knees were slightly better a couple of weeks post-op presumably due to the rest required to recover from the op and my walking range gradually improved over a few weeks (always some discomfort present though) but after a few minor setbacks, possibly due to overdoing it, a major setback sees me back to square one and limited to very short distance walking

Current status:

I will be talking to the surgeon again shortly but in the meantime I'd be grateful if anyone could offer any explanation as to what could be wrong with my knees and/or what I should be doing to treat the condition. There is a fairly constant ache with a sense that there is no cushioning/shock absorption when I walk. The discomfort gradually increases as I walk and there are occasional sharp pains. I can understand how I irritated my knees in the first place through high-intensity weight training but I have barely trained for 8 months and the condition of my knees is on a deteriorating trend.


Thanks for your time, it's much appreciated!
10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline Hopesmom

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Re: Sore knees, no diagnosis
« Reply #1 on: July 01, 2010, 10:37:30 PM »
I as well experienced knee pain after some increased weight training.  This flared up what was a somewhat dormant fat pad impingement.  After trying every conservative method known for a 9-month period, I finally had the fat pad removed.  It had turned completely into scar tissue and was enlarged and impinging between the bones.  It was excruciatingly painful and had to come out. 

I have been trying to read up and customize my own postop protocol for preventing more scar tissue.  So that means rehab is gentle and slow.  My surgery was in January, so 5 months out.  Last week I tried doing some light knee extensions on the extension bench.  Bad idea.  I could hear popping under the kneecap, and also the fat pad in my relatively good leg became irritated.  So I do now believe that it was all the heavy leg extension work last year that started it up.  It's unfortunate as I love to do this weight-lifting exercise, but I no longer can.

I have corresponded with someone who also had a partial fat pad excision (mine was removed almost in entirety), and he said it took him a good year before his knee felt "normal" again. 

My knee is doing some really weird things.  Some days when I walk it feels like the patella tendon is "suctioning" in at the bottom of my kneecap.  It just is a different thing every day and I never know what it's going to be till I get out of bed and start walking.  The good thing is it changes so I can at least that the next day will be a better one.

These knees are such complicated joints.  It seems to me that you just have to be very gentle with rehab and try to be extremely patient and let time heal.  In the meantime, elevate and ice, ice, ice. 
1995 exploratory scope; OS did not diagnose fat pad syndrome
1/2010 AIR/LOA removed most of fat pad, unfortunately didn't know about postop protocol to prevent more scar tissue
8/2010 AIR by Dr. Steadman to release patellar tendon adhesion; found & released suprapatellar plica compressing 1/3 joint

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #2 on: July 02, 2010, 09:14:56 AM »
Thanks for your reply. I can certainly empathise with your condition and experiences, especially the day to day variation in the way the joint feels and susceptibility to setbacks.

My MRI did reveal some fat pad irritation but nothing severe. The surgeon didn't see any evidence of the fat pad being problematic on inspection during the arthroscope but he trimmed off a section anyway as a precaution.

I've decided to try complete bedrest, or as close to that as I can manage, for a couple of weeks initially to see if that helps to calm down the irritation. That decision was partly inspired by a very good ebook on patellofemoral pain that I purchased from saveyourself.ca which draws on some work by Dr. Scott Dye (see The Pathophysiology of Patellofemoral Pain, 2005). The main idea is that the joint tissues can lose their 'homeostasis' from various forms of mechanical stress - this reduces the stress levels that they can withstand until balance is restored. The challenge then is to gradually expand your 'envelope of function' back to pre-injury levels while staying within this slowly expanding comfort zone. I'm thinking total rest initially followed by the sort of rehab protocols I've seen described in Doug Kelsey's excellent blog (http://sportscenteraustin.blogs.com/the_view/knee/).

I'm seeing a colleague of the surgeon that performed my arthoscopy next week to get his thoughts but the above is the best I can come up with from my own research. My surgeon didn't offer much hope at the post-op consultation - basically said that anterior knee pain is poorly understood and he has no idea what's wrong with me.

Hopefully some others can chime in if they had experience of knee pain with no clear structural cause...
10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #3 on: July 05, 2010, 07:35:36 PM »
Wow. I was searching on Google for information about the site saveyourself.ca, and your description of the nature of your pain has to be about the closest to mine that I've found. Here is how it started for me:

I never had any significant pain in my knees at any point in my life. Then, in September of last year, I sprained my ankle while running. I still do not know why it happened, but perhaps to compensate so that I didn't injure my foot further, my groin muscles tightened up (though at this point I didn't know this). I probably should have went to the doctor at this point, but for the next few months I slogged through it, and every time I tried to exercise for any significant period of time, this terrible pain would start to shoot through my knee. For at least the next week, I would have to limp around, and my knee felt inflamed. But after this, my knee felt perfectly fine again, and it wouldn't bother me unless I tried to exercise. Around November, not knowing what the problem was, I decided to wait a long while before trying to walk again, hoping that it would cleared up by then.

Around early February, I decided to try to exercise. Unfortunately, nothing changed and my knee was inflamed again. At this point I made an appointment to the doctor, and he diagnosed me with Patellofemoral Pain Syndrome. I tried doing the rehab exercises he gave me, and wearing a knee brace, and for a couple of weeks I was walking every day without a problem. I thought maybe I was cured. As it turned out, I just wasn't doing anything strenuous enough, and I was again in pain.

But this time, something changed. After limping for a couple of weeks, my knee wasn't getting better. I started getting more sharp pains well after the initial time of injury, and this had never happening before. Soon, it was getting much worse. I decided to go on crutches. Honestly, I had no idea what was wrong with me, and I ended up being on crutches for 11 days before seeing the doctor again. He acted like I was crazy for using the crutches, and told me to get off. I followed his advice, and very rapidly my knee got better. I didn't feel any more sharp pains. At this point, I purchased a book called Pain Free by Pete Egoscue, and tried doing the knee exercises in them. From his descriptions, I realized that my leg was rotating with every step and that this was putting unnatural rotational pressure on the knee, and so the misalignment was fixed. By mid-May, I felt perfect again. I wish this was the end of the story.

At this point, after walking without incident for a few days, I decided to run. Well, I guess the tissue was still sensitive, because it started hurting rather quickly. Interestingly, the pain was less severe than it ever was before, presumably as a result of my leg being in better alignment. But because I thought it was less sensitive to damage, I didn't lay off of it enough. I didn't try to run again, but after a few days, I did try to walk for a long period of time, and this was a huge mistake. It has since gotten progressively worse, and I am at the point now where I can't even walk for more than a few minutes without feeling sharp pains. The only days I didn't feel any such pain was when I came off of a few days on crutches. But I must have still been overdoing it, as I starting getting pains again the next day. So here I am, at rock bottom and I don't know where to go next.

I haven't had an arthroscope done, but it is reassuring that I may not have any underlying damage. Honest, your description of your pain almost perfectly matches mine. There is a feeling of "emptiness", like the padding is not there. There is constantly a feeling of inflammation, sometimes dull pains as well, and frequent sharp pains. I have noticed that more inflammation tends to follow the sharp pains, so I think recovery is mainly a function of avoid these sorts of pains. But I wonder: How is this accomplished, if I can hardly walk any distance at all without feeling this pain? In my case, you might say, go on crutches again, and when you get off, be EXTREMELY conservative. The only problem is, a couple of days ago, the OTHER knee started hurting from the strange contortions I had to put my body through on crutches. So now, I can't use crutches any longer.

The original reason I came to this thread was for information about saveyourself.ca. So you think that the information is useful? I wasn't sure, although the site does look professional, and the fellow who runs it seems like he knows what he is talking about. Maybe I'll give it a shot.

If you have any helpful tips as to what extent I have to reduce activity, I appreciate it. Honestly, I just can't imagine being completely bedridden though. But it may come to that. Thanks.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #4 on: July 06, 2010, 07:58:06 AM »
Thanks for your post.

Your symptoms do indeed sound very similar to mine. It's very frustrating not having a diagnosis on which to base a treatment plan - so far it's been trial and error, with plenty of error, including in my case an athroscopy that may not have been necessary although I understood that at the time.

Regarding saveryourself.ca, in my opinion he's very much the real deal. He distills a huge volume of scientific research and practical experience into a set of very readable tutorials on various conditions. I bought the full set and I'm very impressed with what I've read so far. They're not just conventional advice regurgitated - there's  solid critical analysis and lateral thinking throughout which I found very refreshing after wading my way through countless websites promoting the same mainstream ideas many of which are well established but highly questionable e.g. strengthen the VMO muscle, etc. He's also comfortable critiquing practices from his own professional domain of remedial massage therapy where warranted.

I also just read an interesting book called Explain Pain that describes the neurological basis of pain and how pain can exist and persist independent of underlying physical problems. Kind of led me to a similar conclusion regarding trying to restore function incrementally but from a different angle.

Your point about how to attempt rehab protocols from a base of very limited function resonates strongly with me. That's basically the situation I've found myself in of late and why I've decided to try maximal rest for 1-4 weeks before slowly resuming activities again and when I do start progressively increasing the load on my knees it will be much more gradual than before. You should check out that blog my Doug Kelsey that I mentioned above - the posts go back a few years but it's well worth your while working through all the knee-related ones. Some good ideas in there. There's an emphasis on determining your comfort zone and operating well within that using very high repetition exercises that recondition your tissues over time as you slowly add resistance. The timescales are generally quite long though - of the order of many months for a full recovery though every case is different.

Finding competent doctors and allied health practitioners that can help with elusive conditions such as these is very difficult in my experience. I'm willing to scour the earth for the right folks if I don't make any progress in the next 2-3 months.

10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #5 on: July 06, 2010, 02:36:32 PM »
I think this theory of "homeostasis disruption" as a result of mechanical stress makes perfect sense from the standpoint of evolutionary biology. Think about it. If you are putting stress on your joints that could potentially cause erosion of the soft tissues over time, it would be adaptive for your body to give a signal of pain so that you would back off that activity. If you continue to perform the same activities, the pain threshold changes to increase the warning signal. Unfortunately, like many things in life, a mechanism that is usually adaptive can in some circumstances become maladaptive. I think that is the case we find ourselves in here. Certainly in your case, where you are certain that there is no underlying damage to the articular cartilage, I think this explanation is the only sensible one.

Since I have already been in this downward spiral, and almost fully recovered from it (albeit it was far less severe last time), I may be able to give some helpful pointers. I want to emphasize that the "occasional sharp pains" that you mentioned that you are feeling when you walk is a sign that you are not making progress. I'm sure you notice that the aching and inflammation is increasing, sometimes hours after feeling the sharp pains. There are probably mornings, though, that you wake up and you are feeling a lot better. Then you start walking, you feel the sharp pains, and finally, you are back in the same situation again. Such is the endless cycle that patellofemoral pain syndrome can be.

The first time that I stopped using crutches, a couple of months ago, I noticed that even though it was quite uncomfortable to walk, I no longer got ANY sharp pains while walking. I was fortunate that I felt progressively better every day. I can report that, after getting off crutches more recently, with the far worse PFPS, I didn't get sharp pains the first day after walking. This includes one period of three days on crutches, and one for nine days. However, I was eager to be able to live my life in more of a state of normalcy, and so I was probably overdoing it. I was standing while taking a shower, I was preparing food, I was walking needlessly at times. I probably walked 5 times more than what I really needed to. I regret this now, because I can no longer use crutches.

I do think, though, that less activity is never a bad thing with this disorder. "Walking through it" is not really an option. However, to fully recover, you will need some activity. The question is, how do you judge the appropriate level of activity at any given time? I'm going to try a very low level of activity for the next few days. If I continue to get those blessed "sharp pains", though, I think that I'm going to have to go to non-weight bearing status for a few days. I just can't imagine crawling around like a creature of the bowels of the earth, a troglodyte, for any period of time, but given that I don't have access to a wheel chair, and that there may be no other feasible path to recovery, I'll have no choice but to consider it. I just can't imagine this dragging on for months to come. But I don't want to short-circuit the recovery, since it will only be a longer period of time before I feel "normal" again.

I only want to emphasize, again, that you will feel pain along the whole path of recovery. A lot of pain. But it's the sharp pain that you want to avoid. It feels like someone is taking a sharp implement and scraping the underside of your knee cap when you walk. It doesn't occur with every step, sometimes you only feel it a few times a day. This is what you have to avoid. This only occurs when walking, not lying down. If you feel a pain that has a little sharpness to it, but is mostly dull, then that is not what we are talking about. Dull pain is to be expected, and you will feel a lot of it before you fully recover. But if you are feeling any of the sharp pain, you doing something wrong, and it's time to change course.

I will mention one more thing: If you do go non-weight bearing for any length of time, your muscles will atrophy, the calf in particular. Of course, you can easily regain the strength by doing calf raises, but this is easier said than done when your knee is in such a bad state. Your quads will also lose some strength, and it will be much harder to retrain them, since you can't do squats. So if it is possible to recovery without going non-weight bearing, this is the better path. But as a last resort, non-weight bearing may help. Just make sure that you are ultra-conservative when you start walking again. You don't want to be in the same rut again, but with weaker muscles.

I think above all, if you do recover to the point of full normalcy, where you no longer have any pain, remember that you are likely still not at 100%. There are days when I've said to myself, "what if?". I was almost there, and I threw it all away. If you make what you think is a full recovery, but you start to feel ANY of the patellofemoral pain symptoms again, IMMEDIATELY stop what you are doing and rest. Even though I fixed the issue with the tightness in my groin muscles, if the tissues are at all sensitive, there is the possibility of a downward spiral. If I only knew.

Hopefully this is helpful to you.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #6 on: July 07, 2010, 06:29:30 AM »
Thanks a lot for your detailed post - it's very much in line with the conclusions I have reached from personal experience of sabotaging my own recovery process on a number of occasions as well as consistent with the best advice I have read on the subject.

It's such a delicate balancing act trying to progressively nourish the joints and condition the soft tissues with movement while avoiding aggravating matters further. Looking back, even though my attempts at incremental resistance were minimally intensive compared to the demands of the workouts I used to perform, I can see now with hindsight that I was pushing the envelope too far too fast.

I hear you regarding the sharp pains. Almost certainly an indication of overdoing things as well as being very unpleasant in their own right - they have the power to change my mood dramatically in an instant - not so much because of the pain itself but more so as a stark reminder of the protracted reality and stubborn resilience of the condition.

I also managed a period of a few weeks at one point where I gradually extended my walking range up to a few km's without experiencing any sharp pains. The dull ache and sense of joint grinding was always there throughout though. I never at any point felt that I could break into a light jog without seriously compromising my knees.

I spent last week resting and confined to my apartment in the manner of the cave-dwelling creature that you mentioned :-)  This week more of the same but doing a very light (much less than bodyweight resistance) leg press type movement lying on an exercise ball for 10 mins a few times a day.  Next week I may try some light stationary bike work and try and limit walking as much as possible as that is still very problematic for me.

Anyway, thx again for the input, it's much appreciated. I'll keep this thread updated with my own progress (or lack thereof) in case others can benefit, would be great if you could do the same.


10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #7 on: July 07, 2010, 03:11:23 PM »
I'll certainly post an update if I feel that I'm making any progress.

Isn't troglodyte perfectly apt, though? I don't care which definition you are using, be it the caveman, the hermit, the chimpanzee, or the Dungeons and Dragons monster, they all seem to apply. You just rely a lot more on your hands with this condition. Here's hoping that we can quit knuckle dragging and get back to the bipedal locomotion that should be our birthright.

I'm going to try integrating those Egoscue stretches that I mentioned into my daily routine. I did notice, when this condition was much less severe, that on days when I did the stretches in the morning, I was much less likely to get sharp pains. Unfortunately, I didn't realize the extent that I would have to limit my activity. The stretches helped, I'm pretty sure, but alone, they weren't enough. I'm just not sure that it will matter at this point, though. But I think it's worth a try. If it seems to help at all, I'll report back.

Hang in there. There is light at the end of our deep, dark, depressing troglodyte cave. (Or is the light at the beginning? Just make sure you're facing the right way!)

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #8 on: July 08, 2010, 03:15:39 AM »
Indeed, the troglodyte is an apt symbol of our plight. It's a form of evolution in reverse as we regress from unassisted bipedal perambulation on the open savanas to stooped and faltering navigation of our rehabilitation caverns.

Regarding stretching, I spent quite a bit of time earlier in the year working on my flexibility/mobility with traditional stretches, yoga routines, foam rolling, joint mobility  exercises, etc. I made some modest improvements in my range of motion but it didn't make any appreciable difference to my knees. More recently, I read a few articles that suggested a tight rectus femoris muscle can often be a factor in knee pain - I tried some of the deep stretches recommended but only ended up aggravating my knees presumably from the compressive forces on the kneecap in the stretched position. I'm undecided on whether and how to resume flexibility/mobility work at the moment but I'll check out the Egoscue approach that you mentioned.

« Last Edit: July 08, 2010, 04:16:19 AM by highroller »
10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #9 on: July 08, 2010, 04:55:52 PM »
I decided to purchase that E-book from saveyourself.ca, and I have to say, everything which I have surmised from personal experience was just reaffirmed in 35,000 glorious words. Let's sum it up in just a few:

1. Get rest. A lot of rest. If anything has ever irritated your knee at all, don't do it anymore. In fact, do even less than that as the maximum loading capacity of your knee is now diminished.

2. Slowly, and progressively, perhaps over a period of months, build up that capability of the tissues in the knee to withstand ever greater impacts over ever greater periods of time. If you have any setbacks, you must scale down your activity dramatically or risk losing all of the progress you have made.

3. This is my favorite part. There is essentially nothing else you can do about it. Either follow 1. and 2. with utter precision, while praying to whatever deity or deities you happen to subscribe to (or just hoping the laws of physics will provide an opening for your irritated nerve fibers to calm down), or be crippled for the rest of your life. Wow, you have to love modern medicine.

At least I know beyond any doubt what I have to do now. If anyone with PFPS stumbles upon this thread, that summary is about as good as any. At least you know you're going to be having a thrilling summer '10 (or winter '10 if you're an Aussie or Argentinian).

On another note, I changed 2 things yesterday. I did that Egoscue stretch, and started using a cane. I don't know which helped, but I was able to sleep for the first time in a while without icing before bed. It could just be a coincidence, or it could be that one or both of those things helped. I think I am walking towards the light, but this cave has many passageways and sometimes the light you see is just a crack in the ceiling, a thin shaft of light that ultimately leads nowhere.

Hopefully this will help somebody.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #10 on: July 09, 2010, 04:44:24 AM »
Glad to hear you found the ebook useful. I was so relieved to find a plausible model to work with after sifting through conventional wisdom endlessly rehashed in other resources.

Unfortunately, the dreaded sharp pains paid me an unexpected visit yesterday. A rather excruciating encounter at that. I fear that my experimentation with light repetitive movements this week has backfired. I'm not sure I can go much lower on the intensity scale - I would be able to sustain the exercise ball leg press type movement almost indefinitely for 1000s of repetitions without stopping but only performed 5-10mins 2 or 3 times a day. I find myself once again weighing the relative merits of a trip to the bathroom to relieve my bladder against the discomfort of a 20 metre walk and the potential for further aggravation.

Thinking of starting to use some form of assistance to unload my knees a bit when shuffling around the apartment. A cane of some sort might be the way to go - I'd be interested to hear more of how that works out for you.

You mentioned icing in an earlier post. I have been doing that 2 or 3 times a day for 30mins at a time but I can't say whether it's of any use. Interestingly, the saveyourself.ca guy has written about this recently - he's pretty sceptical of the ability of icing to penetrate deeply and influence inflammation within the joint but thinks it might possibly provide some benefit via neurological disruption / change in stimulus to the area. He also mentioned that heat may be ever so slightly more effective than icing - I might try that as well.

Other than post-op, I've never experienced any clear signs of inflammation such as swelling, heat, redness, etc. in the knee area which further reinforces the credibility of the tissue homeostasis model to me.

Also thinking of going metaphysical and trying meditation and visualisation techniques. Not sure whether imagining myself gamboling gleefully through the meadows will make the return to reality more depressing but it might help with the neurological dimension of injury perception and the pain response.

Anyway, looks like it's back to as fully supine an existence as I can manage for the coming days...
10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #11 on: July 09, 2010, 03:56:15 PM »
The E-book was definitely useful. Can't say that I was overly enthusiastic about the message, though. But I won't shoot the messenger. My only regret is that I didn't purchase it sooner, as it might have saved me from months of suffering.

From reading your earlier posts, it wasn't entirely clear that it was that severe in your case. I'm sorry to hear that. But we are in the same boat. I feel that I have to deliberate over every move I make. There is a virtual Congress or Parliament in my brain. The liberal party is saying, "Move or you will die!" The conservative party is saying, "Don't move or you will wish you were dead!" How can you balance the body's essential need for stimulation against the PF pain's essential need for rest? I've been in the most exquisite pain over the last few weeks. And I'm not even talking about my knees. Literally, my foot, hips, back, neck, and shoulder have all been terribly antagonized since I've been immobilized. I know all of this pain would almost immediately subside if I could just walk around normally. There is a certain sway to your body when you are properly ambulatory. This is how your joints stay healthy. Standing and walking are the natural anatomical positions of the human body. When you sit or lie like a lump on a chair/sofa/bed all day, your body just falls apart.

I definitely ice, especially when my knee is bothering me enough that I can't concentrate on anything else, or I feel that I won't be able to sleep. I actually can't take anti-inflammatory medication, as it seems that is has caused a stomach ulcer. So this is the only prospect for any relief in my case. Do I suppose that the icing will actually help it recover, though? I can't say that there is no benefit, but I'm doubtful that anything other than a slow, progressive reintroduction to weight bearing loads will have much benefit. For pain relief, though, icing is the best thing around.

It's interesting that you mention that you haven't experienced inflammation. I haven't experienced swelling, heat, or redness either. You really can't tell from any external sign that anything is wrong. But some of the pain I've experienced is most accurately described as inflammation I think. It sort of felt like a burning sensation. What is strange is that the pain I've felt recently, I am at a loss to categorize at all. It doesn't seem like an ache, a pain, or inflammation. I guess the best description would be a constant dull ache, with a strong feeling of pressure at the location of the ache. If I bend my knee, the sensation gets stronger. Stranger still, the intensity of the feeling seems to variate inexplicably throughout the day. I really can't explain why it feels decent one moment, and not the next. At times, I barely even notice it, as if my knee is almost healthy again. At other times, it's as if my knee is the central focus and purpose of my life. Forget thinking about anything else.

Most steps I take now I feel a dull ache in my knee. I don't think this is necessarily a bad sign, though. I haven't really felt sharp pains over the last couple of days. Sometimes it is difficult to distinguish between the different genera of pain. It feels much the same every day, so at least for now, I don't know if I am making progress. If only there was some clear signal that it was ready for more activity.

I would recommend a cane, as it seems to target precisely the problem at hand. Because it reduces the load on the knee, it should allow you to walk for a longer period of time without pain. But I think you should only use it when you don't think there is any other path to rehab. And it occurs to me that if you overload your knee while using the cane, it could actually cause more problems. Think of it this way. You are now bearing less than 100% body weight. Let's just say 70%. Now, even with the cane, you still overstimulate the tissue. What do you suppose you'll be able to do after that? If you can't even handle 70%, how will you ever handle 100% again? If you're going to use the cane, it's because you've exhausted all other possibilities. Make sure every step you take is slow and deliberate, so as not to put undue stress on the joint. Remember, the moment of contact with the ground is the point of greatest load. You don't want to exceed 100% body weight if you can help it. And try not to bend the knee much with each step. Remember, the load increases proportionate with the angle of the leg.

If this approach fails, then as I've pointed out before, you've been demoted to slithering like a worm. There are definitely adverse consequences to non-weight bearing, but as I've said, in my experience your knee will be able to handle a greater load when you start walking again. Still, when the condition has degenerated to this extent, that is certainly not a cure. If you do elect to try this approach, I would suggest no more than 1 or 2 days the first time. Any more than that, and there will be a noticeable degradation of muscular strength. Perhaps try the cane first.

I honestly feel like I might be making some progress here. But each day is tenuous, and I'm afraid that when I take the next step, and try to increase my activity level, I'll tumble to the bottom of the cave again. Sometimes this condition just seems so hopeless. The most important thing for rehab, I think, is just to accept your station in life right now. Don't have a timeline in your head when you have to be "normal" again. Yes, we are going to miss the entire summer. Summer 2010 is forfeit. Perhaps more than that. This might be depressing, but it is a necessary precondition to fully recover. If you think you need to get back to something by a certain date, you are going to make mistakes. That's what I did. In mid-May, I was so exciting to finally feel "normal" again. I thought all my problems were resolved. And I especially gave my self a pat on the back for achieving it at just the right moment, right around the time when I most wanted to be active. That was just about the biggest mistake of my life. Psychologically, I would have been better off if I hadn't cared about the change of seasons. If I'd only said, "You know, wouldn't it be grand to be walking/running right about now? But I know I need at least another few weeks to be sure I'm all right. So I'll pay close attention to the signals my knee is giving me, and basing it on that, and that alone, irrespective of the weather outside, I'll get back to activity." If I had done that, I might be cured right now. I'll never know.

About the Pete Egoscue book, Pain Free, it is important to realize that once you fall into the PFP trap/hole/cave, it becomes a sui generis disorder, one which is not amenable to easy intervention. I know now that the Egoscue method is not a panacea. But, based on my experience with it, I still believe it has some merit. I'll delineate a few of its virtues here:

1. Our favorite joint, the knees. When I got off the crutches in early May, my knee was incredibly sore still. Fortunately, it was ready for recovery and I didn't experience any setbacks. About a week after starting to walk again, I got delivery in the mail of the book. I immediately tried to put it into action. There are two separate sets of exercises, one for internal rotation of the leg, and one for external rotation. I wasn't sure which was relevant to me, but I first tried the internal rotation. This includes exercises for glute strengthening, hip flexor strengthening, and a stretch (which requires a lot of time!). Honestly, the first time I finished the exercises, I felt a lot better. The ache in my knee seemed to quite rapidly subside as I was walking. Within perhaps 2 or 3 days, I was actually starting to run/sprint around the house. It was almost a miracle. Then, all of the sudden, I got this excruciating pain in the usual spot. I couldn't believe that something that seemed to help so much, didn't actually fix my problem. So I went back to the book again. I decided to give the method every chance to work. So the next day I tried doing the external rotation exercises. This includes groin muscle strengthening exercises, and another stretch that takes a really long time. After the stretch, I starting trying to walk around again. Again, almost miraculous results. Every other time I ever had that sort of pain after walking, I usually had to limp for about 2 weeks. Just two days later, it was as if nothing had happened. This of course, was because the cause of the pain in my case was that my leg was abducting with every step I was taking. By loosening groin muscles, I was finally walking in alignment again. Unfortunately, as is now clear, even though I solved muscle tightness issue, I still had PFPS. And that is something that is not easy to conquer. I can't blame Pete Egoscue, though. His approach, which is contrary to conventional wisdom, definitely helped me in a way that the doctor's physical therapy exercises did not. Usually, knee problems are attributed to foot pronation issues, knee tracking misalignment, quad/VMO weakness, or hamstring tightness. Egoscue says this is bunk. He claims that knee problems usually originate because of either tightness or weakness in the hip flexors or groin muscles. Based on my experience, it seems that he is correct. Again, this is another one of those things that would have been a lot more beneficial to me if I knew it sooner!

2. I also tried doing the exercises for the feet. I had never had foot pain before, but as a result of my body falling out of proper alignment because of inactivity and use of crutches, I did have some persistent pain in my feet wouldn't subside. After doing the exercises, which in this case only took about 20 minutes total, the results were amazing. It felt like I was using my whole foot, rather than just the outside edge. I guess I was always underpronating and didn't realize it. the foot pain quickly subsided During that short window of time when I was able to walk, I also noticed that I was no longer getting shin splint pain, which had always plagued me when I tried to walk fast for any period of time. Again, it definitely worked.

3. I was also about to try the exercises for the lower back, upper back, and neck before I started having knee trouble again. I had neck pain for a long time, usually triggered when I craned my neck to the side for any length of time. Honestly, after a few times of doing the exercises, this was gone. I had lower back pain and sciatica on and off over the years, and since the start of 2010, I had persistent mild sciatica which wouldn't resolve. Again, after a few times of doing the exercises, for the first time in months, my back was feeling normal. As for upper back pain, that wasn't usually a problem, but if I tried to sit with good posture for any length of time, I would have pain. After doing the exercises the first time, I noticed my shoulders became naturally less rounded, and it was easier to sit up straight in the chair. It wasn't perfect, and I unfortunately wasn't able to continue doing them as a result of my knee flaring up again.

Despite the fact that it can't cure PFPS, I would definitely recommend Pain Free to anyone. Just realize that it isn't a panacea. If I'm able to recover from this, I'll probably do all of the knee exercises in the book for about two weeks, just to make sure I'm in alignment. But I'll also continue to be careful, knowing that PFP does not ride easily into the sunset.

That was a pretty long post. But if it benefits someone else, it was worth the time.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #12 on: July 10, 2010, 10:23:16 AM »
I've actually been taking a course of anti-inflammatories recently - I had one repeat left on a prescription from some time ago so I thought I'd give them a shot again but can't say I've noticed any difference. I was aware of the risk of stomach and intestinal complications and wary of oral NSAIDs but I've never noticed any discomfort so I do take them for short periods occasionally when injury dictates. I've also been taking fish oil and a powdered joint formula containing glucosamine, condroitin and MSM on the offchance that they are of some benefit.

I'm very conscious of the risk of leg muscle atrophy and deconditioning but as you mentioned it's difficult to counteract that when your envelope of function is so constrained. I'm trying now to at least perform some of the movements that were recommended post-surgery such as leg slides, leg raises, etc while lying on my back. Anything to keep the joint from seizing up and the surrounding soft tissues from losing their strength and balance. There's also a cartilage issue - the Doug Kelsey blog cites research suggesting that articular cartilage needs motion to condition its cellular matrix - without the right mechanical pressure the cells are not stimulated to maintain their bonds and the tissue softens and frays. This is the basis for his arthiritis rehab protocols whereby the right level of progressive load can improve the integrity of existing cartilage even if it can't encourage new cartilage development.

I hear you regarding accepting the situation and releasing attachments to activities, timelines, etc. I was actually planning some extended travel but that is obviously indefinitely on hold now. Fully appreciating and respecting the delicate nature of the recovery process and the fragility of progress is also so vital. I fully expect to have further setbacks but they should be much less severe and shorter lived with a more vigilant and conservative approach to managing my activities.

Regarding the relationship between joint pain and myofascial issues, they are so intertwined that it's difficult to identify linear causality. For example, is the joint sore because the muscle is tight or is the muscle tight because the joint hurts? With the interplay and feedback loops it's probably always a bit of both.

I can empathise with your smorgasbord of aches and pains throughout the body - I have quite a few of my own, including what might also be a fairly mild case of sciatica emanating from a tweak of the glute/hamstring area a couple of years ago. I latched onto the concept of trigger points and various self-treatment massage techniques a while back but haven't had great success ironing out the knots so far. The saveyourself.ca ebook on that subject disabused me of getting my hopes up for a quick cure on that front as well! I do believe the trigger point concept provides a crediblr model of he problem to work with though. I've also tried a number of joint mobility routines (e.g. IntuFlow, z-health, etc) which I believe have a lot of merit for general health but as you indicate for Egoscue not a panacea. I will check out Egoscue - looks worthy of investigation with your provisos well noted.

Anyway, thanks for the ongoing contributions, hopefully over time we will chronicle our full recoveries and help others overcome this frustrating and poorly understood affliction.

Anyone else that wishes to join the discussion, please do, would be great to get some more opinions and experiences.
10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #13 on: July 10, 2010, 04:56:56 PM »
I'll certainly keep you posted on any progress, or if I should face such misfortune, any setbacks that occur along the bumpy road to recovery. I don't know that I'll be posting every day as I have been, because as you know, there are sometimes excruciatingly long stretches of undifferentiated aches and pains, where progress is minimal, hope falters, and you question whether you might be crippled for life. But I'd like to chronicle here any significant changes or progress, including after I make a "full" recovery, and any lingering issues such as going up and down stairs, and whether I'll ever be able to return to my previous level of activity. Prior to last September, I never had the slightest problem with my knees. I could do single legged squats, walk up and down stairs all day long, and run up and down hills without any joint difficulties. Sure, my muscles ached sometimes. But my knees were fine. My most solemn hope is that I'll be able to return to full normalcy someday. But, life being as it is, such a prospect will be uncertain for a long time to come. Whatever the outcome, I'll record it here so that others might be able to avoid some of the pitfalls that I've unfortunately succumbed to.

I hope you'll do the same. Indeed, anyone else with any input would be appreciated if you're currently going through the same struggle. If anyone has any questions feel free to ask and I'll certainly be willing to relate my experiences.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #14 on: July 11, 2010, 02:11:17 AM »
I'll also be posting less frequently but I'll aim to update with any significant developments or useful information that I encounter in my research such as the following article which includes contributions from Dr. Scott Dye, the masochistic scientist that prodded his own knee tissues without anaesthetic to advance the understanding of knee pain and proponent of the tissue homeostasis theory.

http://www.runnersworld.com/article/0,7120,s6-241-285--11553-1-1X2X3X4-5,00.html

I have an appointment with my OS in 2 weeks. I'll be better prepared with a barrage of questions this time round but not sure he's going to be of much use in resolving the problem at this stage given that it does not appear to be an operable condition. I'm interested in getting a bone scan though - does sound like a useful diagnostic tool for PFPS.

You mentioned that you've never experienced knee pain in the past. I have had very mild knee pain on and off for years stemming from my early experiences with weight training back in my late teens / early 20s (pushing 40 now) when I was obsessed with the weight on the bar rather than the effectiveness of the training protocol. My training in recent years has been much more sensible and well-rounded - lighter weights but much more intense, metabolically demanding, multiplanar and varied employing loaded and bodyweight movements (such as the 1-legged squats you mentioned), etc. My knees were much better with this approach up until last year. Still, despite the more evolved approach, my knees were likely under just as much stress even if the program allowed for much more balanced muscular development and better conditioning of the energy systems. If only I had backed off at the initial signs of trouble. It's funny how your perspective changes with knowledge and experience - the notion of a month off at that stage was incomprehensible whereas now it's just a logical choice. 
10/09: knees sore from gym, MRI ok, fluid in fat pad
01/10: knees worse, OS recommends PT
03/10: barely able to walk
04/10: arthroscopy left knee, no problems found, fat pad trimmed
08/10: begin PT, rheumatoid arthritis ruled out
09/10: neuropathic pain diagnosed, prescribed Amitriptyline















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