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Author Topic: Sore knees, no diagnosis  (Read 27462 times)

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Offline highroller

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Re: Sore knees, no diagnosis
« Reply #45 on: July 27, 2010, 12:31:38 AM »
The outcome of your OS appointment was a bit predictable all right but hopefully the conventional approach will yield some results. Great to hear of improvements in your condition though - it could just be a turning point that you can capitalise on fully this time with a more conservative progression. Fingers crossed.

My condition is fairly static now. I ended up spending a bit of time on my feet yesterday with travel to and from the appointment. I couldn't really walk any slower without going into reverse and each step is very tentative but I managed to avoid sharp pains and it hasn't flared up today. I will try and walk as best I can for a short distance every day from now on.

I did try a few other activities in recent days but was disappointed in my limitations. Stationary cycling is just not possible as the bent knee position puts too much pressure on my kneecap. Swimming is only possible with virtually no leg movement. Sitting in the pool's jacuzzi was quite pleasant though and I was able to perform a kind of cycling motion with my legs in front of me. I'm continuing to perform the other floor-based exercises I mentioned in an earlier post and increasing the frequency and repetition count.



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 #46 on: July 30, 2010, 04:26:33 PM »
I went to my first PT appointment on Wednesday, and I must concede, it was far closer to the "white glove" treatment than I was expecting. My PT's approach was very professional, and regardless of the general effectiveness of the techniques employed, it's comforting to have a experienced eye observe my progress. The good thing about this is that any progress I make will be measurable. I'll just describe a bit of what happened.

First, I was asking to fill out some paperwork. The most relevant to the assessment, I think, was a questionnaire asking me to rate the difficulty of performing various activities. For example, I put "Extremely difficult or impossible" for running any length of time, and walking more than a mile. I put down "Very difficult" for walking a couple of blocks and climbing stairs, "moderately difficult" for getting into the tub, "slightly difficult" for getting into a car, and "not at all difficult" for rolling over in bed. This establishes a good baseline of what I felt I was capable of doing on the first day of PT.

The PT then observed my posture and gait while walking, to establish a baseline for that. After that, was the only moment that was really at all painful in this process. I was expecting, and certainly wasn't disappointed in this regard, for a squat test to see how deep I could go. That was probably the first time I had attempted to squat at all in at least six weeks, and so I interested to see was I was capable of doing. It ended up being around 2/3 or so of the way to parallel before I felt a bit of sharp pain course through my knee. The PT made the point that you can't establish a baseline without risking a little bit of irritation, and I really can't argue with this. Fortunately, he was satisfied with that and there was no more squatting after that. A little bit later he had me attempt to stand on one leg. I was a bit surprised that I was able to do this for about 30 seconds without much trouble. A few weeks ago, even standing on both legs for any length of time seemed to provoke a crushing sensation in my knee.

He then did a complete assessment of the range of motion, flexibility, and strength of my knee joint, hips, and legs. As I had observed myself, I do now have complete range of motion in my knees. He actually measured it with some sort of device to ascertain the angle of the knee flexion, and it was about the same in both knees. For muscular strength, he would place me into a certain position, and I would attempt to resist movement as he applied pressure in the opposite direction. There are probably some muscular imbalances, but nothing too serious as I was generally able to hold fast. For flexibility, the PT did notice tightness in some areas, and said that would be something we would work on over time. I was a little concerned during this process that the pressures being applied might irritate my knee, but there was no other moment like the squat test, happily.

When this was complete, he demonstrated how to do various stretches that should help to restore a normal gait. I've expressed skepticism in the past about the efficacy of these measures, but on the other hand, I've certainly seen the benefits of stretching with the Egoscue method as I described above. I have no doubt that flexibility plays some role in rehabilitation, but given the severity of the condition, a protocol of rest with a slow progression of activities is clearly still the most important factor in recovery. Even here, though, I think having a PT involved will prove beneficial. He has undoubtedly treated and seen to full recovery a good number of people, and will hopefully help me to determine when I might be capable of increasing my activity levels.

Since June 13th (which was the day that I had my first major flare up of inflammation), this is probably the longest period of time that I've gone without a major flare up. The last time I had a bout of inflammation even approaching that level was on July 12th, and a more minor flare up on the 19th. I decided this morning to attempt to walk at a more normal, but still slow, pace, and I went for about five minutes without any major pain, but I won't know until later in the day if there will be a negative reaction to it. If there isn't any adverse reaction to it, I'll probably do the same tomorrow. My greatest fear is that all of this "progress" may simply be a result of the tissues calming down concomitant with the lower level of activity, and that as soon I start upping the level to something resembling a normal walking gait, I'll be right back where I started. I'll know in the next couple of weeks.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #47 on: August 01, 2010, 09:28:14 AM »
Sounds like you've found a decent PT there. The chap I tried back in Jan was a charlatan by comparison. I have an appointment with a new guy next Friday - he comes highly recommended and specialises in knee rehab so hopefully he'll live up to the hype.

I'd rate your current capabilities slightly ahead of my own. The mere thought of a 2/3 squat is sufficient to trigger a sharp pain in my kneecaps! I have near complete range of motion in the knee joint, albeit with some discomfort, as long as no additional pressure is applied but, for example, a quad stretch, kneeling back on my heels or even the point of maximum knee flexion on a stationary bike are beyond my limitations right now. I did walk for a few blocks today at a slow pace but experienced a couple of sharp pains about a block from my apartment on the return journey which made for a rather uncomfortable and nerve-wracking home straight. I need to be very careful about the time I remain fully weight-bearing for any single contiguous period. Hopefully today's unpleasant episode won't result in a setback but that won't be apparent until I gingerly alight from my bed tomorrow morning.

I have established an exercise circuit that I perform at home once a day now with a gradual progression in the number of circuits and repetitions:

Shoulder stand position: inverted knee extensions, bicycle movement, squat
Lying single leg raises
Lying leg curls
Lying glute/hip raises
Walking (on the spot or moving slowly) raising thighs to 45-90 degrees *
Walking on the spot leg curl *
Calf raise
A few upper body movements such as chins and push-ups

* I hold on to the backs of 2 chairs initially and later transition to unassisted

I repeat some of the exercises at other times during the day for lower rep counts to keep the joint lubricated and maybe build some neurological acceptance of the movement pattern if that makes any sense.   

I managed to secure an earlier date with the rheumatologist (Aug 12) plus I've also scheduled a consult immediately prior to my PT session next Fri with the sports doctor I originally saw at the onset of my troubles last year. So it's a shock and awe barrage of consultations over the next 2 weeks.

One treatment I may pursue with both the sports doctor and the rheumatologist is a more potent cocktail of anti-inflammatory agents than I tried previously, possibly even a cortisone injection. The difficulty with the latter is what tissue to target as well as the risk of tissue damage. I don't have any visible swelling but my instinctive sense of the underlying problem, which accords with the tissue homeostasis model, is a more subtle inflammation of the synovium or other delicate structure.

Anyway, great to hear you're making some progress and under competent supervision now. Just be sure to take it easy, one step at a time so to speak...
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 #48 on: August 01, 2010, 04:19:54 PM »
Such is the intractable nature of this condition, that it has now descended to a state not much elevated above its worst. It's interesting that you mentioned specifically that a quad stretch is beyond your envelope of function. That was also the case for me, and I demeritoriously failed to recognize this before it was too late. My knee has become a veritable Potemkin village which, when it reaches its most tranquil state, elicits a sense of complacent ease, and I have often misconstrued this as a sign of recovery beyond what is warranted. The facade of recovery, unfortunately, belied the true, delicate state of my knee. The pressure was just too great, and my knee succumbed.

On Thursday, I did a standing quad stretch, and afterwards felt that I might have antagonized my knee. I decided that the next time I did this stretch, I would try it lying down, thinking that the one legged stand was the main culprit. It turns out that it was the stretch itself that was bothering it, but by the moment of this realization, it was already too late. Most of the progress, if it was ever genuinely progress at all, is now lost and I find myself once again limited in my range of knee flexion. It is perhaps not as bad a few weeks ago, but it is nonetheless a blow to my psyche to regress, as the Evolution of Man in reverse, to a state more resembling that of the troglodyte.

It's really too bad, as everything else went without a hitch. I couldn't have felt much better on Friday morning, and not much worse the whole of Saturday. My knee just ached throughout the day. I think the best thing to do now is to rest a few days before going back to PT, and report the negative response to that stretch. Hopefully by the end of the week I'll regain most of the lost range of motion.

I'm sorry to hear about those sharp pains during your walk. Just remember, even if you can't notice the difference, you probably will have a lower envelope of function for a couple of days as a result of that. I agree that you do need to regulate the amount of walking that you do. Any increase should be introduced as gradually as possible.

If those exercises aren't bothering you, I think that is probably a good thing. I had integrated some bicycle movements and knee extensions as you had mentioned, and I do feel that it may have played a role in increasing the degree of flexion in my knee prior to Friday's unfortunate events.

As far as those cortisone shots are concerned, even if you do get some relief, how do you know that it is actually therapeutic and not simply, as I put it above, a Potemkin village? You might feel better for a while, but when the effect wears off, you'll be right back where you started or worse. If the pain relief is a mirage, you might not realize that you are further irritating your knee. And of course the always present danger of tissue damage that goes along with steroids. Structurally, your knee is fine. You don't want to change that.

As far as the PT is concerned, all I can say is, while it is a benefit to have professional advice, don't let that override your own good judgment. I should have stopped doing the quad stretch immediately after it first bothered me, and not tried to rig up my own alternative version. I do think that you need to always be your own best advocate, though. And if the PT wants you to do something that you're pretty sure is going to elicit a "Yowie!" (And by this I simply mean a pain response, and not that mythical creature lurking in your own outback. Although, as we know, after a Yowie!, you'll more resemble a Yowie!), you need to suggest a more conservative approach. As far as the quad stretch is concerned, I'd suggest passing on that for a while.




Offline highroller

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Re: Sore knees, no diagnosis
« Reply #49 on: August 02, 2010, 07:28:45 AM »
Sorry to hear about your setback. Looks like we've managed to coordinate flare-ups in anguished synchronicity! Despite feeling a bit tender yesterday evening, I managed to get through my exercise routine this morning without noticing any significant adverse effects from yesterday's ill-fated excursion but not long after I felt the onset of aggravation to my left knee.

Regarding anti-inflammatory treatment, at this stage it's just a topic for discussion with my doctor. My concern is that I am not able to sufficiently diminish whatever tissue inflammation may be at work through rest and conservative activity management alone. Perhaps some external assistance could give me the functional space I need to progress. Snowy mentioned a one month protocol of  high dosage NSAIDs and low intensity exercises in an earlier post that yielded some results. I'm certainly mindful of the risks and issues - just something to consider. Having tolerated oral NSAIDs in the past, I would try a more potent tablet before considering an injection. I'll report back on my doctor's opinion after my consult on Friday.
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 Lottiefox

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Re: Sore knees, no diagnosis
« Reply #50 on: August 02, 2010, 06:26:43 PM »
A conventional quad stretch tends to annoy my kneecaps too - it places tremendous pressure on them when you bend like that to stretch the quad.

It might be worth discussing foam rolling with your PT. I am a convert.

http://sportsmedicine.about.com/od/flexibilityandstretching/ss/FoamRoller.htm

It allows you to target specific areas that are tight, acts as a form of warming up of the muscles and used regularly (at least once a day) loosens the knee and the structures around it. Not saying it is right for you, but the NASM training principles advocate it prior to any training session and afterwards in combination with stretching. It is relatively quick, cheap and can really help with kneecap general aches and pains.

As regards higher dose NSAIDs - I had a month of Naproxen last year when I had my worst flare. They did bring down the swelling but I can't say they made a massive difference to pain. I sometimes use topical NSAID gel if the knee is especially sore - Voltarol is good for me and reduces the nastiness of bunging NSAIDs into your gut.

Lottie  :)
Bilateral patella OA since 2009, no surgeries.
Euflexxa working well x3 to current
Right forefoot CRPS post fusion surgery 2011
Refusing to let the ailing parts stop me....

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #51 on: August 03, 2010, 04:45:24 PM »
That flare up I had on Friday now appears to have been rather minor, and I'm now back on track again. I had my second PT session yesterday, and I'm quite surprised at what I was about to do! He first had me on a stationary bike for about 8 minutes, of course at the lowest resistance setting, and I made it a point to cycle as slowly as possible. Then, and this is where I started to sweat a little bit, he had me doing leg presses at 40 pounds (about 18 kg) of resistance. I did 2 sets of 10 reps, and I'm happy to report that there were none of the dreaded sharp pains. Finally, I did 3 sets of 10 step-ups onto a 4 inch (about 10 cm) platform. Again, a sense of relief that there were no sharp pains. At the end of session, there was a bit of soreness, but nothing major. I was a little concerned that I might have a flare up a few hours later, but fortunately, just a little soreness. Right now I'm sitting here and feeling pretty decent. My next PT session is on Friday.

I asked if I should be doing any exercises other than the ones prescribed. He said that I should just take it easy so that he can monitor my progress. I think he'll probably up the ante at the next session. Maybe 50 pounds for the leg press, or a 5 inch step up. As long as I'm making progress and not in pain from the exercises, I'll keep slowing increasing the loads week by week. Just the fact that I'm capable of doing these exercises at all gives me some hope!

I did mention foam rolling to the PT, and he is familiar with it. He said he actually uses it himself at home. He did suggest, however, that it would probably be more relevant for me when I've progressed a bit more.

Concerning NSAIDs, what has always confounded me is whether the benefits are merely analgesic, or are actually therapeutic. NSAIDs operate by inhibiting COX enzymes which are catalysts in the production of prostaglandins, which is a eicosanoid (signaling molecule) in the process of inflammation. Interestingly, eicosanoids are also messengers in the nervous system. Certainly, it seems that the process of pain response and inflammation are tightly intertwined. But, what I don't know is exactly how they are interrelated. Severe inflammation can damage surrounding tissues, and it seems that whenever I have an inflammatory response, thereafter I have a heightened sensitivity to pain. But in a case of more subtle inflammation, are the NSAIDS merely reducing the inflammatory response, but not actually affecting the sensitivity of the nerves to pain, or are the two processes more deeply intertwined, and COX inhibition will actually intervene in the "pain response cascade" and perhaps provide enough headroom (kneeroom?) to break the vicious circle, and begin a virtuous circle of recovery? I want to also mention that I thought that I tolerated NSAIDS reasonably well, but I did have some stomach upset recently when upping the dose to deal with the severe inflammation last month. Any treatment with NSAIDs taken with the intention of therapeutic benefit would presumably involve rather large doses. If your doctor does suggest that as a possible line of treatment, it might be wise to request a prescription for PPIs (Proton-Pump Inhibitors) or other stomach acid reducer to decrease the risk of ulcer formation. NSAIDs are powerful drugs and shouldn't be trifled with. You're already in more than enough pain, and don't need any augmentation to the pleasures of PFPS.

Offline Lottiefox

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Re: Sore knees, no diagnosis
« Reply #52 on: August 03, 2010, 07:07:51 PM »
Good news that you're tolerating the PT exercises. I tend to find that a dose of ice after things like that also helps with controlling any possible flare ups, but each knee is of course different!

Has your PT said anything about working on your hips and glutes? Clearly the step ups involve all of the lower leg muscles (I trust he is checking you for proper form and that you're stepping up rather than pulling the leg up, and that your knees are not caving inwards etc as you shift your weight....) but a focus on the hips and glutes can also REALLY help with PFS. In fact they are the things I had to start with before I was even allowed to sniff the leg press! I now find that single leg work on the leg press is also more useful than dual leg, but being very careful with the range of extension and not locking the knee out at all. Do you have homework from your PT? I agree you don't want to overdo things but it is good to maintain things at home to allow progression in your sessions. Funny how opinions differ on foam rolling too - some PTs/Trainers get people using it first thing as the principle that the looser and less knotty a muscle is, the more it can be worked effectively. Others want to see what you can do "raw" I guess. No right way - which is what makes rehab so frustrating at times!!

Glad things are improving though.  ;D

Lottie
Bilateral patella OA since 2009, no surgeries.
Euflexxa working well x3 to current
Right forefoot CRPS post fusion surgery 2011
Refusing to let the ailing parts stop me....

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #53 on: August 06, 2010, 11:00:17 AM »
Indeed, great to hear of your continued progress. We need all the good news we can get around here!

Re: foam rolling, I have experimented with it extensively in the past. I even own my own roller as well as a few other medieval instruments of soft tissue torture! I can't say that I've ever noticed any improvements in tissue quality or function from performing the various exercises, even the exquisitely unpleasant IT band roll, but it does feel right on an instinctive level. I have my fair share of trigger points - unfortunately they are incredibly resistant to treatment and any progress in tenderising the knots is usually short-lived.

As for the last few days, I've been pretty much immobilised by the latest setback. On this occasion I've been trying to reduce the time I spend weight-bearing to an absolute minimum while still performing the unloaded movements in my exercise routine. I've resorted to wheeling myself around my apartment on an office chair, sitting in the shower and even scooting around on my butt in a fashion that even a troglodyte would find demeaning, such is the discomfort I have been experiencing merely from standing. With my consults approaching earlier today, I was somewhat desperate to diminish the irritation as best I could to facilitate travel and the assessment process.

Which brings me to the consults themselves.

First up, the highlights from my appointment with the sports physician I approached  with the nascent stages of my affliction back in May 2009 and then subsequently a couple of times toward the end of last  year.

- His assessment of my knees through a variety of manual tests revealed a reasonable level of function that is very much at odds with my hobbling gait, weight-bearing discomfort and other limitations
- He feels that the condition may be perpetuated and worsened in a vicious circle by pain itself i.e. pain (and possibly an exaggerated perception of injury through faulty neural feedback) -> biomechanical compensations and faulty muscle recruitment (e.g. hobbling) -> pain
- Suggested pain medication such as Panadol and anti-inflammatories coupled with PT aimed at restoring healthy recruitment patterns
- Whereas I was concerned that masking the pain response could leave my knees vulnerable to further aggravation, he felt that I need to disrupt the pain response to provide space for the development of function and neural rewiring
- Also need to rule out a number of inflammatory conditions that can be detected via a blood test. This will also be useful for my rheumatologist appointment next week.
- I may also get another MRI on one or both knees. He felt that this could wait until I have tried 2/3 weeks of PT but I was keen to pursue multiple lines of investigation in parallel to accelerate the diagnostic process so he left that decision with me.

Notes from my PT appointment:

- He had a chat with my sports physician so was well briefed on the history of my condition and working theories of diagnosis
- Prescribed a series of exercises mainly aimed at reestablishing proper recruitment of the quads when I walk:
   - Mini walking lunges *
   - High knee walk with bent supporting leg *
   - Single leg balance with bent supporting leg *
   - Lying (supine) hip/lower back rotations
   - Massage knee area
   * very shallow knee bend, maybe 15 degrees
- May work more on the neural dimension of the problem through soft tissue work in the lower back and spinal area during our next session. He mentioned that the nervous system can amplify the intensity of the pain signal disproportionately leading to overcompensation responses.
- I should stop doing my own exercise routine. He felt that the inverted movements, while ok for lubricating the joint, are reinforcing recruitment patterns that do not translate well to functional movement such as walking.

Next steps then are:

- PT exercises daily
- Panadol and Naprosyn daily
- Blood test asap
- Rheumatologist appointment on Aug 12
- Next PT appointment on Aug 16
- Next sports physician appointment on Aug 27, possible MRI prior to this


« Last Edit: August 07, 2010, 11:22:35 PM 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 highroller

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Re: Sore knees, no diagnosis
« Reply #54 on: August 06, 2010, 11:17:27 AM »
I felt that a separate post was warranted to mark tomorrow's auspicious occasion.

Happy Birthday to 'knee always hurts'!

Consider this virtual greeting card to be delivered in an expanded envelope of function addressed to your re-emerging alter-ego 'knee never hurts'!!
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 highroller

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Re: Sore knees, no diagnosis
« Reply #55 on: August 07, 2010, 11:47:02 PM »
I started taking Panadeine yesterday but didn't notice any reduction in pain. I even experienced a few sharp pains while walking around my apartment. It's going to be difficult to find the right balance of activity in order to incorporate my new exercise program (which only takes 5-10 mins in total) while containing the latest flare-up. I'll probably have to do each exercise separately over the course of the day and minimise or eliminate all other weight-bearing activity until the additional irritation abates.

On an optimistic note, I forgot to mention that my PT has had success with a few similar cases in the past and is reasonably confident that I will recover over a period of a few weeks to a few months. In his experience, progress tends to be non-linear with slow improvement initially and more rapid gains later in the process. Time will tell...
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 #56 on: August 09, 2010, 04:06:45 PM »
Hey all,

My birthday was on the 7th, and it turns out it was a bit auspicious. I'll get to that in a bit. I thought I would just be sitting around doing nothing on my birthday, but my brother-in-law, being the gentleman and scholar that he is, invited me over for a few beers. You know, I really had wine in my mind, but how can you turn this down. I'm not sure if my consumption was particularly admirable, or moderate, but it did actually relieve a bit of the ache in my knee. Truth is, I don't drink too frequently, so I'm not that familiar with my tolerance level for the wicked brew. Anyway, I did stagger a bit to the side at one moment, but happily I can report that my knee survived the day intact.

The happenings of the last few days have been quite auspicious, as I've mentioned above. I went to PT on Friday, and quite significantly upped the load levels. I did 40 lbs on a single leg with the leg press, 6 inch step ups (though I did almost get a twinge of pain on a few of the step downs), and did 8 minutes on the exercise bike at a significantly increased speed. My PT also did this massage on my quads, and Good Lord, I guess he found a myofascial knot, because I was in so much pain I was actually laughing. He also introduced me to the foam roller, which was actually less painful than those wretched hands of his. The good news is that none of this seemed to trigger the dreaded inflammatory response.

Now, the good news of the last few days. The PT suggested that I start trying to walk with a heel-to-toe gait, and this of course necessitates bending the knee a fair bit when walking. I was a bit skeptical, but of course, I gave it a go. I've been walking like this since Friday afternoon, and at a decent clip I might add, and no sharp pains! Perhaps my knee is finally crossing the threshold back to good health! It still aches quite a bit, but this seems even this may be diminishing. I'm just hoping that this isn't the quiet before the storm. But if a few days has gone by, which is the case here, and I'm not seeing any setbacks, I'm think that I've progressed to a new stage. Now I just have to keep from regressing to the deeper bowels of the cave.

Keep hanging in there highroller. That's really terrible news about your knee. It was just July 13th when I was last in a similar situation. I think your PT is right about the non-linear progress. It's really at the point when you're able to walk normally that the progress starts to pick up. Perhaps you still can't squat, or have trouble with stairs, but if you can walk for any length of time you can "condition" your knees back to health. Back in May I went from being on crutches to thinking I could run in about 2 1/2 weeks. You need to be able to walk with proper gait and at a normal speed, though. I think what you need to do now is just rest it until you can at least stand without pain. Then, start slowly increasing your walking speed again. One thing I've found is that you can actually handle more weight than you think earlier than you think. The PT had me doing very low rep moderate weight exercises with a full range of extension right from the start. I was quite nervous about it, but it turned out that it may have actually helped. I don't think what you're facing is really all that unusual. You just have to have the right approach to recovery. With time, you'll no doubt improve.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #57 on: August 14, 2010, 03:27:43 AM »
Glad to hear you celebrated in the time honoured fashion and avoided any calamities. The grain is as worthy as the grape for marking these chronological milestones although that being said in your condition you should be wary of anything involving hops.

Also great to hear of your continuing rehabilitation progress. Your feats of strength and athleticism would merit a world ranking in the patello-femoral pain pentathlon!

I have had rather a mixed week since my PT session on Fri Aug 6. The aggravation I experienced just prior to that appointment did settle down and I was able to start the new exercise program. I was actually starting to make some progress and even managed to walk at almost normal speed for short distances.

Encouraged by this, I set off for my rheumatologist appointment on Thurs and planned to walk a few blocks to take care of some errands on the return journey.

The rheumatologist had already received the results of a comprehesive set of blood tests and pronounced all readings as normal. He also found no evidence of any inflammatory condition from a physical exam or from reviewing my x-rays and MRIs.

I did manage to walk those few blocks on the way back without triggering any sharp pains but I experienced the usual gradual build-up of a sense of pressure / fullness in my knees over the course of journey and felt that I was very much at my limit by the time I got home. Unfortunately, by Fri morning it was clear I had triggered another flare-up and was forced to avoid weight-bearing again. The situation may be slightly improved today but I'm erring on the side of caution and resting. Hopefully I can resume the exercises in time for my next PT appointment on Mon.

I have only been taking the pain killers and anti-inflammatories sporadically, partly due to stomach discomfort which may be unrelated but in the interests of not adding an ulcer to my list of concerns I decided to back off the medication. As noted in an earlier post, I detected very little analgesic effect from the Panadeine anyway. 

In the interest of accentuating the positive, I do feel the PT's exercise program has some merit, particularly the idea of reengaging my quads through shallow knee bending movements. I clearly need to be more vigilant about limiting the duration of any individual period I spend weight bearing to a few mins at most for the time being.

The heel to toe gait sounds interesting - does that mean making initial contact with the ground using the heel and pushing off with the toe?
« Last Edit: August 14, 2010, 05:49:23 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 #58 on: August 15, 2010, 12:19:25 AM »
Cue the music to The Good, the Bad, and the Ugly, as that about sums up my past week in the land of pain.

The Good:

Now, before we begin with The Good, let's keep in mind that there is a Bad and an Ugly to follow. With those caveats, there were some hopeful signs this past week.

I almost thought I caught a glimpse of the cave entrance earlier in the week. Like any well behaved troglodyte, I was in no rush to climb out of the cave of course, but had intended to wriggle on my belly until reaching the opening. This would take a few more weeks perhaps, but I was on my way to freedom. If level of knee function = walking speed X amount of time walking X degree of knee flexion, it wouldn't be too immodest to claim a 100 fold increase in function from last week to the present. It's has been well established that there would be a tipping point wherein a certain threshold is reached, and you can truly feel a change, as if a burden has finally been lifted off of my disconsolate knee. The change was not entirely unexpected, but it was sudden. In a moment, I had realized my knee had changed. It still didn't feel completely "normal", but it was certainly the best place I had been in since late May. However, as you'll see in "The Bad", I'm not going to be winning the PFP pentathlon any time soon. However, to while away the time, I have been playing a nifty little strategy game called Defense Grid. It turns out that this afternoon I got in second place on one of the maps. That's second place as in second in the entire world. Not quite as impressive as it sounds since there are only around 3600 entries for that map. But a nice distraction from the pain (and it turns out I'm in quite a lot, look out for The Ugly). At least I have something to be proud of. But nothing regarding my knee, as it turns out.

The Bad:

I have warned myself and others about being overzealous when you think you're making progress, but I guess I couldn't help myself. On Thursday I ended up walking just a wee bit too much. It was in the late evening, but that unmistakable "pressure or fullness" returned suddenly. On Friday, I dialed down what I was doing quite a bit. Yet, I was again feeling sharp pains. Today, I'm not quite sure what I'm capable of doing since I've decided to hobble around at the slowest possible pace. I've so far avoided sharp pains today. It is quite excruciating to have a setback when you can almost taste recovery. But I've resolved that I will avoid the condition ever descending to its previous low. However long this takes, I'm confident now that at least I'm pretty close to the threshold of recovery. I noticed that highroller triggered another little episode on Thursday. You're not joking about our "anguished synchronicity", are you?

The Ugly:

No, I'm not referring to my slimy, scaly troglodyte body. I must confess, a rather unlovely pain has stricken my back! This is nothing new for me, sadly, as I have been dealing with sciatic pain since the ripe, old age of 19. But what an inopportune time to resurface! I must count my blessings, however, as this condition can be amongst the most painful known to man (or woman). A couple of years ago, I was bending over and I somehow tweaked the nerve in my lower spine. Crushed may be more appropriate here, as the pain was ineffable. It sent some sort of shock wave up to my brain, and my vision went blurry, and I heard a sort of whooshing tinnitus in my ears. Not a moment that one cherishes, but I'm happy to at least report that this time it's far less severe. Of course, only relatively. I get a most pleasant (if I was a masochist, anyway) reminder every time I bend over or try to lift myself off a chair. And I know that at any time, I could be completely immobilized.  Maybe I should check if there is a back geeks forum?

I suppose this is a little belated birthday gift from my body. Aww, you shouldn't have, spine! If I am truly fortunate, perhaps for my next birthday my neck, hips, and wrists will also deign to present me with such an exquisite ceremonial dagger. I am rather offended that they forgot this year! (I shouldn't say any more, as they might not think that a week is too late to present me with a gift!)

I've had that music in my head for a couple of days now. Much like a microcosm of life itself, my past week has had a little of The Good, the Bad, and the Ugly.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #59 on: August 22, 2010, 09:50:26 AM »
I do hope things have improved since your last update a week ago. That recurrence of sciatica is truly a cruel twist of fate. It was however encouraging to hear of your proximity to the cave mouth - I look forward to hearing motivating accounts of the lush sun-kissed meadows beyond as you traverse their expanses with the agility of a gazelle in due course.

A quick update on developments in the dank recesses of my own cave over the last week or so.

I did recover from the last setback, at least back to the rather debilitated state I found myself in prior to the flare-up. These episodes have lasted 2-3 days recently which is an improvement of sorts I suppose given that prior setbacks have lasted quite a bit longer.

I had my second PT appointment last Monday. Two exercises were added:

- Step-up onto a platform about the height of a telephone book for 2 sets of 6 reps per leg.
- Seated thoracic rotations with a 5 second hold for 5 reps each side

I was able to perform the step-ups initially but their once unintimidating form has now morphed into the imposing aspect of a sheer Himalayan mountain face after I was greeted with a few sharp pains at the summit of a left leg ascent. I've dropped them for now.

Thankfully I have managed to perform the remaining exercises most days and with highly questionable enthusiasm I have also added walking at at near normal pace for a very short distance as well as a brief stint of 50-100 revolutions on the stationary bike, both just once per day. This seems to be right at the perimeter of or just beyond my comfort zone as I have found my left knee aching quite a bit for the remainder of the day but more or less back to its usual state by the following morning. There seems to be a fairly static limit to the duration of time/distance I can remain weight-bearing, particularly in motion but also when standing still. After this brief experiment, I think I will switch to more frequent sessions of shorter individual but hopefully cumulatively longer duration over the course of the day.

I've been peforming quite a bit of foam-rolling and other forms of self-massage and myofascial release prior to and during each exercise session. I have located a couple of trigger points that reproduce similar referred pain in my knees but kneading them into submission has not yielded any noticeable benefit thus far.

As for the painkillers and anti-inflammatories, they have been jettisoned from my regimen following further bouts of stomach pain and heartburn. This is a concern as my doctor was keen to investigate the effect of suppressing the pain response on the movement pattern compensations that I have developed.

So perhaps a little progress but the pace is glacial and always teetering on the precipice of reversal.
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