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Author Topic: Sore knees, no diagnosis  (Read 27447 times)

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Offline highroller

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Re: Sore knees, no diagnosis
« Reply #60 on: August 24, 2010, 02:43:31 AM »
Looks like I'm in the throes of another setback. I can just about tolerate weight-bearing for about 60 seconds before the discomfort forces me to sit down again for quite some time until I am in a position to attempt to walk again. Admittedly I pushed the pace a little in recent days but only ever so slightly. Such a frustrating, nay infuriating, condition. Hopefully I'll be able to resume the original exercise program in a few days and start over.

I have a doctor's consult on Fri - unfortunately there will be no progress to report since our last session 3 weeks ago.

My worry is that every setback, even the minor ones, chip away at my functional limits and establish a new ceiling for recovery. That seems to be the case looking back over many months. Frightening to extrapolate that trend.

I'll forgo any disingenuous optimism today in the interests of fully indulging my misery!






« Last Edit: August 24, 2010, 11:03:47 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 #61 on: August 30, 2010, 12:44:21 AM »
I was fortunate that I was able to get back to my previous state after about 9 or 10 days. Unfortunately, I had another setback this morning.

I actually was making significant progress. In the last couple of weeks, I've been doing squats almost to parallel at PT, and I was OKed to climb and descend stairs normally on Friday. I think it was the combo of the stairs and the fact that I've walking more and at faster speeds that pushed me over the limit this time. Setbacks are inevitable, as I've learned by this point. I have to be pleased with the progress that I've made though, and hope that more is to follow. I do feel that the worst of this is over, and that it is highly unlikely that I'll ever be going back. Irritating the knee is still a setback, but as long as I rest it enough, it won't go back to where it was again. That is a bit liberating, but sadly, I'm still not able to do much, as the setback today testifies to. Oddly, I felt like I've been at this point before. My knee has felt similarly, and the amount of activity that I did, was acceptable at that point (probably in early May). But it is a truism with PFPS that the longer you've had it, and the more severe it has been, the more difficult it will be to resolve. My experience does corroborate that these setbacks seem to accumulate, even changing the level of sensitivity permanently (or semi-permanently). This doesn't mean that recovery is impossible, I don't think, but that at each step of the way, it is more likely that we will overestimate our capabilities. After my last setback, I had established with my PT that I would really limit activity out of the sessions, and I regret deviating from this. He has generally made the right calls, since I haven't ever had a setback during a session.

This is the first time that I've really got to test out the other knee, though, and I have to say that the plot thickens here. The odd thing is that it really doesn't seem bothered by walking at all, or at least not much, even at faster speeds or for greater lengths of time. However, there does seem to be a correlation between doing things that involve the knee being bent, and the level of soreness in the knee afterwards. So for example, squatting, or even just sitting for any length of time with the knee bent, seems to bother it. The strange thing is that there is really never the sort of sharp pains that I've experienced in the other knee, or the inflammatory response, either. Just a general soreness, or ache in the knee that sometimes seems to subside but rarely for long. The only time I really experienced any pain in this knee was when I forgot that I was having issues with it and walked up two stairs at once. There was a sort of crushing sensation in the knee at that point, but it didn't really hurt much more afterwards and there wasn't an inflammatory response.

I am a little concerned that even if I'm able to resolve the issue with my left knee, the issues with my right knee might persist for longer. I just have that sense. We'll see I suppose. I do regret ever using crutches, though, as it seems like my right knee would be perfectly healthy if I hadn't. It is just strange how the symptoms are so different. I hope I didn't tear the meniscus or damage something else. It seems unlikely, but perhaps PFPS just manifests itself in different ways. The most hopeful thing is that if anything it seemed like it was improving slightly even as I was beginning to do squats and climb stairs. So perhaps if I can keep giving it moderate inputs, it will eventually resolve.

The only thing I know for certain here is that I don't know much about the path this recovery will take. While that is not very comforting, the path out of this wretched cave is long and twisting, and we can hope it leads to pain free knees in the end!

Good luck with surmounting your Mount Everest by the way! I don't suspect either of us will be climbing the real thing any time soon!

Offline SqshPlr8

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Re: Sore knees, no diagnosis
« Reply #62 on: August 30, 2010, 10:44:14 PM »
*I posted this under "To scooter or not to scooter," but just read your posts and was amazed how similar our conditions appear to be. I might give total rest a shot, rather than fiddling with a scooter...† Best of luck!

I have had bilateral knee pain for ~ 4 months.† I stopped playing squash and running in mid-May after twisting my left knee.† † Had x-rays, MRI of my left knee (only x-rays of my right), which revealed nothing.† I was diagnosed with fat pad impingement and CP, for which I had a six-week stint at physical therapy and then a three-week protocol of Voltaren (10 days) and simple stretches, both of which didnít help. Iíve been swimming which, at first, helped a tremendous amount with pain.† Now, though, even swimming Ė both breaststroke and flutter kick Ė can be bothersome.†

The most annoying thing, however, is everyday activities.† Walking anymore than 100 m aggravates my knees.† I can characterize the pain as a din of discomfort punctuated by specific, spear-like pains behind and below my patellae. Sitting for long periods of time sucks, too.

I was just tested for rheumatoid arthritis and Lyme disease, which, thankfully, came back negative.† †I see the doctor again in two weeks, but my biggest concern at the moment is simply trying to deal with physical reality of everyday life.†

Iíve tried tracking braces and tape, along with orthotics, but they havenít really helped.† Iíve also tried crutches to no avail. The pain is not debilitating Ė though it is verging on intolerableóbut I seem to be aggravating it by everyday movements.† As an interim measure, I have thought of renting a scooter to get to, from, and around work, at least until the pain comes down and I can see the doctor.† †

Few questions: 1) Has anyone here had PFS, CP, fat pad impingement symptoms that affected their everyday movements? If so, what did you do to cope?

2) Is the scooter a good idea? I donít want my quads to waste away, but I donít know what I should do.† My PT and doctor said that walking is fine, but the pain just seems to be getting incrementally worse day by day.†

3) Has anyone here with PFS etc. used a scooter/wheelchair for any period of time to let the symptoms die down before going back to rehab?† If so, could you elaborate on the success/failure of your experience.

Thank you so much!

26 y, M

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #63 on: September 03, 2010, 12:21:46 AM »
I've noticed that this thread has grown to quite a substantial size! I'm telling you, when all is said and done, this is going to be one of the largest threads this forum has ever seen! I bet you were never expecting that, were you highroller?† ;D

I went to another PT session yesterday, and out of some sort of miscommunication, I ended up doing a routine scarcely different from last week, despite my setback. There was a moment there when I thought I was descending Everest. Somehow I made it through. My knees were sore afterwards (which could actually be referred pain from my trigger points), but I'm pretty sure they weren't irritated. This thing is finally coming along, I think. I hope you've made some progress in calming down those knees since your last post. I'm telling you, once you past a certain point, it's much smoother sailing from there! There was once a time when I would have been happy to stumble into a billabong and have a saltwater croc chew me to bits, such was my distraught state of mind. Fortunately, wrong country. Anyway, I wouldn't have walked far enough to "stumble" upon it. But I might have liked to! My knees are still petulant, whiny little expletives, but no saltwater croc is getting them now! You'll have to pry them from my cold, dead, corpse, vile croc!† :P

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #64 on: September 07, 2010, 03:30:33 AM »
The thread has indeed grown way beyond my expectations but I may have had some naive notions of a swifter resolution back in the day when I penned the inaugural post. I've been disabused of any such delusions since but it's great to have some virtual company to share the protracted and undulating road to recovery.

Perhaps if we maintain the momentum we might attract the attention of the entertainment industry looking for a moving storyline. Surely no audience could fail to be stirred by the emotional rollercoaster that is the life of a PFPS sufferer. I think we could stretch dramatic license to incorporate your croc attack scene as well - in 3D - that should broaden the demographic and make it a blockbuster!

But returning to the more poignant dimensions of the plot, I've been maintaining a bit of radio silence here of late as I try to dig myself out of this latest rut within ruts. I did see my sports doctor again on Aug 27 and he proposed that I give the painkillers / anti-inflammatory combo another shot in conjunction with the physiotherapy program. He switched the anti-inflammatories to Voltaren as I had not tolerated Naprosyn and also prescribed medication to protect my stomach. His working diagnosis remains nerve irritation and he also suggested a recovery timeframe of 6-9 months.

I seem to be tolerating the latest cocktail of pharmaceuticals but I can't detect any analgesic benefits. Unfortunately, I'm struggling to perform the same exercise program which I could complete pain-free over a month ago. I do what I can but at this point it's not much. I spend 99+% of the day off my feet.

I'm not sure if it's related but I seem to have aggravated my hands and fingers from the self-massage I was performing on my legs. They have been very stiff and painful for about a week now. I'm wondering if I may have a more generalised hyper sensitivity to nerve irritation.

I'm seriously considering getting a wheelchair for mobility as I am confined to my apartment and totally dependent on my girlfriend for shopping, etc. Cabin fever may be imminent if I don't escape the confines of my cave but then again, a psychological disorder might be just the antidote for my faulty neurological wiring - radical, but I'll try anything at this stage!
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 #65 on: September 15, 2010, 05:37:18 AM »
Quick update:

I had another consultation with my doctor yesterday. He is confident that I am suffering from neuropathic pain which he tells me is very difficult to treat. He prescribed Amitriptyline and has also referred me to a pain management specialist - the lady in question is a doctor, anaesthetist and medical acupuncturist. I'll be seeing her in 2 weeks.

I'd be interested to hear any thoughts, advice, experiences, etc. regarding neuropathic knee pain and medication/treatment protocols.

« Last Edit: September 15, 2010, 05:47:01 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 #66 on: September 15, 2010, 04:48:25 PM »
Let's see, who should be the director? How about James Cameron! Though the audience would probably be bored to death with our daily routines. But when we get our avatars...

It's quite saddening that you've come to the point of considering a wheelchair. The thought certainly crossed my mind more than once when my condition was at its worse. I know most other members of this forum would advise against it. But you have to live your life. You're been essentially confined to your apartment for months. I think you need to do whatever is necessary to improve your quality of life. You're sitting 99% of the day anyhow. I'm not sure that everyone understands how psychologically distressing it is not to be able to move around under your own volition. I think just being able to move without anxiety about your knee or having to ask for help with every little thing will be cathartic.

I wouldn't be so quick to assume that the hand pain is from hypersensitivity. I've had aches and pains all over my body during the past few months. In fact, right now, on my right side, my neck, shoulder, elbow, and wrist is quite uncomfortable and stiff. And this isn't the first time I've had such issues. Even back in March-May, I had severe pain in wrists (around where the thumbs attach), which I now think was carpal tunnel syndrome. I had so much pain in so many joints that I has the doctor test me for rheumatoid arthritis and Lyme disease (both came back negative). It resolved almost immediately when I was able to move around again. Unfortunately, after my condition worsened again, the pain has returned with a vengeance.

Isn't it just stating the obvious though, that PFPS, especially when severe, is a form of neuropathic pain? I suppose he is suggesting that it might originate with the central nervous system rather than the localized tissues. It's worth a shot, but if it started as PFPS, I'd say it is probably still PFPS. But it may be that those who tend to suffer from this condition do have more sensitive nervous systems. I know mine is quite wonky. A few years ago, while working on a construction site, I started to get ringing in my ears. At first it stopped, but then a few days later it started up again. It's never stopped again. There's nothing in my ears producing a sound signal. I understand that I damaged some fibers in the inner ear, but why the sound? I expect it will be with me for the rest of my life. Another strange thing happened a few months ago. When my knee was at its worse, in June, I was really "nuking" it with ice. I think I might have damaged a nerve, because my foot started to turn almost purple. I of course immediately stopped icing, but it was already too late. Afterwards, my foot just felt "wrong". In fact, the description of neuropathic pain fits it perfectly. Burning and cold sensations, pins and needles, numbness and itching. After a few weeks, it started to spread to my other foot and to a much lesser extent my hands and face. I think I may have triggered a case of complex regional pain syndrome, which is a form of neuropathic pain. It used to be called causalgia, which many veterans of the Civil War in the United States were stricken with. Of course, with them, they probably sustained serious battle injuries. In my case, it started icing my knee. Lovely, isn't it. The only good fortune is that it isn't too severe. From what I've read, CRPS can be absolutely debilitating. In my case, it's more of a minor irritant. But I'm fearful that it could get worse, naturally.

Having what is certainly a case of some sort of neuropathic pain (I'm not sure if it's actually CRPS, though), and two difference sorts of PFPS (Inflammatory in the left knee, aching in the right), I can say definitively that PFPS doesn't feel much like neuropathic pain. I don't want to contradict your doctor, not knowing all the details that he must be familiar with. But unless you have pain symptoms consistent with what I've described above, I'd be skeptical.

As for my knees, they are a mixed bag. My left knee continues to make progress. In fact, my PT has reduced the number of sessions to one per week. I can now go up and down stairs and do most everyday things around the house without much difficulty. I don't know if it will ever be "normal" again. But even if I can't exercise much, my life may be returning to relative normalcy soon. I'm hopeful. The other knee is a different story. I can't really say it's getting worse, but I don't think it's getting better, either. I've referred back to our venerable old guide, the saveyourself.ca e-book again, and it's really describing what I'm going through to perfection. I think it's even more relevant than it was to my left knee. What's interesting is that virtually nothing I do really causes me any significant amount of pain, or at least sharp pain. Some things are mildly uncomfortable, but nothing that prevents me from doing anything non-athletic. The problem is that it triggers pretty significant aching in my knee at a later time. It's really exactly as described in the e-book. I think the most frustrating thing is that you can be at rest and still trigger pain. At least with my left knee, when I was at rest I knew I was fine. That was true even at its worse. With the right knee, even though it is quite mild, I can't even sit with it bent. I can't complain because it could be so much worse. But it will still be a protracted period before I can exercise again, and it is rather disheartening. If I ever want to have a chance at full recovery, I'm going to have to scrupulously follow the advice laid out in the e-book.† If I'm fortunate, it might take just a couple of weeks. But I'm not counting on it. I've experience enough to banish "naive notions of a swifter resolution" from my mind for all eternity.

Whatever happens ultimately, this whole experience has permanently reshaped my view of life, in ways that I can't even comprehend yet. We are all so fragile, and I'll never doubt that again.

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Re: Sore knees, no diagnosis
« Reply #67 on: September 22, 2010, 02:22:01 AM »
Today is likely my last PT session in a while, as I've had a bit of a flareup with my right knee, and as a precaution I want the doctor to look at it before I continue. After the session last week, which was the most strenuous yet, my knees ached severely that night. The next few days, it was actually a bit painful to walk, which it hadn't been before. I've slowed down considerably as a precaution.

In addition, I've noticed a new issue with my left knee. A few weeks ago, when I was doing step-ups and step-downs at PT, I noticed some sharp pains in my knee. Having pain in my knee is, of course, nothing unusual at this point. But what was strange is that it didn't seem to trigger an inflammatory episode. Over time, the level of tolerance seemed to build, and stairs didn't hurt so much. But then doing squats hurt. I realized the reason this week. The part of my knee that always had the inflammation was the lower lateral quadrant. This pain is in the upper lateral quadrant, an area that had never hurt before. So something else is going on there. Honestly, it might be chondromalacia. I suppose I can only hope that it is not too severe and can be rehabbed over time. For now, I'm not going to worry much about it but it just shows how much farther I have to go for full recovery, and the diminished chances of that ever truly happening.

I'm taking every relevant precaution to prevent my knees from getting worse and to hopefully prepare them for more PT in the next few weeks. I'm still committed to making any sacrifice necessary to achieve a non-surgical recovery. Even if it takes another 6-8 months, that would certainly be worth it to me. The alternative of surgical procedures with uncertain results, or consultations with the pain management doctor for the rest of my life is not too appealing.

The setback this week shows just how precarious this condition is. A Sword of Damocles dangles by a thread over the knees of Patellofemoral Pain sufferers, threatening loss of mobility at any time. The only solution seems to be complete recovery, but what are the prospects of that?

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #68 on: October 02, 2010, 09:39:14 PM »
I should have never given you the idea. Sometimes you'll see with longterm PFPS sufferers, they'll just get sick of immobility and start wandering. Just at random. And then you stumbled across one of those crocs you've got down under, and you just decided to feed yourself to him, didn't you? I should have never given you the idea!

For my part, I'm just about ready to give a croc some knees. He can have 'em. They don't do me much good.

I was recently inspired by a story on these forums by a poster who was told by the doctor that he would never recover. He implemented an approach not too dissimilar from the one suggested by saveyourself.ca, and has experienced a total recovery. I figure it's worth a shot. But if this fails, then I think it's time for acceptance. The most difficult thing is going to be that, while I'm no longer disabled in a strict sense, it still feels quite horrid to walk much of the time. I imagine if I was doing more of it then it would be even worse.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=53006.0

How does somebody live like this over the long term? It's one thing if I'm able to just relax and take it easy. But to actually live every day life? It seems like a heroic feat. Except I'm no hero.

I haven't even left the house since the last PT session. I've been resting, and trying to integrate very modest activity into my routine. But I can't say I've seen much in the way of results. I'm committed to rehab for at least while, perhaps a few more months. But if I'm not making clear progress by the end of this upcoming winter, then I think it will have to be the end of the road. Perhaps there isn't a route out of the cave. I'm starting to think that now.

How did you do at the pain management specialist? This has been your longest interlude, and I pray that this is not indicative of a reptilian induced requiescence.

Offline highroller

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Re: Sore knees, no diagnosis
« Reply #69 on: October 03, 2010, 03:04:52 AM »
Indeed, it's been nigh on a 3 week hiatus since my last communiquť from the Antipodean cavern of despair. Let's rejoin the action right after the doctor consultation scene in mid Sep.

I started on Amitriptyline at 25mg per day. I actually took it from April to July last year for a long-term headache condition. I felt that it was of some benefit but I was experiencing heart palpitations and decided to discontinue taking it for the good of my ticker which was diagnosed with a very mild arrhythmia. I was training quite intensely in those days and was less concerned about resuming it now due to my current lifestyle which would make a tree sloth look hyperactive by comparison. It does take a few weeks to work its magic - the jury is currently out and will reconvene with a verdict around the 4 week mark.

The pins and needles, aching and sensitivity in my hands is better than it was at its worst (when even typing was barely tolerable) but I fear that this latest gremlin in my dysfunctional nervous system has settled in for a long-term residency. I haven't acquired a wheelchair yet but I'm not sure that I could even operate a manual one with the state my hands are in currently.

As for my knees, I can report a slight improvement with qualifications.

I did discover that I was able to perform a slow squat to near parallel about 2 weeks ago. It doesn't feel too good but it also doesn't trigger sharp pains if performed in a slow and controlled manner. I am only able for one at a time and a few per day. I haven't been attending PT but I was inspired to try some isometric holds by another ebook I recently purchased from www.thekneepainguru.com. One of the 5 pillars of the rehab protocol described therein is strengthening the tendons and ligaments around the knee joint via extended set techniques to ensure that the connective tissues are sufficiently stressed to stimulate an adaptive response. The other dimensions of the method are relaxation of tension in the nervous system through breathing, stretching, a healthy diet and adequate water intake. I've only dabbled with the least stressful exercises so far and have quite a few questions on execution and the underlying concepts so I have scheduled a chat with the author next week - he offers a free 25min initial consultation as part of his 'coaching program'. No harm listening to what he has to say.

I've been able to tolerate standing for longer periods over the last couple of weeks. My limit now appears to be 5-10 mins on a good day vs 1 min at the recent trough of my knee condition curve. Over the last few days I have emerged from my cave twice and managed to walk a block and back each time at relatively normal speed and gait although each time I felt the dreaded fullness/pressure sensation gradually returning on the home leg of the journey coupled with some discomfort at home as the day progressed. Nonetheless I was encouraged. Unfortunately this morning I experienced a most excruciating sharp pain in my right knee while walking back to bed from the bathroom. Both knees feel a bit aggravated now and I fear another setback has occurred.

I did see the pain management specialist last week. She suggested I increase the Amitriptyline dosage to 37.5mg per day and has proposed a series of 6 acupuncture sessions aimed at restoring balance and facilitating the body's healing processes. So a fairly holistic type of approach. She did perform a short acupuncture session during the initial consultation and I'm due to have a chat with her on the phone tomorrow before deciding on whether to proceed. My doctor indicated about a 50% success rate with the patients that he has referred to her. I'm highly sceptical but somewhat desperate and willing to try almost anything at this stage so I'll probably proceed with the treatment.

As ever, I'm sorry to hear of your own ongoing struggles with this accursed affliction but the boulder hasn't rolled over the cave mouth and extinguished the fading rays of daylight yet. I do however sometimes feel like the boulder is pursuing me to the furthest recesses of the cave Raiders of the Lost Ark style. There's another action scene for the movie - Inkneeagony Jones and the Cave of Doom as a working title perhaps?
« Last Edit: October 03, 2010, 05:12:13 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 #70 on: October 04, 2010, 01:10:00 AM »
I seem to demonstrate an almost preternatural knowledge when it comes to what you're up to. How did I know you were up and walking around? Thanks for allaying my fears! Though had I simply perused any old atlas I would have known that salties aren't distributed anywhere close to your location. That would be the equivalent to you thinking that alligators inhabited my backyard.† :-[

It sounds as if you were making the most substantial progress since Kevin Rudd inhabited The Lodge. At least you know you can make progress. For a while there you were afraid that you were descending into the depths of an abyss from which you could never extricate yourself, but it is still unfortunate to hear of the setback. I can't tell you how many times the pressure has subsided from my knees, but it has ever been a siren song, luring me to complacency, and the pressure never ceases to return.

Now this is going to be a bizarre tale. Feel free to laugh and cackle if you'd like, I can't hear you. I had a little accident massaging. But it wasn't my hands that hurt, but rather what I was massaging. I think I may have made medical history by being the first case of Illiotibial Band Syndrome inflicted by the hand. I've come to realize recently that a lot of my aches and pains are actually myofascial pain, so I've been regularly massaging. The side of my knee was a bit sore last night, so I decided to rub it, nothing too rough. In my brilliance, and just for good measure, I decided to massage the other side as well, even though it didn't hurt at all. I don't know how it happened, but it hurt like heck afterwards. I am now left with a most pleasant sensation on the sides of my knees, especially when bending them. I guess you're not the only one with gremlins in your nervous system. Now I don't know if it's actually ITBS, but I'll have to see what happens in the next few days.

I have tried to maintain a positive demeanor through all of this, if not for only for my own sanity then for that of those around me. But so often I've found myself plumbing the depths of despondency, searching for a flicker or a fragment or a shred or an atom of hope in all of this, only to come out empty handed most of the time. I've mostly found comfort in the fact that this condition is so variable. If it only ever stayed the same, then that would be cause for desperation. But it does change, and I have to believe that it changes primarily based on what I've done over the previous 24-48 hours. There have been times when I've been able to sit with my knee bent for 30 minutes or an hour without trouble. But then, of course, any longer triggers the dreaded return of pressure to the knee, and eventually aching and burning. Sometimes I've been able to walk for a significant period of time as well, but later that day I'll feel it. And don't get me going on squats. Even if they don't hurt while you're doing them, you're going to wish the evening never came. Having experienced all of this more than once, I've tried to be a lot more consistent in restraining myself to only those activities that don't trigger a response. But even so, my knee still cycles between all of the different states. I do think it may be in a generally better state than when I was doing squats in PT. But there must be something I'm doing to irritate my knees, and my poor brain can't figure out what it might be.

But I think you've just figured out your primary stumbling block. Dodging all of those rolling boulders doesn't make for the ideal convalescence cave, now does it?

As I mentioned, I'm going to be attempting rbcyclist's approach for next few weeks. It certainly won't hurt to try. I'll let you know if I'm experiencing any progress at all, or if I'm not. And I hope you'll keep me updated on how it goes with your guru. If you haven't looked at the link, the rehab protocol focuses on:

1. Adequate rest, and finding positions which allow for this, and
2. Short bursts of light activity, followed by a longer period of rest, and repeated many times throughout the day.

It actually makes quite a bit of sense when placed in the framework of my personal experience and everything else I've read. But it will be the implementation that will be most challenging. Call me Inkneeagony Jones.

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Re: Sore knees, no diagnosis
« Reply #71 on: October 12, 2010, 05:41:31 PM »
Hey,

I was thinking about the original intention of this thread, one part of which was to perhaps attain a definitive diagnosis of your condition to replace that nondefinitive PFPS diagnosis. I was searching the interwebs again and came across an old staple of ours, that old Dr. Dye piece, Therapeutic Implications of a Tissue Homeostasis Approach to Patellofemoral Pain. I'll just quote a specific part which caught my eye:

"In addition, magnetic resonance imaging is poor at identifying which of the patellofemoral tissues are producing pain. As has been shown, even identified structural damage of articular cartilage may not necessarily play a role in the genesis of anterior knee symptoms. A careful examination of magnetic resonance imaging of the patellofemoral joint often manifests low-grade effusions associated with symptomatic peripatellar synovitis. This finding frequently goes unreported by radiologists because of their focus on the structural characteristics of joints. Thus, it is important for the treating orthopedic surgeon to look at the images directly. I believe peripatellar synovitis to be one of the most common, underdiagnosed conditions of clinical significance about the knee. Technetium bone scans, which manifest loss of osseous homeostasis, often correlate well with patellar pain and its resolution."

I was thinking recently, if the conservative approach that I've been trying to follow doesn't produce results, of the questions I might ask the OS, and the tests that might prove fruitful. Did your surgeon ever take a look at the MRI you had done to check for "low-grade effusions". And have you ever requested a bone scan? The strangest thing is that the surgeon didn't find anything unusual during the arthroscope. Is it possible that they missed possible symptoms of synovitis? I imagine that if a surgeon is looking for, say damage to the cartilage, and are not particularly concerned about the synovium, that they could possibly miss signs of problems with it.

I was also looking at a couple of other articles which might be of interest:

http://www.orthosupersite.com/view.aspx?rid=26361 This site also suggests synovial irritating as an underdiagnosed cause of peripatellar knee pain.
http://gait.aidi.udel.edu/educate/syncon.htm

That last one there is just to put out another crazy possibility to consider. Particularly this: "Evidence on imaging studies depends on the stage of disease. Until the loose bodies are ossified or calcified they may be radiographically invisible. This often leads to an unfortunate delay in treatment."

Again, wouldn't a surgeon spot this during an arthroscope? I suppose one has to recognize that surgeons are human, and prone to err. It never hurts to seek a second opinion.

I've come to the conclusion that I've got precisely the same thing as you in my right knee, but probably a good deal less severe. It's just that general soreness, and if I pay close attention, there are subtle sharp pains in there as well. Fortunately they aren't excruciating, but they're there. And the more I experiment, the more I realize that they're triggered by a very minimal level of activity. I've purchased a little floor bike from Amazon.com. It cost about $23. Yeah, I'm cheap. But I'm interested in seeing if cycling might allow for some level of motion that would be within my "envelope of function". But if it ends in failure, I'd like to think that something other than painkillers or Buddhist/Stoic acceptance of the situation could help.

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #72 on: October 13, 2010, 11:06:40 PM »
I attempted a little experiment this morning, which involved a return to the "95 year old" gait pattern which had worked so well to rid me of that dreaded inflammatory condition that I had been afflicted with over the summer. Unfortunately, a pretty severe sharp pain coursed through my knee after not too many steps. Every day my condition is more resembling yours. I sure hope this isn't a sign of what's to come.

That this pain was actually worse than most of that which I have experienced walking more normally, got me to thinking. Why would that approach have worked with the other condition, but not this one? I think the answer lies in the specific tissues affected.

I'm now convinced that the other condition was a pretty severe impingement. Of what I don't know. From extensive reading over the last few months, the most logical conclusion is the Hoffa's fat pad, but since it wasn't diagnosed, I'll never know for sure. But what is relevant, is the circumstances that actually provoked the pain response. In that case, it was not so much pressure that caused a problem. I didn't have the movie goers sign, and standing wasn't a problem except when it was at its absolute worse. But friction definitely did. That's why walking without flexing the knee, and doing so slowly, ultimately proved to be the solution. The inflamed, and probably enlarged tissue, was getting impinged when I was walking.

This more recent condition, I think, is likely a form a synovitis, but could have an osseous component as well. In contrast to the first condition, which was highly localized, this one is peripatellar, with pain experienced around all parts of the knee cap, though it is more intense in the superior lateral part of the patella. I think the key difference here is the sensitivity to pressure. The unfortunate fact is that when the knee is fully extended, which it is when standing, there is still a significant pull on the patella from the quadriceps, which undoubtedly increases the pressure in the patellofemoral joint. It seems that in some cases, the tissue is just so sensitive, that even this force is too great for it. This might be the situation that you and I find ourselves in. The synovial tissues slosh around to some degree, which may be why the symptoms are not completely consistent. You falsely sense improvement, but then the tissues shift around, and suddenly there's that sharp pain again.

I want to consider the possibility that there may not be any amount walking that will not irritate it, but that some level of motion may be acceptable (I can hope, anyway!). Since that floor bike is coming in next week, I might finally have an opportunity to test this theory out. The only thing that is pretty certain to me right now is that when I wake up in the morning I feel pretty decent most of the time. It's only when I start moving that things tend to go south pretty fast. I'm sure that the joint must be capable of some level of motion and pressure. Even standing exerts quite a lot force on the joint. There is a whole lot of space between that and 0. I'll quote Dr. Dye here:

"By suggesting that a patient decrease loading to within his or her jointís current diminished envelope of function, I am not advocating a sedentary existence or treatment approach. On the contrary, it is desirable that the patient remain as active as possible within the upper threshold limits of their jointís envelope (ie, that which is painless). Even joints that are substantially compromised functionally may safely withstand activities such as swimming or light bicycling, which can effectively maintain muscle strength, tone, joint range of motion, and even endorphin production without supraphysiologic overload of the system as a whole."

There are certainly some conditions where patients are instructed to go non-weight bearing for a time. And while that is not appropriate to our situation, it may be that we need a load level that is significantly below body weight, as nearly any amount of body weight loading will overload the tissues. In practice, this would entail finding a method to not walk at all (assuming any amount of walking provokes a pain response. Of course, if you've found a low level that doesn't then this wouldn't be necessary.), but also finding a loading activity that can be performed for some length of time that doesn't overload the joint. One would hope that this stage would not last more than 2-3 weeks and that some walking could then be integrated into the program. But it is becoming an inescapable conclusion that almost any, and perhaps all, walking is a problem for me. Given the persistence of the condition, which has hardly changed at all in 3 1/2 months, and may be getting worse in some respects, I have to conclude that a different approach to recovery may be necessary.

Offline knee always hurts

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Re: Sore knees, no diagnosis
« Reply #73 on: October 17, 2010, 11:42:49 PM »
I've come across a couple of other articles that may be relevant to your situation. The first one suggests saphenous neuritis as a possible cause of anterior knee pain. In most cases there would be more of a medial localization to the pain, but I remember that you mentioned some discomfort in the region of the tibial-femoral compartment as well. It seems unlikely to be the full cause of your symptoms, but it could be a component. Unfortunately, I couldn't find a link to the full article, but here is a summary:

http://www.curehunter.com/m/pubmed11929207.do

The second article might actually be relevant for my own condition. This article posits that hyperinnervation of the lateral retinaculum, which can be caused by recurrent ischemia events and may be possibly be triggered by repetitive microtraumas to the tissue, are an underdiagnosed cause of PFP. The study also suggests that as the severity of pain increases, there is an even greater proliferation of abnormal vascular and neural structures. At the end of the article, they also mention several possible treatment modalities. This would be consistent with the lack of visible swelling or deterioration of tissues in your MRI and arthroscope results. Access the PDF linked on this site:

http://informahealthcare.com/doi/abs/10.1080/00016470310018225

My exercise bike came in, but I'm afraid that even using it with no resistance, it may be like trying to surmount Everest with a mountain bike. It's just difficult to separate out the causes of the pain. By the time I get on the bike, it's already too late. I've noticed two different pain responses. The most obvious, of course, are those sharp, lancinating pains that seem to randomly emerge from time to time. I've gone days without any, and some days I've had more than one. But I'm convinced now that those pains are not the only or even most relevant indication of trouble. Even if I wake up in the morning and my knee feels fine, almost as soon as I start moving there is a soreness or aching feeling quickly worsens as I continue to walk. Standing is even worse, and makes those sharp pains all the more likely. This unfortunately precludes slow walking as a strategy.

I've been experimenting with using crutches to lower the load on my knee, but without success thus far. I'm not convinced that this is a neurological condition, and is simply "all in my head." I still think there is a tissue or tissues that is causing the pain, and I just need to find out what that is and then treat it accordingly. It was definitely triggered by mechanical irritation. My hopes of recovering utilizing a conservative approach continue to slip away, though I haven't given up yet. If it does prove impossible, identifying the involved tissues will likely be the only hope of recovery. It seems that the worst case scenario would be that the sub-chondral bone is implicated in the pain, as this would necessitate a PFJR as the only likely solution. I think many of the other tissues would be amenable to a more cautious surgical approach or possibly even pharmacological intervention.

I've barely even begun the process of pursuing the medical route, so it's a long road ahead if that proves necessary. But when I first entered the cave, I wasn't promised a speedy evacuation if I decided I'd had enough. Nobody promised that the route out wouldn't be long and undulating and sickly damp and slippery, or that there wouldn't be an occasional large boulder Indiana Jones style. Keep me updated, and perhaps you can mention some of this to your rheumatologist.

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Re: Sore knees, no diagnosis
« Reply #74 on: December 06, 2012, 07:44:21 PM »
Guys, how did things end up for you?















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