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Author Topic: Fed up with physio - Possible Inward Rotational Deformity and Hypermobility  (Read 4332 times)

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Offline vlm020

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Hi All,

I will try and keep this brief.  My knee problems started about 10 years ago when I was a teenager.  I have quite badly turned in knees, particuarly on the left side where my foot also over pronates.  At the time I had CT scans and it was decided there was nothing that could be done because my leg was rotated inwards at hip, ankle and knee. 

Fastforward to last April, I was doing an exercise class and tore a muscle just above my left knee (or at least that is what I was told I had done).  I had a few months of physio and all was fine until this April when I redid the same thing.  Now 6 months on I can't walk very far without pain and stairs are pretty difficult, after trying two lots of physio with no improvement I have been referred to a knee specialist within the physio department who has sent me for x-rays and an MRI.  I haven't had my MRI back yet but she has said I might need surgery to realign my kneecap as the muscle problem is probably as a result of my knee joint.  I am also going to see a private podiatrist to get some insoles.

Having had a quick read on here I'm starting to wonder if realigning my kneecap is going to do anything at all when my knee is twisted so far inwards anyway.  I should probably also mention that I am probably hypermobile although I haven't been formally assessed. 

Is there anything that can be done to help rotational deformity (other than trying to build up muscle to try and bring the knee round)?  It seems to me that there must be SOMETHING they can do to sort out my muscle tear (or whatever it is now) but whenever I raise it I'm told if it was just a tear it would have healed by now so the knee must be the culprit!

Thanks!

Offline kscope09

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Have you ever worn orthotics in your shoes?  No doubt if your seeing a poediatrist they will be able to provide some.  I had some made on the NHS and they really help with knee pain
Feb 08 Inurred right knee
18 months of physio, knee tracking but knee still painful
Aug 09 Scope - Small tear in acl, fragment found in postereo-lateral compartment, suprapatella and lateral plica and small defect in mfc.
May 10 Right knee feeling better but left knee causing trouble as a result o

Offline crankerchick

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It has been my experience that fixing rotational deformities requires surgery. You can't exercise away a bone deformity, that kind of defies logic. If your health care professionals are suggesting possibly doing a patella realignment in the presence of a rotational deformity, I would respectfully suggest that you hop, limp-jog, limp-run, crawl or otherwise propel yourself away from this doctor as quickly as your gimped leg will allow you.

As it relates to your possible muscle tear, I question whether your doctor really has a good grasp of your current problem or your history as it relates to your inwardly rotated knee. If your knees point in when your feet point straight, then that is what needs to be addressed if anyone is going to talk surgery. If your current issues are truly related to this possible muscle tear, then you probably need to be seen by someone that knows how to diagnose and treat that instead of suggesting a patella realignment that fixes neither a muscle tear nor a rotational deformity.

To properly diagnose rotational deformities, a rotational CT scan study is in order. To be thorough, a good set of x-rays should also be done to get a complete picture of alignment of the leg. I don't know much about muscle tears, but I can say a patella realignment won't fix one. It won't fix a rotational deformity either.
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Offline vlm020

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I had a CT scan done about 10 years ago and they decided nothing could be done because correcting my knee may cause problems in my hip and/or ankle.  I guess medicine may have moved on in 10 years but I can't see what they could do without drastic surgery to straigten my knee out which I'm not too keen for as at the moment I'm not in agonising pain.

I think the NHS do a great job but my experience thus far has been that because it's not a straightforward case noone is particularly interested.  There seems to be lots of shrugs and scratching of heads!  I have no idea which department/specialist I would be best to see and none of the people I have seen so far really seem to know either.  I'm paying to see a private podiatrist because the waiting list is 4 months and I was told the quality I would get would be much better if I went private.

Offline crankerchick

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I had a CT scan done about 10 years ago and they decided nothing could be done because correcting my knee may cause problems in my hip and/or ankle.
This is an answer from "they" who don't know what "they" are doing, most likely.

...I can't see what they could do without drastic surgery to straigten my knee out which I'm not too keen for as at the moment I'm not in agonising pain.
Good answer. To align the leg is a big surgery, certainly not one to go through if the symptoms are manageable.

My point with my previous post is mostly to say, if you do have rotational deformities, a patella realignment doesn't make a lot of sense to do and the same, I would avoid it, as it doesn't address the rotational deformity, which is likely the root issue.

Perhaps a sports medicine doctor is in order to deal with the muscle issue, if that is indeed what your current problem is (and not something related to your bones being twisted).
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Offline Lottiefox

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Just to echo Cranker - true rotational issues won't be "solved" without surgery. But, depending on symptoms they may be managed to a level that means you do what you want, without too much pain or discomfort. It sounds like your knee is basically stable, which is a big bonus. I have mild rotational issues (my feet need to turn out a bit to have my knees dead straight) but CT scans have shown my patella actually tracks straight, but has a tilt laterally, I guess due to the pull of the leg bones and the fight of the patella. I get tight calves, tight hamstrings and last year after too much running my MRIs revealed significant wear and tear on my kneecaps. I've now stopped running! But I am very active and a comprehensive PT program started right from the beginning (working on ALL lower limb muscles and structures) has helped my strength, stopped the cracking when I bent my left knee as the kneecap moved about, and means I now load up my quads more than kneecap so the rotation doesn't "affect" me as much. To me, at 41, I am OK with this as derotating is a BIG surgery and not to be undertaken lightly and only to be done by someone who understands the whole thing. Patella re-alignment was suggested to me, and I chose not to do it. I am VERY glad I didn't. If you don't have rotational issues, the realignment can work wonders. If you do, then you're cimply creating another deformity on top of others.

Ref orthotics - I tried some 3/4 length rigid customs last year and I thought they made my knees worse. I now have Superfeet OTC orthotics in my trainers and for the rest of the time tend to wear Merrells, or similar, with decent arch support. My Superfeet came from a podiatrist who also did a gait analysis.

The key for me was proper PT with someone who understood rotational issues. It won't stop surgery IF you need it, but it might manage the symptoms.

Let us know what the MRI says. You may have cartilage wear and tear under the kneecap because of the forces working on it. Fixing this is tricky, especially if the adverse forces remain. I am in that boat. Again, the PT has reduced the pressure on those worn out areas. I have also had a visco injection to lubricate the knee (Euflexxa) and I take Celebrex, a COX2 NSAID for when times are inflamed.

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 vlm020

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The MRI came back fine.

I'm giving up on the NHS and going private!

Offline crankerchick

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Of course it did. MRIs are next to useless for these kinds of issues. You need a rotational CT scan study and good old x-rays. Good luck, keep looking for answers.
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Offline vlm020

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Apparently the pain I am feeling is an RSI type injury from bad biomechanics.  My physio has  basically said I should carry on strengthening my hip to get my knee turned round and to expect no improvement for 4-6 months.  Yay!  Somehow I'm not convinced, I tried this all 10 years ago and my knee is still in the same place!  So out of frustration I went back to my GP who has now referred me to a rheumatologist who apparently has some connection to the olympic team so hopefully he'll have some suggestions.  I'm probably being impatient and I appreciate that there are people on this site with far worse problems but I am a naturally a sporty person and don't want to rest until I've got some answers.

Anyway rant over!  :) 

Offline vlm020

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I've got a rheumatologist appointment in a couple of days and I'm nervous!

Since I last posted I've seen two podiatrist and am getting sorted with some orthotics.  One says I have external tibial torsion which at first to me seemed a bit odd as I always thought the problem was inwards since my knees practically face each other.  He thinks as a child I made a concious decision to walk with my feet facing forward rather than my knees.  Both of my feet overpronate badly, worse on the left.  The second podiatrist thinks I also have very flexible feet which means I have no support and adds to the overpronating - she said my feet are as bendy as a small childs and things are supposed to tighten up as you get older (I'm 25).

So... based on these comments and general observations I did a bit of googling.  I obviously have some alignment issues and bone rotation which is probably just genetic.  But now I'm starting to wonder if I have a hypermobility syndrome.  It would explain quite a lot.  I looked at the Breightons scale and I think I'm somewhere between a 4 and a 7 - it's hard to tell if my knees bend back as they're turned in (although if I 'straighten' my legs as far as they'll go when my legs are on the floor I can lift my heels up) and I can't tell if both my elbows bend back.  I certainly cannot put my palms flat on the floor with my legs straight!  I also have a concave chest (lucky me) which I know can be linked to certain conditions related to hypermobility but again could just be a bad luck deformity. 

Basically I'm asking for a bit of advice on how to broach all these areas at my appointment without sounding like a hypochondriac or a know-it-all!  Or am I best just to give a simple bit of history and leave any possible self diagnosis out of it?

Thanks very much!

Offline crankerchick

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Re: Fed up with physio - Possible Inward Rotational Deformity and Hypermobility
« Reply #10 on: November 21, 2010, 03:19:24 PM »
I guess I'm having trouble understanding how a rheumatoligist is supposed to help with bone deformities. It sounds like you are going around robinhood's barn to get answers for a problem that can be easily answered with some diagnostic imaging (ct scan).

You have said your knees turn in when your feet are straight. Look up miserable malalignment and tell me if that is what your legs look like.

If that is what is going on (femoral anteversion and/or tibial torsion) you can do all the physio you want, it won't get your knees to "come around" as your physio has said. It could help make the condition more tolerable to deal with but it won't make your legs straight.

As far as your appointment, there's nothing wrong with brining up your concerns and asking about various conditions. Give your history, hear their take, and then ask about the conditions and the things that concern you.
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Offline vlm020

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Re: Fed up with physio - Possible Inward Rotational Deformity and Hypermobility
« Reply #11 on: November 21, 2010, 03:41:16 PM »
I guess they don't see much point in having another CT scan since there isn't a great deal they could do apart from major surgery so seeing a rheumatologist may rule out any other conditions like EDS.  If that doesn't get me anywhere I guess it's off to ortho department or giving up.

Offline crankerchick

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Re: Fed up with physio - Possible Inward Rotational Deformity and Hypermobility
« Reply #12 on: November 21, 2010, 03:58:15 PM »
I would agree it is helpful to get the full picture to find out what else may be going on so it can be taken into account. I just would hate to see you going round and round to find an answer/solution that isn't there. Been there, done that.

I think what is most important for you, as you are trying to avoid derotation surgery, is not to go with any other "less invasive" surgery until you know for sure if you are twisted and if so by how much.

Good luck with your rheumatologist appointment, I hope they are able to offer you some avenues and help you find out if anything else might be going on.

Don't give up, just don't kid yourself either. Gather all the data points and push for the appropriate testing and then see where you are. If you can't find a way to manage things without surgery then you will have to decide on surgery or not, but at least you will have the full picture.
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Offline vlm020

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Re: Fed up with physio - Possible Inward Rotational Deformity and Hypermobility
« Reply #13 on: November 21, 2010, 09:02:28 PM »
Thanks so much for your comments.  Sorry if I came across a bit short - it's frustrating (as I'm sure you know) as you'd think a doctor (or specialist) would want to be helpful and get you sorted rather than just fobbing you off.  I guess orthopaedics might be where I'd need to go next. 

I'll give an update once I get some more answers (or not as the case may be).

Thanks!

Offline vlm020

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Re: Fed up with physio - Possible Inward Rotational Deformity and Hypermobility
« Reply #14 on: November 24, 2010, 01:22:56 PM »
Well I saw the Rheumatologist and turns out I am hypermobile and score 8/9 on the Beighton's scale (don't quite make the 9 as can no longer put my hands flat on the floor with my knees straight).  It also looks like I have one leg longer than the other, large range of motion in my hips, very poor proprioception, crepitus in my knee and something about winging shoulders. 

I'm being sent for an EKG to rule out any heart issues, a more specialised orthotic assessment and have been given some exercises that I will apparently need to do everyday for the rest of my life to help avoid any further injury and osteoarthritis.

It looks like long-distance running is a definite no and apparently I've probably only managed to run for as long as I have because I'm relatively light.  I've been told I can try track running once my knee/thigh settles down but will need to tape my knees and strap my ankles!  Apparently this helps with stability and proprioception and should prevent twisted ankles, knees etc.

With regard to the rotation it seems my hips are adding to this but I'm less inclined to pursue the orthopaedic route as I don't think my issue is severe enough to warrant derotational surgery since I haven't had any dislocations.  I've been told to avoid joint surgery such as realignment as success rates in hypermobile people are low. 

I guess I'll see how I get on with the orthotics (when I eventually get them) and the exercises!















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