Patellofemoral pain and anatomical leg length discrepancy.

[Kefu]

Chronic anterior knee pain // chondromalacia patella // patella femoral pain syndrome (PFPS) // Excessive Lateral Pressure Syndrome (ELPS) // Lateral Compression Syndrome // Lateral Facet Syndrome of Patella

Let me begin with some backround. I am 23 years old male currently living in Canada. I have had anterior knee pain in my right knee for over 6 years. It started when I played soccer, and it just got worse. I remember my right knee being really swollen for a few weeks 7 years ago. I rested the knee and returned to intense training. I overtrained leading to PFPS. Ever since then my IT bands, quads, and hip flexors are really tight. Nothing seems to really loosen them. I have tried physiotherapy from multiple physiotherapists, ART, osteopathic manipulations, electrically stimulated trigger point dry needling (PENS/electroacupuncture), acupuncture, massage therapy, foam rolling (lacross ball, PVC pipe, rumble roller), suction cupping, strengthing glute medius and maximus, VMO strengthening, core strengthening, orthotics (which I stopped using), intra articular prolozone injections, joint supplements, heel wedge for leg length discrepency (which I stopped using) ->(my right leg is 1.1 cm shorter confirmed on x-ray).

I dont do any physical activity besides physiotherapy and self-myofascial work. My pain is at a constant 4/10 (it fluctuates, sometimes its lower, but sometimes like in rainy days, cold days, stormy weather, or extended periods of sitting its even higher. Basically all the physiotherapists are perplexed at my issue and they say that I should not be feeling so much pain. They think my overall mobility and flexibility isn't that bad (one of them said, hes never seen someone with so much pain with such good mobility). But when they massage they notice that my soft tissue is really tight with lots of "junk" or adhesive knots.

Sometimes the tightness is really painful and feels almost similar to cramp. If I massage, and self-myofascial release religiously for awhile and dont do any activities it will loosen up a little. But even a little bit of daily physical activity will cause it to tighten up (i.e., cleaning the house, sexual intercourse, moving large furniture, dancing, or physiotherapy exercises without lacross ball and Rumble roller rolling and stretching right at the end).

Joint supplements previously taken that havent helped:
1) NEM - natural egg shell membrane (500mg)
2) pycnogenol (100mg)
3) fish oil (2000mg)
4) krill oil (500mg)
5) curcumin (500mg)
6) Serrapeptase (270 000 IU)
7) Magnesium Biglycinate (200mg)
Vit D (2000mg)
9) Fortigel

Diagnostic imaging done:
1) X-ray on knee - showed nothing abnormal besides patella tilt (although when I examine it myself their seems to be a little less joint space when compared to the left knee, I asked the sports physician, he said that's because of the tilt)
2) ultrasound - showed mild inflammation in my right knee, nothing serious
3) MRI (taken in January)-  showed no cartilage, ligament, meniscus or tendon damage. However it showed a possible ganglion cyst in the proximal tibiofibular joint. Sports medicine physician said it probably has not clinical significance and it isnt related to my pain because its in a different area than my symptoms.
4) X-ray for leg length - right leg 1.1 cm shorter (been adviced to wear 0.5 cm heel wedge under my right foot shoes from 1 PM&R physician, but other professionals told me that 1.1 cm is not significant and doesnt warrent a heal wedge. So I was wearing one for 1 month and it did not seem to help so I stopped)

Previous treatments:
1) Physiotherapists/Massage therapist/FMS certified strength and condition specialist- looked at mobility, muscular imbalances, glute medius, glute maxmus, VMO strengthening, core strengthening, stretching, self myofascial release, foam rolling, suction cupping, ART, massage therapy, orthotics, gait analyses, heel wedge for leg length discrepency, electrically stimulated trigger point dry needling, acupuncture, went to Fowler and Kennedy sports medicine clinic in London Ontario and many other places.

2) Dr Robert Banner (London ON) - 7 treatments of Prolozone injections, once every month.. Only noticed temporary relief of pain, maybe for 2 weeks after each injection (relief was dramatic, it decreased pain by 70%). Has recommended EMF (electromagnetic field) protective devices such as diodes. He says it may help since my symptoms are worse on rainy days. Seems very pseudoscience tho. Havent seen him since October. Sports medicine physician thinks the ganglion cyst could have been caused by the injections.

3) Osteopath - Currently seeing an osteopath. Had almost 10 treatments She has noticed that I am kypthotic, and lordosis (which I already knew). Also noticed that my right pelvis is shifted anteriorally (hip misalignment). She has made my back feel good thus far but has not relieved my knee pain and IT band muscle tension. She is not that experienced either but has a very cheap rate (shes only in school). She told me she doesnt think she can help my case and recommended me to see someone with more experience.

Possible Future treatments:
1) Botox (Dr. Gordon Ko in Markham) - into the vastus lateralis (any maybe hip flexor). This has shown to be effective in some recent studies for patients with refractory anterior knee pain. The idea is you shut down the vastus lateralis for 3 months, and you continue to do physiotherapy, this gives you a window of time for selectively strengthening and isolating the VMO. This will help with tracking and tilt issues, and can give symptomatic relief of muscle tightness during the 3 months. Its good for addressing muscular balance issues. Dr. Gordon Ko also does PRP, prolotherapy, hyaluronic acid, and botox into the joint.

2) HGH/testosterone/IGF-1/PSGAGS/hyaluronic acid/dextrose injections - have read this has helped some people. I am looking into injecting into my own knee to save thousands of dollars. This can help regenerate possible cartilage damage I might have.

3) Dr. Anthony Galea (Etobicoke/Toronto) - he is a prominent sports medicine physician infamous for treating athletes and giving them HGH. Don't know what kind of treatment he would give me. I know he does PRP, but I dont know if he can give HGH anymore since its illegal here in Canada and hes gotten in trouble for that.
 
4) Other possibilities (that probably wont help that help) – Chiropractor, Neurokinetic therapy, SFMA certified health practitioner, naturopath, egoscue method, neural therapy, Rolfing, Graston Technique, shockwave therapy.

Help me:
I am looking for some advice and how to proceed. My chronically tight IT Band, quadriceps, and Hip flexors just dont seem to loosen up! One of my more recent physiotherapist had me doing postural work/exercises. I have been going at it for about 1-2 months and they did not seem to help. He thinks that bad posture might be contributing. He thinks I am an unique case, he said I shouldn't be feeling that much pain since I am not even doing physical activity. Previously if I even tried to run my IT band would tense up right away. I havent tried running in months.

[Clarkey]

Hi Kefu,

Your knee problem sounds similar to my current right knee problem and injury as I too have patella femoral pain syndrome (PFPS) and some maltracking. I am older then you aged 35 and ran competitively long distance running, at my prime before re-injuring my right knee again with averaging a pace of around 6 minutes and 50 seconds a mile.

I openly admit going overboard running a 9 miles circuit 3 times a week in just over 1 hour and did go at a good pace, I did feel it impacting my right knee and did get the odd twinge of knee pain and thought nothing of it and carried on with my running.

I did have surgery in November 2009 and had my medial plica removed and fat pad trimmed that was restricting movement at the bottom of my kneecap and could at times feel something catching at the bottom of my kneecap that was always remained swollen at the bottom. 

My OS also diagnosed my knee pain and anterior knee pain and specialises in soft tissue injuries of the knee in younger patient hence choosing him. I too was told I have very tight and knotted quads with a tightened IT band. I had a Botox injection into tensor fascia lata followed by intense PT that theoretically loosen the tight and knotted muscle tension releasing some of the knee pain and swelling.

Both failed and now waiting back for my MRI scan results my 3rd one in 12 years. The last 2 did not show any major knee problems inside the knee. I opted to have an exploratory scope that took a while to recover from. I managed 18 months of long distance running until it got to a stage where I could no longer run and had to freeze my membership at my local running club.

I will stop now as I do not want to overload you with too much information in one go. I have been reading up about ITB release surgery. Only an OS will know if this type of surgery is required for our type of knee problems.

http://www.orthotrauma.com.au/knee-procedures/itb-release/

Good luck and can only advise you from my personal experience, the above link is just an idea not a fix or suggestion.

[email protected]

[Kefu]

Thanks for the reply Clarkey.

I have a suggestion for you before you decide to get ITB release surgery.

After seeing a few more health care practitioners in the past few months: osteopaths, physios, FMS certified specialist etc.. I feel like I am closer to solving my problem. The biggest difference have been:

1) Finding an excellent physiotherapist 1 month ago --> A friend whose had many injuries as well recommended me a physiotherapist after he has been to so many. He said Robert Werstin is the best hes been too and would help me. So, after doing my research on Rob I found out he has excellent credentials in being president of the Canadian Physiotherapy Association .My first visit he did a very comprehensive assessment, much more comprehensive than any other physiotherapist I have been too. He immediately started noticing things that other physiotherapist havent noticed.

Glute medius
For example, when testing for glute medius strength it appears I have good strength, but I was compensating with other muscles (lower back and TFL). However, he has me do clamshells and he would feel for the activation of my glute medius, he was also looking at any slight pelvic rotation. He said my glute medius arent firing at all, and all tho it might appear I can do the clamshell when someone isn't checking from up close, I am compensating by rotating my pelvis, and using my TFL and lower back. This appears to be only happening on my right side (the side with my knee pain).

External  rotation range of motion
2nd thing he finds is that I have very limited external range of motion on my right side (whereas my left side is fine). He said its not the muscles that are restricting the external rotation. Its a tight hip capsule. So the ligaments surrounding the hip joint. Coincidence its on the same side as my knee pain? probably not.

Weak hamstrings, and Quad dominant
3rd thing he found with probably less importance is that I have a weak posterior chain, and I am quad dominant. He noticed a slightly weak glute max, but more significantly he found that my hamstrings were even weaker.

How this relates to patello femoral pain:
1) Weak glute on right side-->tight IT band-->lateral pull on knee-->knee pain
2) Limited external rotation on right side-->less range of motion to activate glute medius, and tight internal rotation structures, femur is being pulled internally--> weak glutes and patella is tracking laterally relative to femur-->knee pain
3) Weak hamstrings-->anterior pelvic tilt-->quad and TFL dominance-->pull on knee cap-->knee pain

Solution he gave me:
1) Activate glutes
2) strengthen glutes
3) integrate new strength into functional movements and exercises

So I am on step 1 which is activate glutes and what he has recommended is to do:
1) Clamshells --> Must be in correct form** Meaning with back against the wall, hand behind pelvis to make sure its not rotating and using only the glutes to perform the exercise.

He has also recommended me to work on increasing my external range of motion and strengthening my hamstrings and glute max. But the emphasize is on glute medius strengthening  and external ROM stretches on right side (twice a day).

I have noticed improvements since using his recommendations. I feel the best results are coming from performing the clamshells. I also did a 3-D gait analysis which showed a trendelenburg sign with a left pelvic drop (meaning the right glute medius isnt firing). This supports the findings of my physiotherapists.

My recommendations:
1) Try finding the best physiotherapist possible, even if its slightly outside your area
2) Get a 3-D gait analysis done to see more clearly what is going on. The analysis shows what your hips, knees, and ankles are doing. 3-D gait analysis might be harder to find, but they are a lot better than a 2-D analysis. I have gotten a 2-D analysis and was also checked my other physiotherapist on my gait and these methods did not find anything wrong for me . But the 3-D analysis picked up a dramatic difference in my hip movement.
3) Try doing clamshell twice a day, every day, with perfect form**, once it gets easy start adding resistance band. Of course it would be best to see by your physiotherapist and the 3-D gait analyses to confirm if you have a weak glute medius. Also, the physiotherapist can check your form for the clamshell.

Other less important things to consider:
1) Avoid sitting for extended periods of time. Try standing. If you do a lot of seated work (office job) Try perhaps a standing desk. I am currently standing and typing this message. I have been standing a lot more often now. Sitting leads to weak posterior chain, inactivated glutes, tight and overactive TFL and psoas.
2) Osteopath/chiropractor: Check alignment, leg length discrepancy, pelvic rotation etc..
3) Consider doing electrically stimulated accupuncture/trigger point dry needling on vastus lateralis, rectus femoris, TFL, psoas
4) Go see a physiatrist/ physical medicine and rehab doctor: Get them to do EMG test to check for what imbalances and faulty motor recruitment patterns you have.

In addition to the clamshells I was adviced a bunch of other exercises but felt they were somewhat less important and the post would be way to long if I talked about all of them.

[Clarkey]

Hi Kefu.

Since my last post I have found out after having had my MRI scan results back in March 2014 that I will need to have an exploratory scope done on 18/07/14. I may need a microfracture done as there are signs of wear and tear in my right knee with bone bruising and signs of the start of arthritis on my MRI scan.

As for the tightness around the ITB, not too sure if it a problem still as the pain is mainly around the bottom of my right kneecap. However twice I have get some bruising coming through my right hip and gets sore and feels tight, it may be linked to my right knee not being too happy and my right hip is taking on more of my body weight.

Thanks for replying with the in depth information you have provided to me, I will look at it in more detail another time.

I am very busy at the moment coming to the end of my studies at college, I will be able to take it all in over a period of time.

Is bruising of the hip caused by a tight ITB?

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=63856.0

[email protected]

[Jae]

Kefu can you update us how you are doing now?