Muscle relaxants and PFPS

[Lanterne Rouge]

Hello (again),

I am fighting with PFPS/chondromalacia since 2 years. I have been discussing a lot with my brother about it and he has a really direct approach at things. I told him that patellar maltracking is usually caused by tight muscles and he offered me to try muscle relaxants. I said it was a stupid idea because of its simplicity. Anyway, I tried it yesterday. It helped me with my tight and fatigued muscles to be relaxed but I don't think it will help with maltracking problem. What would you say?

[MDAL]

There are many things in clinical practice, such as cortisone, or over the counter anti-inflammatory drugs.

They do hide symptoms temporarily, but it is just a mask. On the down side, they also stop your body from healing itself.

From your story, it looks like your problem may be an issue of over-use of cartilage, damage from years of intensive sport activities, such as cycling at competitive level. From what I read from your story, there is no evidence of maltracking, there is evidence of clear over-use...

Anyway, correcting maltracking is often done in physiotherapy by exercising muscles such as the VMO to compensate the force exerted against the lateral side, not by relaxing muscles... relaxing muscles is something you can do in a hot bath... but I really don't see the point...

[Lanterne Rouge]

There are many things in clinical practice, such as cortisone, or over the counter anti-inflammatory drugs.

They do hide symptoms temporarily, but it is just a mask. On the down side, they also stop your body from healing itself.

From your story, it looks like your problem may be an issue of over-use of cartilage, damage from years of intensive sport activities, such as cycling at competitive level. From what I read from your story, there is no evidence of maltracking, there is evidence of clear over-use...

Anyway, correcting maltracking is often done in physiotherapy by exercising muscles such as the VMO to compensate the force exerted against the lateral side, not by relaxing muscles... relaxing muscles is something you can do in a hot bath... but I really don't see the point...

Thanks a lot for your reply. Actually, I am trying to avoid NSAID's as much as I can. As you pointed out, they are just blocking the healing mechanism of the body. If I have swelling I am icing my knees, that's all.

I might have overused my cartilage but as you know cycling is a cartilage friendly sport as opposed to running or jumping based sports. I do believe there is a maltracking going on with my kneecap as sometimes it really moves out of its groove when I try some certain exercises like leg lifting while sitting which I don't do anymore. And my MRI report says I have a lateral tilt, I don't know yet how severe it is because doctors don't want to comment on it.

Regarding the VMO activation, I read a lot about it and it is still debatable whether you can isolate the VMO or not when you work out your quads.

[Vickster]

Cycling is better than running, but only if you are doing it in an ideal way if there is potential for damage.   It's very easy to do damage, by having a poor fit, the wrong saddle height, the wrong gearing, cleats in the wrong place, all sorts.  Also, overuse is possible with each and every sport if you don't rest, allow inflammation to occur, if there is a muscle imbalance or biomechanical/alignment issue.  Once the damage is done as in your case, it's very hard to undo

You need to also work all the muscles in the legs, not just the thighs, also core, lower back, hips

Have you tried swimming, front crawl/backstroke only, no frog kick.  Can be a proper full body workout with no pressure on the joints (unlike cycling)

[MDAL]

We need to be careful when we say that cycling is a cartilage friendly exercise... if done in proper amounts for the age and situation, under proper equipment, yes...

But as far as I read in some other post, you were cycling for endless kms on a regular basis (I don't remember how many you said, but I remember it was something crazy)... This adds to years of having your patella rubbing up and down for endless hours, day after day... Even a perfectly healthy joint will suffer from so much friction...

We also need to have age in account, the repair capability of a teenager is not the same of a 40 years old...

[Lanterne Rouge]

When I place the palm of my hand over my kneecap and flex/extend my knee I can tell it is rubbing over the femur really hard. This should be a maltracking issue. Something is so tight.

[Vickster]

Have you tried a high quality sports massage to loosen things up or something like dry needling / myofascial release?

Does it hurt when you bend or flex?

[MDAL]

When I place the palm of my hand over my kneecap and flex/extend my knee I can tell it is rubbing over the femur really hard. This should be a maltracking issue. Something is so tight.

Hold on there... by rubbing hard, from where does the pressure comes from? Vertically? Or Horizontally? Is it to the sides, like pressing laterally? Or in the bottom of the patella against the femur?

Can you fully bend your knee all the way until your foot touches the buttock or does it get locked at some point?

[Lanterne Rouge]

Have you tried a high quality sports massage to loosen things up or something like dry needling / myofascial release?

Does it hurt when you bend or flex?

You mean like having a massage by a professional? No but I really want to. My muscles are always feel tired. I didn't try dry needling because I don't have faith for that kind of thing. Myofascial release might help with my tired muscles but there is no professional to do that in my area.

It doesn't hurt with bending atm. If I push it a little bit hard (like walking few miles or cycling (commuting, not spotive)), inflammation occurs beneath the kneecap and the area above the kneecap gets tender to touch.

[Lanterne Rouge]

When I place the palm of my hand over my kneecap and flex/extend my knee I can tell it is rubbing over the femur really hard. This should be a maltracking issue. Something is so tight.

Hold on there... by rubbing hard, from where does the pressure comes from? Vertically? Or Horizontally? Is it to the sides, like pressing laterally? Or in the bottom of the patella against the femur?

Can you fully bend your knee all the way until your foot touches the buttock or does it get locked at some point?

Pun intended?

Pressure seems to be coming from the bottom. It is rubbing against the femur. Where else it can rub anyway?

I can't do that full flexion. I am missing last 10-15 degrees I think. My tendons seem to resist and quadriceps feel tight. I am trying that as stretching exercise; lying face down and grabbing the ankle from behind. I am doing it gently not to upset tendons. Maybe I have thickening of the tendons because of overuse and it is causing the patella to tilt.

[Vickster]

Or a good masseur.  I had one that eased the aches and pains while on holiday in Turkey.  I should think you'll find a decent person locally in Turkey.  Certainly worth a try.  Neck, back and legs.  Everything can be connected, especially with your cycling history

[MDAL]

Okay, so based on this, I think you are confusing maltracking (which is when the patella doesn't move centrally aligned and pressures against one of the sides, typically laterally).

What you seem to be describing (according to my personal experience) is loss of ROM due to inflammatory process. Inflammation in a joint is not as an inflammation in any other place, where it is just about a puffy area, feeling warm with increased size. In a joint, a synovium inflammation it's like it commands every tendon, and ligament to lock and become tight. Post surgery, a knee blocks almost completely and it's not so easy to unlock it back. And for example after a simple intra articular injection, my knee immediately locks going to a max of 80 degrees. Then it releases back in the next few days.

But anyway, what I am describing is more like the symptom, the root cause for the inflammation is a different thing.

If you want to check if you really have maltracking, my recommendation is to forget about doctors and consult with physiotherapists. The rational is that doctors spend 5 minutes with you, while physiotherapists will spend long periods, and they have spent years watching knees recovering post terrible surgeries, working on every tendon, muscle ligament. Since tracking is not really visible by imaging, unless you have completely twisted bones, doctors are rarely of any use, because they hardly spend 30 seconds to check it.

[Lanterne Rouge]

That patella is tilted. MRI report also says that. I don't know if tilt and maltracking are considered as two different things. What I understand from the tilt is patella being pulled to the one side by tightened structures around it.

When I visited a physical treatment center - I think it was 2 months ago - they found out that my vitamin D deficiancy was in an alarming state, it was critically low. And I just read it is causing cartilage loss. Muscle fatigue is also a symptom of that. I am going out to get some D now.

[Vickster]

A physio said to me that Vit D deficiency is definitely a contributing factor to joint issues.  Common in the UK as we get less sunshine.  Injection is the most effective way to get it, so speak to your doctor.  If tablets, make sure you get the correct therapeutic dose.  If it was diagnosed 2 months ago, would certainly time to address it.  Also, get yourself out in the sun, but not on a bike