Severely debilitating Chondromalacia Patella problems

[gcoza]

For PFJ problems there will be a reason why there is softening of the cartilage for example.

In my case I had trochlear dysplasia which was addressed by a trochleoplasty. I also have patella alta.

There will be a reason if doctors manage to find one. They have to be smarter than us. I do not have such a obvious reason, actually, I do not have any of conditions connected with chondromalacia, and can (doctors say) cause chondromalacia.

[Jasey122]

Thanks for the input guys. Guess I need to weigh options and think.

[tinydinosaur]

have you looked into hyaluronic acid injections? Durolane and Synvisc are the two I know of, for people with mild arthritic type changes (softening/wearing of cartilage) it can help. My OS told me they have lots of patients who get an injection every 4-6 months and it's worth it for them, it adds a little extra cushioning in the joint to prolong it/avoid surgery or a replacement. I've had it done two or three times and it did not help me, however I was told for most cases it does offer some relief. If the wear is one-sided you can also look into offloading braces (which are quite expensive). Braces do make you compensate so it is important to make sure you have exercises/stretches that will help with balancing, even if all you can do are seated quad or VMO contractions.

I would carefully consider your options as experimental treatment, especially outside of your own country (unless covered by insurance) seems quite risky/sketchy. Look at everything, do you have tracking problems? Muscle imbalance? Did you dislocate or otherwise injure your knee? Do/Did you have a high impact or otherwise joint stressful job or hobby? What exercise aggravates it the most? Which exercises aggravates it the least or not at all?

Sometimes, unfortunately, you have to be your own detective or keep pushing until you find a doctor/physio who will work with you to solve and then treat whatever issue is there.

@gcoza - there is a reason even if your doctors cannot find one, as others say it is better to treat the root cause than the symptoms or it will continue to degrade over time. My OS said cartilage is (what's the word..) finicky? They said something as simple as banging your knee can damage your cartilage and it will start sloughing off, and other times it's fine (which is often the case because otherwise EVERYONE would have knee/cartilage problems).

[gcoza]

I tried injections of hyaluronic acid (Crespine gel brand - manufactured in Germany). Blood injections are much better, at least for me. Injections of hyaluronic acid should be good for thin cartilage.
tinydinosaur,
Of course, there is a reason even if your doctors cannot find one.
However, my point was that the reason that the doctors diagnosed, does not need to be correct.

[Jasey122]

Thanks. Ive had 2 cortisone injections in the past but non of late. I asked my Dr her opinion regarding Orthokine, Stem Cells and PRP. She said in her opinion stem cells weren't right for me, Orthokine didn't have much evidence base but I could do PRP at their surgery. I was quoted £895 per injection per knee which is quite steep. Not sure my insurance would cover it so Im not sure whether it is worth that much money. And also does it matter which clinic gives the shots so perhaps I can shop around?

As to what is causing my problem my OS reports: ' On examination he has significant bilateral genu valgum with pes planus; I note he has been wearing custom-made orthotics for the last year. THere is profound wasting of the VMO's bilaterally and he has weak glutes in that he is extremely reticent to perform a single squat but drops immediately into valgus when doing so. On the couch, he has a symmetrical range of movement in both knees with obvious patellar alta. There is palpable fibrosis in both fat pads which are moderately tender but patellar apprehension and grind are negative. There is no joint line tenderness and McMurrays test is negative. Cruciates and collaterals are intact. He has moderately tight ham strings. Modified Ober's test reveals proportionately tight ITBs with adduction to neutral although this does not recreate his pain'.

What I gather from this is that I have knock knees which is causing my problem. If anyone can comment on the above I would be grateful.

Over the last few weeks I stopped going physio as it seemed to make my problem worse. But having not gone to physio I'm not much improved so I guess Ill revisit my physiotherapist again. Ill give that a go for a little while before perhaps trying surgery. My Dr doesn't think doing DeNovo or Microfracture is a wise idea and has said it won't fix the problem and could make me worse so I should stick to physiotherapy. It is a bold statement for her to make and she needs to clarify why but she said it was hard to explain  .

Thanks guys again for your support

[vickster]

What are they suggesting to correct the knock knees? Without solving the underlying cause of the issue, it's going to be a long and potentially fruitless road to recovery. Cartilage repair will have a lower chance of success if bones are rubbing together

The cost quoted for the PRP sounds about par for the course in the UK.  Bear in mind you may well need multiple injections. They may help with inflammation but they won't straighten the bones. You can ask your insurers to cover the cost, the surgeons secretary should know how the land lies in that respect. Bupa signed off PRP for tennis elbow for me in the past and for a round of hyaluronic acid for my knee. Never requested PRP for knees, my surgeon doesn't feel there's evidence for articular or meniscus cartilage, only tendons

Can you get a second opinion from another orthopaedic surgeon specialised in correcting wonky legs? Where are you in the UK?

The report sounds like you need to go back to physio and work hard on addressing the mentioned muscle imbalances

Good luck

[Jasey122]

Thanks. I live in London and have been told physio is the main treatment. Perhaps Ill ask them what can be done to correct my knees at my next appointment. I  did get a second opinion from a surgeon at the onset in Jan this year. His comment where:

'On examination he is a tall man who walks with a normal gait.  He has bilateral heel valgus with a flattened medial longitudinal arch. The valgus corrects appropriately on tip toe.  He has long slim legs with somewhat reduced quadriceps musculature symmetrically.  There was no effusion in either knee. He had no specific joint line tenderness. On attempting to do Clarks test just gentle pressure on the quadriceps insertion caused significant pain with a slightly less exaggerated response on the left.  His range of movement was 0-0-140° in each knee. There was no crepitus arising from the right knee but there was in the left.  The collateral and cruciate ligaments were stable. Apley’s and McMurray’s tests were negative.  He had a symmetrical range of movement in the hips with 100° flexion, 40° abduction and internal and external rotation and 20° adduction.

He tells me that over the last few years he has managed to loose 35 kg in weight and this probably has something to do with the onset of his symptoms originally.  He came with an MRI scan from this month of each knee. This does show quite significant changes behind each patella but the patella alignment itself is normal. 

In his own words he feels that his knees were settling nicely before he went to a gym. I explained that whilst quadriceps strengthening exercises are important the means by which the quadriceps muscle is strengthened, namely squats, lunges and resisted lower limb weights, often aggravate the symptoms arising from the somewhat worn articular cartilage in the patellofemoral joint. It is my opinion that non-impact exercise such as walking, cycling and a cross trainer should be sufficient to keep his knees in trim.  He has been asked by a sports physician as to what should be done at the present time.  He has apparently had three steroid and Duralane or equivalent injections in the left knee. 

My suggestions are as follows;

1.   Avoid resisted lower limb weights, squats and lunges. 

2.   Avoid running.

3.   When sitting at his desk for long periods of time keep his knees at 45° rather than at a right ankle or beyond. The latter increases the static forces across the patellofemoral joints significantly.

4.   I think he should avoid over-treatment. 

5.   With respect to his back pain I have discussed the correct way to sit at a desk for long periods of time, by enabling the forearm to be supported from elbow to wrist on the desk, therefore taking the stress off the cervical spine.'

[vickster]

Have you tried swimming as a form of exercise and to help strengthen your legs and back? I found it useful in the past when my knees were bad. Very good for cardiovascular fitness too

[Jasey122]

I was swimming in January which led to this  intense pain so am a bit skeptical. I was also using dumb bells as well so not sure if it was the swimming or dumb bells that led to this .

Problem is from my second opinion the OS did not think I had knocked knees . My conclusion is that I am slightly knock kneed if that makes sense .

I guess for now I'll give Physio an intense go and take it from there. Thx

[vickster]

I'd go see someone like Adrian Wilson in Basingstoke who specialises in osteotomy to realign wonky bones. Tests and scans should determine the degree of wonkiness. His Hampshire knee website is very comprehensive

I too am knock kneed. One surgeon thought an osteotomy appropriate, my usual trusted surgeon felt not. 5 years on and my function in the left leg is no worse even if more tatty looking on MRI

[SuspectDevice]

Jassey, sounds like you have similar knee damage and symptoms to me (bilteral problems on the back of your patella) and similar frustrations finding any solution.

Reading all the medical reports you have got just reinforces my view that medicos are mostly just guessing when it comes to what in both our cases they would broadly call PFPS - which means knee pain mostly behind the kneecap which we can't precisely diagnose or fix.

I do agree with your 2nd opinion surgeons suggestions 1-4 however as all those things apply to me.

I am able to swim, but with a pull buoy between legs and an ankle band to minimise kicking.  I also devised a 30min aerobic gym circuit with boxing, some upper body weights and surprisingly 30-40kg barbell deadlifts which does  not seem to make things worse.  But running, cycling, squats, lunges - forget it.  Even my gym circuit is a bit suspect, but it helps keep me fit and sane, having previously been an obsessed triathlete when all this started 3.5yrs ago.  The only thing I can say definitely does not make things worse is moderate walking (see my Richard Bedard book reference below).  Like you however, stairs and downhills are not great.

What makes mine tricky is that usually the pain is not a problem while actually doing things - in fact my knees often feel better during exercise.  But I pay for it in the hours and days afterwards, so it is delayed pain and it is tricky to learn what caused it.

I've reached a stage where I've essentially given up on any medico assisting me with the current level of knowledge, the possible exception being stem cell therapy in the future if it becomes cheaper (currently $9000/knee in Oz) and better proven as a treatment.

I have had PRP x3 in each knee (it only cost $110/knee here in Oz - everywhere else in the world seems to charge stupid prices) and I definitely got some relief but not long-term or a 100% cure.

Also read Richard Bedards book Saving My Knees and his blog - you will find other people with similar frustrating histories and lack of joy from any outside medical or PT intervention.

I doubt the knocked-knee has anything to do  with it.  Medicos and physios always look for some structural imbalance explanation and in many cases it is bunkum, unless very severe.  I went through the same - several saying my VMOs were weak (impossible when you cycled 10000+kms a year for 5+ years IMO) and then one of the top knee Sports Drs telling me they were fine - small like the rest of my legs, but working fine when he videoed my legs doing various exercises.

I suspect what happened in my case and possibly yours is that something triggered patella cartilage damage - not just one focused point of damage, but a general weakening of the entire structure.  In my case, that damage has healed to some degree, but the pain pathways have become over-active and are still sending out pain signals in excess of the damage.  Also, my pattern of damage is aggravated by certain activities - especially cycling.

I'm now working on this approach to deal with the pain - http://www.theaustralian.com.au/life/weekend-australian-magazine/training-the-brain-to-beat-pain/story-e6frg8h6-1227202215911

I have also found using a TENS machine with the pads around my kneecaps gives significant relief.

All the best.

[Jasey122]

Yep, it seems to be a few conflicting stories as to how bad the situation of my knock knees are so I am getting another opinion. Because where it not for me being knock kneed I would be eligible to try ACI or Microfracture. My surgeon replied when I asked him why I couldn't do ACI his comments where:

'The short answer is that resurfacing techniques such as microfracture and ACI do not work unless biomechanics and abnormal anatomy have been corrected. He could have either of these procedures, both of which require extensive rehabilitation, yet they would be doomed to failure as the underlying cause of his chondral defects has not been addressed. The superolateral fat pad impingement, which is likely to be his main pain generator, will, if anything, be exacerbated by either of these procedures so, in summary, I would not recommend this route!'

Wow $110 for a prp. At 2k, i could get a holiday to oz and back lol so maybe I should look into this. I have totally given up on the gym unfortunately which is very frustrating but oh well.

Ive read Richard Bedard's book but not sure how much of it I have imbibed as I think my symptoms have deteriorated and are quite bad. Thanks for the advice!

[vickster]

Sounds like you saw the same surgeon I did in 2010, who refused to do a Maci for a chondral defect due to knock knees! He gave a 20% chance of success with a 2 year rehab. I'm actually quite glad as that knee doesn't seem to have got any worse (kept under control with hyaluronic acid injections and I guess strong quads from cycling)!

[SuspectDevice]

Well Jasey, if you do make it to Oz, this is where I had my PRP - http://www.hunterpainclinic.com.au/
Not sure what the deal is with a UK citizen getting an appointment over here though.  Also, he did 3 injections about 5 weeks apart and was of the view that I should have no more than 3 injections every 12 months.

I also saw another Sports Dr at one of the pro rugby league clubs here.  He also did PRP but it was about $500/knee.  This guy had also had patella chondro problems himself and had good results from what he called 'drilling little holes in the back of his kneecap' - is that microfacture?

[gcoza]

I agree with every aspect of Suspectdevice's, or should I say Triagain's post. Just a few differences. I can tolerate biking well(perhaps because of fact that my chondromalacia is not caused by overbiking), and, secondly, tens machine doesn't help for pain in my knees.
Price of PRP shot should be around 120-150 Euros in Croatia.
Here I get my shots:
http://www.poliklinika-sunce.hr/lokacije/zadar/