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Author Topic: Help reading MRI & broader diagnosis  (Read 273 times)

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Offline BigMac82

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Help reading MRI & broader diagnosis
« on: December 18, 2018, 08:03:35 PM »
Recently had some MRI scans in preparation for a visit to Dr Adrian Wilson in London regarding potential Lipogems treatment. I've shared a link to the MRI, any input/reporting would be greatly appreciated. I've also listed my history / current state below as context but also if someone has any ideas or miracle cures! :)

https://www.dicomlibrary.com?study=1.2.826.0.1.3680043.8.1055.1.20181218193917795.39935553.89389259

More info:
I'm 38, and have had two ops in the last 3 years. The first in May 2016, after a meniscus tear/complaint and known ACL tear. Initially I opted for just the Menisectomy and Chrondroplasty and the knee was largely stable. Upon performing surgery it was discovered that I also had grade 3/4 wear on the trochlear groove. This op actually made things worse, post op the moderate/acute meniscus pain was gone but replaced by a lot more instability in the knee and a severe/acute pain in the patella on bending and climbing stairs, not present before this op. The knee also ached most of the day and night and caused me to lose a lot of sleep and slip into depression. I was a very fit and active person prior to this.

Over a year later (Aug 2017) and despite following rehab religiously, I decided to have the ACL reconstructed. The hope was that this would make the knee stable once more and hopefully address/realign any issues causing the severe knee cap pain. Post ACL recover and rehab progressed well but still with pain in the knee cap, but much more stability. The physio eventually suggested 3 months of inactivity/rehab in a bid to rule our hyper sensitivity. This did seem to help and the chronic pain has largely disappeared.

Now 16 months post op. I wear insoles as I'm slightly flat footed Day to day I rarely get pain in the knee cap now and more often I get aches and pains in the Pes Anserine / Hamstring attachment / high Tibia area. In terms of activity, I'm still not particularly far along. As you can imagine the muscles have wasted away significantly. Walking longer than about 10-20 minutes starts to cause aches and pains in the Pes Anserine area. There's moderate crepitus and following a very cautious physio program I'm now doing single leg press at 40-50kgs with minimal to no discomfort and only occasional aches around 24 hours later - again in the Pes Anserine area. I also do single leg hamstring curls on the gym machine at around 15kg and find that this really takes some of the tension away in the Pes Anserine area.

This impacts day to day activities, even simple walks with the dog become very painful and I certainly could not jog, cycle or row for basic fitness.

The area of pain and ability to do certain exercises leaves me confused as to what's causing my current issues.

Questions in my mind:
  • Given the location of the pain could the hamstring attachment or graft site be causing the pain or changing my mechanics?
  • Could this be referred pain from within the knee?
  • If it is referred is it more likely from the trochlear (3/4 wear)?
  • What treatment options would you consider? (I don't want to do an Osteotomy, currently looking at expensive Lipogems or similar)


Offline Vickster

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Re: Help reading MRI & broader diagnosis
« Reply #1 on: December 18, 2018, 08:22:44 PM »
Unfortunately there are no radiologists on the site who could read the MRI, do you have a written report? Or feedback from Prof Wilson on state of knee or cause of issues?

Has an osteotomy been suggested and why?

Unfortunately, for arthritis if that's what the issue is, there aren't miracle cures. Have you tried hyaluronic acid injections less costly than the many thousands for lipogems?

Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline BigMac82

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Re: Help reading MRI & broader diagnosis
« Reply #2 on: December 23, 2018, 08:42:06 PM »
Thanks Vickster, appreciate you responding. I've not yet received the report, once I have it I'll post it up.

Yes a Osteotomy has been highlighted as an option, by my former surgeon of the ACL recon - Prof David Barrett. Prof Barrett referred me to Prof Wilson knowing that he specialises in both the Osteotomy and the Lipogems so could give me advice on either/both hopefully. I wear insoles to help with flat foot (physio says I have this), but never had any of these problems priori to the first op.

Yes I've read a lot on this forum and can see there are no quick fixes, wishful thinking on my part!

Yes, I've had tow Hyalronic injections, one after the first operation and one after the second operation, neither really offered noticeable relief. Not tried a steroid injection, no one has offered this.

Most of the crepitus comes from the Trochlear and so did the knee cap pain. This pain is not as frequent, but is starting to kick in as my leg press increases. At around 50kg now. I also get some pain on the medial side, but 2-3 inches lower than the knee around the Pes Anserine.

Not sure how long to leave it. I genuinely can't walk for 10 minutes without pain and really haven't got the strength to jog etc - even if I was brave enough! Just not sure what to do, feel in limbo and feel like at 36, this can't possibly be it for my knee, a PKR feels too severe even given my limited activity.

Any thoughts or options I haven't considered? Read so much about benefits of supplements but also a lot of noise out there. Right now I' would give anything a try.
« Last Edit: December 23, 2018, 08:45:14 PM by BigMac82, Reason: Mistake »

Offline BigMac82

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Re: Help reading MRI & broader diagnosis
« Reply #3 on: January 09, 2019, 10:43:22 AM »
Update, I now have the radiology report back. Any advice or lamens terms would be much appreciated here. Meeting with Prof Wilson on the 14th January, hopefully he can advise on my treatment plan / options going forward. Vickster your expertise would be really welcome.

Procedure
MRI Right Knee
Examination Date: 18.12.2018
Reported and Verified by: Iain Gibb, Consultant Radiologist

Clinical Indication
Right knee pain involving the medial aspect and anteriorly.

Findings
A standard knee protocol has been performed and compared with the previous pre-operative examination of 14 October 2016. There has been ACL reconstruction within the interval. There is associated susceptibility artefact associated with the tibial intraosseous fixation. There is some minor tibial oedema adjacent to the medial portion of the tunnel with subchondral position, but the overlying articular cartilage appears preserved. Minor cystic changes seen within the more proximal portion of the graft, but the graft is intact the PCL, MCL and extensor mechanism and lateral stabilising structures appear intact. No evidence of ongoing inflammatory change or effusion. No evidence of cyclops lesion. The medial meniscus appears more attenuated particularly in the posterior horn than previously seen which may reflect further surgical intervention, but no displaced meniscal fragment is identified. There is some minor heterogeneity in the mid third articular cartilage and some generalised but subtle articular cartilage thinning, but no definite full-thickness fissuring or subchondral change identified. The trochlear appearances are unchanged with heterogeneity but no subchondral changes. The retro-patellar articular cartilage remains preserved. No significant inflammatory change within the Hoffa's fat. Soft tissues surrounding the knee appear preserved. There are some minor osteoarthritic changes within the knee with small notch osteophytes noted.

Conclusion / Recommendation
There is some minor anteromedial bone marrow oedema adjacent to the tibial tunnel which is nonspecific in appearance (series for image 13). No generalised oedema or inflammatory change. No significant postoperative sequelae or graft failure to explain the patient's symptoms. There are early degenerative changes within the knee joint as a result of injury and partial meniscectomy with medial femoral condylar articular cartilage thinning but no areas of fuII-thickness fissuring or loss.

Offline Vickster

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Re: Help reading MRI & broader diagnosis
« Reply #4 on: January 09, 2019, 02:06:47 PM »
Doesnít sound like thereís anything immediate to address, sort of normal sounding wear and tear given your age. Maybe see Prof Wilson if not too expensive but personally Iíd be more inclined to get a thorough physio assessment and check everything is tracking well. I donít really know enough about lipogems and whether the data is robust to spend £5k+. Iíve found hyaluronic acid helpful for little cost over the years
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline BigMac82

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Re: Help reading MRI & broader diagnosis
« Reply #5 on: January 09, 2019, 04:47:11 PM »
Thanks Vickster, much appreciated, your words provide comfort - though my symptoms less so. The general pain and inability to walk for 10+ mins.

Seeing a pretty good physio at the moment. Said my legs have pretty much wasted away from consecutive operations and no window for rehab. He advises that it's tracking well generally but not under tension, it's going off anteriorly (outside?) and has advised I build up the VMO this next 6-9 weeks very gradually to avoid any pain. This is with a view to getting the VMO beefed up and start to help the patella to track more 'medially' and therefore minimise bumping/catching on the way down (during squats etc). I'm currently doing things like lunges and squats with a focus on moving back with the hips and keeping the Tibia as vertical as possible, avoiding the knee being over the toes in any way.

I have tried Hyaluronic twice and didn't really find any noticeable benefit on either occasion unfortunately.
Are there any other pain relief or injections you've found to be beneficial?

Slightly concerned by the note of osteoarthritic/osteophytes change as well as the general comments on the condition medially. I get the general feeling my symptoms seem to outweigh what can be seen within the joint...  :o

EDIT: I also forgot to add, the physio also said that I have quite flat feet, so I've been wearing arch support insoles, which I think helps a little with the walking. Noticed on YouTube some arch support exercises this week, so might give those a try, I didn't get this advice from the physio (just to get insoles).
« Last Edit: January 10, 2019, 09:10:26 AM by BigMac82 »

Offline BigMac82

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Re: Help reading MRI & broader diagnosis
« Reply #6 on: January 10, 2019, 03:06:39 PM »
Reading more into the conclusion around the Oedema:
Quote
minor anteromedial bone marrow oedema adjacent to the tibial tunnel

'Googling', always dangerous, showed these two possible causes:
Osteomyelitis or Cysts in the Tibial Tunnel

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597533/

https://www.hindawi.com/journals/crior/2017/6383526/

Mine was a Hamstring graft and using 35mm Endo button and 10x35rnm tibial screw.

Any thoughts or anyone else encountered this?

Offline BigMac82

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Re: Help reading MRI & broader diagnosis
« Reply #7 on: January 16, 2019, 07:29:57 PM »
Another update, I've now had an MRI on a T3 scanner at the surgeons request. This has yielded a slight different report, any thoughts on this anyone? Vickster, same opinion?

Lipogems sounds interesting, but only 70%-80% success.

MRI Report
No effusion or popliteal cyst is seen.
There is truncation of the posterior horn and body of medial meniscus in keeping with previous
meniscal resection. No recurrent tear is seen. There is a moderate chondropathy in the medial
compartment.

The lateral meniscus is intact and has normal morphology. No chondral lesion is seen in lateral
compartment.

Early chondral irregularities present in the central patellar ridge with some fissuring of the
central trochlear articular cartilage. The anterior fat pads, quadriceps tendon and patellar
tendon appear normal.

Some increased fluid signal is present in the pes anserinus bursa.
There has been a previous anterior cruciate ligament reconstruction. The reconstruction is
intact with no roof impingement or tunnel complication seen. The posterior cruciate ligament,
medial collateral ligament, lateral collateral ligament, iliotibial band, biceps tendon, marrow and
synovium appear normal.

Impression
Pes anserinus bursitis. Uncomplicated anterior cruciate ligament reconstruction. Moderate
chondropathy in the medial compartment. Mild central patellofemoral chondropathy

Offline Vickster

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Re: Help reading MRI & broader diagnosis
« Reply #8 on: January 16, 2019, 08:06:43 PM »
Sounds like physio would be a good first step if your issues are muscular and everything else is broadly ok. Maybe seek out a specialist like Clare Robertson in Wimbledon who specialises in patellofemoral and broader knee issues. Iíd spend a few hundred and 6 months on rehab rather than 6k on a fairly unproven treatment with a one in three chance of little to no effect

You could have the consult with Adrian Wilson which is presumably £300?
« Last Edit: January 16, 2019, 08:17:13 PM by Vickster »
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up















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