Help reading MRI & broader diagnosis

[BigMac82]

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)

[Vickster]

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?

[BigMac82]

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.

[BigMac82]

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.

[Vickster]

Doesn’t sound like there’s anything immediate to address, sort of normal sounding wear and tear given your age. Maybe see Prof Wilson if not too expensive but personally I’d be more inclined to get a thorough physio assessment and check everything is tracking well. I don’t really know enough about lipogems and whether the data is robust to spend £5k+. I’ve found hyaluronic acid helpful for little cost over the years

[BigMac82]

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... 

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).

[BigMac82]

Reading more into the conclusion around the Oedema:

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?

[BigMac82]

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

[Vickster]

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. I’d 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?

[BigMac82]

Thanks Vickster, that's very helpful.

Sorry to labour the point but looking at the list of conditions with the knee, you would still summarise it as being broadly OK? I'm not being sarcastic, this actually gives me a lot of hope if that's the case. You can tell I'm a worrier.

I've had the consult with Prof Wilson, it wasn't especially useful, I didn't learn much more about the treatment etc. I've attached his notes back to my GP for your info - see what you think.

Thanks for the recommendation, the physio I'm seeing certainly knows his stuff but is not expert with knees particularly. I'll get in touch with Clare Robertson to find out more.

Notes relating to condition from the letter below:

Partial medial meniscectomy 2 years ago. At this point he was noted to have a fairly significant trochlea lesion. He had a medial meniscectomy. This settled his medial knee pain but his anterior knee pain sadly got worse. He also felt quite unstable.

He obviously underwent a hamstring reconstruction under your care in August 2017 without complication. He noted grade III damage to his retropatellar surface. This has helped significantly. He has less general pain the knee feels more stable. The anterior knee pain is better, but he has now getting medial knee discomfort which he feels just below the jointline.

On examination he has fairly neutral alignment clinically. Scars are consistent with his previous surgery. No effusion. 5 degrees of hyperextension and flexion to 130 degrees. He is lacking the last 5 degrees. His patellofemoral joint didn’t have major crepitus. He is not particularly tender laterally, slightly tender over the jointline medially and slightly more tender just below the jointline medially. The patellofemoral joint wasn’t particularly irritable. The ACL felt rock solid with negative anterior drawer, Lachman and pivot. His collaterals and PCL were intact. His hip movements were good.

His MRI scan shows a full thickness trochlea defect which is quiet without any major osteitis. There is some osteitis medially in the tibial plateau level with the tibial tunnel. He has meniscal deficiency. There is some medial femoral condyle articular cartilage loss.

He symptoms now seem to be more medial than patellofemoral. We talked about the options today of steroid, hyaluronic acid, Ossur bracing or biologics including PRP and Lipogems.

If we are not successful with Lipogems and PRP we are then going to look at the alignment with an alignment x-ray and we will do this through his insurance but for now we are going to go down the route of PRP and Lipogems and see how he gets on. I am also going to ask, Ashley his physio to fit him out with an Ossur Unloader One brace to see if he can benefit from this as this will not only help him in the short term but also guide us in terms of further intervention such as an osteotomy.

[Vickster]

What is he hoping to achieve with the PRP and Lipogems?
How will he measure success?
To me it seems a bit odd for an osteotomy expert not to check the alignment before embarking on v expensive experimental treatment if he thinks there might be misalignment? Ditto why recommend a very expensive brace without looking at alignment as surely that needs to be known for the customisation of a brace (or are you just going off the peg, still cost a fair few hundred afaik).
Has he graded the degree of cartilage loss over the medial condyle? Is there bone marrow oedema which could be the source or pain?
Why didn't you think the consult useful?

In terms of rehab and strengthening, have you tried hydrotherapy? I've found it useful to be able to do exercises in a low impact warm environment and plan to rehab after my knee op in the local hydrotherapy pool once cleared to do so. You do need a physio specialist in hydro rehab to design a programme of course. Much better than a cold or cool swimming pool!

[BigMac82]

Thanks Vickster, I find it very reassuring to have someone reply who has actually been through something similar and is not trying to sell me something!

His POV was that as I would like to avoid surgery having the X-Ray to check on alignment (that visually he thought was OK) would be a waste if there was no intention to have the procedure. No he didn't seem to grade the loss, the closest I've to this was what the MRI report said around 'mild' and 'early', whatever the hell that means.

Do you think I should push over email on the grade?
Do you think I should get the X-Ray done? He provided a referral if I wanted to pursue it, more cost of course.

I think he envisages me borrowing a support from my physio and seeing it helps, the assumption being that if it does then I have an alignment issue.

I was dissatisfied with it overall as I had many questions, similar to the phones you've cited around what impact the oedema has, where it's coming from, what's the situation with the tibia/tunnel, what's most likely causing my pain. The basic answer was that it could be the trochlear or the medial condyle. Basically who knows! I've met 3 surgeons over this period and none of them really come with clear specific information and some have even contradicted themselves over time, very frustrating.

Thanks for the note on hydrotherapy I'll look it up. Do you take any supplements? So much out there and so many kinds with conflicting information, just wondered what your thoughts were.

[Vickster]

Fair enough. He's clearly pursuing your wish to avoid surgery which given that the findings on MRI are mild seems to be very sensible. Surgery should be a very last resort and the evidence for such in mild arthritis is that it may help short term but not longer term. Better to control inflammation especially after exercise and to use the right exercises to make sure the muscles are all working well, hence the need for the right physio

Cartilage damage is graded, 0 (nothing), 4 (through to the bone). There's lots of good info in the arthritis primer in the learning portfolio, including an explanation of the scale.

If he doesn't think you're misaligned, then that's probably enough given this is his area of expertise. Personally I can tell quite easily that I'm valgus and it's obvious to every doctor and physio I've seen, but it's mild I'm told, not correctable by brace and the ship has sailed for osteotomy (One surgeon suggested a DFO 8 years ago but there's no way I was going down that road and I don't think mild misalignment the cause of my issues anyhow).

Your menisectomy is probably the cause of the medial changes, not a lot you can do except exercise appropriately and avoid inflammation.

Interesting that your physio can lend a brace,  never heard of that, other than in the NHS. If you do a lot of walking, then a brace may be worth a try. Have you tried using a simple but decent quality neoprene support? Do you use a walking pole on long walks? Might be worth a go

I take vitamin D and Omega 3 alongside medication prescribed by my rheumatologist. I did try glucosamine/chondroitin years ago but it made me feel sick and the evidence is sketchy anyhow.

Ref pain, nerves are weird and pain can refer, cartilage itself has no nerve endings, so the pain will be coming from elsewhere, caused by tight or shortened muscles etc. That said, degree of damage is not directly linked to pain levels, some people with severe arthritis have little pain and inflammation and vice versa.

[BigMac82]

Yes my current physio has said my leg is very weak and so getting strength back, in a controlled, steady, 'un-provoking' way can only improve my situation. More recently he's keen for me to get my VMO built back up, he believes this will correct the dropping sensation my patella has as it moves down the trochlear from the outside to inside - hoping it might help it avoid or at least avoid irritating the trochlear lesion when doing other activities.

Yes I've seen the grades but the last time I was graded was at the ACL recon 18 months ago.
Prof Barrett cited I had:
"Grade 3 Trochlear Lesions down to bone". So it that a 3 or a 4?!

And the recent MRI 1:
"with medial femoral condylar articular cartilage thinning but no areas of fuII-
thickness fissuring or loss."

MRI 2:
"Moderate chondropathy in the medial compartment. Mild central patellofemoral chondropathy."

Regards avoiding inflammation,  I think this is one area I might be lucky. I get the pain, more often 24 hours after the irritating activity, but the knee is very rarely (ever) noticeably inflamed/swollen. Though it does occasionally get very hot - would you also regard that as inflammation?

Physio hasn't mentioned any swelling/fluid in some time.

Yes I have Glucosamine at home but have never really taken for long enough to say if it helps. I was kind of put off once reading contradictory results on it's benefits. I think I'll give Vitamin D and Omega a go though, are there any brands or sites you would recommend? Would like good quality.

Have you ever explored Green Lipped Mussel, Botsweila, Colostrum, Collagen?

Re: pain, I think I'm low-med wear and high pain, I'm not sure what's worse!!!

[BigMac82]

Tried 10, 20 and then 30 mins this week on a X Trainer, no/low resistance. Felt OK, but after the 30 min one had Patella pain for the rest of the day - possibly the Trochlear lesion I guess. Any cardio / strengthening you would recommended?

Aside from that, doing leg press, shallow squats and single leg lunges (backward avoiding knee pressure), these feel OK, just trying to work it slowly.

Re: Claire 'Patella' - I got in contact and they've advised an initial session, of an hour at £195. Is it worth it would you say? My physio is £40 for half hour, though assume it's completely different approach with her.