Knee Cartilage issues/options

Triathlon Forum
1

Question about knee issues and lack of cartilage. MRI results below as well as summary of last year’s treatments. I’ve been to lots of doctors and some specialists and have an appointment next week with cartilage specialist to see what can be done. I was hoping to get some input from ST to help be better informed for my appointment.

I had my knee scoped June 2010 by a good friend who is an IM. My knee was quite inflamed especially my snovial tissue, she trimmed about 15% off medial and lateral meniscus, removed my plica, trimmed snovial tissue, and debrided my patella. I had mild arthritis.

Month prior to surgery I was diagnosed clinically with Lyme’s as I had many symptoms. I did have deer ticks attach to me last year that I found from a road ride I did. I haven’t tested positive on the initial titer or a limited Western Blot I think 2 bands. I live where Lyme’s is rampant, between Boston and Providence. I was on various antibiotics for 6 months. I’ve had physicians tell me I have Lymes and others that say I absolutely don’t.

Post surgery I did okay, ran about 6 weeks later, built up slowly, listened to my body. In September took a step backward and had some medial pain that resolved in about 10 days. I was able to complete IMFL without knee pain during or after race but under trained for the run. My quad strength didn’t return completely and I wasn’t able to get full 8% hyperextension as my other leg. My knee continued to swell laterally and was warm to the touch. I did my PT.

December my knee acted up quite badly one week with hilly run, short track workout and cross race and by January I couldn’t contract my quad at all without using other muscles and my extension was terrible.

I have seen 4 PTs, 3 Orthos, will see 4th Ortho at the Cartilidge repair clinic at Brigham and Women’s next week, went to a Rheumatologist to rule out inflammatory issues, saw a sports endocrinologist. I’ve had $3K of blood work to see if I had any inflammatory, endocrine or bone density issues but i don’t. I’ve gotten a brace to help work on knee extension. My patella doesn’t move great. I’ve been on 2 alleve 2x a day for 13 months. I haven’t felt like myself much of the last year. I went to a tri camp in March with mostly cycling came home and felt super tired, unmotivated, took 2 naps a day, so backed off and actually stopped training. I swim and bike as I feel but doing about 1/3 or 1/4 of what I normally do. Motivation is gone and I’m depressed about what’s going on.

I had an MRI yesterday and saw a knee specialist Ortho and Sports med doc today at Childrens Hospital’s Sports Clinic (they see adults too), they gave my steroid injection with original thought I may go synvisc until they looked at teh MRI. They thought I need a knee scope and possibly ACI, they only scope folks under 35 so referred me to Brigham. They were surprised how bad my knee was with 3 spots of bone on bone. Spoke to my Ortho who did surgery a year ago and she is surprised how much my knee had deteriorated from a year ago and wondered why?

This is what my MRI yesterday said:

MRI summary:
~Oblique horizontal tear of posterior horn of the lateral meniscus extending to the inferior articular surface with extrusion of the body of the meniscus
~Root tear in the medial meniscus
~small perimeniscal cyst adjacent to the anterior horn of the medial meniscus
~full thickness cartilage loss of the lateral patellar facet and lateral trochlear cartilages
~full thickness cartilage loss in the central weight bearing portion of the medial tibofemoral compartment
~chronic partial tear in the PCL
~Joint effusion

Old repairs show up as tears

I appreciate any thoughts or suggestions. I’m open to seeing other physicians as well. I had planned to do 2 IMs this year but withdrew from LP last month and wonder if IMFL is possible even if I walk. I’m not fast even when heallthy. I’ve done 3 IMs, being doing tris since '04 and will be 50 this year. For almost 20 years I was significantly overweight. Lost almost 100 pounds, tri training is good for my head and my body. I’m pretty frustrated.

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I am not a doctor and don’t have a lot of medical advice to give but I can relate to your frustration. I have had some of the same issues that you have experienced (except for the Lyme’s disease part). I had knee problems in the Spring of 2008 and had an x-ray which showed no arthritis, the doctor thought it was a tear but insurance wouldn’t pay for an MRI and the pain went away eventually so didn’t think much of it. This past August I was running and all of a sudden it was like someone had a vice grip around my knee, hobbled back to the car, the knee swelled and the swelling and limping has been with me ever since. I went to an ortho who did x-rays and was surprised at the amount of damage (arthritis) that happened since 2008. I also had an MRI and it showed several tears and pretty much bone on bone on the medial side. Have been doing PT although the stiffness and swelling is still present. I also had supartz injections which did make a difference, I can move around without has much limping. I was hoping to return to some minimal running, now I am just happy that I can make it through a trip to the grocery store. I am 53 and this wasn’t what I had expected, thought I would be doing tri’s for a long time. For me the lack of motivation was depression, this has slowly improved as I have refocused on swimming and cycling. I signed up for a sprint tri and the aquabike at Rev3 Cedar Point. I still have good days and bad days, I continue to do the strengthing exercises from PT which seem to help. I don’t have any medical advice but all I can say is I feel your frustation.

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Thanks for sharing your situation…sounds very similar.

I had knee x-rays in December '10 and my cartilage was better than MRI from yesterday. I’ve been limping a lot since December. My knee gets stiff after not moving for 90+ minutes especially after being in the car.

I did a sprint relay with my husband and daughter a couple weeks ago and am doing a HIM AB in about 11 days. I train with power and my sprint power was down almost 50 watts from last sprint. The HIM AB will be just to participate as I’m not ready to race it. I hope to get some ideas of what treatment options are available next week and then process what he has to say. Accepting what is and then finding my motivation to get back to what’s possible and finding joy in the doing is my goal.

I’m amazed I was able to do IMFL last November and wonder if it will be my last IM.

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Since you are in the NE area, as a supplement to your current ortho visits, I suggest contacting Neil Feldman, DPM. (A tri guy who as done Kona as well as other full distance tris) He takes a wholelistic view of issues, I saw him for my medial knee issue and now after orthotics referred me out to a PT group in Worcester that focuses on tri type people. http://www.centralmasspodiatry.com/

5

Did you go to Mike Roberts as a PT? I’ve seen him since January. He has been supportive but haven’t made normal progress with PT.

A IM friend had Feldman do surgery on her feet and Mike helped with post surgery PT for that an other issues.

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Your knees sound a little worse for wear, but I am in a similar boat.

– Chronic partial tear of my MCL
– Early onset of osteo-arthritis
– Several meniscus issues
– PFS
– ITBS

In short weak ligaments that have been damaged but never full tears and only something like 10 - 20% of the cartillege that is supposed to be there. My Docs recommendation was no running.

I went through 3 months of PT, switch to Newtons, slowed my running way down and my mileage has tripled with less pain. HIMs are still my longest distance, but looking to step up to full distance in the next year to two years. I think most of my damage came from carrying a lot of extra weight and the best way for me to drop weight was running. My knees are definitely better and healthier with less weight, so the closer you can get to a low racing weight and maintaining, the better the knees will be

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Hi KathyG!

I went to sosma.org when I had my knee issues; given that what I had was very small but they are specialist in knees, ankles, shoulder, and hips if I remember right.

I will get a second/third opinion before I do something drastic. IMO

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A non conforming treatment is being done up this way in NJ. My buddy had it done and is seeing some improvements as he is now training for the Worlds… He is a PT and has had 9 knee surgeries and feels this was the last hope. So far so good… you may want to locate a Dr exploring this process:

here is my buddies email summary of the process:
PICTURES FROM KNEE PROCEDURE of thursday 10.21/10. VERY FUTURISTIC.
THEY TOOK OUT MY BONE MARROW, WHICH ACT AS EMBYONIC CELLS SIMILAR TO STEM CELLS.
FAT CELLS ARE TAKEN OUT, YES NO LAUGHING IT IS LIPOSUCTION. THEN MY BLOOD IS TAKEN.
MY BLOOD IS SEPARATED OUT INTO PLASMA AND RED BLOOD CELLS. THE RED BLOOD CELLS ARE THROWN AWAY AND THE PLASMA IS MIXED WITH THE BONE MARROW. FAT CELLS ARE FIRST RE-INJECED INTO THE KNEE TO ACT AS BUILDING BLOCKS FOR THE BONE MARROW BLOOD MIXTURE WHICH IS INJECTED NEXT. THIS WAS DONE INTO THE KNEE JOINT AND THEN ANOTHER INJECTION UNDER THE KNEE CAP

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The tricky part comes when both compartments are involved. You said that the meniscal issues are old? Meaning the tears have been clipped/repaired? Or ar they still there?

As far as the lesions go, they are patellar and medial–but not lateral? Depending on the size of those lesions and some other factors, some cartilage work might work–like an ACI/OATS/MFX–might be an option, I’d guess (but not a doctor, and couldn’t say), or possibly an unloader brace to take the brunt of the impact away from the medial side.

The tricky thing about cartilage wear, as I learned, is that “mild” can go to “all gone” in the span of decades–or only a few months. Yes, there are some biomechanical predictors, but sometimes it can sneak up on you. So the rapid wear could be b/c of how your body is built/aligned. It could be b/c of the stress you put on it. It could be b/c of some underlying medical condition. Or it could just be…the way it is. If that makes sense?

Were I in your shoes I would probably see two folks (or two sets of folks): one, a sports orthopedist dealing with knees (and if you can get a cartilage/arthritis type specialist, even better). I’d probably gather several opinions (and I guarantee there will be several, at least). And two, a therapist. Yes, the lethargy and lack of motivation and all that COULD be auto-immune or some such. But it could also be depression. And I will tell you first hand that when you are struggling mentally, it will exacerbate all your physical problems (and, at times, vice versa). Not only can the pain be worse, your ability to deal with it declines.

Not sure any of that is helpful, but speaking as someone who has been on the same roller coaster for several years, I can certainly empathize, and I wish you the best.

10

The road to recovery is paved with many small victories. You’ve got to get your mind right and believe you can do it. I myself had left knee microfracture surgery to repair a cartilage injury and came all the way back to racing IMs. 2 years of really really big effort and I kona qualified. Cheer up, keeping working at it, work hard, work smart. Here is an inspiring and educational story. Marc posts here on ST.
http://www.10-hours.com/about-marc_rubin_blog.php

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Yes, this is the PT people I am seeing, taking a completely different approach than my other PT.

12

The tricky part comes when both compartments are involved. You said that the meniscal issues are old? Meaning the tears have been clipped/repaired? Or ar they still there?

I had both trimmed last June. From MRI appears I have a new extrusion of the lateral meniscus

As far as the lesions go, they are patellar and medial–but not lateral? Depending on the size of those lesions and some other factors, some cartilage work might work–like an ACI/OATS/MFX–might be an option, I’d guess (but not a doctor, and couldn’t say), or possibly an unloader brace to take the brunt of the impact away from the medial side.

Reading more about the size of defects this is what is listed on MRI. The Patellofemoral full thickness loss no mention of size. The medial tibiofmoral loss is listed as central weight bearing portion of the cartilage with 1.2 cm defect with adjacent subchondral edema. The is also a full thickness fissure with delamination measuring 5 mm in the central weight bearing portion of the tibial cartilage. Lateral tibiofemoral: no significant cartilage loss.

The tricky thing about cartilage wear, as I learned, is that “mild” can go to “all gone” in the span of decades–or only a few months. Yes, there are some biomechanical predictors, but sometimes it can sneak up on you. So the rapid wear could be b/c of how your body is built/aligned. It could be b/c of the stress you put on it. It could be b/c of some underlying medical condition. Or it could just be…the way it is. If that makes sense?

Not sure any of that is helpful, but speaking as someone who has been on the same roller coaster for several years, I can certainly empathize, and I wish you the best.

Seems my cartilage went quickly as a year ago MRI and surgery it was normal for my age. Your input is very helpful. Do you have suggestions of website to read and learn more?

13

Hi Kathy,

I’m sorry to hear about the knee. The last thing I’m sure you need is more info thrown on top of what you have already, but more opinions can be good options.

I know you’re in the NE so NYC might not be too far of a drive for a specialist. Dr. Jordan Metzl at HSS is a primary sports med physician and 10x IM finisher. Ive been to a few of their symposiums on sports medicine and he always leads the endurance athlete portion. He’s written for triathlete magazine as well so I’m sure he can appreciate your position.

Best of luck!