Question for Deak (or other knee experts)

Triathlon Forum
1

Hi! I’m sorry to make an account here just for this post, but I’ve had an 8 month knee injury and I’ve been looking for anything online that slightly resembles what I have.

A Google search led me to this post (http://forum.slowtwitch.com/gforum.cgi?post=3170536;&t=search_engine) which is about the closest thing I’ve found that is similar to my injury. Like the OP, I am a runner (I run in college) and became injured in December when after being sick for 6 weeks (no mileage) I suddenly jumped back into intense speedwork. Well, both knees suddenly got intense pain and now I haven’t been able to run for 8 months. Even walking is very painful.

In February, I had an initial MRI and was diagnosed with a bone bruise in both knees, and because the damage was beneath healthy cartilage, the orthopedic surgeon said there was nothing he was able to do. After almost no improvement in pain in the past 5 months, I just got a second MRI and am still waiting on the official diagnosis, but I’ve been pouring over the results myself.

As far as my untrained eye can tell, it looks like a medial femoral condyle bone bruise or perhaps even a fracture. What’s bothering me though is that on studies I have found concerning bone bruises (using my university access), even giant, horrible looking bruises on radiographs seem to resolve fully in a few months – even for 60+ year old patients. My injury appears much smaller than these and doesn’t seem to really be doing anything, so it’s rather disturbing.

Anyway, I was hoping if you’re not too busy Deak that you might be able to shed some light on this mystery. You provided some good advice to SHock, and anything you could contribute would be great for me.

Here’s my original MRI from February. Contrast is bumped up way too much just to highlight the injury:

http://dl.dropbox.com/u/9699560/mri.jpg

And here is the MRI I just got. I only got it in my right leg this time, but this MRI is a 3 Tesla scan as opposed to a 1.5 Tesla scan from the first one:

http://dl.dropbox.com/u/9699560/Bone%20Bruise%2011-7-28.png

Again, any insight you or anyone else can provide is greatly appreciated by me.

-Nick

2

OCD

Best guess based on the images & your history. Let me know what the formal report says, and what you end up doing. Where are you located?

3

Wow, thanks for the reply! I should have the formal report tomorrow, but I’ve found there’s value in getting multiple opinions.

I’m located in Atlanta.

4

As always, I have to preface my response by saying that I will give you a general reply and not one specifically dealing with your case as one can not make an accurate diagnosis with out a thorough history and physical examination as well as a review of all diagnostic images. Having said that, I need a little more information before offering any opinions. What is your age, height and weight and how long have your been running? Any previous knee injuries? What was the illness that kept you off running for six weeks? Any swelling in the knee associated with the onset of the pain? If you would prefer you can PM me but I would assume that seeing as you already posted your own MRI images that you don’t mind discussing this on the forum.

5

I don’t mind discussing on an open forum. Hopefully it can assist future Google-searchers.

I just turned 21. I’m 5’10" and have weighed about 140-144 lbs for years now. I’ve been running for almost 8 years and was never injured at all before this (not even slight pains). What happened was that in late November, I caught the flu pretty badly – badly enough that I couldn’t run. In addition to this, my training schedule already called for low mileage, so I had about 5 weeks of almost no mileage. Before this I was running about 65-85 miles a week.

The very next week I jumped back into running full throttle (very bad idea in retrospect). The first speed workout left every muscle in my body aching. Everything was tighter than it had been before, but I’d never gotten injured so I saw no reason to ask for a day off. I remember though that my body was so tight that my run the next day consisted of running to a lamp post and stretching for 20 minutes and then running back. I had another speedwork the following day, and again my muscles were incredibly sore all over. The next day after that I think I limped half a mile because I was so sore. Of course, the next day I had a one mile race, and it was shortly after this that I felt a bit of a pain in my left knee. I iced it and it seemed to go away, so I kept running. Later that week I was walking through a Target parking lot and I took a step and my left knee just gave out completely. I was carried over to the car. The next two weeks I couldn’t put any weight on my left knee because it hurt so bad (this was over Christmas break). I just sat in a chair for two weeks. As far as I can remember, there was no swelling or outward signs of injury. Going up and down steps was incredibly painful though. (This has improved somewhat over time, although walking has not).

Well I got back to school, and the injury was diagnosed as patellofemoral pain syndrome. The doctor told me if I could stand the pain, it wouldn’t hurt me to run on it. I was very hesitant to run because it felt so unstable but I was losing training and I figured that since he said I couldn’t hurt it, I might as well try. I might mention at this point that the doctor had me taking 3 Motrins a day, which – looking back – was probably masking the pain. I wouldn’t have been able to run otherwise. So I got about a week of unstable running in before my right knee gave out in the exact same manner that my left knee did.

At this point, the coach told me to quit running because she was afraid I was going to damage something permanently. I got an MRI, and the doctor diagnosed it as arthritis and chondromalacia. I wasn’t quite sure the MRI looked like arthritis (it’s the first MRI in my post above) and my symptoms didn’t quite match arthritis. Anyway, over the period of about three months, the doctor tried various things that would hopefully make the pain go away. He didn’t want to try anything too severe to begin with. So first he gave me a cortisone injection. After this did nothing, I got Synvisc One injections in both knees. That also did nothing.

That doctor then advised that I see the orthopedic surgeon (my current doctor) who works at the same location as he does, and the orthopedic surgeon said that MRIs could be misleading and that I didn’t really have arthritis or chondromalacia since there was no cartilage damage. This was when he diagnosed my injury instead as a bone bruise.

I can PM you a link to both of my full MRIs that I uploaded to Dropbox if that would help.

Like I said, I greatly appreciate any sort of insight you are able to provide.

6

I don’t think I need to see all the MRI images as the ones you have posted are pretty representative. It seems that you have suffered a stress injury to the medial femoral condyle because you were off for six weeks and then resumed running and more importantly speed-work with out the requisite gradual ramping up of intensity and distance. Your knee joint was in a vulnerable state when you over-stressed it. This caused a sub-chondral stress reaction (read stress-fracture). This has led to the development of a cyst under the hyaline cartilage/articular surface. The first MRI shows a sub-chondral cyst with intact overlying articular cartilage. The latest MRI shows some irregularity of the overlying articular cartilage. The best initial treatment is to stop running for 6-12 weeks until symptoms subside. Water running and cycling can be substituted for running. Now at eight months, you need an arthroscope and possible debridement of the irregular joint surface with drilling of the cyst. The drilling of the cyst relieves the pressure (this is what probably causes the pain) and brings in some blood supply so hopefully the cyst fills in. This is a very difficult problem to get to resolve and can take many months to achieve healing. There are other surgical options if the scope doesn’t do the trick and these are best addressed with your orthopaedic surgeon.

7

Is a cyst the same thing as an osteophyte? For some reason I was thinking that what was embedded in the articular cartilage was an osteophyte… and I had read that osteophytes do not go away over time, but it looks like the cyst/black dot has faded between the first and second MRI.

It’s good to know that arthroscopy can help – I assume my OS will recommend something like this when I hear back from him.

Have you seen cases like this that eventually resolved to such an extent that the person could train again?

Once again, I’m very grateful to you for sharing your knowledge on this.

8

No. An osteophyte is a boney spur that develops at the edge of a worn out joint surface. The bone essentially grows outward in response to wear and degeneration of the joint surface. A sub-chondral bone cyst is essentially a hole in the bone that arises in response to excessive force and stress fractures occurring with this excessive force. Cysts, similar to these, are also seen in osteoarthritis and eventually become filled with a jelly like material. I have seen this condition frequently in my practice and it can be difficult to treat. Usually I am happy if I can reduce the pain level to 2 out of 10. Most people with this problem are not advised to continue running long distances.

9

docjeter, I just got the formal report today.

The radiologist says it is a medial femoral osteochondral defect. He says it is a full thickness defect, but the OS thinks it may be partial thickness.

He said my options are exploratory arthroscopy with a possibility for performing microfracture.

I’m not entirely sure, but I think this agrees with Deak’s diagnosis. Correct me if I’m wrong.

10

Deak, have you seen the study titled “MRI-Demonstrated Outcome of Subchondral Stress Fractures of the Knee After Treatment with Iloprost or Tramadol: Observations in 14 Patients”?

It seems to show promising results for non-surgical treatment, although the study was performed only a few years ago so I’m not sure if I’d be allowed to try it:

Patients: Fourteen patients with at least a single subchondral stress
fracture of the knee, surrounded by bone marrow edema, visible on
T1-weighted and short tau inversion recovery magnetic resonance
images.

Results: After three months, the SSF volumes had decreased by a
median of 42.2% in group 1 and increased by a median of 2.2% in
group 2 (P = 0.008). After 1 year, the median decrease in SSF volumes
was 100.0% in group 1 and 65.7% in group 2 (P = 0.017).

Conclusion: This small case series suggests that healing of SSF is
more pronounced after Iloprost treatment.

11

Deak, have you seen the study titled “MRI-Demonstrated Outcome of Subchondral Stress Fractures of the Knee After Treatment with Iloprost or Tramadol: Observations in 14 Patients”?

It seems to show promising results for non-surgical treatment, although the study was performed only a few years ago so I’m not sure if I’d be allowed to try it:

Patients: Fourteen patients with at least a single subchondral stress
fracture of the knee, surrounded by bone marrow edema, visible on
T1-weighted and short tau inversion recovery magnetic resonance
images.

Results: After three months, the SSF volumes had decreased by a
median of 42.2% in group 1 and increased by a median of 2.2% in
group 2 (P = 0.008). After 1 year, the median decrease in SSF volumes
was 100.0% in group 1 and 65.7% in group 2 (P = 0.017).

Conclusion: This small case series suggests that healing of SSF is
more pronounced after Iloprost treatment.

This treatment is in fact the treatment of choice for the first couple of months along with protected weight bearing and activity modification. Unfortunately your problem is now quite a few months old and not likely to respond to acute phase treatments. I think you need the scope and probably drilling of the defect.

12

Best of luck Runner77, and cool on Deak!

13

Thanks for the help and luck everyone! I’ll let you know what I do and how it’s going in a few months.

14

Well, I’m kind of upset.

I just got back from my meeting with my OS, and he said I didn’t have OCD – he said I have a cartilage defect.

He said I could risk microfracture although he highly discouraged it, and he said if I went through with it, then it would be a year or more before I could attempt running at all, which he also recommended against.

Furthermore, cycling 22 miles (a little over an hour) is apparently considered high mileage and is not recommended anymore, even though it causes no pain.

And he said the Iloprost study was garbage that was made up by people with a financial interest.

So I’m doing nothing for another 8 months as I wither away and lose health. I’m at a loss.

15

Oh, and that white spot in the subchondral bone isn’t a fracture. It’s bone marrow edema. I still think it looks like a fracture.

16

You don’t have OCD. You have a sub-chondral cyst with irregularity of the overlying cartilage. I still think you should go ahead with a scope, debridement of the cartilage and possibly drilling of the defect. Maybe you need to find an ortho who better understands the endurance athlete. I would limit your running but not your biking. I would tell you to spin and try not to stand up or push big gears. Definition of high mileage is averaging over 100 miles per day. Swimming and water running are of course, fine.

17

Yeah, the not having OCD was for docjeter above.

Honestly, I agree with your assessment.

As for the cycling, I’m just going to continue the high mileage and not mention it to anyone. I have developed a case of something going on with my IT band and my kneecap is kind of “jumping” in and out on each stroke until I pop it. I suspect it is from overall weakening muscles since I have avoided activity for a while now. My OS’s advice was to “stretch” and that was about the extent of his help.

18

Thanks for the update…soRry to hear the news. I’ll definitely defer to deak on this one. He truly knows his stuff. I’d listen to him. Like I said, I don’t deal with this too much. Good luck!

19

Yeah, the not having OCD was for docjeter above.

Honestly, I agree with your assessment.

As for the cycling, I’m just going to continue the high mileage and not mention it to anyone. I have developed a case of something going on with my IT band and my kneecap is kind of “jumping” in and out on each stroke until I pop it. I suspect it is from overall weakening muscles since I have avoided activity for a while now. My OS’s advice was to “stretch” and that was about the extent of his help.

Is this the same knee? If so, you are correct, it usually gets better with medial quads (VMO) strengthening. Best way to do that is straight leg raising and near full extension, leg extensions. ART on the IT band by a good massage therapist also helps.
See a new ortho with Tri knowledge.

Good luck

20

Yes, this is the same knee. And I will try to locate an OS with more experience with endurance athletes.

Thank you for the help.