Triple Jeopardy -- 3 Conflicting Opinions on Knees

Triathlon Forum
1

Greetings STers. Long time, no post. That’s because I’ve been enveloped by depression over a knee that just won’t get better.

My knee always feels inflamed under any kind of load, including standing and walking around. The bike was the worst, so I pretty much have stayed off of it for 18+ months. I began spinning easy for 10-30 mins a couple months ago, but that still clearly annoys it. For for all of that time, I got no useful answers from any orthos, as they chalked it all up to chondromalacia and shrugged. Then I started seeing the best in the field (renowned researchers, famous name clinics, etc) and suddenly I’ve found doctors with opinions. Sadly, they are in conflict with one another. See what you think?

Dr. “A”… suggests my kneecap doesn’t quite glide perfectly well, thinks my patellar tendon and the area around it may have some very subtle scars from two previous arthroscopes (looking for a reason I couldn’t fully extend in '85 after a bike crash, and then exploring the inflamed feeling and “fullness” at extension in '08 which continues today). Suggests an anterior interval release procedure where the tendon would be freed up, some fat pad removed as needed, and an area enervated. I saw someone he referred me to at a top university hospital, and he concurred (though he wants to see hip/glute physical therapy first, just because).

Dr. “B”… says that’s wrong, the kneecap glides fine and scar tissue is not an issue. Patients come from around the world for him to work on their scar tissue, and he said I’m absolutely not in need of that. He knows Drs A above and B below, and was even trained by the same famous knee genius. However, he believes it’s all related to patellar tendinosis, entirely extracapsular (note: MRI report says tendon is normal). Suggests an eccentric squat routine, maxed out physical therapy, and PRP (platelet therapy) if that fails. And says no surgery.

Dr. "C’… is known worldwide, and is a “renegade knee theorist”. Super interesting character. He says all the others are wrong, and thinking too much about structure and not enough about the metabolic biology of the knee as a system. He says I have synovitis, points to it and excess fluid in the knee, and that I need to rest rest rest, take anti-inflams, ice, and avoid all irritating movements. I’ve already done that on/off and had zero improvement. He suggests it wasn’t enough and that I should get a bone scan to look for any irregular metabolic activity (Ok, I will).

I really have no idea what to do now, or which direction to choose. It’s been so long, I just want results NOW. I’ve already done stuff like cortisone shot, synvisc, ART, acupuncture, yoga, strength training, drop squats, months of rest, etc. Nothing. I seem to have built up more ability to tolerate more intense work, like one-leg squats, but my baseline symptoms never improve. And it’s keeping me from cycling the way I want to.

At least no one can say the usual ST line of “you’re asking on an internet forum? go see a doctor!” BTDT.

Thanks for ideas and thoughts.

2

Wow - good to hear from 'ya Aztec!

Now way anyone here can help via the screen … but my gut instinct is Dr. "B"s opinion/treatment plan. For whatever that is worth.

Good luck!

3

I couldn’t find it in your post, but what is keeping you from cycling the way you want to? I didn’t see any reference to any excruciating pain just that it feels swollen. I would suggest keep up the ART and yoga and build your mileage slowly. Surgery isn’t going to make it much better IMO. As far as the tracking is concerned, is your VMO weak? Are you doing the leg press with the ball between your legs? Have you looked at your hip adductor/abductor and quad/hamstring ratios? That will affect tracking as well.

4

Wow - good to hear from 'ya Aztec!

Now way anyone here can help via the screen … but my gut instinct is Dr. "B"s opinion/treatment plan. For whatever that is worth.

Good luck!

Thanks, Rod. I’m hoping for a comeback. One thing all the docs agree on – my knee isn’t that bad. Some say I shouldn’t even really have symptoms.

Dr B’s path is obviously very conservative, so combining it with rest rather than the eccentric squats may be the most conservative possible way to go. I figure it only costs me time if I start that way and resort to more aggressive approaches as time ticks by. But I’m freaking out about one thing… I’m already 44. The clock of fitness capacity is ticking!

5

I’d go with a vigorous PT routine, like Dr. B says. Also, perhaps have it drained… And, perhaps, just learn to live with the fluid.

Have you been checked for gout?

6

I couldn’t find it in your post, but what is keeping you from cycling the way you want to? I didn’t see any reference to any excruciating pain just that it feels swollen. I would suggest keep up the ART and yoga and build your mileage slowly. Surgery isn’t going to make it much better IMO. As far as the tracking is concerned, is your VMO weak? Are you doing the leg press with the ball between your legs? Have you looked at your hip adductor/abductor and quad/hamstring ratios? That will affect tracking as well.

No pain, at least not material. Just an uncomfy swollen feeling in the knee made worse by riding and standing. That’s enough to keep me from riding at all. Small aches/pains are in the knee under loaded riding.

I can’t really build mileage at all, as there’s no material amount that doesn’t worsen the symptoms. And I have the symptoms before going on the bike in the first place (I have not been asymptomatic in 18+ months).

VMO is an outdated line of thinking, according to all the leading orthos now (that was news to me!). But no, my VMO isn’t really weak – in a one-leg squat, I get a strong contraction. It’s hard to just flex it while laying around, though. But tracking doesn’t appear to be the issue.

Leg press, no. Awful for my low back. Single leg squats to a box, yes. 25 reps to parallel while holding a 25lb plate across my chest. Pretty solid. I squat like you’re supposed to, keeping the shin nearly vertical, so this means my hips/glutes are carrying most of the load. The quad gets relatively little. I also do some step-ups. I am weaker with those because they are so much more quad

Quad/ham, not specifically. My ham is a little weak comparatively, but keep in mind I can do 25 glute-ham raises. So the absolute strength is good. Quads we haven’t tested because that’s such a high load on the knee, but the hand testing the docs and PTs have done didn’t make them think it was weak.

Adductors/abductors, same thing, docs/PTs are happy. However, the abductor is a little weak in the push down test. But when we got to the PT floor, I completely crushed their assigned exercises, and same thing for all the glute work. Weakness doesn’t appear to be a problem at all. But I’m going through the abductor and glute anyway, because as the first doc said “let’s just see anyway.”

7

I have a similar issue with my right knee. I had a lateral release done on it years ago. My knee swell often for no reason. I have found that if I wear only my running shoes with orthotics all the time (or barefoot) then the problem is definitely reduced. I too have done all the stregthening routines to little avail. I have found that using a knee brace with a horseshoe in it helps considerably. I don’t always use it but when it’s bad I find it quite helpful. I also ice it often even if it’s not hurting. I also do the one legged squats often. When ever I wait for a bus I start doing them. That seems to help also.

Good luck,
John

8

MMrocker 13 - I knew you couldn’t resist a good knee question!

I too would vote for B, and if this fails, do A.

9

I have had “knee pain syndrome” that was VMO, Patella, inflammation & various strength imbalance caused. It took me 3 years to get it under control…that said not being a Dr but trying to be positive and helpful to a fellow athlete- Dr B’s philosophy combined with strength & flexibility efforts as well as a smart approach to cycling (also get a bike fit from a “health professional” bike fitter) and, as sad as it sounds (but it worked for me!) basically give up any running goals for a year- and realistically give up running for at least 4-6 months. Depending on your level of inflammation, scar tissue & your body’s habits it will likely take that long to re-train yourself to have strong legs that better support your knees. This is basically an outline of what I went through…but I am pain free and getting faster all the time now!

10

Have you looked into the anti-inflammatory diet? Compression socks?

11

Very sorry to hear that this is still going on.

I’d go for Door A. Get in there and see what they find and hopefully get it fixed. You’ve done all the other less invasive things and that hasn’t worked.

I’ve been having knee pain since about May (a remnant of the bike crash in February). The pain has been getting progressively worse at all times EXCEPT when I ride. Sitting–hurts, walking–hurts, trying to jog–really hurts, going from sitting to standing–freaking kills me. Riding the bike–no pain and it actually helps it. Rode the best I’ve ever ridden last week at nats–personal best times in all events. But, a week of going up and down stairs (through the tunnel from the outside to the track infield) about 100 times has it really going, so they are scoping it next week.

Good luck on whatever you decide. Who have you seen?

clm

P.S.–How is Azteca?

12

“but my baseline symptoms never improve”

Aztec,
Had my share of nagging shoulder, back, hip, knee, foot and IT Band issues over the 30+ years of sports (football, lacrosse, ice hockey, water polo, swimming, track, yada, yada). If you rest your knee for 18 months and it’s still sore, then I suspect you have a muscular or skeletal imbalance causing your pain.

Someone on ST suggested the book “The Egoscue Method of Health Through Motion”. This was a game-changer for me and I’m pain free ever since. The author will suggest running in a low-heeled, neutral shoe. Doing so solved my foot and heel problems. The stretches and strengthening exercises helped resolve recurring IT Band pain and a slight functional leg length discrepancy. The upper body exercises helped eliminate recurring shoulder pain from swimming. My posture is improved and that pinched nerve in my neck rarely flares up anymore. The key driver in Egoscue’s method is to treat the body as a unit; feet, ankles, knees, hips and shoulders should all be square and in alignment. Turns out all those years lifting weights in my 20s threw my body way out of whack. A few weeks of this method and I saw huge improvement. I haven’t had an ache or pain in over a year.

A sore knee heels itself with rest. If yours still hurts after 18 months rest, the root cause is probably somewhere else. The book costs about $10 at Amazon and the exercises can be done in your living room. Sounds like 3 good knee docs don’t have a silver bullet…maybe look somewhere else.
Best,
Rich

13

I’d go with a vigorous PT routine, like Dr. B says. Also, perhaps have it drained… And, perhaps, just learn to live with the fluid.

Have you been checked for gout?

No one has suggested draining it (only one doc believes that there is excess fluid, and the MRI report says “no joint effusion”).

I haven’t been checked for gout specifically, but have had plenty of blood work done (looking for crazy stuff like lupus, etc).

14

Have you looked into the anti-inflammatory diet? Compression socks?
Compression socks, no. Anti-inflamm diet… you bettcha. I went all the way, pretty much 2 months gluten-free, too. Zero difference. And I was kinda glad, too, because that diet sucked! :slight_smile:

15

Very sorry to hear that this is still going on.

I’d go for Door A. Get in there and see what they find and hopefully get it fixed. You’ve done all the other less invasive things and that hasn’t worked.

I’ve been having knee pain since about May (a remnant of the bike crash in February). The pain has been getting progressively worse at all times EXCEPT when I ride. Sitting–hurts, walking–hurts, trying to jog–really hurts, going from sitting to standing–freaking kills me. Riding the bike–no pain and it actually helps it. Rode the best I’ve ever ridden last week at nats–personal best times in all events. But, a week of going up and down stairs (through the tunnel from the outside to the track infield) about 100 times has it really going, so they are scoping it next week.

Good luck on whatever you decide. Who have you seen?

clm

P.S.–How is Azteca?

Azteca is good, and likely to be reappearing in the athletic scene soon.

To be clear, my knee has been looked at from the inside already (Feb '08) after the symptoms returned (I somehow PT’d or rested my way through them in '06 for awhile). The doc say nothing of interest in there. And just that took 4+ months to recover from. My knees apparently are very sensitive to being poked around!

Best of luck with your knee. Hopefully they just find something to trim without a big deal.

16

“but my baseline symptoms never improve”

Aztec,
Had my share of nagging shoulder, back, hip, knee, foot and IT Band issues over the 30+ years of sports (football, lacrosse, ice hockey, water polo, swimming, track, yada, yada). If you rest your knee for 18 months and it’s still sore, then I suspect you have a muscular or skeletal imbalance causing your pain.

Someone on ST suggested the book “The Egoscue Method of Health Through Motion”. This was a game-changer for me and I’m pain free ever since. The author will suggest running in a low-heeled, neutral shoe. Doing so solved my foot and heel problems. The stretches and strengthening exercises helped resolve recurring IT Band pain and a slight functional leg length discrepancy. The upper body exercises helped eliminate recurring shoulder pain from swimming. My posture is improved and that pinched nerve in my neck rarely flares up anymore. The key driver in Egoscue’s method is to treat the body as a unit; feet, ankles, knees, hips and shoulders should all be square and in alignment. Turns out all those years lifting weights in my 20s threw my body way out of whack. A few weeks of this method and I saw huge improvement. I haven’t had an ache or pain in over a year.

A sore knee heels itself with rest. If yours still hurts after 18 months rest, the root cause is probably somewhere else. The book costs about $10 at Amazon and the exercises can be done in your living room. Sounds like 3 good knee docs don’t have a silver bullet…maybe look somewhere else.
Best,
Rich
Wow, Rich, you are lucky! I bought a different Egoscue book 2 years ago for another pesky injury in my hip/adductor area. I even signed up for 15 Egoscue 1:1 sessions locally. I got nowhere, and found most of it ridiculously easy and useless as I passed all of their exercises with A+ grades. Well, except for the one thing that zapped my back for a month (my fault, not theirs). But hey, it’s worth a look again. Thanks for the idea.