T Nation

Ongoing, Chronic Knee Pain

Hi everyone

apologies if you happen to see this more than once. i regularly visit, and value the opinions of, 2 weightlifting forums and a knee rehab site, so i’ve cross-posted this on all 3.

i am really struggling with knee pain, and wanted to share what im going through, in the hope that someone may be able to offer advice, or suggest something i’ve not thought of.

i have a fairly lengthy history of knee complaints which are (briefly) as follows

Pre Summer 2002
my right knee, for as long as i can remember prior to my ACL, always hurt before i bent my leg. i was never able to squat, but the pain wasnt terrible, and didnt intefere with day to day life, only squatting. i could cycle.

Summer 2002
tore my ACL - LEFT knee

January 2003
had ACL repaired. several months of rehab followed, during which i lost about 60 lbs and my right knee stopped hurting - i could squat! all was good.

Summer 2004
tore meniscus in left knee. don’t know how, but MRI showed it and knee hurt. had meniscus repaired, got nerve damage in left leg. saphenous nerve was severed by scar tissue. was in an incredible amount of pain - had to have another emergency operation to free up the nerve

April 2005
left leg started hurting again. turned out i’d torn more meniscus. had to have another operation to fix the tear. all went well. however upon recovering from the surgery my right knee had started to hurt again when bending

June 2005
left my job - had 5 months of not working. went to the gym most days and heavily trained hamstrings and glutes via good mornings, stiff legged deadlifts, hamstring curls, etc. eventually the right knee pain went away, but when it did, it was pretty much an overnight ‘getting better’. literally i woke up and it didnt hurt any more. i dont know what the trigger was.

January 2006
left knee started hurting again. had to have another meniscal tear operation :expressionless: :expressionless: :|. recovery went badly, within 2 weeks it was hurting again. fast forward a few months…

June 2006
left knee in agony - could barely walk. paid privately for MRI scan, showed medial meniscal tear (sigh). had another operation to fix this, except i had to pay ?4000 to have it done privately because the NHS said it would be 9 months, and i couldn’t walk. surgeon was excellent, he also found a plica and removed it, he stipulated that may have been the reason my meniscus kept tearing.

recovery went well for my left knee, but my right knee kept hurting when bending. i was dilligent with the usual reahabilitation techniques but nothing seemed to work.

i saw another surgeon about my right knee, who wanted to perform a microfracture or lateral release ( he considered both ). i read up on these and was not keen, at all. sought second opinion at droitwich knee clinic.

i started going to the droitwich knee clinic about my right knee. they were confused - they couldnt find any tender spots etc, but it hurts like hell when bending, especially when under stress. they said my symptoms are that of patellafemoral syndrome but none of the normal treatments seem to be working.

tried rehabilitation for a few months but nothing worked. left knee feels pretty much OK (although not great, since i can’t rehab it properly, because everything i do hurts my right knee)

September 2006
droitwich knee clinic are confused as to lack of progress. they reason i definately have a plica in my right knee, and since removing it seemed to help my left leg, they want to remove it. i had surgery to remove plica. after surgery, i felt the exact same. not any worse, but not any better either.

… which brings me to now. left knee feels OK, but not great, since i haven’t been able to be active and build up muscle strength due to my right knee hurting.

right knee hurts like crazy. whenever i bend it beyond about 45 degrees it clunks. sometimes this only hurts a little, sometimes it feels like my knee is dislocating and everyone in the room hears it. squatting, cycling etc is out of the question. when i wake up in the morning, the weight of the blanket hurts my knee.

usually it pops out of place a few times before i even make it to the toilet. i’ve gained around 40-50 lbs through inactivity, which doesn’t help (i’m 225 ish now), but i don’t feel like my weight is the reason my knee hurts - i’ve been this weight before without knee pain.

last week i had a session with an ART practitioner (one of about 4 in the UK) on the off-chance he could spot a muscle tightness or similar that other physiotherapists had missed. he said i was an anomaly - my muscles are all very flexible, and i have good strength in my quads, hams etc, so he doesnt understand why my knee is hurting. he agrees my patella in my right knee seems to be all over the place.

one thing he did notice is that i have hypermobility in my joints. others have commented on this also.

it’s also worth mentioning that 3-4 years ago i saw an orthotic guy who said i have ‘flat foot’ (he mentioned it’s not actually called flat foot, but i can’t recall the condition name he mentioned). he perscribed orthotics and told me to stregth my calves regularly, which i do.

other stuff that may be worth mentioning: I sit at a desk all day (I’m a programmer). i go for walks every 20-30 minutes. i drive for around an hour each day.

i have built up a reasonable buffer of cash (i’m a contractor) and have enough money for 2 months off from work. if i can figure out a way of spending this time to help my knee pain, I’ll do it in a heartbeat. similarly, i have no problem with paying for potentially expensive treatment, if i think it will help.

if anyone can recommend an amazingly good physiotherapist, I’m in Birmingham. however as i mentioned i’ve been seeing the guys at Droitwich, who have an excellent reputation, and they haven’t been able to spot anything.

i have absolutely no idea what to do any more:

  • nothing seems to be working
  • every day the pain is getting worse, and i’m worried about long term joint damage (i’m only 25)
  • i feel like life is passing me by - i can’t be active, this is affecting my ability to do my job properly, sleep at night, and see my family/friends.

i don’t want to sound like i’ve given up hope, because i haven’t. i just geniunely don’t know where to go from here.

if anyone can offer any words of advice, or suggest anything i could possibly do, then i’d really love to hear from you. if anyone has been through a similar experience and would like to chat, post here or PM me.

thanks for reading this, i realise it has been a lengthy post.

many thanks.
jim

Heh, pretty interesting history there.

I’m not going to try “internet diagnosing” this, but some questions and brainstorming might give you some clues.

Since they say you have patellofemoral pain syndrome, what have they done to verify this?

Have you had any special tests done, fx isometric contractions with patella stabilized?

How is your 1-leg stance balance with eyes open and closed? How long can you stand without moving your foot off spot and without locking out your knee?

With your leg straight and relaxed (not weight bearing), does moving the patella in any direction hurt?

Is the clinking “inside” the joint or is it perhaps the IT-band clicking over the side of the knee? Has the “noble compression test” been performed? Have you tried to make it clink with some external stabilizing like a very tight wrap? Does it clink with the patella stabilized?

Has anyone looked at your hips, low back and ankles for any possible cause? Fx hip version can cause flat feet and anterior knee pain.

Is your posture normal-ish? Since you sit a lot, are you over-lordotic at the lumbar back?

Do you ever get any pain in any other region of your body besides the knees?

How old were you when the right knee pain started? Were you active then? Was there a single event the signaled the beginning or was it gradual?

The blanket hurts in the morning, are you more stiff in the morning then evening? Does the blanket feel fine when you go to bed at night? Morning stiffness can indicate an inflammatory disease rather then a disfunction.

Did the MRI not show any wear in the cartilage or bone in the knee? Have you had an x-ray to assess patellar tracking?

They say the normal treatment isnt working, what exactly is this normal treatment? What does your rehab include? How about an EMG?

Hi Muppet,

Thank you for your reply. You’ve obviously taken a fair bit of time to put this together and I really appreciate it!

In reply to your many questions:

This has been the conclusion of 2 different physiotherapists and a couple of surgeons, based on the fact my knee constantly clunks out of place, and i have pain that i find hard to localise - seems to be both above and below the kneecap

i don’t know what this is, so i assume not. i’ve had MRI scans on the affected knee, and i have had an operation it to remove a plica (around 9 months ago), during which they said inside everything looks fine anatomically - no wear and tear

its been a while since i tried this. ill try it now.

eyes open - feels like i could hold it for a long time, although my calf and foot seem to be doing a lot of stabiliser work.

eyes closed - knee seems to want to cave inwards, and really struggling not to fall over…

i’m not sure what you mean by this. do you mean, while not weight bearing, does it hurt to bend my knee? the answer used to be no, but now it’s yes.

i’ve asked before whether it could be my Illiotibial band, after reading about runner’s knee etc.(and been told by both physiotherapists that it’s not)

the clicking feels like its below the kneecap. the pain is both above and below when bending past a certain point.

if i hold my patella to either the left or right, it doesnt click as much, although still does a bit

i’ve been told before that i have flat feet and was perscribed orthotics, which i wear in trainers. lower back and hips, i think they have had lip service paid to them, but no-one’s ever sat down and said ‘right, maybe it’s your (lower back/hips) - let’s give them a proper examination’.

one thing i have noticed, is that i can almost clunk my right leg (remembering it’s my right knee in pain) out of place, at what feels to be the hip / buttock joint, it never hurts though.

also, when doing single leg squats, i feel like when i’m doing them on my right leg, my hip / butt wants to rotate outwards. this doesn’t seem to happen when doing with my left leg. i’ve mentioned it to physiotherapists and none have been able to come up with an answer.

i believe my posture is OK. i still train my upper body as pain allows, and try to sit in a decent position and go for walks often. having said that, i’m sure there’s room for improvement.

not really, no

maybe 17 or 18? not really active until the age of around 21, tore my ACL at age 22

i feel more stiff in the morning, but it hurts in the evening too. the weight of the blanket, and being in bed in general, have turned sleeping into a most unpleasant experience :expressionless:

i’ve had x-rays, although i’m not sure what they were fore. i think they were checking the patella for any wear/tear to the bone. neither MRIs nor x-rays showed anything of interest.

usual VMO activation type stuff, light weights lots of reps, cycling, terminal knee extensions, mini squats, leg raises, squats on wobble boards, squats with a band tied around my knee pulling me in the other direction, reverse hypers but with one leg at a time, light hamstring curls, etc…

i’ve never had an EMG

Thanks so much if you’ve made it this far!

[quote]jim2406 wrote:
Hi Muppet,

Thank you for your reply. You’ve obviously taken a fair bit of time to put this together and I really appreciate it!

In reply to your many questions:

Since they say you have patellofemoral pain syndrome, what have they done to verify this?

This has been the conclusion of 2 different physiotherapists and a couple of surgeons, based on the fact my knee constantly clunks out of place, and i have pain that i find hard to localise - seems to be both above and below the kneecap
[/quote]

The same exact description can come from hip alignment issues as well as ankle issues. If its not responding to treatment I’d suggest an EMG to rule out patella tracking stuff and even a positive EMG doesnt tell the whole picture since its a chicken/egg issue.

Even if it sounds like a horse, it may well be a zebra here.

[quote]jim2406 wrote:Have you had any special tests done, fx isometric contractions with patella stabilized?

i don’t know what this is, so i assume not. i’ve had MRI scans on the affected knee, and i have had an operation it to remove a plica (around 9 months ago), during which they said inside everything looks fine anatomically - no wear and tear
[/quote]

Basically its contracing the quadriceps like you want to straighten the leg, but without any movement (the therapist provides resistance manually), if that produces pain its a positive test that the pain does in fact come from the patella grinding against the femur.

Its tested at 120-90-60-30 and zero degrees of knee bend usually. A positive test is redone with external fixation on the patella, if that alleviates pain its a patellar tracking issue.

A patellar tracking issue can be hip or ankle oriented.

[quote]jim2406 wrote:How is your 1-leg stance balance with eyes open and closed? How long can you stand without moving your foot off spot and without locking out your knee?

its been a while since i tried this. ill try it now.

eyes open - feels like i could hold it for a long time, although my calf and foot seem to be doing a lot of stabiliser work.

eyes closed - knee seems to want to cave inwards, and really struggling not to fall over…

[/quote]
An inability to stand on one leg with eyes closed is indicative of muscle control issues and/or ligament/tendon damage. Very often a damaged knee will be an unstable knee. This is however not a diagnostic test, just a hint at how bad it is.

[quote]jim2406 wroteWith your leg straight and relaxed (not weight bearing), does moving the patella in any direction hurt?

i’m not sure what you mean by this. do you mean, while not weight bearing, does it hurt to bend my knee? the answer used to be no, but now it’s yes.[/quote]

Actually, I meant if it was painful to manually move the patella around in any direction or if it was stiff/loose in any particular direction.

[quote]jim2406 wroteIs the clinking “inside” the joint or is it perhaps the IT-band clicking over the side of the knee? Has the “noble compression test” been performed? Have you tried to make it clink with some external stabilizing like a very tight wrap? Does it clink with the patella stabilized?

i’ve asked before whether it could be my Illiotibial band, after reading about runner’s knee etc.(and been told by both physiotherapists that it’s not)

the clicking feels like its below the kneecap. the pain is both above and below when bending past a certain point.

if i hold my patella to either the left or right, it doesnt click as much, although still does a bit[/quote]
Try wrapping it tightly (like a powerlifter would) and see if it still clinks.

[quote]jim2406 wroteHas anyone looked at your hips, low back and ankles for any possible cause? Fx hip version can cause flat feet and anterior knee pain.

i’ve been told before that i have flat feet and was perscribed orthotics, which i wear in trainers. lower back and hips, i think they have had lip service paid to them, but no-one’s ever sat down and said ‘right, maybe it’s your (lower back/hips) - let’s give them a proper examination’.

one thing i have noticed, is that i can almost clunk my right leg (remembering it’s my right knee in pain) out of place, at what feels to be the hip / buttock joint, it never hurts though.

also, when doing single leg squats, i feel like when i’m doing them on my right leg, my hip / butt wants to rotate outwards. this doesn’t seem to happen when doing with my left leg. i’ve mentioned it to physiotherapists and none have been able to come up with an answer.[/quote]

After so many years, one should take an honest, good look at the other joints. If it were normal patellofemoral pain syndrome it would respond to treatment. Very often, if you have a knee pain and go to a knee-specialist, you’ll get a knee-solution even if its a hip-problem.

Same goes for other joints, try seeing a hip-specialist physical therapist. It COULD be something else then a knee issue. At least check it out, even if its a waste of time in the end the more you know the better off your therapist is.

[quote]jim2406 wrote Is your posture normal-ish? Since you sit a lot, are you over-lordotic at the lumbar back?

i believe my posture is OK. i still train my upper body as pain allows, and try to sit in a decent position and go for walks often. having said that, i’m sure there’s room for improvement.[/quote]

Its worth the time correcting it just to rule out all possibilities, even if its minor. Why buy one line at the lottery when you can buy them all.

In what position do you generally fall asleep?

[quote]jim2406 wrote usual VMO activation type stuff, light weights lots of reps, cycling, terminal knee extensions, mini squats, leg raises, squats on wobble boards, squats with a band tied around my knee pulling me in the other direction, reverse hypers but with one leg at a time, light hamstring curls, etc…

i’ve never had an EMG[/quote]

With full respect to your therapists (after all, I’m just a student), those treatments aren’t really proven to be effective. While its the standard treatment it only works in a few situations (which might very well have resolved on their own).

McConnel and others have determined that the most effective treatments for patellar tracking issues is biofeedback using EMG, which can significantly improve your condition in several days, so you know pretty quickly if it works.

Of course, you need an EMG machine (some can be bought relatively cheap) but you only need two channels and the time-to-activation, not the amount of activation.
[/quote]

I just want to leave you with another warning of internet-diagnosing something like this. Just don’t leave any stone unturned, be a demanding costumer to your therapists and switch your treatment until something WORKS. Doing the same stuff over and over and expecting different results, is after all insane :slight_smile:

Good luck.

Dude,

I’d consider seeing Matt Walden in Surrey. He’s a CHEK 4 and an Osteopath. He’ll give you a fucking good assessment.

My knee used to pop and feel like it dislocated if i did a full squat. I eventually tore my meniscus just sitting up in bed one day. I was told it was a mobile meniscus and they had to remove 2/3 of it.

I’d go see Matt, or someone he could recommend in your area. Get your nutrition in order and work your upperbody so you dont gain weight.

I’d be interested to here how you go.

Good luck,

Andrew