My knees: My experience with patellar-femoral syndrome

I wrote this story in part because people have asked about my knees,
and in part that I hope someone else will benefit from the details.
Of course it is important to note that I am NOT a medical doctor, and
you should never substitute internet anecdotes for professional
medical opinions. It is long, and probably only of interest to fellow
knee pain sufferers.

Let me start first by thanking DougPaul for sharing his experience
with knee problems and for his gentle guiding me down the proper path.
I'd also like to thank all the other various folks who've inquired,
encouraged, or otherwise wished me well.

(continued)

Summary

SUMMARY:

In November, 2006, I began having knee pain (both knees), which varied
in severity, location, and with activity. While it never quite
reached a debilitating level, it was painful enough to preclude
participation in hiking, cycling, and skiing at the level to which I
was accustomed. It was aggravated by sitting with my knees bent, and
especially aggravated by driving my car, a standard (of course).

Over the course of time, each knee took the front-runner position in
the hurting department, and although rare, they sometimes hurt the
same. In fact, it started out primarily as a right knee problem, and
towards the end, has been mostly a left knee problem. My diagnosis
primarily centered around "Patellar-Femoral (Pain) Syndrome", aka
"Chondromalacia Patella" ("softening of the patellar cartilage"), aka
"Primary Osteo-Arthritis". After a variety of tests and treatments
(x-rays, PT, MRI, cortisone shots, bone scan, sports trainer, RICE),
and after a period of 10 months, there is a bright light at the end of
the tunnel!

(continued)

Detail (part 1)

DETAILS:

Background

At age 30, I gave up the sedentary life of a couch potato, quit
smoking, started exercising, and got into the best shape of my life.
Along the way I lost 70 pounds, rode a bicycle an average of 4000
miles per year, raced for 7 years (road and cyclo-cross),
cross-trained in the gym, XC (skate) skied and ran during the
off-season (winter). At age 40, I raced the cyclo-cross national
championships in the 40-44 group in Rhode Island, finishing 82 out of
160 or so. The training and traveling to races was too much of a
burden on my wife and two kids and so I gave up racing. On May 28th,
2006, my mother-in-law's husband talked me into hiking Moosilauke with
him. I had a cycling camelbak with 70 oz of water, a sandwich, and
10-year-old hiking boots that had seen Monadnock (and the Packs) a few
times, but otherwise mostly yard work. On this trip I learned of the
48 4000-footers, and a quest was born. The quest I called "48 by 48",
figuring that 7 per year gave me 7 years to finish.

I bought a 'real backpack', with the 3L bladder, new boots, better
shorts, and some EMS Techwick shirts. In 2006 I hiked a total of 14
of the 4Ks: Moosilauke, Osceola and East Osceola, North and Middle
(and South) Tripyramid, Whiteface and Passaconnaway, Bondcliff and
Bond and West Bond, Flume and Liberty (FOT48 '06), and Lincoln and
Lafayette. I was well ahead of the 7 per year average. Some of the
longer downhills (Dicey Mills from Passaconnaway) caused me
lateral-inferior knee pains, which stopped after I started walking
level, and never hurt on an ongoing-basis between hikes. Before
Licoln and Lafayette, I bought poles, which allowed me to come down
faster, steadier, and with far less pain than ever before--I was
converted.

In November I resumed the off-season cross training and started
running again. Always cautious, I began with 10 minutes per day and
slowly worked up to 30 minutes without any problems. One day I tried
a new loop which included a moderate, but measurable downhill section.
It was on this section that the lateral-inferior knee pain returned.
I walked the rest of the way back. From that moment on, I had ongoing
knee pain accompanied by very noisy knees (clicking, popping). I took
it easy for a while, but even hiking West Rattlesnake with my family
really hurt on the descent. I asked around for orthopedist
recommendations, and settled on a doctor near home in Manchester. He
appeared in many road race results, including some hill climbs, and
billed himself as a 'sports medicine' doctor.

January 2007: At this office, you don't get to see the 'real doctor'
without first going through the PA (physician's assistant.) He gave
me the usual spiel about getting older, and not doing so many
activities, ... yawn. I'm not interested in hearing that. I set the
stake in the ground: I will consider myself healed when I can do the
Presidential Traverse without pain. Anything else is unacceptable. I
walked out with a diagnosis of "Patellar-Femoral Syndrome". The PA
told me that the PTs are specially trained to figure out and treat the
cause(s), and so following the standard protocol, I went to PT
(physical therapy) for 6 weeks. Despite being singularly focused on
becoming 'functional', I steered the process, best I could, to being
performance-focused.

January-February 2007: I went through six weeks of PT. The initial PT
exam determined there were three likely causes for my PFS:

1. My feet pronate, which rotates the tibial head outward, pinching
the lateral menisci. SOLUTION: proper insoles. Green SuperFeet
turned out to undo my natural tendency to pronate and in the opinion
of the PT and PA, they were nearly perfect for me -- no need for
custom orthotics.

2. My illio-tibial band (ITBs) and hamstrings were too tight.
SOLUTION: stretching regimen. I can say for sure that I am much more
flexible than I used to be.

3. My quadriceps muscle is imbalanced. Specifically, the vastus
medialis obliquus (VMO) is much weaker than the rest of the muscle.
This is from 10+ years of riding the bike without much impact
absorption (such as you get from running, or hiking down 3000+ feet.)
The VMO is responsible for holding the patella in the femoral groove.
When it doesn't, then improper tracking occurs, which wears away the
cartilage under the knee, hence the "chondromalacia patella". Since
the VMO absorbs all that energy you lose when coming down hill, it
needs to be up to the task. SOLUTION: strengthen / balance the quad.

So I undertook a program of stretching and strengthening. Stretching
included:

1. hamstrings: lying on my back in a doorway with one foot on the
jamb, butt cheek touching the bottom of the jamb -- HAH couldn't come
close initially)

2. ITB: lying on my back, shoulders in contact with the ground,
crossing one leg over the other and 'hanging' the foot. Ankle
weights, ski boots, etc., help stretching a lot.

3. calves: "heel chords", or standing on a stair using the ball of my
foot and holding with the heel lowered alternating with the heel
raised.

Strengthening included both open kinetic chain (non weight-bearing)
and closed kinetic chain (weight-bearing) exercises like leg
extensions (last 30 degrees only), stair step downs, single-leg
balancing exercises (put down 4 cups in a semi circle, and pick them
up), etc.

Six weeks later (mid February), the discharge notes said I was cured
because my flexibility was vastly improved, and my VMO was 4/5 of the
way to where it should be.

However, most activities still caused pain. Mainly I was interested
in skate skiing at this point. I went back to the PA's office was now
allowed to see the orthopedist.

March 2007: Met with the orthopedic surgeon/sports medicine guy. He
did his own examination and decided things looked and felt pretty
good. He also reviewed everything that the PA / PT had done and told
me to scratch a large number of them (leg extesions: bad, lunges: BAD,
...) I wanted to cry. The same office put me on that very program.
I left with a modified exercise program, and a 3-week treatment
program of using a knee brace (one of those C-cup style braces), along
with a twice-daily 800mg ibuprofen. The theory was the knee brace
would assist the VMO in keeping the patella tracking properly while
the ibuprofen would dent the inflammation, and the combination would
give things a chance to heal. Specifically, he told me to wear the
knee brace on either knee at random, and to note if it helped. I
opted to wear it on the left knee, which hurt more, while XC skiing.
Well the left knee continued to hurt more (much more) than the right
knee. In fact, the right knee felt almost normal, even with no
brace. After 3 weeks, I concluded the treatment was not effective.
He also suggested that taking a glucosamin-
chondroitin supplement could not hurt.
Next step: MRI.

(continued)

Detail (part 2)

April 2007: I had both knees MRId at the Eliot MRI center. Since they
only did my knees, there was no claustrophobia to worry about. The
machine is noisy and although they do offer you music, it is not over
wire but rather the air tubes like airplanes used 20 years ago. After
the MRI report was complete, things were not really any clearer. The
report read (and I'm paraphrasing) "The left knee is essentially a
normal MRI. The right knee shows signs of chondromalacia patella and
a fluid pocket consistent with a lateral meniscus tear." The
translation from the orthopedist was that it is not a stark diagnosis
with an obviously solution. He suggested three options in order of
invasiveness: RICE + exercising; Synvisc/Euflexxa (aka "the grease")
which is hyaluronan, a substance naturally found in the cartilage.

I should pause here and mention that the cartilage itself does not
have a direct blood supply, but rather derives its nourishment and
disposes of its waste products via the synovial fluid in the joint and
the process of squeezing it like a sponge, which naturally occurs
during joint movement.

The third option was to get 'scoped and investigate and possible clean
up or repair the cause of the problem. This was unattractive to me,
and to their credit, neither orthopedist suggested I was ready for
scoping just yet. Option 2 was a possibility.

May 2007: I decided to get a second opinion. I picked a knee
specialist orthopedist in Ashland (Dan O'Neill, NH Knee Center). It's
an hour from my house, but the guy answers his own e-mail, and returns
(or answers!!!!!!!) phone calls promptly. He also lists among his
hobbies "Road Bike and Cross Country racing, Alpine and Nordic skiing,
Hiking and Snowshoeing". He works with an athletic trainer as a team,
and focuses on getting athletes performing again, rather than just
functional. He did the usual physical exam, again saying things
looked/felt mostly good, although the clicking does indicate wear and
tear. He also reviewed the MRI and pointed out the items mentioned in
the report. He recommended trying a cortisone shot, as the ibuprofen
was ineffective. I figured one can't hurt (many can harm your liver)
so again I opted to treat the left, and currently more problematic
knee. (Much to my delight, Dan called me personally the next morning
to see how my treated knee felt.) He also strongly recommended I seek
out a sports trainer, rather than a PT, to continue the strengthening
and training, and said not to be surprised if it takes longer than 4-6
weeks that typically go with PT. His final recommendation was to take
my bike to the shop and have them check the fit.

I was dubious about the bike fit - after all I've been riding forever,
and any maintenance I do involves careful measuring and reassembly so
as not to change the geometry on any way. Being desperate enough, I
went. To my surprise, the bike fit check revealed my saddle was at
the extreme low-end of the acceptable range. I went home and measured
it and gosh-darn-it-all, the thing had slid down almost 2 whole
inches. That's what I get for trusting the shop when the previous
seat post failed. I am sure I measured it when it was returned, and I
am sure it was correct, but obviously the sleek new carbon fiber $110
post didn't stay put. And, it had bonded to the steel seat tube and
had to be cut out. Whether or not this contributed to the knee
problems is unknown, but I was not at all happy at being out $110 for
a nice seat post plus $100 labor to cut it out of the seat tube. I
replaced it with an old aluminum post I had lying around and so far it
feels so much better. My theory is it had been sliding down a tiny
bit every time I went over a bump and I just never noticed it.

June 2007: I start seeing the sports trainer recommended by
Dr. O'Neill, a man named Scott Prunier from Top Fitness in Nashua (at
the Conway Arena.) He took classes taught by O'Neill. He put
together a program which included self-massage (using a foam roller
system), activation, movement preparation, strength training, bicycle
intervals for energy system development, and regeneration (cool down)
aka stretching. Unlike PT, which focused on stretching the ITB,
hamstrings, and strengthening the VMO, this is a training program
designed for performance and includes an emphasis on not just the
legs, but the core (abs, back and glutes), which figures prominently
in ascending and descending mountains while carrying a load on your
back. I did this for 5 weeks with Scott, and have continued it on my
own, twice per week, for about an hour, and I can do it from home
having purchased only a foam roller, stability ball and a few
dumbbells. I've also adopted the streching routine any time I watch
TV (Red Sox, Les Stroud, ...)

June 23, 2007: Up to this point, I'd done some smaller hikes with
various subsets of my family, such as North Uncanoonuc, Pack Monadnock
and Major. I wanted to give the 4Ks another shot. I chose Tecumseh
from Tripoli Road: 6.2 miles and 2600 feet, which I completed in 4
hours. I took my time. I worked on landing each foot fall carefully,
keeping the foot, knee and hip in a line. No twisting or rolling or
"bounding along". Combined with cycling intervals 2 days later, I had
the worst knee pain in a while, but it was not as bad as even simple,
flat XC skiing back in March. I put the 4Ks back on hold, but did
continue all the other programs. Meanwhile, Dr. O'Neill recommended a
bone scan.

July 2007: The bone scan is done to detect osteo-arthritis (OA).
Presumably, if I was causing damage to my knees due to lack of
cartilage, then I would be accumulating calcium deposits (this is what
OA is), and faster-growing bone such as this (and bone cancer for
example), are easily detected using the bone scan. A bone scan is a
nuclear medical procedure where you get an injection of technetium,
specially-manufactured and dosed for your height and weight, and
shipped in a lead-encased syringe, go away for 4 hours or so, and come
back for a CT scan. Luckily, or unluckily (depending on your
viewpoint), it came back all clear. The good news: all diagnostic
information so far points to nothing really being wrong. The bad
news: no presidential traverse in sight.

August 2007: I got a new job, and took 3 weeks off. During that time,
I hit five more 4Ks over 4 trips: Pierce and Ike, Cabot (and The Bulge
and The Horn), Isolation, and Waumbek. With each trip, there was less
and less reaction. All the while, I've continued the
strength-training program. The activity level graph is trending
upwards nicely while the pain level graph is trending downwards
nicely. A bright light is visible at the end of the tunnel!
Beginning with Waumbek, I started leaving the knee brace behind with
no adverse effects. I'm not sure it ever really helped me, and it did
kind of rub the back of my knee raw.

September 2007: Since last year, I've been holding the date for Flags
on the 48. Various combinations of trips have been mulled over for
weeks. In the end, the weather, and a desire to both feed the gray
jays and increase my peaks-per-trip average, pushed me into bagging
Tom, Field and Willey. During this trip, as with the previous few,
there has been nary a hint of pain while hiking. Of course I have
been following the prescribed warmup and stretching program before the
hike, and the stretching and cooldown post hike (including icing
during the trip home.) While not northern-presidentials-steep, both
the Avalon Trail and A-to-Z Trail have fairly long, fairly steep,
fairly rocky sections. This trip is the biggest test of my knees so
far. Historically, the post-hike reaction has been at T+48 to T+72
(2-3 days) and diminishing at T+96 (4 days).

In the end, I'm not really sure what the cure was. It may have been
one or more of the various treatments above. Or it may simply have
had enough time to get better. I'm pretty convinced it was both --
the stretching and strengthening preventing further inflammation and
time allowing things to heal themselves.

I think DougPaul was right when he said something to the effect of
"once you find the right treatment, plan on 6 months to recover to the
point of no pain".

Is this the end of the story? I'm not sure. It sure feels like I am
98.6% recovered and on the way to 100%. I do hope that someone finds
this useful or interesting (anything beside just long ).

If you're still here, thanks for reading

Tim

I read it...whew....good news for you....sometimes I wonder if getting scoped (3x's on right, 1x on left ) was the right thing to do....going back to dr. on 9/24, probably getting mri's on both....3 of those scopes were done in the last 4 years and that's when i got into this hiking stuff....I wonder if hiking made it worse....I sure do miss going on those trips...met a lot of really nice folks....so weird also, I keep dreaming about hiking when I know that I can't go for now....be well..

Great News!

Tim, I imagine you're doing your stretching regimen, since the Sox are on...
I'm sure your story will be useful to someone else here. I'm glad you're close to 100%. Happy hiking.

I think we have the same knees. I have done/am doing all this stuff. Glad to hear you're feeling better. I'm right there with you with the 98.6%, in fact I don't think I'll ever be 100%. But I'm trying.
Best of luck with your continued pursuits.
For anyone else out there that has an injury, the best thing you can take from this post is don't listen to the doctor that says "Just don't do the things that hurt." Find a doc/PT combination that focuses on getting you back out doing whatever you love to do. Any doc can prescribe some meds and tell you to sit on the couch.

You'll notice that I named the doctor who was most helpful and who adopted the good-as-new strategy, but did not name the less forward thinking doctor

For those of you picking up the pass time, be sure to ease into it -- had I done that, I would probably have not had the problems I did. Aerobically speaking, I had no problems, but the muscular adaptation from cycling to hiking was problematic. Runners will have fewer problems, obviously.

Tim

bikehikeskifish said:

For those of you picking up the pass time, be sure to ease into it -- had I done that, I would probably have not had the problems I did. Aerobically speaking, I had no problems, but the muscular adaptation from cycling to hiking was problematic. Runners will have fewer problems, obviously.

Click to expand...

There still may be the issue of downhills. If one runs on the flat, the legs (knees in particular) may not be adequately prepared for steep and long downhills.

And, of course, we hikers are stupid enough to throw a bunch of extra weight on our backs just to make sure the legs get an adequate workout...

Doug

Great thread, thank you! Good luck with getting to 100%!

Tim,

What an amazing road to recovery. I admire your tenacity! As both a therapist (OT) and an aging athlete I share your frustration with some of my colleagues who define “functional” in a very pedestrian fashion, rather than based on the value system of the patient. Functional for you is 3000 vertical feet of hiking, not getting to and from the bathroom. I think it is important when choosing a doc/therapist to ascertain that they have experience in treating aging athletes and understand the importance of performance, as you say.

I have a question about your current training. Are you doing any eccentric strength training? This is weightlifting while the muscle is lengthening, not contracting. For instance, I had chronic inflammation of my Achilles tendon, called Achilles tendonosis. I treated it by standing on a step and doing toe raises where I emphasized LOWERING rather than the rising portion of the exercise. This is especially important for hikers transitioning from biking as muscular contractions are always eccentric when hiking downhill and there is no eccentric contraction at all involved in biking.

Yes, I am definitely emphasizing the lowering / eccentric aspect. As you correctly point out this is missing from cycling (unless you ride a track bike in which case you brake by resisting the forward momentum.

In particular, step downs, squats, and a variety of single-leg balancing-while-the knee-is-bent exercises. Lunges were problematic early on and so they haven't been a focus. In fact the first orthopedist said "don't do them, they are bad." The trainer taught me to do them backwards which is less stressful -- I may add them back shortly.

Tim

FWIW, it is possible to recover 100% from chondromalacia patella. I had a nasty bout in the 80s--the docs were able to diagnose it, but their treatment (sitting knee extensions) simply made it worse. A PA suggested arch supports and I got some custom insoles. That and working out my own rehab exercise (straight leg quad sets) finally fixed the knee. If you add up the time to deal with original injury and the collateral damage (various wear-and-tear problems), it took about 10 years. Once healed, there was no noticeable trace of the original problem.

Two of the hardest parts of recovery are patience (knee articular surfaces heal very slowly and the lack of real-time feedback (if you do too much today, you won't feel the pain until tomorrow or later).

I now use manufactured insoles (superfeet green), pay a little more attention to training and the problem has remained out of sight. Given my current leg problems (broken leg in Feb) and enforced inactivity, I may have to be a bit careful as I return to the mountain activities.

Doug

Thanks again, Doug, for the benefit of your experience. It helped more than you know.

Tim

bikehikeskifish said:

Thanks again, Doug, for the benefit of your experience. It helped more than you know.

Click to expand...

Glad I could help--chondromalacia patella is a nasty one to beat. My PA told me that many simply give up.

Besides, hopefully before too much longer you will be dragging my sorry carcass up some molehills...

Doug

Nice job

Nice to hear things are coming together.

Tim -- Thanks for sharing your experiences. What a relief -- what a journey! Glad that worked out. I'm glad that your knees are nearly back to excellent condition.

I agree - great thread, too!


---Mike

PS I had knee & back trouble over the summer - I don't run, but I do bicycle (and hike of course). A friend of mine noticed I was sitting too far back during a fun cycling race in Loudon. When I had my bicycle fit checked in mid-august 2007 --they adjusted cycle seat height, moved my seat position forward and replaced my handbar stem. What a difference. Most of my knee and back problems have been relieved. I need to repeat the process on my cross bike.

Your training regimen

Great thread. Your training regimen appears to be similar to what Mark Verstegen recommends (see http://www.coreperformance.com/). By following his programs off and on I've been able to hold my own knee problems at bay.

Tim just read this as I have just started having knee pain (too much hiking, maybe? 43 miles in 18 days). This was the first thing that came up on the web when I searched hiking related injuries. Thanks, Roberta

Tim, great story and outcome. Thanks for sharing with all of us 'knee problem' folks.