In need of Knee advice

Moved thread to General Backcountry so those outside NE will notice.

For the record, I'm a chiropractor and I treat knees. For a group of ten patients with the same diagnosis you could easily end up with 10 different treatment approaches and exercise prescriptions.


The current thinking regarding a lot of knee issues is that the hip steers the knee and as such, hip muscle weakness and tightness must be identified and addressed for successful treatment outcomes. As an example, not that long ago for patello-femoral pain it was all about patella tracking and the Vastus Medialis Oblique muscle. For a while people were taping the patella (some probably still are) trying to pull it into better alignment via the skin.

One of my toughest cases, a fellow hiker, finally acquiesced and took a 6 month break from activity, did the prescribed exercises and guess what? He healed! (In addition to the hip imbalances I had him work his VMO and do a lot of single leg stuff, including balance.) Maybe he got better in spite of my intervention.

Surprisingly (to me anyway), the research doesn't show much in the way of results from correcting flat feet with orthotics. Sometimes yes sometimes no.

Cycling was a contributing factor in my knee problems, mainly because the VMO does not get engaged while riding a bicycle with a freewheel (coasting). This was the cause of the muscular imbalance in my particular case.

The good news is I've been pain-free now for 6+ years

Tim

I felt the kneed to chime in on this post. I had an acute injury 40 years ago to my left knee. Was never diagnosed properly, stayed active (basketball, volleyball, skiing) and eventually reached a point that the throbbing pain in the middle of the night was too much. After several different docs told me to slow down and essentially ( give it a rest) I eventually found my way to Dr Dan. We chatted ..he poked..he said that I had a damaged ACL in the knee, ordered an MRI which confirmed. He advised that at some point replacement was in my future due to years of hard use. He did the acl, I rehabbed like a crazy person, and was soon back playing a little volleyball (since retired) 50 days a year of down hill skiing, and..decided to try some hiking. After a few freak falls (always on the bad knee..it always is) I knew the time was coming to consider TKR. Consulted with DR Dan, also went to Mass General but settled on the Dr and facility at Mount Auburn in feb 2009. Back on the trails in 9 weeks, will finish a post knee grid next summer. My points are I guess..with proper diagnosis you can deal with knee issues. I really like Dr Dan..had a picture on his wall in Plymouth for many years. when i was in discomfort I found ice to be the best relief and also did multiple light weight knee lift reps to keep the muscles strong. During rehab times I found a stationary bike was by far the best thing for me. Good luck!!!

summitseeker said:

I am doing a lot of homework and trying to be proactive. Obviously a diagnosis would be key but at this point I will be doing a lot of armchair diagnostics until then.

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I'll admit that I do the same thing. However, there can be many causes of knee pain. IMO, one is better off letting the pros diagnose the problem and then searching for the cure. (In my case, their diagnoses was correct and their conclusion that I needed to strengthen my quads was correct, but I was given bad advice on how to strengthen them. It was only a "minor" problem in their eyes and I was eventually left to rot. After a number of years I figured out how to cure it myself...)

Once I know what is wrong I can move on from there but it will be quite a while before I can get any real answers from medical personnel.

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It can be frustrating... It isn't life threatening so they aren't likely to be in any hurry. I don't think life-style threatening quite registers as high with them as I think it should...

Doug

MattD said:

I have been dealing with knee issues as well. Its like a shooting pain right at my knee cap. Sometimes I am fine and there are times where just sitting down or walking up and down stairs hurts it. I am an active 30 year old who has been in the gym for 14 years now. In regeards to what is causing it, you really should see a doctor. My X-Rays came up clean for arthritis or any bone issues. My MRI came up clean for any tears.

I have a good friend at my gym who is a chiropractor. I went for a visit and he was able to tell that I had a muscle imbalance in my legs causing a tracking issue. Pretty much my outer quad was over developed and my inner quad was using the tendon to help stablize it which was causing this pain. He did alot of therapy on me including stripping of the muscle, uv light, and the shock pads. Felt good but the pain was still there. For about a year I was not able to squat at the gym or do basic leg exercises.

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<my suggestion for what it may or may not be worth>
You might consider straight-leg isometric exercises for your quads. (Easy to do standing up, perhaps in a nice warm shower.) Such exercises will work all four of the quads without putting any wear and tear on the joint surface behind the kneecap. (A bent knee will put high pressure on the joint surface.) This exercise cured my kneecap tracking problem and cured my chondromalacia patella which caused knee pain on descent. It takes a while, so don't rush it.
</my suggestion for what it may or may not be worth>

Doug

DougPaul said:

I'll admit that I do the same thing. However, there can be many causes of knee pain. IMO, one is better off letting the pros diagnose the problem and then searching for the cure. (In my case, their diagnoses was correct and their conclusion that I needed to strengthen my quads was correct, but I was given bad advice on how to strengthen them. It was only a "minor" problem in their eyes and I was eventually left to rot. After a number of years I figured out how to cure it myself...)


It can be frustrating... It isn't life threatening so they aren't likely to be in any hurry. I don't think life-style threatening quite registers as high with them as I think it should...

Doug

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Hi Doug,

All of this advice and different approaches for treatment has made it clear to me that I am in way over my head. I will indeed let the experts decide what the proper diagnosis is and the treatment plan. My current plan is this: rest, rest, ice, and try to get in to see someone sooner. The last thing I want to do is further injure my knee by coming up with a strengthening regiment on my own.

Thanks for your advice. You're right it is frustrating.

Z

well...

i've had SEVEN knee surgeries, everything except joint replacement...

few of things to consider from someone who's 'been there and done that,' lol:

1 - MRI w/o contrast (no dye) usually won't show near as much as with contrast, but injecting the dye will usually cause some swelling and discomfort...
2 - Orthos ROUTINELY miss stuff on the MRI because they usually don't spend enough time reviewing the CD and are looking for gross abnormalities - so borrow the CD and have someone else fly-spec it (typically there are many 'slides' on one CD)
3 - as mentioned by others, always better to have a conservative non cut-happy surgery-as-a-last-resort ortho, but ... there is a limit to that as you can remain in needless pain and even cause further damage IF it is 'just' a cartilage issue
4 - in a general sense the best insurance against further knee issues is a strong 'exoskeleton' of strong, balanced, full range muscle support however you obtain that

Bottom line is the first step is a definitive diagnosis which to me means MRI with contrast reviewed in greater detail than just looking for routine abnormalities

Gris said:

i've had SEVEN knee surgeries, everything except joint replacement...

few of things to consider from someone who's 'been there and done that,' lol:

1 - MRI w/o contrast (no dye) usually won't show near as much as with contrast, but injecting the dye will usually cause some swelling and discomfort...
2 - Orthos ROUTINELY miss stuff on the MRI because they usually don't spend enough time reviewing the CD and are looking for gross abnormalities - so borrow the CD and have someone else fly-spec it (typically there are many 'slides' on one CD)
3 - as mentioned by others, always better to have a conservative non cut-happy surgery-as-a-last-resort ortho, but ... there is a limit to that as you can remain in needless pain and even cause further damage IF it is 'just' a cartilage issue
4 - in a general sense the best insurance against further knee issues is a strong 'exoskeleton' of strong, balanced, full range muscle support however you obtain that

Bottom line is the first step is a definitive diagnosis which to me means MRI with contrast reviewed in greater detail than just looking for routine abnormalities

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Thanks Gris,

I will definitely keep this in mind throughout. My knee is starting to feel better after a week of rest and nightly icing, but there is still discomfort (at times) when I walk or go up stairs. I am curious if the lack of pain during short walks and occasional stair ascents may rule out some possible diagnosis.

On Feb. 3rd I should know more once I have my fist appointment with an ortho. I am tempted to do a very short hike to see if the symptoms appear again. Another piece of the puzzle is that after back-to-back hikes (Tripyramids and Hale via FWT) I played ice hockey a few days later and took several spills. Oh well, I suppose some patience and continued rest are the best remedy until I get a more accurate idea from an MRI.

Thank you again all,

Z

FWIW, the result of my MRI said "fluid pocket consistent with a meniscus tear" - and that was only for one knee where both knees hurt.

Tim

summitseeker said:

I will definitely keep this in mind throughout. My knee is starting to feel better after a week of rest and nightly icing, but there is still discomfort (at times) when I walk or go up stairs. I am curious if the lack of pain during short walks and occasional stair ascents may rule out some possible diagnosis.

On Feb. 3rd I should know more once I have my fist appointment with an ortho. I am tempted to do a very short hike to see if the symptoms appear again. Another piece of the puzzle is that after back-to-back hikes (Tripyramids and Hale via FWT) I played ice hockey a few days later and took several spills. Oh well, I suppose some patience and continued rest are the best remedy until I get a more accurate idea from an MRI.

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First of all, no single diagnostic technique will definitively identify all problems. I suggest that you not become obsessed with a single test which happens to be high-tech and expensive.

If it is a wear-and-tear problem, it may feel ok during a single day of heavy use but become painful or sensitive the day after. (A "monday morning" problem...) Freedom from pain after resting is not sufficient to indicate a cure. (The cure is use without pain.) Some wear-and-tear problems can be pain free for months of rest but still be ready to reinjure after just a single day of moderate use (ie quick to reinjure and slow to heal). (Been there done that...) In fact one of the big difficulties of wear-and-tear injuries is the lack of feedback from partially healed tissue.

Some of the tissues in the knee have a very poor (to no) blood supply and will heal very slowly--think months to a year or so. If you keep poking it, you can keep the injury for the rest of your life.

Give up on your activity goals for the time being, find something else to do, and wait for the doctor's diagnosis--Feb 3rd is only 2.5 weeks away. Continued poking it may simply increase your overall healing time or increase the damage. Yes, your winter may be done. Yes, it is frustrating. (I'm speaking from experience...)

If someone gives you the choice of a broken bone or tendonitis/chondromalacia/a wear-and-tear injury, take the broken bone. They generally heal within ~8 weeks...

Doug

MattD said:

I moved to Boston last Fall and I have been riding my bike to work everyday. Just a few miles a day and four months later I built up the strenth and my legs and I am able to lift heavier than I ever have.... pain free. My suggestion after getting an MRI and x-ray is to add biking into a daily work out if you have an issue similar to me. I swear by it.

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bikehikeskifish said:

Cycling was a contributing factor in my knee problems, mainly because the VMO does not get engaged while riding a bicycle with a freewheel (coasting). This was the cause of the muscular imbalance in my particular case.

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There is another problem with using a bicycle to train for hiking--the vast majority of bicycles have freewheels. This means that a bike works your concentric (power producing) contractions but not your eccentric (power absorbing) contractions. Thus bicycle trained legs that can get you up the hill may not be strong enough to get you back down without pain or injury. (Been there, done that...).

The mechanisms involved in concentric and eccentric contractions appear to be sufficiently different that both need to be trained independently.

Bicycling is a fine part of training for hiking, but make sure that you also do some eccentric work (hiking downhill, walking down stairs, lowering weights, etc) too.

Doug

To the OP - glad you are seeing some improvement - I always feel that is a ray of hope!! Good info DougPaul....

From experience, I would, personally, not hike until you are pain-free... If you are almost pain-free, I would choose zero-pain activities.... I would ask myself, "Does it just feel 'weird' or does it hurt"? Can you walk on flat ground pain-free?

It wasn't clear to me how you hurt your knee - was it an injury or a tweak?

While Doug essentially reiterated my point on the imbalance, I would like to add (for any who may be cycling-focused) that

DougPaul said:

Bicycling is a fine part of training for hiking, but make sure that you also do some eccentric work (hiking downhill, walking down stairs, lowering weights, etc) too.

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the reverse of this is not necessarily true. Namely, running and the downhill component will negatively impact your climbing skills (during racing season this is a particular concern... every coach I've talked to or read suggests something non-impact like swimming if one cannot ride one's bike during racing season.)

Tim

UPDATE

Hello All,

I would like to start by thanking all the members who offered suggestions and advice for my knee issue. The pain has been on the inner front of my left knee. I gave it plenty of rest, elevation, and ice but it still bothers me on uneven surfaces or stairs.

Last week's MRI results revealed cartilage damage. The orthopedic surgeon gave me three options. I went in favor of option 1 and took an injection this afternoon. I might see some relief in as little as 2 -3 days. Otherwise a procedure may be necessary.

Thanks again everyone,

Z