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504 Views 3 Replies Latest reply: Apr 6, 2013 9:19 AM by JamesJohnsonLMT RSS
mamainpain Rookie 2 posts since
Apr 4, 2013
Currently Being Moderated

Apr 4, 2013 7:57 PM

please help, I am in so much pain:(

I'm a 33 year old female. When I was 23 I started having pain in my knees. It felt like my kneecaps were just throbbing. Then I started having pain that would radiate down the outside of my leg towards my outer ankle. At the time I was not into exercise at all and never exercised. I had an arthritis panel done and my sed rate was fine but my CRP was extremely high.  I saw an orthopaedic doctor who said I had patellofemoral pain. I did physical therapy and tried several different pain meds, Celebrex, Advil, Tylenol, etc. I lived with it for a while and then I had a lateral release on my left knee. It made the knee stop hurting but I still had pain going down the outside of my leg. My ortho doctor said it was a pinched nerve in my back. At that time I was pregnant so I dealt with it some more. Fast forward, 4 years ago I got tired of living in pain. I saw my family dr NUMEROUS times. I tried Neurontin, Vicodin and Ultracet. They all made me sick and fuzzy headed. I saw a neurologist, neurosurgeon, 2 more orthopaedic specialists, a rheumatologist and a sports medicine doctor.

 

The neurosurgeon ordered MRI's of my low back, my knee and my leg. They  didn't show any problems at all with my back. They did show a small joint effusion under my knee and chronic shin splints. At that time I still never exercised so I'm not sure how I would have chronic shin splints. The sports med doctor said it probably was a pinched nerve and the MRI just wasn't showing it. He did a couple of epidural steroid injections and it did seem to help.

 

Here I am now: I've lost 80 pounds. I'm at a normal weight. My kneecaps hurt, my outer leg hurts. To begin with it was just the left leg but the last few weeks my right leg is also hurting. I'm hurting,I'm in tears from the pain and I don't know what to do next.

 

If it were a pinched nerve wouldn't it show on the MRI and would it make my other leg start hurting also?

 

I have a family history of Multiple Sclerosis but that has been ruled out. I haven't had any other surgeries on my back, leg or knees except for the lateral release on my left knee.

 

Where do I go from here?

 

The pain is and has always been from my knee down to the ankle/foot. I've never felt anything in my hip or thigh.

 

Things I have tried that do not seem to touch the pain at all: Tylenol, Tylenol Arthritis pain, Advil, Mobic, Aleve. Ultracet takes a bit of the edge off but not much. Neurontin and narcotic pain meds just make me sick.

 

The only other thing I can think of that maybe important is that I also have bone spurs in both feet with plantar fasciitis, that started about a year before the knee and leg pain.

 

I'm posting this here because I was thinking since all of you are runners that maybe you had advice or have dealt with this before.

 

thanks for any and all advice!

  • JamesJohnsonLMT Legend 1,146 posts since
    Aug 23, 2009
    Currently Being Moderated
    1. Apr 6, 2013 7:50 AM (in response to mamainpain)
    Re: please help, I am in so much pain:(

    With the state of medicine today, I am not surprised when a lot of drugs and imaging studies have been thrown at a problem before all known causative factors are duly analyzed. In your case, I think you would have been better off if you had seen the physical therapist first. A study of your anatomical structure and body mechanics may have saved you a lot of suffering. Unfortunately, PT is often brought into play after surgery, with a specific prescription for treatment that could have been preventive as well as instructive. As it is, we do not know what led your doctors to resort to the knife, but I will hazard a guess..

     

    Pain does not always correspond to anything visible on a scan, nor does it always have an inflammatory component. In the absence of these, there is almost always an anatomical or biomechanical explanation for it. When you were 23 and pregnant, with no history of repetitive leg motion from exercise, it is almost guaranteed there was a structural or functional explanation.

     

    Of course, lack of exercise at the time implies "sedentary activity," or no activity. If you were inactive, and did not spend a lot of time standing, it is likely you spent a good deal of time sitting. A number of problems can result from time spent in chairs, even among the athletic population. Dysfunction in your core muscle group, particularly the hip flexors and intra-pelvic muscles, could have been the cause of pain in your knee and lower leg at the time, and would only have been made worse by deformation of the pelvis that occurs during pregnancy.

     

    But let's look at the course of action being followed by your medical providers today. With meds and steroids, they have pursued inflammation. Anti-inflammatory meds won't affect neurological or myofascial problems when they are not due to inflammation. If there was no direct evidence of arthritis at the tender age of 23 (no surprise here), meds such as Celebrex and their weaker OTC counterparts would only have value for the placebo effect (often used in medicine). Didn't work, because the pain was real, and probably not caused by inflammation.

     

    So why pursue it? CRP levels, of course. But it turns out that CRP, traditionally associated with inflammation, is notoriously high in the sedentary population. When blood sugar levels are not regularly modulated by exercise, they can become less stable. The apparent overlap was probably due to the effects of inactivity on metabolism and the heightened risk of systemic inflammation under such circumstances. In this case, a red herring, because systemic inflammation (eg: arterial) probably had little or nothing to do with your knee problem. Therefor, efforts to lower CRP with drugs had little or no effect on the pain. Manipulating the symptom of one problem does not necessarily address the cause of another.

     

    Then there was an expensive search for something that would show up in an MRI. Nice to know there wasn't much wrong, after the surgery. Given that few visible problems were found with a direct relationship to lower leg pain, "release" is a term that bothers me. Surgeons who use it know the technique has been frequently overused. Surgical changes to your anatomy cannot always be successfully reversed, and in some cases may exacerbate the structural problems that are likely to be important in your case. Did it enhance the stability of your knee, or just buy time?

     

    If there was an imbalance in the musculature controlling your kneecap, and resulting fluid buildup (effusion), I can see why they might attempt a "release," but a surgical release, even 10 years ago, is hard to justify today. It is well-known that an imbalance in tone among the muscles controlling the kneecap can result in knee pain and/or swelling under the kneecap. Moreover, swelling under the kneecap can trigger muscle weakness on the other side of the knee from where the release was performed, a viscious circle. If the medial muscles were weak in contraction force, the lateral muscles were tight by comparison, leading to patellar tracking problems and the unfortunate conclusion that a release was necessary.

     

    Another approach is to strengthen the weaker muscle in order to equalize the tension on either side of the patella. This works in some cases, but there are circumstances under which this approach will not work. We already looked at swelling under the kneecap as one cause for muscle weakness, but if unequal tension was found and surgically treated, swelling could not logically be the original cause and the symptom. It's not a chicken or egg question. Barring a history of direct trauma, the unequal tension most likely came first. One explanation for how this could be is your inactivity, but there are plenty of couch potatoes without the severe knee problems you've had. Another explanation is muscle weakness caused by myofascial trigger points, in which case there would be a cascade of problems originating from unequal tension on your knee. Here's an example of someone living with this.

     

    I believe there has been dysfunction in your core muscles from the lower back and hip down through the thighs, and possibly some structural peculiarities with your feet as well, that led to the slow decline of biomechanical health and a domino effect, expressed in the form of pain, in everything from the knees down. Now, why could that be the case? Any PT can tell you that balance and symmetry in form, function, activity, and inactivity, goes a long way toward ensuring a pain-free lifestyle. Sometimes imbalance and asymmetry are anatomical, as in a leg-length discrepancy (one leg longer than the other), and sometimes our activity is unbalanced, as in too much typing or too much sitting (such as I'm doing now), even too much exercise (perish the thought). Pain from stress on muscles and joints can originate above or below where it is felt, causing symptoms so severe, they distract us from the big picture of how we are built and how we move.

     

    I'm a big fan of original causes, and lasting solutions. Sometimes these are simple, but sometimes they point to major lifestyle changes. Don't give up on the quick fix, but I wouldn't hold my breath waiting for it, either.

     

    First of all, chairs are your enemy. If the weight-bearing portions of your anatomy do not show damage upon examination, you are cleared to be more active. Chairs, even the ones in cars, force you to fold your legs in such a way that important muscles become shorter and fail to function properly when you stand. This can lead to patterns of pain, such as Piriformis Syndrome. The Piriformis is found deep in the butt between sacrum and hip, but can cause pain to radiate down from as far up as the back, through the legs to the foot.

     

    Another cause of this same problem can come from below. Certain types of bone structure in the foot can cause excess pronation of the foot, requiring, among other things, external (outward) rotation of the leg to the extent that it tires the Piriformis muscle. All that twisting can be just as hard on the knee as unbalanced quads, which may also serve as cause or symptom. So, just a small anatomical flaw, or an average chair, can begin a chain of events that eventually expresses as severe pain, even without exercise being involved. Sure, as runners we may encounter these problems sooner, because we rely heavily on physical balance, but most people move about in some way, and almost everybody sits for extended periods of time.

     

    Shin splints, or something that feels like them, can indeed result from structural causes or muscular dysfunction. Ditto for Plantar Fasciitis and heel spurs. You've had so many symptoms that point to the general breakdown that occurs in response to issues of structure and function, that a course of therapy to address these probable causes is the only therapy you should have been subjected to. It does not mean that you would experience relief right away, but that any problem that takes 23 years to show may take some time to fix. Sometimes there is a quick fix, as with proper shoes, certain orthotics, etc., but most of the time there are major lifestyle changes required. Your patience is the difference between apparent failure and slow but steady progress. The pills, shots, and surgery have been tried. Now, for this physical problem, it's time to get physical.

  • JamesJohnsonLMT Legend 1,146 posts since
    Aug 23, 2009
    Currently Being Moderated
    3. Apr 6, 2013 9:19 AM (in response to mamainpain)
    Re: please help, I am in so much pain:(

    Wow..  1, 1-1/2" is a major discrepancy, almost guaranteed to make you suffer. I worked with one lady with this large a difference, and she's been on a wild odyssey with dozens of doctors around the world pursuing the symptoms. I was able to help her, but major work needs to be done to eliminate ongoing causation. There has to be some correction of the stresses this causes before you can experience anything but temporary relief.

     

    However, I would not stop there. Leg length is probably only one of the problems. Any evidence of bone structural abnormality in one place should prompt a search for others. Pelvic asymmetry is another possibility, though it may appear to be due to leg length. Once again, these things may not hurt in themselves, but will cause lasting problems with muscle function until they are corrected or compensated for. I included links with examples of this. Keep searching. I'll bet you will find more.

     

    Muscles work overtime trying to compensate for skeletal asymmetry. Some pain meds can help to a certain extent, but pain from muscular overuse or spasm can be severe and ongoing, as well as misleading. The muscles themselves often do not appear to hurt, but pain is felt, or at least perceived, in the joints the muscles operate, among other places. Sometimes there is corresponding physical damage, and sometimes it is a mirage that shows nothing on scans. The term is "neuromuscular." I use trigger point therapy to address spasms, but all methods of pain control are temporary until the cause is eliminated.

     

    One thing I failed to mention is that muscular tension, and resulting tissue build-up, can compress nerves as well. It does not always have to originate in the spine or between bones. Fine imaging can reveal this. The upper gluteal muscles can also compress portions of the sciatic nerve that are responsible for relaying sensation from the lower legs. Misleading symptoms can result. An issue could arise all along the nerve, but there are frequently seen "choke points" in our physiology that can help narrow things down. Scar tissue due to overuse or the strain of asymmetry can be eliminated, even without surgery.

     

    One problem I see with insurance all the time is the limitation to immediate symptoms. I hope someday they can fix this flaw with the healthcare system. Medical professionals are almost being forced to turn symptoms into a cash cow, rather than solve with a macro approach.

     

    In defense of insurers, I can say that not enough is known about the relationships between various components of the human body to guarantee the efficacy of myriads of therapies, some of which work for only a few. They can't just throw the money around willy-nilly either. Symptom control is easier to boil down to a science. We clearly have a long way to go.

     

    I am glad you may be able to independently pursue a comprehensive solution. Too often, the story is no insurance, or little insurance and no money to spare. There are self-directed therapies that can help in any case, but it can take a lot of time and effort to stay on top of a condition like this. I was able to correct for a small leg-length discrepancy with a simple layer of tough padding in one shoe, with dramatic results. Not everyone is so lucky, but that does not mean there aren't things we can do in any case. Remember that for any change, it takes time for the muscles to adapt, and sometimes the problem will switch sides.

     

    Good luck, and keep us posted. Most of the runners in this forum have been through bouts of chronic pain that can be traced to similar problems, so it may be your experience that helps them.

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