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1085 Views 4 Replies Latest reply: Oct 31, 2013 11:54 AM by shipo
CoachSC Amateur 8 posts since
May 30, 2007
Currently Being Moderated

Oct 27, 2013 11:25 AM

left knee pain

I have been having left knee pain since July.  I went to the doctors and got a cortizone shot in Sept.  It helped slightly for a few weeks.  I then started Euflexxa injections.  Since the shots ( 2 weeks) my knee is worse than before.  Constant pain and feels like it will lock and buckle.  Running has basically stopped at this point.  My doctor is pushing for a knee replacement.  I have looked into a brace but $540.00 is a big check to write if it doesn't help.  Any thoughts?

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    1. Oct 28, 2013 4:07 AM (in response to CoachSC)
    left knee pain

    I have some thoughts, but a lot more questions. Missing from your account is an explanation of exactly what is wrong with your knee other than the perception of pain there. I'm looking for physical evidence that something is actually wrong with your knee that is a proven cause of pain. Otherwise, I would have to draw the conclusion that something is wrong with the muscles and/or associated fascia controlling the knee, which are the most common source of knee pain.

     

    Buckling and locking of the knee, as well as knee pain, are symptoms associated with Quadriceps muscles. The only tie-in with the knee itself would be a flaw in the joint that the muscles are attempting to control for, possibly due to a reflex from the spinal cord based on sensory input, or minute muscle damage. Since a lot can be mechanically wrong with the knee joint without producing such input, I am inclined to think the muscles are acting of their own accord, possibly due to damage in the muscles having little or nothing to do with the knee itself. Location of the resulting perception of pain is less relevant than most people (including too many medical professionals) think.

     

    It is possible, and all too common, for patients to be tested for signs of knee dysfunction without evaluating for myofascial disorders that present as knee pain. Turns out a lot of doctors don't even wash their hands between patients, so you can expect them too miss things less fundamental than simple hygiene. Even if muscular problems have been tested for, they are a frequent cause of actual knee damage, whether initial or chronic, and need to be treated concurrently, if not first. I see no evidence that this has been done before the rush to (possibly unnecessary) surgery.

     

    Regarding the brace, you already have one in the form of the muscles controlling your knee, and it sounds like they are working overtime. You need to find out why and how the splinting of your knee by these muscles is related to your symptoms. A brace can appear to work when it allows overworked muscles to rest, recover, and become asymptomatic, but this effect can be achieved without a brace by working directly with the muscles themselves. In some cases there is no knee problem other than this, and in others a mechanical problem can be controlled successfully without symptoms. There may be an underlying structural/biomechanical issue that is congenital and requires special training or orthotic support, in order to address your obvious muscular dysfunction and the pain that is likely to be caused by it.

     

    There is a tendency in medicine to focus too closely on symptoms, and to look too closely for suspects while ignoring the 800-pound gorilla in the room. If a gorilla is standing on my foot, I can call in a host of experts armed with microscopes to analyze my foot pain and any resulting problems there, or I can ask the gorilla to stop standing on my foot and let the problem heal itself. Even if there is evidence of knee joint damage, the question remains as to why. You would remember sudden trauma, but absent this, there is usually a biomechanical cause that is to blame for the damage, with which pain may or may not (as is frequently the case) be directly associated. In many cases, mechanical flaws found near the site of pain are irrelevant to pain and the real motivation for this medical inquest is, has been, and will remain muscular.

     

    If you are a runner with any biomechanical flaws, you will eventually experience pain, often before mechanical damage is done. If this pain is new to you, do not allow anyone to leapfrog to any conclusions of relevant physical damage until myofascial symptoms of biomechanical deficits have been thoroughly explored. Most professional athletes who compete over time, have substantial mechanical damage to show for it. In many cases, they have no associated pain. There are lots of weekend warriors out there with plenty of pain, and little or no mechanical damage. These folks are a godsend to enterprising medical personnel looking to make a quick buck on the burgeoning fitness crowd. Don't be one of them.

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    3. Oct 31, 2013 11:30 AM (in response to CoachSC)
    left knee pain

    I wonder how much material was removed due to the infection, how much was reconstructed, and how much healthy tissue is left. There are neuromuscular interactions between what is going on under the knee cap and tone/behavior of the supporting quadriceps. All well and good, but I hope the suggestion of a replacement isn't to cover up a botched job with the initial surgery. If they were repairing a torn ACL, introduced an infection, and had to clean it up, there is some question as to what was clearly explained to you (you felt you could run on it), and how complete the rehab protocols were. Recovery from torn ACL should not be left to chance.

     

    I'm going to take a wild guess that there is still something wrong under there that the cortisone can't control. However, there is an outside chance the pain is generated by the supporting muscles because of the way they behave.Splinting/buckling concurrent with pain is not normal behavior, generally speaking, but the rest of us can experience this temporarily after over-training. It has happened to me after really long runs leading up to the marathon, or during the marathon itself. That being the case, there is hope that a break, coupled with proper conditioning of these muscles, could solve everything you are experiencing now.

     

    You mentioned further training - no doubt that is in the cards - but the knowledge gap between the average pt (personal trainer) and a PT (physical therapist) can be huge, regardless of experience. I did not hear what post-op rehab you underwent, but I am hoping it included a lot of carefully targeted quad strengthening and ROM exercises. Pre-op PT is also recommended. Even if that was the case, protecting the reconstructed ACL during a run might tire this muscle group, resulting in splinting and pain during use. You can see how this effect, though related to the initial damage, can mislead as to the actual cause of pain at this time. While the response can be complicated, I've seen evidence that suggests buckling to be more indicative of under-knee problems than splinting, but these problems can be interrelated and self-perpetuating. It is something of a chicken or egg question.

     

    As stated earlier, please evaluate for myofascial pain syndromes so they can be treated first. This can reduce pain that does not respond to anti-inflammatory treatments such as cortisone, and can reduce pressure on the joint itself. Make sure the subsequent strength training is professionally prescribed and monitored. You can over-train into this set of symptoms, as well as under-train. This post-op ACL scenario requires real know-how, especially if there is relapse long after the initial problem or surgery. In the business this is called neuromuscular re-education. There is un-learning and re-learning to take place. It's not simply a question of raw strength. You've seen so-called "muscle-bound" athletes, and your splinting and loss of ROM suggests some form of overuse. You don't want to add to this, but want to de-construct and re-educate your supporting muscles and their behavior. I am hoping the internals of your knee joint allow for this, so normal re-growth can occur.

     

    It's possible you can beat this if you get serious about rehab. Joint replacement is not the end of the story, but the beginning of another. It may seem like a panacea to the sedentary, but is not the key to a long running career. It can be a near guarantee you will introduce further muscular problems, and may look forward to yet another replacement in the future. Artificial joints do not self-maintain like real joints, and their limited lifespan will be further reduced by a repetitive high-impact sport like running. Find out if there is anything wrong with the mating surfaces of the joint itself, and why. Replacement has to have a better rationale than pain alone.

     

    There is also controversy about whether and when a brace can help to rehab this injury. You want to rest the joint and muscles enough to prevent further damage, and to protect the repair, but there also needs to be enough challenge to recoup tone and function. Beneath a safe threshold, tissue grows to adapt to the stresses placed on it. My money is on rehabilitation, not replacement or prosthetics. Stay on it, and don't get up-sold.

  • shipo Legend 499 posts since
    Aug 9, 2013
    Currently Being Moderated
    4. Oct 31, 2013 11:54 AM (in response to JamesJohnsonLMT)
    left knee pain

    JamesJohnsonLMT wrote:

     

    There is also controversy about whether and when a brace can help to rehab this injury. You want to rest the joint and muscles enough to prevent further damage, and to protect the repair, but there also needs to be enough challenge to recoup tone and function. Beneath a safe threshold, tissue grows to adapt to the stresses placed on it. My money is on rehabilitation, not replacement or prosthetics. Stay on it, and don't get up-sold.


    I've always had a gut feeling this was the case but I've never seen/read/heard anything which supported my feeling; thanks for that. 





    Fat old man PRs:

    • 1-mile (point to point, gravity assist): 5:50
    • 2-mile: 13:49
    • 5K (gravity assist last mile): 21:31
    • 5-Mile: 37:24
    • 10K (first 10K of my Half Marathon): 48:16
    • 10-Mile (first 10 miles of my Half Marathon): 1:17:40
    • Half Marathon: 1:42:13

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