[briguy]

So after 4+ years of issues with my knee, I recently got what I think is a definitive diagnosis of “patella arthritis.”

Previously I had what I considered “runners knee” or Patellar-femoral-syndrome (PFS) and I am pretty sure I posted about it here seeking advice though I can’t find that thread anymore.

Typically PFS/runners-knee is a maltracking patella/kneecap that rubs and causes pain running,cycling, going up/down hills/stairs, etc.

I’ve tried some conservative treatments including a lot of leg strengthening (step ups, squats, etc) but these generally have made things worse, certainly in the short term.

Recently, since I confirmed the maltracking patella via xray and MRI (which also showed the arthritis – presumably from 4+ years of “rubbing”) I have also added some specific stretching/rolling of the outer thigh/quads to try to loosen up the tightness pulling that kneecap to the outside. This actually brought some relief and I was encouraged. But an ill-conisdered mountain-bike ride recently brought it all back with a vengeance.

Is there any guidance on what I can do in this situation? Should I stop all activity altogether? This hasn’t helped in the past when I was sidelined for 8 months with a hip surger, as soon as I started back the knee pain returned. Avoid just cycling?

Anything other than the strengthening that I should consider? I’ve read that KT Tape can help but I am pretty skeptical about that stuff. Maybe a knee brace to realign that kneecap in the short term?

This injury has been dogging me for a long time, I’d really like to figure it out and determine what my prognosis is.

Topic

[Thomas Summer, MD]

Thomas Summer, MD on October 18, 2021 at 12:39 pm #58251

Patella femoral pain syndrome is just the term that describes pain in the area behind and around the patella. That can have many reasons. One of them can be retropatellar arthrosis (arthritis on the back of the knee cap).
The term “runner’s knee” usually describes pain on the lateral part of the knee. That’s the insertion point of the iliotibial band. That’s why it is also called Iliotibial Band Syndrome – ITB Syndrome. Although it’s not that clear what really causes the pain.
Radiological signs of arthritis can be, but must not be a cause of pain.
So where exactly is your pain? I assume that someone examined your knee?! MD or physio!? What did they tell you?
And one more question: Why did you get hip surgery and what was done? Was it the same side that is bothering you now?

Sorry for more questions than answers. But I hope that I can really help you when we have figured that out;-)

lg!
Thomas

[briguy]

briguy on October 18, 2021 at 12:54 pm #58254

Hi Thomas – The hip surgery was 2018, opposite side, and it was a labral tear repair (rim trim too). The knee issue started in 2017, specifically when I was doing some step-downs and sissy-squats as part of a strengthening program. I remember the day it happened…BAM, pain started and has continued since, though it will retreat a little when I cycle less. Generally it gives me trouble until I’ve warmed up on a run, and is tolerable even then.

I see as many references to runners-knee as PFS as I do for ITBS but they must be pretty interchangeable, certainly they are both afflictions of runners. Anyway I am familiar with ITBS and that is not what I have (I wish it were, I abolished a previous bout with ITBS pretty easily).

Yes, have had a few evaluations by MDs on this knee, all pointing to PFPS due to the pain description (directly behind the knee cap – and particularly bad going up/down stairs and when cycling)…and since xrays all looked okay (no arthritis in the joint). A more recent Xray clearly showed the patella/kneecap shifted to the outside when compared to the opposite knee.

That prompted an MRI which disclosed the arthritis behind the kneecap, presumably from all these years of rubbing in that area.

My conservative treatment regimen thus far has been quad strengthening (quad sets, isometric holds —- step ups and leg extensions dramatically flare up the condition). Have been foam-rolling and stretching for a long time too…but recently targeting the outer-quad/thigh area seems to have shown some improvement over my more general approach from previously.

[Thomas Summer, MD]

Thomas Summer, MD on October 18, 2021 at 1:01 pm #58255

You remember the day it started? Did you dislocate your patella back then? What did the MD say about why it’s shifting to the outside?
I would recommend a good PT who can guide you with the right exercises for you.

[briguy]

briguy on October 18, 2021 at 1:16 pm #58259

Yep, I remember it happened when I was doing the sissy squats, a strengthening exercise I hoped would prepare me for the downhill pounding of a mountain race (Pike’s Peak Marathon).

Could I have dislocated the kneecap simply doing that? My uneducated imagination thinks that patella got “pulled” to the outside as a “tweak” during that exercise but I don’t know if that’s even possible.

I’ve seen several PTs for this and it’s always the same strengthening regimen – quad sets, isometric holds, etc. Some PTs recommended I just needed to get stronger and would have me do step ups and step downs and that the pain needed to simply be worked through until I was strong enough. I’m not sure how strong I need to be? I can already do pistol squats with that leg – I can do step ups until the cows come home —- lots of people don’t have that kind of strength and yet can ascend/descend stairs without pain.

[briguy]

briguy on October 18, 2021 at 1:31 pm #58260

P.S. I’ve noodled around a bit on my own and discovered an exercise that would target my inner quad (the VMO) as that is often recommended to “pull back” the kneecap to the right direction.

Split squats dropping the affected knee straight up and down from the ground – I can feel the VMO engage on this and the lack of knee flexion means I don’t get any pain.

Meant to mention I’ve been doing these as well and they seem to help as both a “pre-hab” for my running as well something to do in conjunction with the other-thigh stretching routine.

[Thomas Summer, MD]

Thomas Summer, MD on October 19, 2021 at 7:39 am #58277

So now it gets difficult without seeing you and the knee;-)

I would recommend only doing strength training that does not give you pain. As the split squats work for you that should be fine. But it looks like strength in the quads is not your problem. Are you doing anything for the hamstrings? Too much tension in the quads?
I would like to know if there is a specific reason why your patella is moving to the outside!? What are the docs saying about that?
And then I would think about getting a cortisone shot. Getting rid of the pain could help you move better and also be effective for much longer than the effect of the cortisone.

[briguy]

briguy on October 19, 2021 at 8:01 am #58278

Thanks, I appreciate your help in trying to get to the root of this.

None of the MDs could really say “why” the patella is misaligned, just that it’s a common culprit with PFPS. Common speculation is due to muscular imbalance and or mobility/flexibility issues.

So for years I’ve been doing the #1 prescribed exercise for this condition (quad sets) which I generally do about 10 sets of those a day. They are very interesting exercises, as they can often make the pain go away – which is why I tend to do them as pre-hab before a run for example. But I think I’ve reached the limit of how much that quad-sets can help me. I have Robin Mckenzie’s Knee Pain book but other than the quad-sets that program hasn’t been helpful.

It’s interesting that you ask about the hamstrings, as I also do some hamstring flexibility stretching and that seems to help too.

Might be helpful if I list out everything in my current regimen – I do the stretches daily (At least) and the strength-work 2-3 times a week.

Flexibility:
Foam rolling (quads, IT band, etc)
Hamstring stretches
Quad stretches
Twisted leg stretch (targets the IT band/outer thigh)

Strength:
Single leg deadlifts
Step ups (when able – can be painful so I at least will do the opposite “good” leg)
Quad sets
Split squats – trying to isolate that VMO as much as possible)
Band work – targeting the glutes (this is a byproduct of my hip surgery)
Previously I have done version of the Uphill Athlete ME program too but currently on break from that.

Interesting that you asked about a cortisone shot as my MD suggested that as an option (as well as euflexxa). The pain will almost completely vanish when I go on a round of NSAIDs for 2 weeks so I’m sure the cortisone shot would do the same.

[Thomas Summer, MD]

Thomas Summer, MD on October 19, 2021 at 8:42 am #58280

The routine looks good. But if you do it daily, it’s maybe just too much!?
I would recommend the cortisone shot and some days off. Do you know the “broken TV approach”? When there was trouble with these old, big TVs you just hit it hard and the screen was clear again. And you didn’t know why. So hit your knee with the cortisone. Whatever hurts will get away. You don’t need to know what exactly it is;-)
Euflexxa / hyaluronic acid could be good as a combination in the long run.

You’re welcome! I’m happy, if I can help a bit!

[briguy]

briguy on October 19, 2021 at 9:18 am #58281

Just to clarify, only the flexibility regimen is daily, the strength work I do 2-3 times a week.

I like the idea of trying the cortisone shot, at the very least it’s something I haven’t tried yet!

What’s odd about this knee condition is that even before I discovered this current semi-effective routine, I’d have “good days” where the knee wouldn’t bother me a bit on the bike and I always tried to deduce what I had done differently to bring that about. In hindsight, something I had done had allowed that patella to shift over a bit but maybe it was just having a “good day” itself. 🙂