Back again with new knee pain

[doublemom]

Hello all.. I was on this board a lot this spring after I found out I have a tilted, laterally subluxed patella (both knees, but the right is much worse than the left). After shopping for surgeons (that was fun!!!) and finally finding someone I trusted, we decided to handle only the lateral and medial meniscal tears, and debride the patellar cartilage. That surgery went fine in May and the horrible grinding sounds finally went away. We decided to wait on a LR and TTT because I was still very highly functional at the time. Three months after surgery I was hiking through Ape Cave, biking, gardening, doing all the things I love to do, as long as I was very careful with bending and weight bearing on my right leg. Stairs are still my main enemy

Now 7 months later.... Last wednesday I was getting out of a very low chair that I swear had me sucked in, it was very hard to get out of and I kind of twisted while trying to get out of it. I had a bit of pain in my knee at that time, and since then it's only gotten worse. It's not meniscal pain, I know what that feels like. It's a very sudden, very sharp feeling right under my patella toward the lateral side... right where the patella is grinding up against the side of the femoral groove on my x-ray. Any time I move my knee outward and bend at the same time now, I feel it. Rolling over in bed, getting in an out of a car, just standing up from a chair wrong, and it takes my breath away.

Grrrr..... I felt I was doing so good, and now right before the holidays this just had to happen. I'm hoping I just twisted it a bit and it's angry, and will settle down over time. There is a very dull ache all the time, and the sharp pain like a piece of glass right under the patella when I move wrong. If I keep my knee rotated internally a bit, it seems to help, but any outward rotation is what hurts.

So... I just wanted to post on here because I know that so many of you have felt the same frustration I'm feeling right now. I felt like I was finally back to my normal life, doing the activities I wanted to do (carefully, of course), and now I'm in denial that the subluxed patella is back to haunt me Just venting my frustrations here, as i know you'll all understand.

To finish on a happy note, I hope you all have a wonderful holiday season!!

Andi

[doublemom]

I managed to take a photo of my xrays from this spring showing my patella....



My DH didn't quite understand what he was looking at until I went online and pulled up xrays of what normal patella alignment should look like. It was an eye opener for him

[digginit]

YIKES! That's a very subluxed patella. Does it ever dislocate? I'm guessing you've done lots of strengthning exercises for your quads to get whatever benefit you can from that.

~dig

[bavage]

I am really sorry this has happened to you. Has anyone you've seen made any suggestions?

[doublemom]

That's my normal patella angle with my knee bent at 30 degrees at rest. It's actually slightly better at 60 and 90 degrees, but still subluxed. I had a dislocation about 10 years ago that was the single most excruciating pain I've ever been in. It hasn't fully dislocated again since then, but it's obviously not behaving well any more.

I went to physical therapy for several weeks before my meniscectomy/debridement for quad strengthening. Wonderful therapists! Taping really helped, though my skin didn't like the tape much and I ended up with wounds almost like burns from the tape, even though they tried different things with me to keep my skin from reacting. Also tried several braces that medially rotated my knee that felt good... as long as I didn't move around in them, but with any activity at all they ended up not staying in place.

You know... I just thought of something. I've been gradually getting on the elliptical trainer at the gym and am up to about 2 to 2.5 miles twice a week. The elliptical allows me to get a nice cardio workout with virtually no knee pain (or foot or hip pain). But I've just in the past couple of weeks ramped it up to get to 2 miles regularly. I wonder if that has anything to do with this new pain I'm having. I don't notice any swelling, but when I get the knife-like pain, it's enough to stop my world on it's axis for a second or two.

I'm still throwing around the idea of going ahead with the LR and TTT to keep any more cartilage damage to a minimum at this point, versus just waiting it out and not having surgery until I can't do my regular daily activities any more. I don't know if there's a correct answer. Part of me just wants to get it over with to preserve what cartilage there is left, and the other part of me is in denial and I tell myself that it's not so bad, I can still do most of the normal things I need to every day so i ignore it.

Anyone have thoughts on that after seeing my gorgeous xray? Should I just go through with it and get it over with, or hold out as long as I can? I finally have a wonderful orthopedic surgeon that I trust completely, he is now in private practice but he used to be the team physician for University of Washington sports teams for years, and he graduated from and taught for years at an excellent teaching medical school.

What to do?

Andi

[Riosilia]

The only suggestion I have is when you go see your orthopedic surgeon, ask him if you would be a good canidate for medial patellofemoral ligament (MPFL) repair/reconstruction. LR use to be very common but current research is starting to show that often time it's not so good over the long run (in fact I had my LR "undone" due to medial instability postoperatively). Many studies now show that the main patellar stabelizer is the MPFL, which often gets streatched or tears during patellar dislocation. This could be contributing to your laterally subluxed patella. Ask your doctor how he know's what's causing your latellarly subluxed patella (i.e. is it a tight lateral retinaculum or is it torn MPFL?). There's a huge difference in the two that needs to be recognized when deciding the proper tx.

Sorry, I had to vent a little... everytime I see someone on the board considering LR my heart sinks (that was a horrible mistake my ex-doctor made). I know some people are good candidates for LR because their dysfunctions is truely due to tight lat retinaculum. However research trend is starting to show this is not nearly as popular as what they originally thought it was.

[doublemom]

Rio - Thanks for your thoughts, I really do appreciate it! The reason it took me so long to find a surgeon I trusted was because all the other surgeons I saw just wanted to do a LR and they said that would solve the problem, no issues afterward, very good outcome, easy recovery, blah blah blah.... I was smart enough to *RUN* out of those surgeon's offices and never go back. (I'm a medical transcriptionist, so I know basically what they're talking about and I'm not going into this blind).

My knee MRI from this spring confirmed no problems or tears with the medial ligaments, or any other ligaments in the knee at all. When I had the meniscectomy in May, the surgeon said that everything looked good from viewing through the scope, except for the meniscal tears and patellar cartilage/lateral retinaculum. My lateral retinaculum is extremely tight and painful, so much so that I can hardly stand to have it massaged or stretched, or even touched by my therapist. My ITB is also very tight and gets adhesions. I've had massage (ouch!) and therapy for that, and I do ITB and piriformis stretches regularly to keep that as loose as possible. So in my case, it IS the lateral retinaculum that is pulling so tightly on the patella.

The doctor I type for is a physiatrist, an osteopathic physician, and she does prolotherapy injections. We've talked about doing these injections to the medial side of my knee to try to strengthen and tighten up the medial ligaments, and I think that is what I'm going to try next. It is definitely much less invasive and risky than major knee surgery. The only problem is that she's going to have to give me enough valium to put me into orbit for the injections, as I cannot tolerate anyone touching my knees in any way, much less injecting them! I can barely type other patient's medical transcription when she does knee injections, much less have her actually do mine eeeek!!!

But... I really do appreciate your concern about lateral releases, and I agree wholeheartedly that it is way too common among most orthopedic surgeons, and done too quickly without people knowing the implications of what can go wrong. I think it CAN help, but only in very specific situations like mine. In far too many cases, it's the wrong procedure for the wrong problem, and just ends up being worse in the end.

andi

[Silkncardcrafts]

Hi Andi,

My heart goes out to you. I know how frustrating it can be.

If your patella is like that the injections you talk about will not fix the problem. You probably need some sort of surgery to fix the problem. You may have a shallow trochlear groove which means that the patella comes out quite easily. I had that problem and had a trochleoplasty in May to deepen the groove. It has made a massive difference and my knee cap never comes out any more. This is something I would ask about. A MRI generally won't show this sort of problem. CT scans and plain x-rays are the best for showing these type of problems.

As for a MPFL reco you don't necessarily need it to be torn to have this operation. If your patella is incredibly loose it can help to stabilise the knee cap more. A lot depends on your anatomy and what can be done. I've also had this operation and did help for a long time until I developed medial instability.

I am not a real fan of lateral releases either. I developed medial instability in both knees after my lateral releases about 9 years after. It has not been fun trying to get it fixed. My surgeon does a lot of them and am the only patient to experience the medial instability. So, I guess I was just unlucky. In the right situation they can work really well. The problem is that a lot of the time they are done for the wrong reasons.

It is great you have been able to build up in the gym. Your legs must be pretty strong if you are using the elliptical at the gym. I've just started back in the gym and aren't strong enough for that yet.

My suggestion would be to find a knee surgeon that specialises in patella problems and is very conservative. Fortunately mine is, so always thinks through things thoroughly before doing anything.