possible patella baja

[kneedsomehelp]

Wow i just found this forum and I love it! I kindly request some help from those who have experience with patella-femoral joint pain as I could really use some guidance at this point. I'm a 25 yr old male. My sordid affair began about four years ago with serious lateral pain in both knees from cycling. After about a year and 3 months of PT, i saw a knee specialist who said i have pretty severe lateral tightness in both and he recommended a lateral release. After releasing the right one, i felt much better. Its at this point that i think i screwed up - i started doing a little running 2 weeks after surgery because it felt so good. BIG mistake. I recovered from the release but have always had pain laterally just off the patella.

6 months later my left knee was released and a debriement was done on the right. Similiar deal with the left - significant relief of pain and better tracking but still continued pain laterally just off the patella (like right where the patella connects to the tendon). I have never had any pain where the debriement was done on my right (was an open incision), but the pain just moved up my leg and is right above the old spot just off the patella. I've been told this is possible neuroma.

Fast forward about 1.5 yrs and I couldn't take it anymore. After a number of injections and PT, I was told my right LR failed and i had tightened down again. The surgeon was highly recommended. I had a revision release performed, and the pain is slightly less now but i'm still had 0 activity. I have pain all the time in both - just off the patella laterally. I continue to do PT exercises to maintain quad strength.

I saw another specialist for a 2nd opinion about a month ago. He says it is patella baja - but he said it will eventually heal and may take 1 -1.5 yrs. He said swimming with fins is the best thing. I must have a mild case because i have full range of motion in the left and almost full (can get my ankle almost to my butt) on the right. My current OS says baja is possible - but i'm borderline. My current symptoms are pain all the time in both, trouble going down stairs, no activity. I do patella tendon lengthening stretchs (will this help) and quad work and those actually seem ok - but the relief is short term. Please help!!!! I've seen mention of Dr. Steadman, Dr. Noles, and Dr. Fulkson (i'm from CT) - which one should i see? what should be my next step? is there a brace I should try? Please help!! Thank you.


matt

[heather_rae]

Matt:

Hope I can offer some help here. My measurements on my injured knee reveal mild patella baja, too. The PT said it could possibly be scar tissue pulling it down. Has that ever been mentioned as a possible cause? I've been told for what seems like an eternity to strengthen this profound quad atrophy and it should get better. I've been doing PT for 13 months now. Not sure about swimming with fins, sounds painful. I swim with a floatation device. Yes, I cheat, but the knee pain/no strength just won't let me go without it.

I have pain all the way around the kneecap and underneath. Mobes are extremely tight when compared to the good knee. Mostly the sensation I get from maltracking is medial pressure/pain from pulling laterally and a sharp pain in the lateral retinaculum. Baja causes sharp pain at the base when I'm up and moving around. I wear a lateral J brace for the maltracking problem. Subsequently, when I have subluxation, the entire thing throbs. Somehow, the brace helps the pain at the base of the knee, too.

I have recently been referred to an OS (Dr. Wojtis) who specializes in soft tissue problems due to my PF syndrome. Maybe you can search the net for a similar OS in your area. Alot of surgeons don't do much in the area of pain, as I've found. You may have better luck in that dept. with a GP. I've recently sought a doc for some PTSD problems and the meds subsequently help chronic pain, too. On about day 6, I noticed that they began to take the edge off the pain and I am better able to tolerate it. Good luck and feel free to post back with questions!!

Heather

[kneedsomehelp]

Thanks for the reply! My pain is completely localized in one spot laterally right up against the patella. I was also told this is likely scar tissue pulling it down, as I had no pain here after surgery but 6 weeks later it was back. Same deal for me too - I still have some quad atrophy. The cause of the baja has not been mentioned - but I did get a hold of xrays and an MRI from 3 yrs ago prior to any surgeries that I'm going to take in for comparison to the current ones. That should give a definitive answer on the baja. I do not have any pain under the patella tendon or the knee cap itself. If FEELS like the cap is hitting against my femur laterally - which the revision release was suppose to fix. The possibility of a neuroma has also been raised. Based upon the causes of baja people have written and the symptoms reported it doesn't appear I have it (which would be awesome I'm scared to death of it).

I've read that baja is caused by scarring of the petalla tendon from surgery or a rupture. I've been doing some patella tendon massage and stretching, and it's real supple when I'm done. I do not know if this achieves anything. I continue to do PT on my own. The one exercise that kills me is any kind of leg press - the patella just bangs away laterally. The good news is I still have good cartilage per my scope which was 3 months ago. I will see the OS in another week.

I think I will also start seeing a pain doc as I believe i have some severe anxiety/possible depression as a result of the pain and inactivity. Thanks again for the reply.

Matt

[kneedsomehelp]

Oh I also wear a SERF brace for hip control - it helps a little. I've heard of the J brace and am considering trying it, what's your thoughts on this?

[heather_rae]

Matt:

There is a specific test that my PT used to detect the baja. Sorry, I'm not sure what it's called. He placed marks around the knee with a pen and used some sort of measurement from that. Is that how yours was found? I think comparing where you are now with the old films is a good idea, too. So, the doc said it should clear up on it's own in a year or so. How is that possible?

I hear you about the painful spot on the lateral edge of the patella. That's right where mine is. Very tender to touch it. Actually, I have a few areas like that. The quad tendon constantly stays flared up. The J brace is more of a biomechanical aide. It's supposed to help guide proper tracking. Similar to McConnell taping. I still subluxate if the knee is bent more than 60 degrees or so. I just push it back in place with my hand. When the PT put the brace on the first time, I stood up and said WOW!! Somehow, the compressive nature of it helped the pain and it felt like it was tracking better when I walked?!? Wierd!

The leg press is bad for me, too. Curious if pain hinders your ability to push much weight. UGH! I work out while wearing the brace. If I'm not careful about keeping the flexion to a minimum on the press, the kneecap likes to bury itself UNDER the side of brace. The leg curl jacks up knee pain, too. Lots of grinding and maltracking on there. So, I see the PT was correct in banning me from the bike. He said it's very hard on the joint surface.

I've had a very hard time since my accident. Prior to that, I'd never had surgery or broken a bone. Recovery from it has turned my life upside down. Lots of issues there. I put off seeing the doc until I had a panic attack. That was my cue and I was scolded by the doc for waiting. The meds used for PTSD are also used for chronic pain. So, it was a smart decision on my behalf. Hope you find some relief, too.

That's great if your cartilage is still intact. Guess mine was pretty damaged by the direct blow with the fracture. I was told I have PF arthritis already. Have you been told that maltracking can cause it to wear away? Sorry you've had so much trouble with the LR. Even though it wasn't a good thing, you WERE able to run. I can't do that yet. If I walk too fast, I limp. Can't squat or kneel either. Stairs cause alot of pain/grinding for me, too. Good luck with your OS appt. Hope you can get something straightened out soon. Keep posted and TTYL!!

Heather

[kneedsomehelp]

No my PT didn't do a test for baja, I don't think he was too familiar with it. My doc took measurements from my xray when he was checking for it and came up with - you may be borderline. Everything hinges on the old xrays i'm waiting for.

Yes that lateral spot is extremely tender - and I have it on both sides. And definitely the leg press, knee extension, and bike hurt. I can't push much weight because of the pain for sure. Maybe i should try the J brace. I kind of figured long term pain down here would lead to something like arthritis - another cause for anxiety (just great).

Now I had an open incision debriement for this same pain after the first LR just below the spot where it is now - and it worked. No pain ever there - which lends itself to the idea of a neuroma. BUT if I were to try this again it would be a total shot in the dark and I'd risk furthering the baja (if I have it). Sigh.....so i don't know what to do. I'm really thinking about flying to Colorado and seeing this Dr. Steadman I've read about before any more surgeries.

Thanks for your encouragement. This has also turned my life upside down. This is not where I want to be. I live with my two brothers - one is training for a marathon and one to go into the Navy Seals. That just makes it worse.

Matt

[heather_rae]

Matt:

I think it is extremely strange that the PT is the one who detects all of these problems with me. Don't you find that odd? I switched PT's at the first of the year because the other one was pushing me really hard and I stopped making progress. On the inital exam with PT #2, he found all kind of things wrong and started appropriate treatment. For example, iontophoresis for tendonitis, the brace and exercises for lateral maltracking, the baja issue, foot pronation, scar tissue problems, to name a few.

Basically, my OS monthly appts are just for questions and he gauges how I'm doing. He doesn't even check the knee himself. The only things he has recommended are the bapsboard for the ankle weakness and restarting E-stim for the quads. Based on my symptoms, PF arthritis was the last diagnosis. I'll be starting all over again when I see the new OS specialist in Oct. Maybe they'll readdress some of those things and take an MRI or something.

So, at your next OS appt, is the possible neuroma problem going to be checked? Think an MRI would detect it? I've wondered about the same thing with mine. The kneecap hits something on the lateral side. One of the PT assistants says it's a bump in the road. Are you still having the subluxations? If so, the brace may do you some good, too. It helps the pain even with walking. I can go further than without it. I am really surprised that you never braces for your knees.

Arthritis is from cartilage damage. If yours was good, maybe you won't have to deal with that, too. Think that's why it's so important to address the articulation problems early. You've probably been told to strengthen the quads, too. It's just sooo hard to do that with increased pain. I know!!

Anytime your injure yourself or have surgery, you can develop scar tissue problems from it. I have a ton but was able to get the ROM going while it was still pliable. Sounds like you did the same. I had a MUA with the hardware removal, too. I've had 2 open surgeries so, I think you'd probably have more scar tissue than with just scoping. It wouldn't surprise me at all if you had some at the base of your knee. Good that you do massage around the knee because that helps to mobilize it. Does the patella move around ok?

Maybe you can get a referral from your OS when you go. The one I'll be seeing is in Michigan. Maybe that would be better than Colorado? I chat with someone else who swears by hers. He's in New Jersey, very thorough. Maybe some options there. I do know alot of Os's aren't that familiar with AF so, if that's causing your problems, you really do need a specialist for it.

I really know what you mean about seeing everyone else have normal functioning. I've been trying to get back to my career since the day I was injured. I'm jealous of my co-workers and working friends. My OS himself had a TKR and was back in the office several weeks later. WOW! Watching little old people come into the gym after joint replacements and be discharged good as new. There's a running joke between myself and a funny old man about me having part ownership now at PT. LOL! Take care and hope to hear good news from you soon.

Heather

[kneedsomehelp]

Sorry for the short response, i'm at work, but, what exactly is a sublexation? Sometimes when i'm standing up straight for a while, and then go to step forward, and i get a little catch just in that one spot that can be pretty painful. That is worrying.

I was told the test for a neuroma is to inject just some standard pain killer in the spot and see if that helps. That's just to diagnose it though -they would have to fix it surgically. There are people that specialize in neuroma diagnosis and treatment. You cannot detect a neuroma from an MRI.

I've been stretching and strengthening lately - it's about all I can do till my next appointment. I do feel like the lateral sides of my quads and the release area stretch out a bit from doing this. I need to get back to trying the leg press machine and leg extensions - the pressure when i do the leg press goes up my foot through my shin and stops in my knee. It does not transfer up to the muscles in my quads, hamstrings, and glutes. I'm not sure why, seems like an alignment issue.


Matt

[missmyknee]

Matt

I had patella baja and infrapatellar contracture syndrome, so has another poster named Janet and another Jaci. You can read my story on my blog. I have about 10 stories on my 8 yr journey with arthrofibrosis.

http://www.kneeguru.co.uk/KNEEnotes/node/260

Start reading thru the Arthrofibrosis section on KNEEguru beginning with the tutorial written by Dr Noyes, one of the foremost experts on this. Read this over several times as what he says is very important. Then read thru all the clinical insights , journal articles, etc.

/KNEEnotes/knee-dictionary/arthrofibrosis

Also: /KNEEnotes/knee-dictionary/patella-baja

You need to have your OS take xrays of your patella. This is how patella baja is diagnosed. This will show a patella sitting too low and the OS should take measurements on the xrays to confirm this. MRI can show changes to the patella tendon such as shotening and thickening as mine did. Physical exam can show a low sitting patella and a patella that lacks mobility but not totally diagnosed this way. Scar tissue under the patella, patella tendon and on the tendon pull this down. As the condition worsens , the patella tendon shortens and becomes thick. These are permanent changes to the patella tendon , known as infraptellar contracture syndrome. The patella articular cartilage is permenently damaged from the low position. I too had terrible pain, catching, subluxation where the patella would lock until I manually moved it to unlock. I could not do stairs either.

You need to have an OS who is experienced in this to give you the best outcome and not cause more damage. There is a list of OSs in the link I provided that have a proven track record of successfully dealing with this. Dr Steadman and Noyes are excellent choices. I see Dr Noyes for my OS, Janet sees Dr Wojtys and Jaci sees Dr Steadman. I travel 700 miles to see Noyes , just to show you how crucial it is to get proper treatment by one of these experts.

I have dealt with arthrofibrosis starting with patella baja for 8 yrs and had salvage procedure surgery to correct my baja because it was not diagnosed early when debridement could have corrected along with proper PT. Strong QUAD is also crucial to keep the patella up and tracking properly.

I also have dealt with neuromas caused by scar tissue compressing the nerve. I have had 7 of those removed. Neuromas are extremely painful.

Usually patella baja /arthrofibrosis post in the soft tissue/arthrofibrosis section on the forum and also writing arthrofibrosis out each time is time consuming so we abbreviate it to AF.

Pam

[kneedsomehelp]

Thanks for the post Pam! Its good to hear what sounds like good results by the time you were done. I'm reading your article and am sifting through the Dr. Noyes's pages now. Honestly it doesn't sound like i have it - and my doc did perform measurements on my xray (said i may be borderline). My patella tendon does seem long when i contract my quads and is supple after message. But my knees sure hurt like hell laterally. I'll know when i receive some old xrays in a few days. Also i never had any blow to the knee nor was immobilized and currently have full ROM (can you blame me for trying to sound optimistic?). I do have 2 questions:

How did they diagnose your neuromas?

How do i find a good PT that is familiar with patella femoral joint issues? The PT i had seemed to just string me through a standard knee rehab regimen.

Hmmm i do feel kind of guilty for this thread being all about me....

Matt

[missmyknee]

Matt

My neuromas were diagnosed thru local lidocaine blocks. The trigger points were located by finding the most point tender spots and doing a lidocaine injection. I had immediate relief from nerve pain, but only lasted 8 hrs. My nerve pain showed up as burning, skin sensitivity,very tender to touch, toothache throbbing and needle jabs. I had this starting on the far medial side going all the way across to the patella. I would have horrendous nerve flare ups where the pain was unbearable. Cortisone shots, medrol dose paks, neurontin , lyrica, ultra sound, TENS were tried before doing surgery. Surgery took 3 hours mostly from micro surgery on the nerve plus I did have scar tissue debridement too. The trigger points were located just before surgery and marked with surgical marker. I had my midline incision reopened. When the neuroma was located with a conduction needle, it was cut out, the nerve ends cauterized. The ends balloon up and the ends are buried in the muscle or fascia. Dr Noyes was the one who did the blocks and surgery.

The best way to find a PT who specializes in PF problems is to ask OS, other PTs or interview PTs on their knowledge and experience with PF problems, until you find one . Sometimes you have to guide a PT thru the rehab you want. Your OS can write specifically what he wants done for your rehab on the script.

You can have full ROM and still have scar tissue problems. Does your patella move well in all planes ? When your OS took xrays did he take lateral views and xray the other knee too? Your bad knee's patella height needs to be compared to the opposite patella's height.

http://www.wheelessonline.com/ortho/patella_infera

If you think you have only PF problems, Dr Fulkerson would be a good place to start or Dr Grelsamer in NYC. Dr Grelsamer wrote a tutorial on PF pain

http://www.kneeguru.co.uk/KNEEnotes/node/761

Pam

[heather_rae]

Matt:

Sorry, to answer your question, I was referring to the lateral maltracking when I was discussing subluxation. Didn't mean to confuse you. Basically, the darned patella won't stay in the grove, ya know? Yeah, it does hurt like crazy. Do you have increased lateral pain with over use, too? Think that I did too much on Friday after PT because that whole area is so tender I can't touch it. Kept me down most of the weekend. Lots of medial pressure/pain, too.

Massaging the knee is good but, scar tissue matures after about 6 months. Don't know how pliable it can be after that. You can develop thick bands called adhesions, too. Continued imflammation just makes scar tissue worse.

The basics to PT for both PF problems and AF is to keep inflammation down while strengthening. Any exercise that causes knee pain over a 3 or so on a 1-10 scale is too much. Things like running, the bike, squats, kneeling, the leg extension machine have been banned for me. Even though you have more, working at about 45 degrees of flexion keeps stress of the joint. It's a very delicate balance. I still leave the place limping very slowly sometimes. I don't have much feeling of quad use while on the leg press, either. Think we are compensating with other muscles?

I hope they find the neuroma if you have one. BTW: I am going to see the OS (Dr. Wojtis) that Janet sees. My OS referred me at my last appt after diagnosing the patellofemoral arthritis. I had considered doing that anyway but, never said a word to him. I just had a sigh of relief when he said I want you to go. Think the man has ESP or something. Good luck in finding a close OS who can help your problems. Knee problems can so easily be missed, too. Very tricky! I really do wish you the best. Take care and TTYL!

Heather

[kneedsomehelp]

I received my old xrays and MRI today prior to any surgery and have an appoitment with the OS next Tuesday, and with the pain doc on Monday. My OS is familiar with Baja and has done the xray measurements, and says using the old xrays he can make a definitive diagnosis (i have it in both knees so comparison doesn't really help). If I do have it, I need to make some serious decisions ASAP and see one of the guys discussed above I think. I'm really struggling at this point.

Pam those symptoms you described of your neuromas fit mine to a T. The pain is completely localized, flares up, aches, burns, tightens, and shots and massage haven't touched it. So that's a possibility. Are there neuroma specialists if I end up going that route? What's weird is the pain is exactly the same bilaterally.

While reading Dr. Noyes's course on Anthrofibrosis, the description of the scarring down of the infrapatellar fat pad also seems possible. The spot on the knee where the red arrow labeled "fat pad" is pointing to is exactly where I have my pain. The picture is at http://www.kneeguru.co.uk/KNEEnotes/node/755. I will mention this at my next appointment. I have been trying massage to see if this helps - the results so far are inconsistent.

Yeah i'm pretty struggling at this point. Thanks all for your responses.

Matt

[heather_rae]

Matt:

I'm so sorry you are stuggling! Next Tuesday will hopefully offer you some answers and you can get to the bottom of this problem.

Have you contacted another doc, yet? I would think that any OS who does soft tissue repair (like the one I have to go see) would be suitable for you. Keep posted with your pain management appt ok? BTW: if your kneecap is catching on a neuroma, does it have a sensation like it's hitting something? Mine does that when the PT checks the lateral mobes. Take care and let us know what you find out ok?

Heather

[missmyknee]

Hi Matt

If it was me, and knowing what I know now ( my first OS experience ruined my knee for life), I would get thee to Steadman or Noyes or one of the other docs on the AF list. With your history of releases to both knees, ongoing problems, and baja , plus all the symptoms you are reporting, you want an OS who has EXTENSIVE EXPERIENCE with patella baja and scar tissue. You can be scarred down to the fat pad and the fat pad can become scarred and fibrotic itself. You can have scar tissue under the patella tendon in a space called the anterior interval, all these can pull the patella down. These doctors know the correct techniques removing scar tissue so surrounding tissues are not damaged. It's not just ripping the stuff out. These doctors know the correct techiniques of surgery and treatment with the right meds. the correct post op protocals and the very, very, important rehab techniques.

To answer your question on the nerve, Dr Noyes has done all the diagnosing and treatments/surgery for my neuromas. I trust no one else with my knee, that why I am willing to travel 700 miles to see him, which I am doing tomorrow for my followup appointment as a matter of fact.

There are plenty of former posters and some current ones.....Me, Jaci, Janet and Sharon/skibum9, hottub pam, willp, EDd, Heather M,Jennifer 123, Bumleg,Teachergirl,allstardiva,Knick knack, Jim mac, QBknee,jeepgirl,Mee, to name a few, who travel long distances to see one of these scar tissue/arthrofibrosis experts.

Neuromas are balled up areas of a nerve usually from scar tissue. This balled up area sends out feelers like spaghetti sticking out with no purpose and cause tremendous pain. Neuromas will form on the medial side usually on the infrapatellar branch of the saphenous nerve.

You won't have regrets seeing one of these docs but you will have regrets not seeing one .

Pam