Pain under the knee cap

[Left Coast Chris]

Many of us are getting into the "high millage" range of our lives and even though I am only 51, the four years of college sports and amature sports after that ran up the miles on the knees.    Ive had one cartilege surgery on each knee and now the one done a year ago is giving me trouble again.    After surgery the lower quadracep around the knee atrophies and causes the tendon(s?) under the knee cap to derail or ride to one side and inflame.  At least that was what was explained.   Physical therapy after surgery concentrated on strengthing the quad and the problem went away until recently when it came back.

I started some of the exercises again..... but it is also poping.   Im hoping there are not some floaters in there since it did tighten up pretty good the other day.    Its likely another surgery will be needed, but I was wondering if anyone else had the same issue and how they deal with it or keep it under control.  : :P

   

[Gary_C]

I had quad repair surgery back in 2001 and have not had any problems since. And my problem was a near complete tear of the quad tendon where it attaches to the top of the kneecap which seems to be a little different problem than what you have.

As far as advice on what you can do, the first thing is to keep your weight down. My knees are the first thing to tell me when I gain even a few pounds. And as far as exercises, you should be doing some type of quad strengthing exercises all the time. I do not do anything special but I also am on my feet for long periods of time regularly so my knees and legs stay in good condition. And the other thing that is extremely important is to do stretching exercises before doing any strenous exercises. But you probably know all that.

And you also should go and see a knee specialist. If your knee cracks or lock up, the problem is probably not going to go away with out some assistance from a professional and could cause further damage. It may get better with exercise and strengthening therapy but you should have it checked first.

And make sure the doctor you see has the experience and qualifications to handle your problems. Most all orthopedic specialists want you as a patient, but not all are experienced to handle the more difficult cases such as yours. I am extremely fortunate to live near the Mayo Clinic and they routinely handle the most difficult cases that other facilities can't or will not fix. Things like replacing a knee for the second time and cleaning up problems left by others. Enough said on that.

[Left Coast Chris]

Thanks Gary.   I did go back to the Orthopedic doctor and he is sending me to a physical theripist.   Im like you, Im on my feet alot and legs are strong but I did stop specific quad strengthing excerises.   I do feel a little better today after the exercises yesterday.    My weight has been stedy for years at around 250.   My high school weight was 230 so I plan to get down to there and that may also help.  Im 6'6" so Im not too over weight.

As fate would have it Im taking time off work to attempt putting in 1500' of underground irrigation pipe on our farm.  No choice but to keep moving.  Im hoping to get into the theripist in the next couple of days.

Glad your knees are doing well....... thanks for the insight.

[red oaks lumber]

doc gave me a small roung shaped brace that goes in the joint lifting the knee cap up, made all the diffreence in pain and swelling.

[Left Coast Chris]

Is the brace you mention in a sock that you put on every day or is it inserted in the knee by surgery?   Gald to hear it is working.    The brace I have worn is just the elastic sock type with the hole at the cap so it bends easier.  It seems to help keep the swelling down.

[doctorb]

LCC-

You must have patella-femoral arthritis by now.  You have had cartilage surgery, which can advance arthritis.  You have had kneecap tacking issues, which means the knee cap slides from side to side a bit. The cartilage under the kneecap doesn't like anything but straight on tracking.  And...you are a big guy who does strenuous stuff.  That means you load that patella more than most.

If I add up what I gather from your posts, your knees are beginning to wear out.  Your symptoms can be from the patella, but the other weight bearing compartments may also be involved.

How to keep your parts for as long as possible? 1) Loose weight  2) Strenghen the quad  3) Avoid high load patella-femoral activities (climbing stairs, bicycling, lifting from the floor).  This is nothing like the quad tendon rupture described above by Gary C.  Totally different.

I'd advise a self direced PT program, anti-inflamatories daily, and an alteration in activity (Boy is that easy fro ME to say!).  With your age, size and history of knee issues, the wear and tear will continue.  You may benefit from cortizone injections or other injectables.  If patella tracking is the dominant problem, then the elastic knee brace with a whole in the center to hold the patella in line better may help.  Let's see what the ortho doc says  when you head back to him.  Did he take x-rays on your recent visit?.  Doctorb

[Left Coast Chris]

Thanks so much doctorb!

The ortho doctor did not take x-rays I believe because I am only one year after the cartlige trim/cleanout he did.   I will have my first physical therapy session this week so I will see how that goes.

So far just putting my back against a door jamb and bending at the knees until 90 degree bend then holding for 30 seconds has brought relief.   The swelling is pretty much subsided and I got around really well yesterday.   I do 2 sets of 5 of the door jamb squats to get the quads burning and wear the sock all day.   

Im hoping the physical therapist will add some more excercises and I can continue relief that way.   

The catch 22 seems to be that working the quad by squating seems to help so during routine work I squat at the knees also thus putting more wear and tear on the knees.  Is the object to not bend below 90 degrees for the knees?  Ive always heard that through the years by weight lifting coaches.

Thanks,
Chris

[doctorb]

The patella is a sesamoid bone, meaning that, unlike most bones, it sits entirely encapsulated within the tendon of the quad muscle, and slides back and forth with it.  Why do we have a patella??  It holds the quad farther from the knee joint and distal femur.  This small increase in distance causes a lever arm effect, increasing the mechanical advantage of the quad muscle.  If you have your patella removed after injury(patellectomy), you will have a lifetime of decreased quad strength, because you have lost the optimum position of the quadriceps pull with respect to the axis of rotation of the knee.

Strenghtening the quad helps patellofemoral pain. When you do the exercises you describe, contracting your quad muscle pulls the patella back into the anterior femur, greatly increasing the contact forces between the two.  So if you do a squat, the increased bending of the knee makes the patella be compressed into the femur.  With the knee at 45 or 60 degrees of flexion, instead of 90 degrees, the pull along the quad is more longitudinal, with a corisponding decrease in patellofemoral pressure.  

So, most patients with patellofemoral arthritis do not tolerate the 90 degree flexion loads that you describe.  As long as it makes you knee feel better, I would keep doing it.

[Stephen1]

Just what I like about this forum, there is always someone that knows what you need to know. I just had my knee scoped, was great for 4 weeks, then I started back milling, swells all the time, back on the ice, leg wrapped, doc, says to expect swelling for 3-6 months as long as there is no major pain, and I can go skiing  8) which I am really happy about. I am in therapy and exercising also.
Good Luck Chris

[trapper]

My patela was removed 30 years ago after being shadered in a  motorcycle accident.  That knee is beginning to bother me now.  Lets go when going up stairs or turning.  Need to follow doctorb advice about weight  and excorsize.

[Left Coast Chris]

One of my stratigies is to take up fishing again.  Slow down on the heavy work.  8)

The weight loss is significant also.  I have knocked off 10 lbs and have another 15  to go.   Suposedly reducing just a few pounds reduces stress on the knees proportionally higher than just the reduced weight alone.

I will be keeping up with the excersises this time also.  If things get worse the fishing will kick in to compensate hopefully. 

Nothing like this forum........ thanks all for the feedback.   Mobility is a blessing we often overlook.    Much to be thankful for!

[bond-lumber]

I am by the week a Physical Therapist and by weekend and after 'work' busy at the saw mill.  I am new to the forum but may be able to help?  I wonder how tight your quad (thigh) is??  my experience is we are classically quad 'dominant' instead of using the hip (butt) for lifting and a tight quad tends to press the back side of the patella into the end of the femur and increase friction there.  My favorite quad stretch is to go prone on a bed with your 'uninvolved' foot on the floor under your hip (knee bent) then either A)reach back to grab your 'involved' ankle  or loop a line or strap around your ankle to provide extra reach - to pull it toward your hip - bend your knee to provide quad stretch.  There is good research to say that a long held, lower load (not painful, just stretch to discomfort) is the way to lengthen tissue - so hold this about a minute and repeat 2 times.  Normal knee motion is to be able to bend to about 145 deg...often I find tightness in symptomatic knees of about 90 deg (vertical or plumb lower legs in this stretch position).  please let me know if this makes sense and or actually works!!!

[Left Coast Chris]

Thanks so much for the stretch suggestion.  Im trying it now and will let you know.  I have been standing on the uninvolved foot and grabbing the cuff of the pant leg of the swollen knee and pulling it up to the buttocks then leaning the chest forward.   That has seemed to help along with hamstring stretching.    The quad begins tighting or stretching at about 100 degees or a bit past 90 degrees.  Its pretty tight.   

Much appreciated,
Chris

[doctorb]

L C Chris-

I agree with bond-lumber.  Stretching is a good way to ease pain and potentially increase the longevity of your joints.  His points are correct, IMO.  Doctorb

[Tom]

Great !!  A Therapist!

You have sure come to a place that can use your knowledge.  If there is one something we all suffer from, it is joint damage and muscle tension.   I'll be honest, I've had less than positive impressions for Physical Therapists.  I've had several knee operations and both shoulders, being told now that my only recourse is replacement of all of them.  Arthritis got me early but heavy weights and repetitive motion get the rest of what I had left..

General Practioners only knew to send me to a specialist.  Surgeons only want to carve and then send me to a therapists for recovery. The Therapists, every one of them, showed me a few exercises on the first day and I seldom saw them afterwards.  It was all about the money.  I would go to the therapists office/gym, be met by a sweet, young high-school girl who took my money, and then be told, "OK, you know what you have to do, start on *such'n such and I'll be here at the desk if you need me."

Stupid me. I went with the program through four knee surgeries and two years of very painful Frozen Shoulder Syndrome.  I finally told the surgeon to just give me the piece of paper with the exercises  on it for my shoulder surgeries and I wouldn't waste my time with the therapists.  He didn't even question me, but gave me the paper.  I did my own therapy and survived but never recovered.  I'm sure that with proper care and hands on therapy I may have done better.

You will be a life saver around here if you continue to offer this kind of information.

Hopefully there will be some good sawmill and woodworking information offered  in return.

Thanks!

Doctorb, you are already showing your worth.  Your recent bed-side manner with the head injury in Peru has certainly helped at least on member.  It's also been watched and admired by the others, me included.

Y'all are as much needed here as a benevolent chainsaw mechanic. :D

[bond-lumber]

Tom, I am happy to try to help if I can...I have frustrations as well with PT's that get into the 'assembly line' type of treatment and 'farm' the patients out to just and exercise program.  We have a small town clinic and actually put our 'hands on people' - get much better results with a combination of careful exercise and hands on 'work' (much more rewarding for us as well).  Send specific questions and I would be happy to try to help or better yet try to find a PT in Florida that has some 'manual' skills.  We are a long ways from Florida - but next time you are in our part of the country (Washington State) we could show you our Mob. Dimesion saw, old Newman 8b planer and the PT clinic!  Best wishes...Andrew

[Left Coast Chris]

Bond and DrB.... thanks so much for the help.   After three days of twice a day stretching and quad exercises, the inflamation seems to be under control.  It is amazing how deabilitating inflamed tendons can be.   I also started stretching my shoulders and it has helped them also.   

Trying to do large projects with alot of physical work at my age is a real minefield for us that have pretty much tapped out our bodies earlier in life.   I normally do not have to push the work so hard but this 1500' long underground irrigation pipeline project has to be done quickly to avoid payment issues.     I did get a couple of teenagers to help with the shoveling and they have turned out to be well worth the $ paid in wages.

After this I can take up fishing on the weekends again and hope to get back to normal.   Thanks again for the help.