Nagging knee problem

[Jake]

Hey guys,

Question about a knee issue: It cropped up about a year and a half ago. I was doing a decent amount of running, mostly on an indoor 200 meter track because Wisconsin winters are frickin' cold. Finally, after a 10 mile run (on the track--very stupid, I know) I was barely able to walk because of pain in my left knee. My sports medicine doc diagnosed it as some kind of cardiladge inflamation common among runners (I don't remember the technical term) and told me to stop running until I could do it without pain. That turned out to be about a 5 month break.

Now, I can run/jump/squat, etc. without pain 99% of the time, but every once in a while it starts to ache. Particularly during hikes with a moderately heavy pack, and very occasionally the day after a hard run. Usually, if I just keep going, the pain goes away.

So, the question: I'm joining the military with the hope of getting into special operations. This will require extreme amounts of hiking with heavy packs, as well as running--basically it will be hell on my knees. I will be leaving for basic training in about 9 months. Is there anything I can do to help improve the condition of my knee? Should I be wearing some sort of brace during hard runs and hikes? Also, if anybody knows the name of the injury, that would be great, too.

Many thanks in advance,
Jake

[bryanc]

It's probably WAY better if you call the physician who diagnosed you and ask him what the diagnosis is and let us know (heck, you can just ask the nurse or receptionist to look it up in your chart). A certified sport med doc is going to be way better than an online forum--we'd just be guessing without having ever seen you.

[Jake]

Even better--I had them email the report to me: Apparently, I'm a 'very pleasant male.' [img]smile.gif[/img] Sorry about the weird spacing.

March 17, 2003:

This 19-year-old Caucasian male, who is otherwise healthy and has
had no previous history of any problems, about four weeks ago did a
ten mile run on a 200 meter indoor track at UW Madison. Since then,
he has been having pain and sometimes the kneecap feels like it is
giving out. He does not really have any swelling. He has had no
locking episodes. It is painful to squat. It is painful if he sits
for a long period of time. He did ice it the first couple of days
and he took a couple Aleve and that seemed to help. Since then, he
has not been icing and he has not been taking any pain medication.
He tried to run about two miles the other day as he normally runs
outside, and he states it became painful. He denies any nighttime
pain. He denies any pain with his ADLs.

He has no previous history of trauma or fractures to the lower
extremities.

PHYSICAL EXAMINATION:
VITAL SIGNS: P: 66 WT: 192# HT: 69 1/2"
On exam, he is a very pleasant male, ambulatory, in no acute
distress. On exam of his lower extremities, he ambulates without a limp. He
is able to bear full weight on his left lower extremity. He is able
to fully extend the knee and flex to 125 degrees bilaterally. He
has no effusion. He has some crepitus and tenderness around the
kneecap. There was no patellar tenderness. He tracks slightly
laterally. He has no medial or lateral joint space discomfort. No
discomfort with varus or valgus stressing at 0 or 30 degrees.
Anterior drawer, Lachman's, pivot shift and McMurray's are all
negative.

X-ray of the left knee shows some mild lateral tilting of the
patella, otherwise normal films.

ASSESSMENT:
1. Left knee patellofemoral pain.
I discussed the etiology with him. At this time, I gave him home
exercise for VMO strengthening. I discussed ice and anti-
inflammatories. He will contact me if symptoms worsen.


Another question: What does it mean that I have 'left tracking' and 'mild lateral tilting of the patella.'? And thanks for all your help. I really appreciate you guys (bryan especially!) taking the time out of your day.

Jake

[Jake]

Any comments on this advice from Runners World:

The best way to strengthen your VMO is to focus on the last third of the traditional leg-extension exercise, says Lewis Maharam, M.D., medical director of the New York City Marathon and the Rock 'N' Roll Marathons. Use both legs to get in full-extension position, then lower the weight 30 degrees and extend again with just one leg. Dr. Maharam recommends that runners with chondromalacia do this exercise five times a week, with each session including 5 sets of 10 lifts each to near exhaustion. When your knee is better, says Dr. Maharam, you should still do this exercise three times a week.

[Bill Hartman]

I think that's great advice to make your symptoms worse.

Do a search on this site. bryanc has a great protocol for patello femoral pain around here somewhere.

You may also want to have your gait, ROM, and strength assessed by a qualified health professional to address any biomechanical issues that may be contributing. Any VMO weakness is usually the result of something, not necessarily the cause.

Bill

[Jake]

Thanks for the reply, Bill. Unfortunately, I don't have access to any quality medical care (living in a 3rd world country) so I'm trying to get by as much as possible without it. Here are a couple questions that have come up from my online research:

1. Will post-exercise icing help my knee over the long term, or will it just provide temporary pain relief?

2. A lot of info sources recommend arch supports or motion control shoes for running and hiking. I think that I do slightly overpronate while running. What do you think about these options? What are the benefits of a motion control shoe vs. a heavily cushioned shoe with added arch supports?

Thanks again for the replies. By January I should have access to a physical therapist, but until then I have to make do....

Jake

[Jake]

And a question about bryan's program:

Since I have no pain right now, should I go straight to the maintenance program, or should I do the buildup first?

Also, I am able to do all bodyweight exercises (no access to weights here) including lunges, jump squats, bodyweight full squats, etc. with no pain at all. Should I stop doing any of these?

[Jake]

And, last question. After an hour of research on glutamine, I'm just confused. What's the verdict?

[bryanc]

1) Tracking: Your kneecap tracks up and down when you flex and extend your leg. However, the anatomy of the tissues surrounding the patella is such that on the upper bit (superior), a bunch of tendon attach coming at the kneecap from different angles. Vastus lateralis and vastus medialis come in from an angle (crudely, like the figure below. I can't get the kneecap in the right spot. Pretend it's shifted over to the right by one space. Same with the tendon under the kneecap):

\|/
o ----knee cap
|


In 'normal' people, when these are balanced, the kneecap tracks normally. However, if one is quite weaker than the other, then you get abnormal tracking during activity as well as patellar dislocation (or subluxation, which is like a small dislocation) at rest due to the fact that the resting tension of one is greater than the other, causing the kneecap to migrate sideways while you're at rest. This is what is called patellofemoral pain syndrome (PFPS). Most people with PFPS report that extending the knee when they get pain at rest, removes the pain--the action presumably 'resets' the kneecap in its proper place for some reason.

That's abnormal tracking in a nutshell. The fact that your left patella tracks left, means that it veers to the left when you flex and extend your knee. Mild tilting I can't remember. Russ probably knows more about that, but it's probably not _that_ important.

2) I agree with Bill on the leg extention thing.

3) If icing helps your pain, it can't hurt you (unless you're icing to the point of frostbite)

4) The issue is primarily with your quad muscles. In our study with PFPS patients, we didn't find any relationships between anatomical 'abnormalities' such as bow-leggedness or knock-knees or low or high arches with PFPS (i.e. we had about equal proportions of everything). So changing your shoe may or may not help.

5) You should start at the very beginning of the program (buildup). The fact that you have no pain means that you'll progress at the fastest speed through buildup. Remember that the downphase of drop squats is supposed to be rapid--basically you're letting your knee buckle under yourself and catching yourself at a preset angle. Don't forget the stretching portion of the program!

6) You can do whatever activities you like so long as you don't have pain while or after you do them.

7) Er..why are you considering glutamine?

[Jake]

Thanks, bryan. Scratch the glutamine idea then.

Last question, I promise (for now at least!):

I'm going to integrate the drop squat program. Should I make any modifications to my current program


My current 'lower body' schedule is as roughly as follows; I change things up often, but generally will be following the same template for the next 8 weeks or so. All exercises are bodyweight only, as I don't have access to weights, and all 'off' days except one include a 1 mile recovery jog. Also, I'm at 10,000 feet elevation, if that matters):

Monday
-Jump Squat 4x5
-Walking Lunge 4x15 (each side)

Wednesday
2.5-3 mile run (moderate pace 6:30-7:30 miles)

Friday
Sprints (5 x 150meters)
Bodyweight full squats (a few sets of high reps)

Sunday
6-7 mile run (slow)