Knee Report

I’ve mentioned before I have some knee pain but I don’t think I’ve ever written about the whole story. This is going to be kind of long but I think it might be good to write it all out if for no other reason than to have a record for myself even if no one else reads it. For the conclusion/current plan/plea for advice, skip to the last couple of paragraphs before the italics. First of all, I started running in 1992 after I finally left retail and decided to try to get my health back. I slowly built up to running several miles at a time, started enjoying races and ran the Long Island Marathon May 1995. After a while I quit doing races but kept running. I was always sensible about training and never had any real injuries. Anytime I’d feel something coming on, I’d ice, take a couple of days off and I’d be fine. I began seriously training for marathons two other times over the years but I’d start getting tendinitis or some other nagging problem and again, sensibly back off.

Before I had the hysterectomy in 2007 I had to take a couple months off from running because it was causing pain and discomfort with the girly bits. When I returned to running after the surgery, I began noticing some knee pain which I chalked up to starting over again and being 20 pounds heavier than I’d ever been. It persisted for months, I took ibuprofen and switched to running every other day. I kept my mileage down to 16-20 miles per week. The pain never really went away and began getting worse this year, which is what prompted me to finally see the orthopedic doctor that did my shoulder rehabilitaiton and eventual surgery back in June 2005 (mumford procedure/sub-acromial decompression if you’re wondering…makes me think I must’ve been sold some bum joints all together). After an MRI, she told me I had osteoarthritis and chondromalacia, which basically means a bunch of cartilage damage in the knee. She put me on diclofenac and I got a cortisone injection in each knee which didn’t really help. They contacted my insurance and I was approved for Synvisc, which is pretty much like a nice, cushy oil change for the knees. I did feel better after that and I think I was pretty much in denial…I convinced myself that this could be my last chance to run a marathon and proceeded with my training as planned for the Phoenix marathon in January. Overall it was going as could be expected, I was still in pain but at a tolerable level. The longest run I got to was 13.5 and while not totally pleasant while actually doing it I recovered fine.

The next week I had 15 miles scheduled. On my shorter runs I’d been having a sharp pain on the outside of my right knee that would immediately go away maybe 2-3 times a run. The frequency increased a bit and I thought maybe I’d have to back off training soon. I figured I’d go ahead with the 15 as planned then make a decision. Well, I should have known it would go poorly…the indicators were there but I wasn’t listening to my body as well as I had in the past because I was being stubborn about this possibly being my last chance to run a marathon given the state of my knees. I had to cut it short and had several instances of that sharp medial pain. The next day we left for Hilton Head to go to a wedding. At that point, I had pretty much decided I had to stop training for the marathon but I had no intention of quitting all together. I figured I’d back off the long runs and I’d be back to “normal”. So I took a day off then followed up with my scheduled 4 & 6 miles Friday and Saturday. The running and biking trails in Sea Pines, SC are amazing! There are miles and miles of paved trails and some of the vegetation makes it feel like running in a jungle. In addition to my runs, we did a lot of additional, walking around, played golf for the first time in about 3 years and did a 10 mile bike ride…in retrospect none of which was probably good for my knees considering the current state of affairs.

Finally on Sunday we planned to spend the day in Savannah before we had to be at the airport to head home. We began a walking tour and after 2 hours I noticed my knee was very sore and I was beginning to have a lot more of those sharp pains. We had lunch and I had trouble getting up…I had pants on so I didn’t really notice it but when I checked in the bathroom my right knee was about 3 times normal size. It continued to get worse and I hobbled back to the car leaning on Jim. By the time I got to the car, it was so swollen and painful I couldn’t walk at all and had to use a wheelchair in the airport. I called my orthopedic doctor first thing Monday morning but ended up going to the emergency room because my whole leg swelled and my foot was numb (we were worried I might have a clot) in addition to being in a lot of pain. They did an x-ray, doppler test, gave me drugs and recommended follow up with my orthopedic (DUH). Tuesday Dr. Andrews drained 45 cc of fluid from my knee, injected more cortisone and ordered another MRI. By the end of the day I was getting around without crutches. I took a couple of days completely off then tested it Friday with 30 minutes on the elliptical. It was still tender but pretty good. I walked 4 miles with Jim and the dogs on Sunday then helped with the leaves with no pain. Yesterday I ran 4 miles…I had just one little pull on the outside of the right knee again. Which brings me to today, one week later. While the serious pain is gone I have the soreness I’ve had every day for the last couple of years.  The MRI showed no tears.  This pretty much boiled down to a case of doing too much with a compromised joint.  She still never said I totally had to quit running but when I pressed it said I had come to her in pretty bad shape and that I should focus on non-impact exercise like swimming, elliptical and cycling.  By they way, I enjoy cycling and do it a lot when I’m in Arizona but it’s not practical in OH (weather, lack of bike lanes and inconsiderate drivers make it downright dangerous).  When the time comes that we finally move there I’m pretty sure cycling will become my knee “solution”.

I’m now at a crossroads. This has been really difficult to take the last couple of months. I have a feeling it is the same for other runners or cyclists or triathletes, etc. Once you’ve been doing it for a while it becomes part of your self image and self worth. It’s part of who you are. And what am I without it? I’m having a serious crisis of self.  Add that to the fact that I’ve never enjoyed the gym and you’ve got a very depressed diva.  I guess it comes down to my goals and health for the future. I have to force myself to realize I may need to modify my behavior now in order to enjoy a pain free future, no matter how difficult that may be for me now.  I’m almost crying just writing this…pitiful. I’d love to hear from other athletes about how you’ve dealt with similar situations. I need all the help I can get!

On a related note, my MRI reports. I’d also like to hear form any one with experience in this area. Chondromalacia patella, from what I’ve read is very common and lots of people will show this on MRI even if no pain is present. Prognosis is a little more uplifting, though it requires complete rest from aggravating activities for up to 6 months and can be hard to get rid of. From what I’ve read, osteoarthritis is hard to distinguish from this so I’m not really sure how to determine which is primary. This would have been a great question for my doctor, but I think even they have trouble differentiating. I’ve been on glucosamine/chondroitin for months and while I haven’t reduced pain it certainly can’t hurt. I also take flax oil for the omega-3.

Technical:

MRI 1, 9/21/09:  Mild patellar spur noted.  The articular cartilage of the lateral patellar articular facet is at least moderately narrowed.  Focal severe areas of narrowing of this lateral patellar cartilage are present.  Subchondral degeneration involves the patella dn teh adjacent anterior femur at the lateral aspect of the patellofemoral joint.

Mild to moderate focal narrowing of the articular cartilage of the distal femur is present.

No joint fluid or bursal fluid collections are present.  The meniscal cartilage cruciate ligaments, the patellar tendons and collateral knee ligaments are normal.  No stress fractures or marrow edema is present at the knee.

Impression:  Moderate chondromalacia of the knee and patella.  Focal areas of cartilage loss noted at the lateral patellar articular facet and at the distal femur.  Osteoarthritis patellofemoral joint.

MRI 2, 11/17/09:  The popliteal vessels are patent.  There is distention of the knee joint, which may relate to the injection of medication or pre-existing joint effusion.

The quadriceps tendon is not torn.  There is soft tissue swelling superficial to the quadriceps tendon and adjacent portion of the lateral retinaculum, which may relate to the therapeutic injection and arthrocentesis.  The cruciate ligaments, MCL and lateral ligamentous complex do not demonstrate tears.

Multifocal chondromalacia at the patellofemoral joint.  Chondral fissuring extending to the depth of cortical bond with subchondral arthropathic cystic change in the median ridge.  Narrowing of the hyaline cartilage at the lateral facet of the patella.  Subchondral arthopathic systic change of the lateral facet and anterior portion of the lateral femoral condyle.

The retinacula appear intact.  Slight patellar tilting but without evidence for lateral subluxation.  Medial and lateral meniscus do not demonstrate tears.  There is edema within the superolateral aspect of Hoffa’s fat pad, which may relate to the procedure prior to the imaging or this may relate to an abnormality of patellar tracking.

The popliteus tendon sheath is mildly distended.  There is soft tissue swelling within the popliteal fossa and extending superiorly and interposed between the musculature of the thigh.  There is also extension distally and interposed between the musculature of the proximal posterior calf.

Focal region of intraosseous ganglion formation at the anterior aspect of the intercondylar eminence and slightly medially.

Conclusion:  The dominant findings relate to patellofemoral chondromalacia.  Multifocal regions of shondral narrowing and fissuring.  Subchondral osteoedema of the patella, as well as similar findings associated with the anterior aspect lateral femoral condyle or lateral portion of the trochlear groove.