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Patella Tendonosis or 'Something Else'?
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Patella Tendonosis or 'Something Else'? - June 26, 2006 9:19:00 AM
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Pete.
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Hi - this is my first post and I want to be upfront and say that I'm not a physiotherapist - I'm a patient. The reason that I'm posting is that there seems to be an awesome level of knowledge on this forum.
My problem is that I've had left knee pain/discomfort for some time which got dramatically worse four weeks ago. I had been experiencing aches and niggling around the patella after activity, particularly running. There was a particular niggle on the outside edge what I presume to be the quadriceps tendon (connecting quadriceps to patella). 4 weeks ago I started trying to stretch the outside of my hips by sitting on the floor with my legs crossed (like lotus postion, but nowhere near what yoga people get into: I'm very inflexible). After 3 days of this I woke up in the night with fairly severe aching in the knee. This has persisted, on and off, since then - still waking me up at night every few days. It's mainly just outside the patella, upper and lower parts
I've seen a couple of physios and my family doctor. One physio thought it might be a VMO firing disfunction, the other says it's Patella Tendonosis, and has done two sessions of friction massage and ultrasound. I think this has helped a bit, but the knee still aches a lot of the time with daily activity.
The background to this is that I've had knee pain since February 2005 (sudden onset while running on a treadmill). Had an arthroscopy September 2005 - the surgeon expected to find a torn meniscus but when he got inside the only problem he could see was a large medial plica, and portion of fat pad which were clearly impinging on the medial condyle. He also said that the cartilage was 'pristine' and that the knee looked in great shape. Before the surgery I had done 3 months worth of exercises aimed at resolving what the physio described as 'patella maltracking'. The exercises made little, if any difference. It took about 3 months for the knee to settle after the surgery.
Sorry this is such a long winded post! My questions:
(1) Does this sound like patella tendonosis? Both physios said the patella tracking and mobility look fine. What else could it be?
(2) Should I be expecting more improvement after 2 sessions of friction massage?
(3) I've read the really helpful posts on tendonosis and I'm thinking about starting eccentric squats or leg press with heavy weights, but I'm wary of doing more damage. What do people think?
Again, apologies for the long post, and for being a patient(!) but I feel like I could do with a second opinion on this one.
Thanks very much
Pete
(based in the UK)
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Re: Patella Tendonosis or 'Something Else'? - June 26, 2006 1:48:00 PM
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rwillcott
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From: Canada
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Pete,
I've attempted to answer your questions in order:
1) Patella tendonosis would cause pain and discomfort directly over the patella tendon. The tenderness is typically directly over the tendon inferior to the patella. You state that your pain is on the outside of your patella. My first thought is iliotibial band friction syndrome. There is a larger muscle on on the outside of the hip called the tensor fascia latae. It turns into a thick band called the iliotibial band and inserts on the outside of the knee. This structure tends to become tight on people expecially athletes. Over time it can rub on the outside of the knee causing pain. Tgihtness of this structure can also pull the patella to the outside affectine the tracking of the patella.
What activities cause pain? Stairs, squatting, prolonged sitting?
2. Two sessions of friction massage is still early. I would try a few more sessions of treatment. Also, the hip and foot is important to address as well. Weak hip muscles can affect the knee. The alignment of your foot and footwear is important to investigate as well. When you were treated for patella tracking problems initially, were these addressed? Do you remember performing hip endurance exercises?
3. I wouldn't start heavy weights quite yet. The fact that your still having pain is a sign that your not quite read for haevy eccentric work. If it is a patella tendonosis then yes eccentrics are helpful to perform. However, when starting you do not need heavy weights. I would begin by simply perforimg movements using your body weight alone.
Hope I didn't cause too much confusion. As you can see there's a lot of factors to consider. Sounds like your on the right track.
Rob
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Re: Patella Tendonosis or 'Something Else'? - June 26, 2006 11:27:00 PM
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Pete.
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Hi Rob
Thanks very much for the reply!
1.I hadn't really thought about ITB - I had it years ago and it felt like a much sharper pain, and it was very apparent when going downstairs. But when this current knee pain first started to niggle I had mild irritation/tightness around the upper lateral aspect of the patella - and cycling seemed to aggravate it. I do know that my quads are very tight. Also, I have (and always have as far as I can remember) a boney lump on the top outer corner of the patella - does that mean that something has been pulling on that area?
It's really hard to say what causes the pain - I don't get more pain when doing anything specific, it's simply a continuous aching that comes and goes. When it's bad I avoid sitting and using my left leg when going up and down stairs. I think driving the car (manual gearbox) aggravates it. Just before it got bad I did notice pain above the patella when doing deep lunges - in the back knee, which was also bent to 90 degrees. I'm often most aware of it at night when the pain seems to shift depending on which side I'm lying on - feels like there's some kind of irritating chemical which settles on different sides of the knee!
2. I'll give it a few more friction sessions - I can handle it taking a long time to recover so long as I know it will get there eventually. My concern is that I might not have the right diagnosis and we won't get anywhere
3. I've done loads of hip and alignment exercises before and after the operation (pilates and one legged squats focusing on good alignment. Lots of glute work). A podiatrist who had a look at me running on a treadmill a few months ago said that my gait was fine.
3. I'll hold off the heavy weights for a while. At the moment I'm doing eccentric squats on an incline board (increasing by 1 per day, up to 10 now) and leg extensions sitting on a table with ankle weights (3 x 10 per day) as well as quad stretching.
Thanks again for your thoughts Rob - I'm open to any other ideas that come to mind!
Best wishes
Pete
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 2:19:00 PM
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ginger
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From: Melbourne Victoria
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Hey Pete, you have a lumbar spine problem, specificaly at L3 and L4. A state of hypomibility and attendant inflammatory state gives referred symptoms from L3 , or more correctly from the nerve immediate to this facet joint, to the anterior(front) part of your thigh extending down to and interfering with normal sensations and function of the patello femoral joint. L4 ( as above ) does the same to the lateral ( outside) aspect of the thigh , extending towards the knee on the outside . This situation is often misinterpreted as a local problem requiring attention to the site of the pain . The correct and certainly most valuable treatment you can get now is to have someone mobilise these facet joints untill the protective responses ( muscle tighness and inflammation ) let go. By this I DO NOT mean manipulation ( pulling apart) of these joints, but a prolonged passive movement therapy providing the necessary movements to these joints such that these protective mechanisms are turned off. Done well this will immediately relieve these symptoms. Further attention will eliminate the problem. No amount of attention to the leg/knee will be of value under the current circumstances. . Seek out a physiotherapist or a PT who is skilled in mobilising.
Good luck
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 3:04:00 PM
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drbuddy
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Is Ginger a chiropractor? Maybe I missed something...
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 3:33:00 PM
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jlharris
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From: Nebraska
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Ginger,
Not trying to negate your advise, so please bear with me. What part of Pete's presentation tells you that it is NOT musculoskeletal and in fact neuromuscular in origin? Truely interested. Thanks.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 4:08:00 PM
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ginger
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From: Melbourne Victoria
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Buddy , whatever you missed I hope you didn't miss the big game between the aussi socceroos and the italians the other night, what a tragedy.
Jason. The give away was in several ways.the lengthy span of his difficulty, the pristine condition of the knee , the site of the pain and mention of associated "maltracking' of the patella. This situation requires the observer to do one very important thing first. Ask and provide the answer to the question , is this referred?, without this answer a lot of time will be wasted and unnecessary treatment ( the arthroscope for one ) will be given with little or no result. The informed therapist must observe the ritual of most likely first , least likely last. The most likely being that ALL the pain and dysfunction is a product of altered neural activity. My work over twenty years certainly reveals that this is so. Please don't waste post space by asking me for references. My advice to you and others reading this is , the effect of mobilising , when done with skill, attending to the correct lumbar facet levels , in this case L3 and L4 , will reveal the truth of referred effects to anyone willing to put their trained professional hands on and mobilise. It is not difficult or dangerous, neither improper or risky, other than to be likely to offer powerful evidence immediately that this is the way forward.
If you or anyone else need more information on the continuous method of mobilising facet joints by all means ask and I'll describe this yet again . Don't waste time with local treatments for " ilio tibial band friction syndrome' , this is as simple as ten minutes of L4 mobs can be, a referred problem.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 4:17:00 PM
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drbuddy
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From: Pennsylvania
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So, straight chiropractors are right? All problems originate from the spine?
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 4:28:00 PM
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ginger
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From: Melbourne Victoria
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well buddy you should know , you are a chiro aren't you. The difficulty I expect you will arrive at this situation with ,is having only a distant relationship with mobilising facet joints, at least in the way that the average australian trained physiotherapist will have. Manipulative effects rate a very poor second to mobs, particularly done acc. to the continuous method.
I'm not sure I'm willing to accept the broad sweep of your assertion as to the origin of all. Particularly as you have not etered this debate with anything other than a brief attention getting remark.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 4:34:00 PM
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MikeBptatc
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From: North Attleboro, MA
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I would be careful with saying ALL to anything however I would agree with most of Ginger's points. I find that when the answer can be found within the spine that there is pain and/or stiffness found at that facet junction. I have had less success with painless and normal facet jt. mobilizations in situations such as this.
Also, my understanding of tendinosis is that it is tendon breakdown without the presence of inflammation. Whereas tendonitis is tendon breakdown in the presence of inflammation.
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 5:13:00 PM
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drbuddy
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From: Pennsylvania
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Interesting...
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 7:55:00 PM
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nari
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I would modify Ginger's ALL statement a little: in that ALL pain originates in the brain via the CNS and PNS, so a neurodynamic approach (spine or other) would seem a logical place to start, rather than strengthening a whole bunch of muscles as separate segments.
Maybe not ALL conditions respond to such an approach, but the majority would.
Pete, your state of affairs sounds non-musculoskeletal: chronic+++,variability of pain/ache, is related to positioning, not responding to local stuff..the list goes on. Your CNS is talking to you. Can you find a PT who would do appropriate testing of spine/CNS? Slump, SLR and all the variations?
Nari
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Re: Patella Tendonosis or 'Something Else'? - June 28, 2006 10:16:00 PM
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ginger
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From: Melbourne Victoria
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Thanks Nari , it wasn't my statement about ALL by the way. The full adventure into CNS /referred pain/neuralgic effects will demand attention to dural length as you suggest Nari, completely agree. Although slump in this case is unlikely to offer much as most of his symptoms are femoral nerve related ( L3). Some attention to other sciatic involvement may yield direct nerve tightness and so on related to L4, though best effect in terms of restoration of pain freedom will be gained with attention to joints. ( I say this knowing you may have some disagreement with this Nari , though I'm a firm believer in going with the evidence of my own experience, same me same you.)
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 2:29:00 AM
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Pete.
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Blimey. Thanks very much for the insights. Some kind of back issue had crossed my mind, mainly from reading on this forum, but also because (a) I've been having lower back pain (b) my other knee plays up from time to time (c) the severe pain was triggered after doing hip/pelvis exercises (I'm not sure whether having crossed legs was the key factor or not). So I'm open to the possibility of a spinal issue. I have two questions:
(1) Is there anything I can do in the 'self help' department? Stretching or something?
(2) What do I say to the physio who is treating me? Sorry if that sounds feeble but I can imagine him not being thrilled when I march in and say something to the effect that "I read on the internet that I might have back problem so could you abandon your original diagnosis and manipulate my spine?" To be fair, the guy is an osteopath as well as a physio so he should know his way around.
Also, and I'm a bit wary of mentioning this as I suspect it will cause some eye rolling and gnashing of teeth on this site, but I had a session with a craniosacral therapist on Monday and have felt a distinct improvement since then....
Thanks again for the insights - I really appreciate them
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 7:21:00 AM
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proud
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Well it is good news that the knee pain is subsiding...I really don't think the CST had anything to do with it. You could have poured snake oil on it and luck of the draw...the symtoms would have settled...
CST...my professional pet peeve.
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 7:36:00 AM
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drbuddy
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From: Pennsylvania
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It will be interesting to see if the pain releif is long term. With all the talk of neural tension and simple contact on this site, maybe the contact in the cranial area creates some sort of reflexive response. I know nothing about CST, so I may be way off.
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 10:38:00 AM
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proud
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Buddy DC
You know nothing of CST...then you are one of the good ones in my opinion.
As a Physiotherapist, it astounds me that those within my profession choose this route. Their is so much to know about exercise prescription, muscle imbalance, etc. You could spend years learning this vital aspect of our profession, and still not know it all. Why waste your energies with such things as CST? You want evidence based practice? No better route to take than being an expert in exercise don't you think? Or should we let Athletic Therapists steal that title, while we all monkey around floating our hands over someones head???
Not only does CST lack the credibility of evidence, it also lacks a very important part of being a professional...ethical accountability.
As Physical Therpists we spend a great deal of time talking about our superior skills over the Chiropractic community. Every now and again I check out CHIROWEB and wonder why waste energies arguing with a trade that is already in trouble (for good reasons). My question would be why bother beating a dead horse? Chiropractors are already up against the fence for the silly subluxation theory. Leave them alone and focus inward on our own profession to force professional accountability (eliminate passive modality practioners,the ability to bill CST under the Physical therapy umbrella etc)
At the end of the day, I figure those that pay the bills for treatment will eventually scrutinize who is providing the best patient outcomes regardless of credntials( DO, DC, DPT, a Masseur...whatever). This will likely happen within the next 10-15 years. Last thing I want is 2-3/10 Physical therapists doing CST representing this as "PHYSICAL THERAPY".
IT IS NOT.
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 11:45:00 AM
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nari
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Proud,
Fair enough - re CST. It has no known physiology to back it up, but that is not to say it doesn't work, despite a swag of mysterious practices.
There is some evidence that exercise prescription and muscle imbalance correction helps with function - but anyone can do that - chiros, osteos, PTs, even some exercise physiologists. It's not exclusive to PT.
It is time to look at other aspects of managing pain and dysfunction - ie, through neurophysiology, or else PT will be left in the dust doing exercises to people while the others move on into origins of pain.
Nari
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 1:56:00 PM
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proud
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Nari...I agree but I never suggested that we focuc ALL our energies towards excercise prescription...rather that this would be a superior endeavor over CST.
Perhaps put a better way...focus on understanding the research about subgroups. i.e some clients will likely respond to exercise prescription in the form of stabilization, other will respond to mobilization/manipulation, while others will respond to a more cognitive behavioral approach. The trick is to identify these subgroups in a valid and relaible manner with superior outcomes both short and long-term. It is going to happen I figure.
Or perhaps a combination of treatments. Various prediction rules are being published. I doubt there will ever be a prediction rule for CST :rolleyes:
On the topic of "the origin of pain". I figure much advancment in this area is already taking place. Pain appears to be much more a subjective experience than we once thought( Pain perception, pain beliefs, depression etc). Physiotherapist who do not already understand this are way out of the loop. The FABQ when used appropriatly is a vital tool for specific clients.
Oh and low and behold...what do we already know about depression and exercise???
Sure other trades can prescribe exercise...but the acedemic's in Physiotherapy are proving that an understanding of pathophysiology, biomechanical anatomy and psycho-social factors is required to treat many MSK issues.
Physiotherapists should be without equal in applying the above. So no Nari, I disagree that other trades can do that as well as we can. Not even close ;) .
My overall point being that those of us who are guided in their practice by such evidence based medicine, are unmatched...
I only wish that for every 10 Physiotherapists, at least 8/10 practiced this way. My fear is that the number is currently upside down. We need to eliminate the Physio slackers. Trust me, there are plenty. Why waste our energies on towel whipping Chiro's? That trade is in desperate trouble. They don't need any help drowning from us.
So rather, we should be focused on our own profession and work towards eliminating those that skew our outcomes as a collective group in a negative manner( i.e passive modalities, CST, Feldenkrais etc).
I only hope that Pete did not see a PT who practiced CST and got "duped" himself. Trust me Pete, if your symtoms subsided after CST...??? Makes me wonder...Because I can be pretty sure that CST had zippo to do with it...
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Re: Patella Tendonosis or 'Something Else'? - June 29, 2006 3:15:00 PM
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rwillcott
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Proud,
I couldn't have said it any better. I wish there were more Physiotherapists as passionate as yourself!
Thanks!
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