What do I do next?

I had a nuclear bone scan on my leg in April last year following an undiagnosed issue with my shin. The shin issue turned out to be a stress fracture which I think has long ago healed (flares up now and then but I just take time to cut back and it goes away, I haven't had to stop running as a result.) The scan picked up cartilidge damage in both knees and the doctor/specialist said I needed to stop running, never run again and said that "some of us just aren't built for running".

I took it all as stuff to bear in mind but as I had no pain and as a result of the last comment (wtf?!) I kept on running, just cut back by about 30-50%.

Now I am starting to get pains in my knees, mainly after sitting down for longer periods of time and after things like climbing stairs and riding a bike, running does have an effect but not as much as the previous.

I have in the past seen a physio who just seemed to have little to say to help, just "don't run" was the only thing, infact all the physios (second opinions) say the same thing as they all seem to work in a very single minded group (if you have the same experience as me you'd understand why I say this) I cannot afford to look privatly. They seemed to think cycling and swimming were my only options which is daft as cycling hurts way more then running does!

I know if I ask my GP for help they will refer me right back to the same group of physios who will not offer me any help, not if I say I still run even though I have cut down and watch what I do now -even saying I ran last time had them with looks on their faces that said "here we go again" followed by silent sighs and a recommendation to join their piltaes classes. I'm now feeling pain but not sure what I do or where I go or if there is any point, I was told surgery was 50-50 at the best of times and not recommended as I am not 50 (I'm 30). Do I wait for this to get worse or is there anything I can do?

Knee probs are a beast to manage but there are are a few things you can try which might help.
First take glucosamine 400mg/chondroitin 100mg tabs. 3 a day, get them from healthspan.co.uk. Glucosamine helps lay down new cartilage & chondroitin increases the production of lubricating synovial fluid. Takes 3-4 weeks for full benefit but does help battered joints.

Second wear elasticated knee supports when running. The support doesn't particularly benefit damaged cartilage but I think the extra warmth around the knee seems to help.

Try to reduce impact on your knees by running on grass as much as poss. Local playing fields are good. Also I've found Noene 4mm shock absorbing insoles (from wiggle.co.uk) have helped.

As you said long periods of not moving the knees, like sitting in front of a computer, make it worse. Make a point of bending & straightening each knee for a minute every 15 mins or so - you can do this while you're still sitting/working.

Hope some of this helps & goog luck

Hi Jenn

Hopefully I can offer you a private opinion, not only that I am also a long distance fool (although not sure I can say that any more since the birth of my baby daughter)

Primarily it all comes down to how much cartilage damage there is and if it is in any of the important weight bearing areas. As you said you are 30 - if there is significant damage and running will accelerate this then you are looking at early surgery and at worst knee replacements earlier in life - not what you want at a young age. That is where the physios and docs are coming from. Right that is the worst scenario.
(Very often a simple piece of surgery can sort out the cartilage damage and you get on with your life as if there has never been a problem. It all depends on the findings on your scans and your signs and symptoms.)

Onto the helpful stuff:
A reduction in mileage and intensity is a good start.
Also need to address the tensions in the leg and buttock muscles, especially the quads (front of thigh). Tension in these causes an increase in the tightness of the patello-femoral (knee cap to knee) joint. This leads to an increase in pressure on the cartilage behind the knee cap and on certain surfaces of the end of the thigh bone (femoral) - this might explain why you have pains with sitting and stairs. Reduce the tension and you reduce the pressure and hopefully the pain.
Next common sense thing is to avoid the activities that aggravate the knee - going to keep running no doubt - so you have to try sit with your legs out straighter rather than bent, try not to use stairs where possible etc etc.
All of this allows the cartilage in the knees to settle - look up a condition called Chondomalacia Patellae and movie goers knees.

So much of this problem depends on the individual case and it is difficult in this format but I have a simple rule when treating my clients:
Run to what is comfortable - if it is making it worse then back off (not stop) a bit and allow it to settle and then see if you can slowly work your way back up again. If the pain worsens and you have addressed all the bio-mechanical and external factors then it is time to stop and consider whether their is a surgical option.

I have many ex-footballers with horrid cartilage issues who now run - so it's not the end of the road but it is very case dependent.

I hope this have given you some insight on how we think about these cases and has provided a starting point to look at all the factors you can address.

Let me know what you think

Greg

Excellent advice from Greg, he's right it's more about modifying your running to find a way that doesn't aggravate the knees than stopping altogether. I find that with fellow physios if they don't run it's hard for them to understand a runners view point so will often just say stop doing it!

Luckily there are lots of things you can change with running; distance, speed, running surface, type of workout (interval, hills, endurance etc) stride length, running shoe, swap in some treadmill work, frequency of runs (rest days between each run might help) etc etc.

Do you do much strength and conditioning work? Strong quads, hams, glutes and calf will help offload the joint. Good balance and control of movement important too plus as Greg says maintaining flexibility of surrounding muscles. The balance with all this is finding a level of activity that doesn't increase your symptoms.

Chris- thanks for the advice, I'd not considered knee supports, would you suggest wearing them in the day too? (this would mean an end to my love affair with skinny jeans and leggings...!) I guess I know about long still periods and the pain getting worse but it can ust be hard to implement when asleep or travelling for example but will try to do something about it, thanks for the advice. I'm guessing ibuprofen is another thing to try though not too happy with having to take pills every day (I worry about what the long term effects are).

Thanks Greg thats really helpful and well explained stuff! I live in Blackheath actually! (though save my running for the gym) am NHS all the way though sadly purse strings define what I can obtain, seeing a rheumatologist at the hospital after a 5 month wait after my last scan so awaiting results to see if my back is also affected by this.

I took a look at C.P which makes a lot make sense- is this a given with cartilidge damage? I never got a full explaination as to what was going on from the doctor, the appointment after the scan was little over 10 minutes and the bulk of it was along the lines of "all running is evil" before being discharged. It is good to hear footballers are able to go running as I'd imagine the impact and so cartilidge damage by repeatedly running and kicking a ball would create far more injuries then running/cycling, so there is hope yet- I hope!! I think I just worry because what now feels like twinges has gone from nothing at all to feeling enough to get my attention within a few months, I wonder at the speed of this thing and at what point is it something I end up in surgery for. A year ago I thought I was fine....

I hope I have sorted out some of the biomechanical issues. I used to have a growing over pronation, started off mild and within 2 years had become enough to require maximum support trainers, I took on a barefoot style in the summer of last year and now run with a midfoot strike. I don't over pronate now when I run now. I don't tend to stamp when I run- infact I can't hear myself run anywhere near as much as I used to, I don't bounce and I can listen to earphones without them jarring and falling out. I run with far less impact and think the barefoot style (all be it in Nike Free TR+ trainers) seems to work for me as the stress fracture which seemed to keep coming back has not come back since taking it up making me think the impact issue has been reduced.

Tom, I don't tend to do much stregnthening on my legs because I rarely find I need to. I do a lot of what I call "cardio under resistance". I crank up the machine resistance or the incline on the treadmill and go as fast as a can- which is never very fast! I have as a result quite large legs, I can squat, lunge and spin (bike) for ages without any real pain- well, now my knees tend to give! and where the stationary machines are I tend to find I can take on higher weights with not too much of a problem. I don't think I have a lack of stregnth, I think I have a problem over using my muscles over putting pressure on my joints. I know I have a hypermobile spine for example, picking something up off the floor I just lean over and pick it up- no knees bent (I do this without thinking), my muscles don't get used, my lower back/spine does, hence the pain. I wonder how much this extends to my knees with my knees taking on the pressure my thighs really need to be doing. I'm not really sure what to do about that, I know with my back its about constantly reminding myself to bend rather then stretch but with my knees I'm not so sure.

Hi Jenn,

I've noticed your previous posts on cartilage damage on here before. I was in exactly the same position as you up to a week and a half ago.

I've got to say I'm confused with the advice that you've received from health care professionals because that hasn't been my experience at all. To be fair, I no it differs depending on the type and position of the meniscal tear as to what treatment is recommended and also the people actually treating you. Treatment I've had has all been nhs too.

I suffered a twisting injury to my right knee which resulted in anterior horn tears in both the medial and lateral meniscus. My GP and Consultant told me that the tears would not heal themselves due to them being in the white zone - no blood supply in the white so they can't re-heal. I had an MRI scan and after examining my knee, it was recommended I go for an arthroscopy where they would do a partial meniscectomy. I was told with my age and level of fitness etc (also in the same age group as you) that I would recover well and was better off having it now than if I was in my 50's etc.

Like you when I first tore the cartilages (medial and lateral) apart from the first week or so, I didn't have any pain and could still run. That was the end of sept/oct. I stopped running end oct but continued with x trainer and swimming to maintain fitness etc plus weights. I noticed in Dec I was starting to get pain after walking for 15mins, again walking down stairs and pain when getting up and sitting down. The pain gradually got worse until I had surgery just over a week ago.

I was also told to stop running for the time being until I had fixed my knee issues, they also explained continued running may present problems in the future - my consultant suggested I take up a different exercise but said he couldn't say much more until I'd had the surgery. After doing a lot of research I decided to go for the arthroscopy because I knew the tears wouldn't heal and that would be my best chance at recovery and having any kind of future with running. I knew that delaying could maybe result in further damage to the meniscus as well as surrounding tissue.

Cont...

If you're being told not to run - especially by so many people, it must be for a reason. I know it seems harsh and incomprehensible, I was devastated when I was told the same thing (I was due to run my first marathon 2 weeks after the injury) but after a while it made sense to me that I should stop until I've had treatment for my tears because I'm potentially making the injury worse. Sometimes the knee area just needs a rest from any running for a few weeks to be given a chance to heal.

Unfortunately, in my case, there has been damage to the articular catilage behind my knee cap, a) as result of the injury to my knee and b) due to the torn meniscus irritating the cartilage behind the knee for the last few months. I had my surgery on the 23rd Feb, my consultant also performed a patella chondroplasty which I hadn't anticipated. The irritated cartilage behind my knee was what was causing the pain when I was getting up and sitting down.

Maybe you should consider getting an MRI scan or a second opinion from an orthopaedic consultant to see where you knee is now or what your options are now as the issues you've had are quite a few months old. Things could have changed. They did in my case. The tears partially healed themselves by the time I had surgery (part of the tear in the red zone)! I really feel that only happened because I stopped running and gave my knees a break.

In my case, I felt surgery was the right option in looking after my knee for the long term. Yep, i can't run for a while now, I can't even bend my knee at the moment! In a few months I hope to get back to it, meanwhile, I intend to nurse it back to full strength and do whatever my physio/doc says.

 

Thanks for your reply,

See, I could understand the 'no running' thing had it not been for being told by all the medics that things like cycling or using a cross trainer are good options (not just better but the best options) when infact these exercises hurt a great deal more then running or walking. I get the sense that I have been unfortunate and met with one to many run-haters and they have naturally assumed my knee degeneration was all due to running. Infact prior to the knee scan I'd only been running 4 hours a week for about 4 months- before then the stress fracture was so painful I was unable to ever get past an hour collectively in a whole week yet was spending hours and hours and hours (15 to be exact) cycling, doing circuit classes, swimming, using the cross trainer.....etc so I am not so sure the "all running is bad" mentality from my doctors really spins from logic as much as assumptions.

I have had so much pain with my lower back, I've just been through an MRI scan (it showed wear and tear but the specialist wasn't happy to say it was degeneration causing the pain and I have been referred for a Dexa bone scan to see if its osteoperosis in my lower back). As I have now had in the past year, 2 MRI scans (different parts of my body) several X-rays (teeth, leg, back...) and a nuclear bone scan both myself and the doctors are wanting to do any more scans for a while, the radiation being the main concern. Hence the Dexa scan which apparently has very low amounts of radiation to rule things out rather then to diagnose.

I can see your point about resting though- I know that nothing will recover if its going to recover at all when I'm creating more damage and applying more stress as a result of running, but its so confusing as I am told not to rest, to work on building up the muscles and that movement is far better then sitting still. This is what I have been told by various physios...its hard to know what the right thing to do is especially if although running does make my knees twinge, its nothing on cycling or stair climbing which I am supposed to be doing. I've mentioned this before to physios and doctors who at best shrug their shoulders and otherwise say they don't understand it (helpful when they don't then give advice as to what to do with that!).

But I have cut back a great deal on running, my 4 hours a week has become somwhere between 1-2 hours. And my additonal exercise has gone from 6-7 hours down to 3-4 hours, so a collective 5-6 hours a week which is far far lower then it was. The lower back pain was my main reason for doing that but its not made a blind bit of difference, my knees had no symptoms last year and in the past few months have only now started to complain. I know I needed to cut back but surely no exercise at all can't be a good thing, its not an injury I'm dealing with, its a wear and tear issue so if I were to take a few weeks or months out to allow things to repair surely they'd all come right back again as a result of the way I use my body or its condition to begin with?

Jenn, did your scan show damage in the articulate cartilage or the meniscus or both?
Did it show any problems in the joint between the patella and femur?

Jenn, a bone scan is a very blunt instrument for diagnosing cartilage problems - it can only show changes in bone, and rather blurry ones at that! It's certainly a dodgy leap to start inferring that you shouldn't run from the results of a bone scan.

Presumably it showed either changes in the patellofemoral joint (most likely, given the symptoms you've described), or possibly in the rest of the knee (you could try asking your GP to send you a copy of the results). At your young age, this could easily represent a degree of overload without significant cartilage damage, and by taking Greg's advice you can heal and alter your biomechanics to reduce the stress on the joint.

Hi Jenn

Sounds like you're really going through the mill with your legs & back.
When I need knee supports I wear them during exercise & for 30-60 minutes afterwards. I don't think wearing them all day is likely to provide extra benefit if your knees only hurt during workouts - however you could start a fashion trend! Many of my exercise buddies (all of us are rather older than you) wear them routinely for various chronic knee injuries & find them helpful.
I wouldn't take ibuprofen routinely to exercise as it may mask pain so you do too much & deteriorate the condition.
I also took to wearing Nike Free's a few years ago & found much of my knee & shin discomfort improved a lot. Sometimes I think we overemphasise medial support for moderate overpronation. I've moved onto Nike Lunaracers now which are just as good and provide a bit more cushioning than the Frees.

Hi Jenn

In reply to your earlier question about cartilage damage and CP: Not all cartilage issues are CP - it is a specific injury to the cartilage of the patella.

So much of what is going on in your knee is dependent upon the findings of your scans. As others have mentioned depending on where the damage is can make a huge difference to the outcome.

Questions about the patello-femoral joint and your knee cap alignment spring to mind not to mention the meniscii, unfortunately this is where a good musculo-skeletal examination is so important to ascertain your condition and to give you good sound advice.

I am sending you a PM, let me know what you think

Greg

Hi Jenn
See that I can't send you PM, wanted to chat further about your knee. Let me know if you wish to.

Greg

Tom Goom wrote (see)

Jenn, did your scan show damage in the articulate cartilage or the meniscus or both?
Did it show any problems in the joint between the patella and femur?

To be honest, I don't remember! I had the results given to me last year at the end of the Spring and my focus had been on the stress fracture, the knees were news to me and as they didn''t hurt I just didn't take too much in about them. I remember the scan showing the problem wasn't in the same area of each knee, it was the inside of one and the bottom of the other, the top part of one and the outside of the other sort of thing and was blamed on mechanical issues with uneven pressure being put on my knees as I run -despite being fitted for running trainers and replacing them frequently !

I think I will ask my GP to get me copies of the knee scan so I can see exactly whats gone wrong and then see what I can do about it.

joddly wrote (see)

Jenn, a bone scan is a very blunt instrument for diagnosing cartilage problems - it can only show changes in bone, and rather blurry ones at that! It's certainly a dodgy leap to start inferring that you shouldn't run from the results of a bone scan.

Presumably it showed either changes in the patellofemoral joint (most likely, given the symptoms you've described), or possibly in the rest of the knee (you could try asking your GP to send you a copy of the results). At your young age, this could easily represent a degree of overload without significant cartilage damage, and by taking Greg's advice you can heal and alter your biomechanics to reduce the stress on the joint.

I hadn't thought the scan was a poor choice for the knee diagnosis which seems a bit odd for the specialist to have requersted them - I had wanted to rule out a stress fracture yet having the scan done the doctor seemed intent on scanning my knees- kept reading stuff written in my file so I'm unsure if it was his idea or the orthopedict specialists idea. Either way it what they used! I had no pain in my knees at the time, and didn't really notice any pain until a few months ago when I started to get twinges which I doubt I'd have picked up on at the time had I not had the scan results.  

I'm hoping what you say is right- though the scan was seen by no less then three specialists I have worked on my biomechanics- on building the muscles on my food so I don't roll in as there is muscle to prevent this. I have also taken on a midfoot strike following the ideas of barefoot running and run quite differently to how I did before. I know the stress fracture hasn't come back and that had been there for a while and kept returning so I'm hoping I'm doing something right! As I land on my mid-foot rather then my heel I don't have so much impact when I land. (I know this because I can't hear my every step when I listen to earphones and also don't find my earphones jumping out of my ears!) I had hoped this would be enough to help- that and cutting down.

Now I'm beginning to wonder if running is actually the problem and if not maybe walking in non cushioned shoes plus cycling is whats to blame. If its wear and tear could it not be possible that running impact isn't soley to blame and that overuse (cycling, cross trainer machines, stair climbing...) is equally to blame?

Physio in Blackheath wrote (see)

Hi Jenn

In reply to your earlier question about cartilage damage and CP: Not all cartilage issues are CP - it is a specific injury to the cartilage of the patella.

So much of what is going on in your knee is dependent upon the findings of your scans. As others have mentioned depending on where the damage is can make a huge difference to the outcome.

Questions about the patello-femoral joint and your knee cap alignment spring to mind not to mention the meniscii, unfortunately this is where a good musculo-skeletal examination is so important to ascertain your condition and to give you good sound advice.

I am sending you a PM, let me know what you think

Greg

Hi Greg,

 Well I've not been told CP and the results summary I saw on the doctors computer screen on monday about my back (she showed me what had been written as she had students in and I was referring to it) said "degenerative disease" (less the spelling mistakes!) there was a paragraph above describing it in a bit of detail but only about 4-5 lines and I didn't read it properly, just skim read. I can't remember too much of what was explained to me last year when I had the results given back last year so I will request the full thing sent to me (rather then a copy of the paragraph) and hope it will explain things. What was clear though was when I asked various doctors "is this osteparthritis" they all agreed that it was.Though they were all going on what the blurb read and not having seen the scan or spoken to the specialist themselves, just seen his letter/write up.

Sorry about the PM thing, I didn't think it was possible to prevent PMs and not a clue how to amend that! Do have to add though that as I am veeeery low wages I am NHS all the way (or make for a good guinepig for various sports massage students!!) but any afree dvice and help is more then welcome especially from you

Hi Jenn

I am organising some free injury assessments at the studio I work at on a Saturday - not sure of the date yet but I thought it may be an opportunity to take a look and see if there is anything else we can add in for you.
Try and push to get a copy of all your scans and reports - I know the NHS are very protective of this info.

Let me know if you are interested and I will let you know once the arrangements have been finalised.

Greg

Hi Jenn,
You've said maybe the running isn't aggravating your knees and that sometimes cycling hurts more. Some knee problems are fine with running and worse with cycling or prolonged sitting. If the problem is beneath the patella you might find you can run with minimal aggravation. Depends on you! Everyone is different and I have patients who run pain free but can't kneel or squat!

So to get a clearer picture be scientific about it. Make a list of potential aggravating factors. Cut out all but running for a couple of weeks, keep a short diary of pain, rating it out of 10 each day. See what happens. If your pain is less despite still running then that tells you running might be less of a factor than you think. Then you can gradually bring your other activities back one at a time (e.g. Start cycling again but nothing else) and see how the knee responds. It'll take around 6 weeks and some trial and error but you'll have a clearer idea of what really is aggravating your knee.

Superb advice!

Physio in Blackheath wrote (see)

Hi Jenn

I am organising some free injury assessments at the studio I work at on a Saturday - not sure of the date yet but I thought it may be an opportunity to take a look and see if there is anything else we can add in for you.
Try and push to get a copy of all your scans and reports - I know the NHS are very protective of this info.

Let me know if you are interested and I will let you know once the arrangements have been finalised.

Greg

Oooh- yes please!

I'm seeing the doctor tomorrow (they had no appointments left for wednesday) I stupidly did a yoga class and my lower back went from bad to worse! I'm hoping they can do something for the pain as I'm waiting for a scan to say what the pain is in 2 weeks (could be osteoperosis could be osteoarthritis). Will ask for the results of that as well as my knees.