It just takes time...

Realised I hadn't put anything up here for ages - so just a quick update.

Month by month (year by year ..grin) it all just got so much better! Thank god for that operation! Now I swim, play squash, cycle, climb in the mountains.....pretty certain I could run if I wanted to...but I'll never get back to my old level..so new sports is the way to go.

Took a whole to get over the op..I'd say 6 month and then slowly (so that you would not really notice) the stiffness and tendon pain got less and less. So I guess, if there's any lesson for me - the surgery helped but I had to be prepared to change my life/sports and I had to be patient!

Good luck to you and you can always email me if you've got any questions about my experiences

Plica Removal and Patellar Chondroplasty: Four MONTHS Since Surgery

Though a quick update on progress might be a good idea!

Basically, to recap,  I had 3 distinct problems before surgery:

1. Sharp pain caused by inflamed plica - this one was the real show stopper in life as it made me limp and really hurt
2. Grinding noise (but perhaps no pain?) caused by degenerated patellar cartilage
3. Irrritation and soreness on patellar and quad tendons close to the knee

Since the operation I now no longer suffer from 1 and 2. This is a massive step forward! Now, if I do too much, I feel it in the tendons and fascia around the knee - but I no longer get the savage pain that the plica caused. I also no longer get a grinding noise when the knee is bent under load and the nasty 'crack' when rotating the upper leg with lower leg planted has gone.

I would say it took 8 weeks for the majority of the post-ops symptoms to go. At that point I had full range of motion and could compress the joint fully without pain. I would say 12 weeks until I could kneel (sitting on heels pose) - thus placing full body weight on fully compressed joint without pain that was caused by the op.

I still (now) find a static, fully extended concentric contraction of the quad uncomfortable - partly because I still suffer from some tendinosis - but also because lost muscle bulk around the quad/knee means this forces the underside of the patellar down too far. As my physio points out - this will probably will improve as muscle bulk returns - and its not a hugely useful functional movement anyway.

One downside is that I have a pea-sized knot of scar tissue on the the edge of quad tendon (caused by the incision where the RF went in) - this did not respond to mobilisation or ultrasound and is pretty fixed now - in the longer term it could be a problem as it creates a weak link in the chain

So..what can I do now? I have build up to being able to:

• Cycle 11 miles - cycling is lovely - I never did much before so it was not a contributor to the tendinosis and seems to put the knee into a very 'comfy' place for exercise. Has also helped to fill the hole that losing running left
• 90 mins of yoga
• Walk up to 10 miles (but around 6 miles is most comfortable)
• General life is much more comfortable (I'm a teacher and am on my feet most of the day)
• Swim (a bit) - does seem to flare up my tendinosis though
• General physical work is now all fine (gardening, moving firewood etc etc)

What next?

• Push out the cycling further
• Badminton
• Squash
• Try some more swimming - but very cautiously

The physio suggested (with caution) badminton and squash since both of these have limited amounts of running but are good for strengthening thigh muscles - lots of squatting, lunging and flexibility. I'll need to start these carefully and use some support (pro wrap + neoprene) at first. They will be much more intense that what I am used to so far

The exercises I found most useful during and post rehab (still doing them) are heel slides to get the knee warmed up and mobilised first thing and squats with a medicine ball at my back (all other squats seems to place too much load on the joint - causing clicking and flaring up the tendinosis). I still do these plus a range of stretchs twice a day - first thing and in the eve after exercise

I don't think I will ever be able to fully get rid of the tendinosis/scarring on my pat/quad tendons. My plan is to be able to do as much as I can and enjoy it - I won't be running marathons or trekking coast to coast (UK not US :) - but that doesn't mean I can't do and enjoy some sport most days. Here are some tips I use for managing the tendinosis to a bearable level:

• Unless bad - some gentle motion is often beneficial (and has a big psychological boost)
• When I do get a bad flare up - Voltarol Gel is by far the best thing at getting down the pain - don't think there is ever much inflammation in there as no heat - but the gel does still seem to have a pain reducing and calming effect on the tendons (interestingly oral Voltarol (diclofenac) does nothing and hurts my stomach. The gel seems to get to the problem area and does not hurt my stomach. My guess is that this is because tendons have limited blood supply - so an oral treatment may not be very effective. Conversely the gel is absorbed in to the tendon area but not the blood (as much) meaning I get reduced side-effects.
• Ice is great too but makes the joint very stiff. So good for numbing down the joint - but does not seem to do anything to reduce the flare-up duration and makes the joint un-comfy if I need to be mobile after icing
• Avoid large chunks of stamina type exercise. I try and never let myself get into bone-tired, plodding it out, repetitive motion type exercise - like when I ran or hiked long distances. It's when I get into that situation that I am most likely to get a flare up. For me it is better to say "I'm going to take 45-60 mins exercise and whatever I can do in that time will be just fine"
• Be careful to warm down and stretch my quads as soon as possible after exercise
• Avoid long periods of sitting on a chair in one position. Cross legged on bed/sofa is much better for using the laptop than sitting at a desk

So given that the surgery seems to have nailed the two things it targeted and done nothing (unsurprisingly :) for the one it didn't I would say that it has been well worth the discomfort and rehab time. I reckon I will be able to find a manageable balance of exercise/sport that keep my happy whilst acknowledging that the dodgy knee tendons are pretty much there to stay (perhaps they will improve more over time - I'll just have to see)....

Plica Removal and Patellar Chondroplasty: Two Weeks Since Surgery

Doing well now. Stitches and dressings came off two days ago and the incisions have healed nicely. Mostly I'm a bit sore and stiff. I can get up stairs fine, down is still a bit tricky - but I'm getting there. Went for a 35min walk yesterday with no problems. Stuck to all the physio exercises I was given by the hospital and went for my first appointment with my normal physio since the op. She tweaked my routine to just the following:

• Leg raises with a towel under the knee (see earlier post)
• Knee bends (see earlier post)
• Some mobilisation of scar tissue on the upper incision (apply sliding pressure across it against the grain of the muscle fibres)
• Carry on icing to get the rest of the swelling down. Also ice the back of the knee as swelling there is preventing full extension of the leg (don't force it!) and probably causing the calf muscle pain
• Dips on a small step (just like going downstairs) - making sure my knee goes over my 2nd toe and my hips are level
• Carry on with walks as far as is comfortable - but don't limp, strong core and hips level

Here's what is still troubling me:

• Calf is very sore still
• Cannot quite push the knee to full extension with getting a stuff, 'bulgy' feeling at the back
• The upper incision is standing out a bit - with a sort of gristly feel. Physio felt there is where the instrument pushed aside muscle tissues and I need to mobilise it to prevent scar tissue forming. That area is still quite sore
• Going down stairs I still feel tentative and tend to twist and drop my other hip rather than bend my knee properly - naughty!
• Still some swelling above and below - but not too much (see photo)
• Lost some definition and bulk of right quads despite exercises

Here is what it looks like now:

Plica Removal and Patellar Chondroplasty: 8 Days Since Surgery

Rubbish today. I really noticed coming off the pain/inflammation meds (diclofenac). Felt stiff and swollen when I work up and I felt more sore and 'vulnerable' than yesterday. Got some cocodamol so that should take the edge off it. Felt like a psychological blow to find stairs so hard again (yesterday I had been able to go up and down pretty normally, albeit with a hand on the rail). I still went out for a walk and also to the shops - it does seem important to keep mobile and not to let myself slip back - but took it all pretty easy. The incision which has been sorest all along is the the superior lateral one (where the RF went in - see day 0 post) and that one really flared up. The inferior pole of the patella is painful as well when the knee is at full extension and lightly loaded (when doing physio or standing for a while) - before today I only felt that if I tensed the quads quite hard. Calf is still very sorry - icing it last night helped but only for a while.

Hopefully this is just a blip and over the next few days I'll carry on improving like I have been to date. On the plus my stomach is so happy to be spared the dicolefanc. Another plus is that the area where the plica was removed seems to be settling down and 'catching' it when turning is much less common (but still a nasty shock when I do)

Here's what the knee looks like now (looked better than this yesterday - I could see the edge of the patellar in places then):

Day 8

Plica Removal and Patellar Chondroplasty: 7 Days Since Surgery

Good day today. Over the last four days I have gradually transitioned to being up and about all day, going out for very shorts walks (10 mins) and being a bit more active around the house. Drove myself to the doctors today - which felt like a big step forward in terms of life getting a bit more normal. Also walked for 15mins which was nice - lovely to be in the fresh air. I went to the docs because I've had a very sore calf since the op which has not really improved (in fact got a bit worse). I was worried that this might be a blood clot which I had been warned to look out for as it is a possible (albeit rare - 1:750) complication. Was relieved that the discolouration was only a bruise (either from me rubbing it or from the op) and the pain was in a muscle area rather than a deep vein area. Guess it's just a side effect of the stress to the knee and all the swelling draining. In retrospect I have not been doing enough to keep my ankle raised - which has probably not helped. Guess I'll just ice it, ignore it and it'll go away eventually. In case anyone else gets this problem, here is why the doc discounted it being a clot/DVT:

• No heat from that area
• No redness (the marking was a bruise)
• Pain was on the medial part of the calf muscle and not 
• Pain was sore rather than severe
• No swelling

Onwards and upwards........I'm coming off the diclofenac today (thank god - it's killing my stomach) so I reckon I'll feel a bit worse over the next few days.....

Plica Removal and Patellar Chondroplasty: 2 Days Since Surgery

Very sore, tentative and ginger. Stairs are too hard and I can only do them by crabbing. I'm still mostly resting in bed, but doing my physio every couple of hours and pottering about a bit. The swelling is going down quickly (see photo). Mostly I just get soreness, apart from if I rotate the upper leg on top of the lower (e.g when turning without moving feet) and then I sometimes get a sharp pain - exactly where I used to get my flare ups and catching/cracking noise - so I'm avoiding that like the plague :). The cryocuff the hospital gave me (knee sleeve that you fill with ice/water and pump up with air) is brilliant and is really helping to get the swelling down and manage pain .The diclofenac is already starting to irritate my stomach - knew it would. Basically going well - but them I'm not really doing anything....

Day 2

Post-Operative Physiotherapy Routine for Arthroscopy

Plica Removal and Patellar Chondroplasty: The Operation

Operation seems to have gone well. The surgeon found (and removed) the medial plica which was inflamed. There was also some degeneration of the lower, medial patellar cartilage which he tided (and hopefully stabilised) with radio-frequency. He did not remove any tendon material as he felt that the above two would dramatically reduce the pain I get - sounds good to me!. Walked out (albeit very gingerly) 5 hours after the op - no doubt made easier by the long lasting anaesthetic inside the knee joint. The swelling of the knee is enormous (yuck!). Check out this photo I took once I got back to my room.

Day 0

I think the medial incision is where the scope went in, the lateral one is where surgical implements went in and the superior lateral one is where the RF was introduced. For pain management I have been given diclofenac (twice a day) and paracetamol (4 times a day). Have also been given a basic physio routine to be followed until the stitches out. This routine seems geared to maintaining some mobility and muscle strength/firing. I'll put that up in a separate post in case it is useful to anyone

Plica Syndrome

Interesting this.....ages ago a physio once wondered if I had a plica problem and it came up again with my consultant. So, what is it?

"Often called "synovial plica syndrome," this is a condition that is the result of a remnant of fetal tissue in the knee. The synovial plica are membranes that separate the knee into compartments during fetal development. These plica normally diminish in size during the second trimester of fetal development. In adults, they exist as sleeves of tissue called "synovial folds," or plica. In some individuals, the synovial plica is more prominent and prone to irritation.The plica on the inner side of the knee, called the "medial plica," is the synovial tissue most prone to irritation and injury. When the knee is bent, the plica is exposed to direct injury, and it may also be injured in overuse syndromes. When the plica becomes irritated and inflamed, the condition called "plica syndrome" results."

©2010 About.com

That really is very consistent with the medial problems I get (but not those directly above and below the patellar). Good news is that the best diagnosis (and treatment) is via arthroscopy) - which I am having, so it should get picked up. Of course by the time I've had the artoscopy itself, plus tendon decompression AND plica removal it could take a long time to get back on my feet....no point second guessing...just have to see what comes from the arthroscopy

Arthroscopy: Going in for the Op!

Well, finally decided to have an operation on my knee! Decided to go for it now because I'll have my long Teacher's summer hols to get past the initial soreness and get back to driving. I've scanned in some of the details of the consultation here:

Although I initially decided to wait longer, one relapse too many and the offer to 'go private' from my very kind parents (thanks mum and dad!) changed my mind. I'm having an arthroscopy to check for other problems  followed under the same anaesthetic by decompression of the tender parts of the tendon. It feels like the right thing, with the physio and the walking I have regained good mobility but have plateaued now - hopefully this operation can correct the remaining stubborn problem and I can further increase my function beyond that. Feel quite nervous about going back a few steps, the level of pain I might be in after the op and also the (albeit very low risk) possible complications - but I'm just not ready to give up an accept that this is a good as it will ever be. Discarding the possible nasty complications the worst case is that I end up much better informed as to what is wrong and can get on with my life without 'wondering what if'. Likely case is that I do get a further reduction in symptoms (studies of arthroscopic decompression seem to show good results, for example a and b) and best case is that I get substantial improvement.

I'm going in on weds - just keen to get on with it now....fingers crossed.....

Possible Tendinos/Tendinopathy Treatment: Shockwave Therapy

This is the second treatment that my consultant mentioned. More properly called "extracorporeal shockwave therapy" it relies upon bombarding the injury with ultrasound in an attempt to increase new blood supply and healing (perhaps via the triggering of a new inflammatory process to 'remind' the brain of the injury). Again, not something I have tried. But here are some links:

Efficacy verdict on shockwave therapy (from NICE)

I decided not to go down the path of either of these since my consultant has not had good success with them on knees (some success on elbows) and also he wants to be certain that there are not other issues underlying which the arthoscope would show. From reading around I just did not feel that confident that these would not just be a waste of time and money - but they are much less invasive than surgery and might be worth a go before resorting to that - I'm interested to hear from people who have had a positive experience

Possible Tendinos/Tendinopathy Treatment: Autologous Blood Injection

Finally got my appointment with the consultant. Given the amount of time without recovery and the lack of substantial response to physio he recommended an arthoscopy and decompression of the tendon (more on this in a later post...). But we also talked about two other possible treatments (which would have to be privately funded). The first of these is blood injections into the tendon - the idea being that the platelets within the blood stimulate/help healing. Not something I have tried - but here are a couple of links:

Details of the autologous blood injection procedure
Efficacy verdict on autologous blood injection (from NICE)

Astanga Yoga

If, like me, you get laid up for ages by this condition - you are going to need some kind of exercise to keep sane. I have (despite all my preconceptions ) found yoga (in particular Astanga yoga) to be fantastic. I think Astanga suits me because of the flowing, moving cardio side to it and also a number of the poses provide lengthening (i.e eccentric) strengthening of the legs - just what you are after for tendinosis. The format of the classes (I got nowhere without an instructor) lends themselves to taking it gently and not over-reaching. I was amazed by how physically tired I got during/after these sessions and found them an amazing workout as well as leaving my muscles and tendons feeling warm, full of blood and well stretched.

I had always (as a runner, gym, bike, swim enthusiast) been a bit dismissive of yoga - but I'm a convert. You would need to find a class that suits your mindset, age, gender etc - and I would suggest that Astanga might be a good choice to suit the mindset of sports-mad people?

Go on...find a class, give it a try....at least you'll be off the sofa doing something..and you never know...you might catch the bug. I really like this poster (credit: http://dailycupofyoga.net/yoga-resources/) and love some of those bent knee standing poses - great eccentric strengtheners (but take it easy to avoid a flare up!)

Possible Tendinos/Tendinopathy Treatment: Kinesio Taping

I have found Kinesio taping to be quite helpful. Basically this kind of taping (which has a 'wrinkly' look when the tendon is compressed (full leg extension) provides a gentle 'lift', rather than constrictive support. I have been using it on my longer walks when I don't have knee supports (once a week) and when I know I'll have a heavy day. I would not say that it had a strong impact - but does seem to provide some relief and also a psychological distraction by changing the way the knee feels. My physio trained me up on how to apply it (not too hard) and you can buy the tape online. Below is a picture of what it looks like when applied (this one had been on for two days and was starting to come loose in a couple of spots). The 'wrinkles' pull up a convolution in the tendon and skin - its not just loose taping....

Eccentric Decline Squats - Third Progress Report

Over the last few months I've been gradually adding weight to my one legged squat routine. I've stuck to 3x15 squats (on each side) before bed, and added 200g every four days. Although no miracle cure I have continued to see gradual improvement and am now at 3.6Kg. I no longer get any neurological feelings and am less prone to pain on the pat and quad tendons. I would say now that I suffer mostly from very stiff and sometimes sore knees - rather than pain. If I do too much then I will still get a flare up though. Those flare ups begin with twinges in trigger points on the outside of my thigh above the knee and then spread to cause a wider flare up. Sitting and driving are still the worst for causing it to stiffen up and feel nasty

My physio has had me on a gradually increasing walking program as well - which has been a huge psychological boost. I walk three time a week, one without any support and add 10% to the time each week. I have gone up from 15 mins to 70 mins - which is a huge improvement. I have continued to benefit from accupuncture into the sore area - and get a strong, positive improvement for a few days - particularly on the quad tendon directly where it joins the patella - which is my last remaining spot which is regularly sore.

Tendons/knees are still very grindy and clicky - maybe that will never go and I just have to accept it. Now it seems like carefully managed gentle movement, walking, yoga, physio is the most effective thing at managing the stiff, sore feeling. Also interesting has been my gradual mental shift - it is true that, given long enough, you can get used to most things! I'be sort of adapted my life to not running, swimming, cycling and instead look forward to my yoga classes, walks etc. I would not have believed it - but there it is. Perhaps one advantage of this whole awful experience is that I'm learning to be more gentle with my body and exercise. When I do get back to a wider range of exercise I'm going to approach it in a much more 'for fun' and gentle kind of way

I think I have now got as far as I am going to go with the squats though. At the weight I'm at they now feel like they are starting to antagonise other parts of knee and overload it - I really don't want to cause a whole new set of problems. Through my Astanga Yoga I've learnt loads of eccentric leg exercises which are static loading and seem to have the same benefits - so I think I'll focus on those, gently building up my walking etc and see how that goes.

I'm not sure if I'll ever recover 100% - but I can already do so much more now - perhaps it's a case of finding what I can do, gradually building that and see what happens in the long term. So many of my problems seem to have come from 'heel-striking' and poor running posture - so I'm also reading a lot about barefoot running and walking - could be a way for me to go in the future. Might start up a blog on that as I get into it a bit

Eccentric Decline Squats - Second Progress Report

Next target was to get to 3x15 squats (still once a day, just before bed) using only one leg. Again, with one exception this has gone well and I have got up to target. I have used the same approach of adding one a day. When I went to one legged I dropped back down to 3-3-3 for my three sets. I went on the assumption that a one legged squat was more than twice as hard as a two leg (due to the balance and adjustments that the leg would have to go through). I still do gentle stretching after the squats and also use my leg roller (although not getting much from that now).

Almost at the end I caused a really big flare up though. I have been gently resting my index fingers on the wall in front of me throughout to balance me. I decided to try and switch to not needing any balance assistance - daft really because I have poor balance at the moment. Instead of following my one by one approach (i.e only take away my fingers for 1 squat then 2 next day and so on) I just went for it and was in a lot of discomfort the next two days. I took a few days off and then eased back in (1 set day 1, 2 sets day 2, 3 sets day 3) and have got myself back on track and up to 3x15 - but still feeling a bit niggle after the flare up - which has slightly taken the shine out of getting to this point because it showed clearly that the really nasty underlying problems are still there, lurking and waiting to get me!

Here are the same two graphs as the last post - expanded to cover this additional period:

Note here how we do see an offset between a week of higher activity and a week of higher pain. E.g Weeks 5/6 and Weeks 8/9. The pain spike in week 13 (without an activity increase in the preceding week) is due to the flare up mentioned above. Also, the generated trendline still shows a decline in pain levels over time (or does it show the fact that I have become more generous in how I have assess my pain over time). If it were indeed a linear progression (probably unlikely) this would predict that I would be 'cured' sometime in Jan 2011 - note the big shift from last post April 2010 prediction. Perhaps it is linear and this is a more realistic projection - or perhaps it is non-linear....

It has been a shame to finish this period with a big flare-up as I had been feeling pretty positive before that and was feeling improved. Ah well....onwards and upwards....Next target is to stick at 3x15 one leg for a week and then start to add weight VERY slowly....

Eccentric Decline Squats - First Progress Report

So, the first target I set myself was to get to be able to do 3 sets of 15 two-legged squats, once a day just before bed - noting I had failed to achieve this up the Xmas by trying a more aggressive approach of 3 sessions a day and adding 3 squats per day.

I started on just 3 sets of 3 squats and added just one squat (so 3-3-3 on day one, 4-3-3 on day two, 4-4-4 on day three and so one). I do this once a day, right at the end of the day. After the squats I do some light stretching and use my foam leg roller, then bed. This is just about the most gradual increase I can imagine. This time I have been much more rigorous about keeping a diary. Every day I score my activity (I don't do any exercise - this just means how much walking about I have had to do out of 5 and my pain out of 5. The calibration of this scale is as follows

Activity

0 = In be all day - example when ill

1 = Just at home all day and being particularly inactive

2 = The load incurred by walking around the house, driving to work and being at work

3 = Same load as a normal day but also includes something like a short walk (1-2 miles) with the kids

4 = Loads of on-and-off walking all day long. For example a day sightseeing and going around attractions

5 = Guess this would be if I took some kind of exercise :-)

Pain

0 = When I am cured! I.e I get no problems at all in an normal day or with gentle exercise

1 = Some twinges and stiffness but no pain. Generally feels good most of the day and I don't get any discomfort from siting for long periods. Would tend to feel mentally positive, walk briskly and go up stairs two at a time

2 = Average day - stiffness, areas of soreness, on my mind quite a lot, would walk more slowly, feel stiff on rising from sitting and go up stairs one at a time

3 = Lots of soreness. Unable to ignore it, perhaps limping a bit when walking. Not keen to put weight onto it and slow on stairs

4 = Lots of soreness. Unable to ignore it, limping when walking. Specific bad spot on patella tendon (or quad tendon) lit up

5 = Like after the marathon. Can't bear to bend it, any touch/impact is painful. Whole knee one big lump of pain

This has been much more successful. In the whole period I only had to skip one session and have got up to this target point. Combining this with some physio work on trigger points (see other post) and my leg roller I have some reduction in neuro symptoms. Here are some graphs derived from the data in my diary:

Here is a graph showing the weekly average for activity levels and pain levels. It is interesting to note how they do indeed follow each other - but perhaps with an offset. For example

an activity spike in week5 is followed by a pain spike in week 6. I wonder if I will get a similar spike in Week 9 to match the activity spike in week 8?

I have also extracted just the pain values and generated a predicted linear trend line to see if there is any week to week decease and, if so, how substantial is the rate of decrease. This trendline is based on day-values and not on the weekly averages.

On the plus side the trendline shows a decrease - but there is a caveat to this. That decrease could be because (over long periods of time) I may become inconsistent in my use of the pain level scores (is a 2 now the same as a 2 eight weeks ago?). I might be measuring my desire to see progress rather than actual progress! If it were indeed a linear progression (probably unlikely) this would predict that I would be 'cured' sometime in April 2010. This does indeed feel unlikely suggesting that it won't be a linear approach.

That said things definitely do feel easier at the moment - far from cured but I do see some minor gains.

Next target is now to go to one legged (drop right back down on the numbers ) and work back up to 3x15 one leg squats......

Possible Tendinos/Tendinopathy Treatment: Leg Roller

Another technique that I have found useful......

So that I could work on my trigger points myself I got hold of a foam leg roller which I can use to apply my body weight to the trigger points and also roll the muscles and tendons to condition them. I used this over a period of a month and found that in the beginning pressure on the points was very very painful (could not apply body weight) and caused the nerves and tendons around the knee to 'fire' in sympathy. I stuck with using a mixture of straight on pressure and rolling and it got easier and easier to the point at which the physio can no longer find the trigger points and pressing down (using the roller) on those areas no longer causes any sympathetic firing around the knee. This seems to have had a good impact on the wet/cold/neurological feelings I had around both knees (and seems to have helped sitting still for long periods) but had not had any impact on the deeper and problematic areas of pain and stiffness on pat and quad tendons. SO - another useful technique for management but does not lead to a cure!

Possible Tendinos/Tendinopathy Treatment: Trigger points and Accupuncture

Thought it was worth a post on this treatment as I have found it very useful. Between early Nov and now - along with my eccentric squats my physio has been working on some trigger points in my right leg. These manifest as very sore patches in my muscles which, when pressed, seem to stimulate trigger prickly, tingly feelings (similar to the neurological ones I experience) around my knee. Often when pressed they appear very 'active' and a trembling, fluttering pattern appears under the skin. There are a couple of big ones close to the ITB on the outside of my quads, a minor one on the front right and one in my hamstrings

My physio has used a mixture of warmth, pressure and also needles to work on them. It has taken several sessions but they are improving and, after treatment, I get a reduction in tightness/stiffness. I don't this has a curative effect - but it does help with management and I would definitely recommend it

Using the Eccentric Decline Squat Protocol

This post records my experience of the first two months of trying eccentric decline squats as a therapy for pat and quad tendinosis. Mid October I checked in with my physio and we talked through my problems to date and the protocol. I started on two sessions a day (first thing and last thing), using both legs (so no one-legged squats at all yet) , in sets of three and adding 3 squats each day (so 3x3x3 twice a day on day one, 4x4x4 twice a day on day two and so on). We added in a late afternoon session as well.

In parallel to the squats I was also seeing the physio for regular massage and acupuncture of specific trigger points in my quad muscles (see other post) - which proved very effective in reducing stiffness and some of the minor symptoms.

Progress was very good for the first three week. I saw a good reduction in symptoms and was building up the squats well. But then it all started to go wrong, increases in discomfort turning into a running battle by which I kept laying off the squats because of a flare-up, restarting them only to see it flare up again and so on. By Christmas I had to accept I was (apart from benefit obtained from the massage sessions) not really getting anywhere. from reading this blog and other discussions it looks likely that my rate of increase was way too high. So the plan now is to rest for a couple of days and then restart doing only one session a day and only adding one squat a day - let's see how that goes....

Possible Tendinos/Tendinopathy Treatment: Cissus Quadrangularis

I've been taking Cissus quadrangularis to see if that had any curative effect. The product I used was "Mega Cissus - 50% Ketosterone" taking 400mg tablets before breakfast and bed. Having taken it for 50 days I have noticed no effect at all. I will continue to take it for another 50 days to see what happens. So far, for me, whilst this may have some effect on muscle and connective tissue growth, it seems to have no value in tackling tendinosis. Interestingly it does seem to have made me slightly leaner and made it easier that usual to keep weight down even though I'm not training - an effect Ihave read about

End of the first 100 days

So, I'm setting out to rest for 100 days and then do 100 days of eccentric protocol....this post marks the end of 100 days of complete rest. I can categorically state that (for me) resting has achieved absolutely nothing. All the symptoms I had before, I still have and at the same level. Audible crepitus in right knee tendons. Overstretched, creaky feelinging in pat and quad tendons on both knees.If I overload it, pain on right knee pat tendon.

At least I know that I have tried rest and won't be spending all my time now thinking - "perhaps I should just be resting". I'm going to crack on with an eccentric squat protocol and see what that does for me. I've been reading this excellent blog about eccentrics squats and will have a go at it. Will also get back in touch with physio and get their guidance/supervision.

The 200 day plan....

One good thing about tendon injuries is that they teach you to slow down and have patience:)

I really think I know the extent of my problems now and can plan a way out. The two things wrong are:
(1) general crepitus and tenoditis type feeling above, below and around both knees - caused by doing too many weights too often when trying to come back after the Marathon
(2) localised tendinosis in the right patella tendon - caused by over-training before the marathon

To date any attempts to start an eccentric protocol to work on the second cause the first to flair up. So here's the plan......

First of all I need to kick the more general problems. I've read in a number of reports and journals that it takes 100 days for Type I tendon collagen to lay down and mature. So I'll do no exercise on my legs for 100 days (bar walking around and a tiny bit of swimming as a treat). I would expect this to show a marked improvement in the more general problems. Perhaps later on I will be able to add in some gentle stretching. Other things I should do in this period would be some work on ballance/proprioception (mine is rubbish now!) and some deep tissue massage as there seem to be all sorts of rough, painfull areas on innner and outer thigh muslces and nasty trigger points. It's already 6 weeks since I laid off the gym leg weights and there is already a slight improvment in the general tendon crepitus - which is promising -but the trick is to stick to my guns. If I count from when I stopped the gym weights that puts me at 50 days right now

Then.....

I've also read that any significant improvements from an eccentric protocol aimed at tendinopathy takes a min of 12 weeks (consistent with the time above taken to lay down and collagen and re-model the tendon). So the second part of the plan is a 100 day eccentric decline squat protocol (starting incredibly gently and building up slowly). Hopefully this second phase will then start to address the specific area of tendinosis. I'm also expecting to continue the eccentric work for a long time beyond this - but I'm hoping to see improvment by the end of those 100 days

Maybe I'll be able to go for a gentle bike ride at the end of the winter (forced grin)...

Heat or Ice?

I've tried both applying heat and ice and thought I'd jot down my observations. As with all this blog - consult your GP (Doctor) or physio first.

Icing is normally recommended (as part of RICE) soon after the injury to help reduce inflammation and bring down swelling and numb pain. Most advice says not to use ice before activity. Heat is normally recommended before exercise to warm up tight muscles or in the ongoing management of conditions where increasing the blood supply to an area can reduce stiffness and help. Never apply heat to an area with inflammation as it can make it worse

There is a brief summary of the differences here:
http://orthopedics.about.com/cs/sportsmedicine/a/iceorheat.htm

So, what might we speculate would be the affect on tendinopathy? Going with the expectation that tendinopathy is not an inflammatory problem (but one of collagen degeneration) I have tried both and found the following:

Ice: Icing (freezer gel pack with cover to prevent frost-burn) worked well to numb pain (and also my weird tingling and wet/cold feelings). It left the area feeling stiff afterwards. Despite repeated and regular use over time no obvious improvement in the condition was observed

Heat: The warmth of a heat pad helped to reduce stiffnes and felt pleasant but did not provide any relieve from pain. In addition on a few occasions, where at that time I had a particular small spot of increased crepitus and wet/cold feelings it seemed to be slightly worse afterwards.

So, on balance I guess the icing was marginally more useful and probably safer in case there is some minor inflammation (perhaps caused by the rehab protocol). Heating did not some quite as useful and I had a worry that improving blood flow could be bad thing if it worked to the benefit of abnormal capillaries growing into the damaged area. Neither seem to have any curative effect at all - but ice seems the most useful palliative

Weeks 15 - 17

Whilst on hols felt pretty good when on beach and in the (cold!) sea - but right knee got very tight and sore driving home. In a fit of frustration (sigh) attempted to start some eccentric decline squats during week 16 - but was flaring both knees up the next day - clearly not ready for that yet. By the end of this period the pain on the left quad tendon had gone (good news!) but still now got extensive crepitus, 'over-stretched', prickly feelings below and above both patella. If I walk a fair way (say a mile around shops) it goes wetter, feels less stable and a bit sore. After a few days this shifts to feeling more dry and scratchy. The palpable crepitus (all over both tendons on both legs) is constant - and there is still an audible crepitus on the right leg when going from full extension down a few degrees (but I've had that for months). The right patella tendon feels much worse than the left one (as I would expect).

RIGHT KNEE: 3/5
LEFT KNEE: 2/5

So.....think I'm going to just rest if for a couple of months (despite my intentions I've never really rested my legs completely - bar walking and driving for longer than about 4 weeks!) and get some more physio advice for an eccentric programme for when this more general tendinitis (inflamatory) attack eases off

The Medical Care I had before starting this Blog

This might be useful for other people under treatment. Loads of detail below - but here's a summary:

• GP's didn't seem to know much about these kinds of problem
  
• Expensive MRI's confirm what a (free) good understanding of the symptoms can tell you
• A good physio is a god-send - but you need to explain very clearly where it hurts and how so they have fair chance of helping you
  
• There is still a common approach to offering steroid shots - and I've read bad things about their long term effect on tendon health
• Lots of folks warned me away from surgery!
  

June 2008: Saw GP (doctor) because I was getting come crackling when bending knee and a tingling on side of right knee and bit of tingling on quad tendon. Told me to stop running but carry on swimming and cycling to keep fit, Prescribed ibuprofen. So told me nothing I didn't know and not very supportive and did not prescribe any specific exercises/stretches or refer to physio

July 2008: Got some spots of pain on the knee so (still not running) and started seeing a private chiropractor. I was not great at describing where it hurt and she went down the path of patella tracking causing rubbing and soreness (under the knee cap). Not the right diagnosis - but not really her fault. Very emotionally supportive - got me into some good stretching routines. Introduced me to the idea of trigger points. Also suggested I get sports massages. I was still cycling and swimming (which I think was probably bad) but all of this (plus, of course, the time off running) helped to reduce the quad tendinopathy. Back to running at start of October

Jan 2009: Through the Autumn and winter I trained hard and ran a half marathon. Was still getting some quad tendon niggles but managed them with stretching. But then after a long run (14M) a few weeks after flu, in the cold I got the first taste (of what I now know to be) patella tendon problems -sharp pain just under the kneecap and also a flare up of the quad tendon as well. Went to see a private knee specialist because I wanted to know what was wrong. Had an MRI and he was able to diagnose the quad tendinopathy but thought the lower knee pain was wear under the knee cap (no MRI evidence of this though). Offered a intra-articular steroid shot for this which I took (probably a bad call given that it was really my tendon that was the problem - but where the pain referred made it hard to describe at that time). I've uploaded one image he gave me. The paler parts on the quad tendon he said where the tendinopathy. I'm no radiographer.....but isn't there one of those a but further down below the patella as well? Anyway the jab worked like a dream (hmmmm..perhaps I was more inflammatory than tendinopathic at that point - otherwise I would not have thought the steroid would have done much). So this was expensive only partially correct, but I was back to running and now knew about tendinopathy. Started seeing a physio at this point as well. She was fab - got me strengthening my hips, more stretches, regular sports massage and strength exercises for VMO, buttocks. She also explained about eccentric exercise - but I did not do much of them (she gave me lunges which I hate!). Good emotional support and encouragement as well

March 2009: Through Jan, Feb and March I gradually eased back in and got up to 16 miles as my longest run - before a short but fast run caused the patella tendon pain to reoccur. Resting did nothing, tried to run anyway (felt really stressed as I'd raised 3K for Oxfam for the marathon in 7 weeks time!) the pain got really bad (in fact it has never been anything like as bad as it was at the end of March when I could barely walk). Saw the GP (different one) who had got the private MRI results - he agreed with the consultant and offered another steroid shot intra-arcticualr. I had a niggle this was a bad plan but just wanted it to work so I could finish my marathon training - so took it). Did not work this time - so I'm now guessing I now had tendinopathy rather then '-itis' type inflammation. The pain was now so diffuse that it felt like the whole knee - so the physio still never got to a diagnosis of patella tendinopathy - but I was rubbish at explaining exactly where it hurt.

April 2009: Rested, swam legs only and did leg strengtehning. Was getting patella tendon pain throughout. Just before the marathon the pain went (for walking - but would come back from running) and I could feel my right MPFL was tight. Pressed on and did the marathon - wow! what a fab day - but painfull ;-)

Week 13-14

Pretty much straight after I started to get pain on LEFT knee quad tendon (up and down stairs) I knocked off the weights and went for resting (with wretched knee supports back on again...grrrr). Despite resting I got gradual build up of palpable crepitus symptoms in patella and quad tendons of both knees along with that pain on the left quad tendon attachment. This big surge in problems above and below both knees is a real blow! Looks like the gym weights have been overloading the tendons (despite trying to focus on eccentric phase) but it took a while to build up and become obvious

RIGHT KNEE: On the plus the pain on the right patella tendon seems to have disappeared. Still feels wet, squashy (often) and very scratchy and crepitus and still with a tight MPFL. 3/5

LEFT KNEE: 3/5

Full List Of Symptoms

Thought I'd just jot down a list of all the various symptoms I've had. I get problems in both legs but generally the right is much worse

LL = Left Leg. RL = Right Leg

Patellar Tendon

• Diffuse and very nasty pain all across the face of the patella - spreading up from the lower focal pain spot (RL)
  
• Sharp pain just where it joins the patella - felt quite deep inside (RL)
• Occasionally unstable and gives way (RL)
• Audible crackling noise wen going from a straight locked leg to a small amount of bend whilst the tendon stays tensed (RL)
• Squashy feeling (RL)
• Does not look (when fully relaxed) quite as substantial as the left one and has a slight concave. No visible difference between legs when patella tendon tensed
  
• Palpable (but not really audible) creaking when the tendon is tensed a bit and then gently touched (LL and RL)
  
• As if my trouser knee fabric were wet and cold even when the skin in warm and dry - really weird feeling (perhaps neurological?) (LL and RL)
• Prickly burning feeling
  

Quadriceps Tendon

• Palpable (but not really audible) creaking when the tendon tensed a bit and then gently touched
• Warm (but not to the touch)
• Prickly, mild burning feeling
• Tingling (neurological? - in fact this was the very first symptom I ever had - imagine if I'd taken a few weeks out then...sigh....)
• Wasted VMO caused by limping and avoiding that leg

Also a very tight band going from my medial patella - I think this is MPF Ligament (might have aways been tight but I just noticed because I now spend so much time fiddling with my knees :)

Weeks 6 -12

So, from the start of this period I've put away the neoprene knee supports (which make me feel a lot more normal!) and been in the gym doing leg weights. Having read a bit about tendinopathy I've been trying to focus on the eccentric phase over the concentric phase.
At the start there was visible wasting of the right VMO (I guess caused by all the limping) and a dramatic strength imbalance. After gradually building up the weight over 6 weeks the legs were the same strength and VMO had plumped up on right leg. Gained a lot of strength back and was feeling very mentally positive. Did try a bit of cycling but that flared up the pain on the patella tendon.

But it's gone a bit wrong at the end of this period....Started to get pain on the quad attachment of the left knee. Carried on despite for a few sessions and then common sense kicked in (I've learned something after all!). Just going to rest for a few weeks and see what happens.

RIGHT KNEE: The weights do seem to have helped the pain and wet feeling in the right patella tendon - but still got plenty of stiffness, twinges and wet feeling there. So would still say this was 3/5 for right knee

LEFT KNEE: Pain at quad tendon attachment on ascending, descending, lowering and rising from sitting - but not to sharp. 3/5

Weeks 2-5

At the end of these 5 weeks my symptoms were:

• RIGHT KNEE: No pain across face of knee (big improvement!). Medial patella pain point gone but feels like a very tight band going from medial patella to underneath VMO I think this is my MPFL. Still focal point of pain just under right knee slightly to medial - intermittent (whereas was constant before the marathon whenever moving). Also the right patella tendon feels kind of wet and squashy. I can tense the patella tendon without pain now but can feel crepitus (and hear it at maximum extension). Lets call that 3/5 for future reference
• LEFT KNEE: No problems. So lets call that 0/5 for future reference
  

Originally I was thinking I'd got PFPS (Patello femoral pain syndrome) but now I reckon the pain across the face of the knee was just diffuse pain from the patella tendon and really its nasty case of patella tendinopathy - which is consistent with problems from the prev year. I had audible crepitus before the marathon and thought it was coming from under the knee cap -but it's clear now that it's coming from where the patella tendon attaches to the lower patella pole

Week 1

Here's how my knees felt this week

• RIGHT KNEE: awful pain all over the knee. Specific focus (palpable spots) of pain just below patella on the medial side and on the medial edge of the patella. Could not bear to bend it, move it or even really touch it. So lets call that 5/5 for future reference!
• LEFT KNEE: had a nasty bit of ITBS on the outside of the knee and a corresponding medial patella niggle. Lets call that 4/5 for future reference.
  

Getting up and downstairs with two knees out of action was tough.

The story so far...

January 2008 - I decided to run the London Marathon in the following Spring. The next 15 months were a roller-coaster ride of injury! Increases in my fitness were interspersed with long lay-offs. Basically I trained too hard and did too much road running causing all sorts of problems with tendinopathy of my quad tendons in both left and right knees and pain right on my right knee. The start of 2009 was pretty good but one hard, fast run in the dark, in the cold, in the rain, in mid March saw it all flare up. I struggled on and still ran the marathon, firstly because it was a goal I was desperate to achieve and secondly because I had gathered pledges and donations worth nearly £3000 for Oxfam. In an attempt to clear the injury I had never run further than 16 miles and had not run at all in the 6 weeks before the Marathon. It nearly worked and, by the big day, I could walk, ascend, and descend stairs without pain – but running still hurt.

So here's the thing – it was still one of the most amazing days of my life! Yes my knee hurt. Yes I wasn't fit enough. Yes it was a real struggle to get round. But I still got a time I was pleased with and the sounds, colours and crazy things I saw will stay with me forever. The relief of stoping after 4 hrs 16 mins and 3 secs of running was enormous and the sense of achievement is huge. Perhaps having to dig that deep (I never walked despite how tired and sore I was) has changed me a bit inside as well?

Of course afterwards, and the next day (in fact week) my legs (and feet and arms, and stomach and lungs!) were sore – but it was worth it and I'd make the same choice again any time. Before the Marathon I knew that I was letting myself in for a huge relapse with my right knee and, sure enough, it was extremely painful the day after and only marginally less painful now, a few days later.

Going into the marathon my plan was to achieve that goal and then take the time out from exercise to really sort out my knee. To rest, rest, rest until pain free and then work back in incredibly carefully. I am guessing this will take something like three months – but I don't really know. I am expecting it to be a bumpy road with slow progress and lots of disappointment. I am hoping that keeping a blog will give me an outlet for that frustration but also, hopefully, let me look back and see the progress I am making. I'll try and collate hints, tips, links etc. - I've a fair few already from the last year believe me! Perhaps this blog will also be useful to other people with knee problems.....