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