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."

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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.....