Chronic inside upper knee/thigh pain

[Roberts]

Hello, I am hoping that someone can help me as I am thoroughly fed up with being injured and think I might go crazy!!

I have been suffering with injuries since september 05 now and as one seems to heal another part of my body flares up. I originally tore my right calf muscle which took ages to heal and caused me to limp for months resulting in pain in my left buttock which became chronic. I eventually managed to get rid of this buttock pain last year by doing a muscle energy technique stretch every day which apparently released my piriformis from spasm. But then whilst trying to do glut medius strengthening exercises my left knee started hurting and it still does now and it won't get better!!

So it was summer 07 that I tried doing 5 shallow 1 legged dips and I got a sharp pain above my knee cap and to the inside (vmo muscle area). I then rested it for a week and tried again and got sharp pain again. I then tried swimming and it flared up big time so that I couldn't walk on it. It was slightly swollen in the same place I had the sharp pain (around the top right hand corner of the knee cap) and felt hot.

I was given gentle physio exercises and told to rest and walking became easier over a couple of months.

Now I have seem to have got stuck, I can walk for about 5-10 minutes on the flat without pain but anymore and the knee starts to get sore and hot and swells slightly. I haven't been able to go upstairs since the summer and anytimes I have tried has ended up in the same results of a sore knee, swelling and heat. Going downstairs makes it worse but not as quickly and just one squat flares it up. So basically I can't do much.

I have been diagnosed with patellofemoral pain now and have a nasty uncomfortable feeling under my knee when the dr pushed the palm of his hand down onto my knee cap. I have also developed pain in my tendon under the knee cap and have just recovered from fat pad impingement using tape. Also my knee is uncomfortable bent but feels great when I do nothing!!

My left glutes are really weak from the limping and my quads are wasting away. My itband is quite tight but apparently not pulling on my knee cap. The knee cap is mobile. I have orthotics.

I am in the nhs system and expect I will have an mri at some point.

The last thing I was told by a physio was that pain on the top half of the inside of the knee wasn't normal so he didn't know what to do. Also he was a bit concerned that my knee had swelling.

Has anyone got any ideas on what I have done?
Thanks in advance

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[Canuck Physio]

I believe your problem can be solved if properly managed, but I think the term consistency applies here. Several different problems appear to have come up at different times, and each time a different solution? Have you been self managing or have you consistently been managed with one therapist?

[Roberts]

When the knee pain started I was seeing an nhs physio that I had been referred to for sorting out the chronic pain in my hip/buttock. She signed me off in November after seeing me progress from limping to walking normally but not being able to go up steps. She said that she could do no more and thought that I would eventually get better over time. I never managed to progress in the leg exercises that she gave me, they just irritated my knee.
I seemed to start making progress when she got me half price sessions at the local gym and I would do level 1 on the exercise bike, walk on the treadmill and after a month I could use the cross trainer for 10 minutes. If I did no other exercises this didn't aggravate my knee. But 2 months ago the morning after one gym session I couldn't walk without pain below my knee and somehow I had developed fat pad impingement and hurt my tendon.
I saw a new physio that showed me how to tape my knee and said that I should try going down into a squat and staying there with my quads contracted as I had pain when I came up from a squat. I tried this but it hurt my tendon but I agree that it would irritate my upper knee/muscle less when my tendon is better (I think).
The 2nd time I saw him he said he didn't know what else to do, which is what every physio has said eventually ever since I tore my calf, and thats what is so frustrating.

The physio that taught me the muscle energy technique stretch that got rid of the buttock pain, I was seeing him when the knee pain started but he just said that it was because my biomechanics were wrong, weak glut med etc, and pain was to be expected and could give me no advice to make it better. Also he said my right side of the pelvis was rotated forward and my SI joint was stiff one side and flexible on the left side.

[Yarok]

hi

can u give some details about yourself
age/occupation/activities/sports/posture/weight/ back problems
any health problems/stress etc

is range of motion of ankle, knee, hip without ressistant in norm?

[Roberts]

Hi
My range of motion in my hips and knee are good. I sprained my left ankle (same side as bad knee and buttock) April 05 which wasn't too bad but I carried on playing football so it turned into more of a chronic problem. It improved after cross friction massage a few months later and I went back to playing football with an ankle brace, then my calf started twinging!
On the inside of the ankle its just a little tight in the ligament that was strained but it hardly affects the range of motion.

Other details: I'm 27, I help run supported housing for young adults with learning disabilities and do some care support. I used to be fairly active and cycle quite a bit, then I got glandular fever which led to a year of chronic headaches where I did practically nothing (2002) so I guess my body lost a lot of fitness. I then joined a football club and did training once a week and sometimes a game at the weekend. I also played quite a bit of football at work for fun and jogged with the dog. I found that I was getting painful hamstrings quite often after football, their flexibility was pretty poor too (I couldn't touch my toes). My quads have always been flexible though. My glutes were tight but ok now.
I saw an osteopath after neural stretches helped my calf. This is where I was diagnosed with a locked SI joint on the right hand side and had manipulation to sort this out. This made my calf a bit easier but put my lower back in agony so I couldn't sit down. I've always been uncomfortable sitting for long periods of time when I was younger but nothing too big.
I used to have quite a bad posture - bum sticking out style! I have now been taught to tighten my core and pull my buttock muscles in. I saw a chiropractor and he did an xray which showed my discs were getting narrow in my lower spine and a loss of curve, and slight scoliosis. On an mri (nhs) I was told that my back and pelvis were fine.
I also have a really weak core.
I am 8st8, 5 ft5.
I have no other health problems.
I am stressed now as I can't do anything! But before I was injured I'd say I was under a standard amount of stress - moving house, working with inlaws, but having fun!

I also now have quite a stiff, bit painful and clicky shoulder from doing arm exercises in the gym for a couple of months. So at times it just feels like if I overdo an exercise my body can't cope.

[Roberts]

Also after I moved house (March 03) I did a lot of diy including shovelling ballast for making concrete and lots of digging which left my lower back pretty painful. In fact thinking about it maybe my lower back got achey more than I thought.

[Roberts]

Well I'd like to share my latest guess of what is happening.

When I developed pain in my buttock/hip area I tried to carry on walking through the pain (as obviously it is hard to carry on with daily life sitting on the sofa) and by doing this I developed a limp which meant that I avoided using the muscle that was giving me pain (glut medius, piriformis?). As this carried on for such a long time maybe my body adjusted to this limp and the pain and thus decided not to use this muscle anymore to break up the pain cycle (neurological pathways?). So now I can use this muscle/s but my body has taught itself not to use it anymore in my normal body biomechanics, resulting in pain to my knee as it is not being supported properly.

So my plan, after reading someone else recover in the same way, is to get taught pilates which along with strengthening my very weak core, will also train correct neurological pathways.

I wonder if this makes any sense?!

Is the term neurological pathways also to do with the term getting muscles to 'fire' in the correct order??

[Canuck Physio]

Although I have no direct experience with pilates, I think it is a higher level program that may or may not solve your problems directly. I feel you have significant postural and muscular imbalances that need to be solved first. Yes, it appears that your muscle recruitment patterns are altered, this is the bodies way of protecting itself, however it is now time to solve this problem.

Without full assessment I couldn't say what your real problem was.

I am a muscle balance and function practitioner, normally in this situation I would provide specific postural and muscular balance program, as I believe based on what you are saying that these are your problems.

Will keep in touch later this week, Regards

[Roberts]

I did think that pilates theory was good but agree that I would probably struggle with the exercises.

I have started doing clamshell strengthening exercises for my left glut med and have been practicing standing whilst recruiting my glut max and med. I can feel that this supports my knee better. If I move to standing on just my weak leg the glut med fatigues very quickly and starts to shake.

[Yarok]

hi

agree its a lumbar and pelvic imbalance, and pain in your knee can be reffered from a lumbar spine, SIJ, hip, or/and from trigger points ie glut med, tens fl, ili tibial B,hamstrings, vastus L, as well as from calf area.
all the best

[Roberts]

Is the best way to sort out lumbar and pelvic imbalances, to do strengthening exercises? As it is a weakness in these muscles that has caused the imbalance?

I saw a physio up near london who specialised in pelvic biomechanics and it was he who got rid of the pain in my left buttock/hip with the muscle energy technique (to release spasm in my piriformis). He also said that I had a forward rotating right ilium and I had a muscle energy technique to perform to rotate it back. 2 other things he gave me to do were a neural stretch and a glut med strengthening exercise.
But this was also when I started getting the knee pain. My problem is that I was getting treated for a pelvic imbalance yet my knee pain got no better.

I guess I have no option but to try this treatment again.
Its just that any glut med strengthening exercises then aggravate my knee even more. Could this be that I am tiring my glut med so my biomechanics are even worse and therefore my knee gets sore quicker?

I am going to try very gradual increases with my clamshell exercises to see if I can build up strength without hurting my knee. Does this sound like a good idea?

Thanks for your help

[Yarok]

hi

thanks for respond

ur saying exercises for glut med make the knee worst?
can u describe them if i missed them somewhere in previous posts.please

re;pelvic imbalance- balnce can be disturbed and caused by various factors ie, central neural control, peripheral coduction (sequence,recruitment timing), muscular weaknes, to short, to long muscles, joint problems, to tight to elastic, state of soft tissues (miogelosis, trigger pints, adhesions)etc etc

sorry but it's complicated,

fingers crossed

[Roberts]

It is the clamshell exercises that aggravate above my knee.
Basically any exercise I do that involves muscles in my left leg ends up with my knee getting sore.
To be pain free I have to avoid all rehab, but this will get me nowhere in the long term.

Do you think that as I initially had a sharp pain in the muscle above my knee that I could have strained one of my quad muscles?

[Roberts]

I have seen the knee specialist today and he confirmed that I have wear and tear under the knee, chondromalacia and that I am in a vicious circle and I just have to keep on trying to strengthen the thigh muscles, so I have been referred back to the nhs physiotherapy so I can keep on trying!

But I will try and strengthen my core for the time being, then work on my knee.

[Yarok]

hi

i hope u are in good hands,
i still think a good hands on session makes a difference, massage with neuromuscular techniques on gluts, ilitibial band, quadriceps should be very helpful, followed by exercises.
all the best

[Roberts]

I have just started seeing a lady who has done sports massage training plus myofascial release and trigger point stuff.
By neuromuscular techniques do you mean massage like this or should I be looking for something else as well?

I have also worked out today that when I walk I don't put all my weight onto my bad leg and that my pelvis is tucked in sideways so that my abductors don't have to do any work. I must have subconsciously been walking like this to avoid stressing them as they used to be painful when I walked. I think my pelvis has gone wonky from limping for so long.

[IceMan]

Has anyone ever thoroughly evaluated your lumbar spine?

[Roberts]

I have seen a chiropractor a couple of years ago and he did an xray of my lower spine and said that it had too much of a curve and the SI joint was unstable.
I had treatment for this but it got too painful and I stopped after about 5 months of treatment.

I have seen lots of info on the internet about people doing eccentric exercises to treat tendonitis but for the patella tendon I think. I was wondering if this was as effective for the tendon above the knee. There seems to be less info available for quadriceps tendonitis/tendinosis

[IceMan]

I have seen a chiropractor a couple of years ago and he did an xray of my lower spine and said that it had too much of a curve and the SI joint was unstable.
I had treatment for this but it got too painful and I stopped after about 5 months of treatment.

When I say thorough eval of the Lumbar spine I mean a full evaluation by a physio looking at the lower back in detail. Not just an x-ray from a chiropractor. Has a physio actually done a detailed evaluation of your lumbar spine? It doesn't sound like anyone has based on your previous posts and the lumbar spine could certainly be at least partially responsible for your lower extremity symptoms.

[Roberts]

Hi Iceman, I have seen a physio who specialised in pelvis biomechanics and he said my right side of the pelvis was rotated forward a bit and that was putting a strain on my SI joint and giving me pain in the ligament on the rhs of the SI joint.
He gave me a muscle energy technique stretch to help this where you lie on your back and bring your knee up to your chest.
I think it was just my SI joint he talked about when he examined my lower back.

I stopped seeing him when I started getting knee pain because he said it was to be expected as I was re-strengthening my muscles, but I was struggling to walk and it was getting worse. And it turns out I was developing tendonitis above my knee cap and I should have been resting.

Another physio I saw a few years ago was unsure about my lower back and used to push into it with her fingers and say it was tight and a bit higher up it was too flexible when she pushed in. But she wasn't sure why this was but did wonder if it was linked to the nerve pain I was experiencing in my calf. She gave me neural stretches which helped my calf improve.

[Roberts]

Hi Yarok
To balance the quads I now do straight leg raises and quad muscle contractions where I just push my knee into the ground to contract the vmo.
But I'm not making any progress with these as I can't manage to do 10 reps without aggravating the tendon, which then aggravates the knee and it goes purple and swells slightly.

I have been told to start ems for the vmo but the nhs physio doesn't have a machine, so I have borrowed one from a friend and am about to try it.


I don't do any exercises to stabilise the SI joint as my knee is so irritable I can't do things like bridging. I have found that I can do clam shells now since I had a cortisone injection into the tendon, so I guess I should be working on my glut med a bit more now as it is still very weak.
I have tried glut max exercises but it hurts my knee again.

Actually I'm not sure if I have been given many SI exercises, maybe I should be heading to a physio who knows more about the back or be doing some pilates?
I keep meaning to do pilates but always get scared that it will hurt my knee more.

I have been told I have a very weak core.

[IceMan]

Hi Iceman, I have seen a physio who specialised in pelvis biomechanics and he said my right side of the pelvis was rotated forward a bit and that was putting a strain on my SI joint and giving me pain in the ligament on the rhs of the SI joint.
He gave me a muscle energy technique stretch to help this where you lie on your back and bring your knee up to your chest.
I think it was just my SI joint he talked about when he examined my lower back.

Yes but did he actually evaluate (and treat) your Lumbar spine? Problems in the SI joint and torsions of the sacrum are often accompanied by Lumbar problems (particularly L5/S1 issues if the sacrum is not moving as it should).

I stopped seeing him when I started getting knee pain because he said it was to be expected as I was re-strengthening my muscles, but I was struggling to walk and it was getting worse. And it turns out I was developing tendonitis above my knee cap and I should have been resting.

I would have stopped seeing him as well.

Another physio I saw a few years ago was unsure about my lower back and used to push into it with her fingers and say it was tight and a bit higher up it was too flexible when she pushed in. But she wasn't sure why this was but did wonder if it was linked to the nerve pain I was experiencing in my calf. She gave me neural stretches which helped my calf improve.

Just pushing into the lower back does not a lumbar eval make. A full evaluation might include range of motion testing in multiple planes, repetitive motion testing, segmental joint mobility testing, an assessment of alignment (along with sacral and pelvic alignment and dynamic tests), soft tissue assessment, muscle strength, reflex and sensation testing etc. The fact that neural tension stretches helped to reduce your calf pain is further suggestive of a possible nerve impingement in the lumbar spine. From all that you've said in previous posts it just doesn't sound like your lumbar spine has been adequately addressed.

[Roberts]

Hi Iceman,
how do I find a physio who will give me a thorough lumbar evaluation. Do I need a physio who specialises in this to get the best treatment?

All the nhs people I have seen say that my back isn't involved, I have had it mri'd and that is clear so they say its not causing any of my problems including my initial calf problem.
No one has said anything about my back being linked to my knee yet.

I think the feeling I used to get in my buttock, (which was finally sorted by the met stretch to release the spasm in the piriformis) is similar to the feeling I get in my vmo. When I walk the muscle slowly gets more tired and then eventually its too achey/tired to walk on anymore, it kinda gives up. This always leaves me wondering if it is linked to the buttock problem I had, and if it could be as easily sorted as that was.

[IceMan]

Hi Iceman,
how do I find a physio who will give me a thorough lumbar evaluation. Do I need a physio who specialises in this to get the best treatment?

I would look up all the clinics in the phonebook and call and speak to physios to see what kind of experience they have in treating these kind of symptoms. Maybe an internet search would yield some results. What many people don't realize is that within the profession of physio there are many different philosophies of treatment. For example for your symptoms a physio who follows the McKenzie approach may choose an entirely different plan of care than someone who is Maitland trained. That's not to say that one approach is necessarily better than the other. I believe that there may be a number of different ways to treat a particular condition but it is important that the patient is diagnosed correctly.

When calling ask what percentage of the patients they see are lumbar spine patients and the number of years experience the physio has had in treating these conditions.

All the nhs people I have seen say that my back isn't involved, I have had it mri'd and that is clear so they say its not causing any of my problems including my initial calf problem.
No one has said anything about my back being linked to my knee yet.

Forgive my ignorance but is the nhs some sort of government setup in the UK? Anyway a negative MRI does not mean you don't have a lumbar spine problem. An MRI is just one piece of the puzzle. A solid clinical evaluation(ie interview followed by hands on testing) should always be the primary driver in determining the plan of care from a physio perspective.

I think the feeling I used to get in my buttock, (which was finally sorted by the met stretch to release the spasm in the piriformis) is similar to the feeling I get in my vmo. When I walk the muscle slowly gets more tired and then eventually its too achey/tired to walk on anymore, it kinda gives up. This always leaves me wondering if it is linked to the buttock problem I had, and if it could be as easily sorted as that was.

What you're describing could indicate a lumbar radiculopathy ie impingement of a nerve root in the lumbar spine which is causing muscle weakness. If you find someone who can test for this, along with a comprehensive look at your back, pelvis and legs, and then treat you appropriately you may well find some relief.

[Roberts]

Hi
I have found a person who does structural massage and re-alignment therapy they say they identify and correct postural/structural misalignments by deep focussed massage and soft tissue release techniques. They have qualified as a McTimoney chiropractor so this should mean that they know more about the back. Do you think they would be any good? I'm also still looking into another physio.

Oh now I understand why the clamshells hurt my knee! That makes sense

Yarok please could you give me an example of nonresistive in free of pain range of motion exercises, as I'm unsure what you mean by these.

Iceman the nhs is a government set up allowing us to have free health treatment but unless its urgent you have to wait a long time to get it. In fact when I first tore my calf they told me it would take 6 months till I could see a physio, its a bit of a joke!

What you're describing could indicate a lumbar radiculopathy ie impingement of a nerve root in the lumbar spine which is causing muscle weakness. If you find someone who can test for this, along with a comprehensive look at your back, pelvis and legs, and then treat you appropriately you may well find some relief.

Its definitely worth looking into.