Knee injury caused by impact still not fully healed after nearly 8 months

Hi, new to the forums. I'll give the full story.



I'm 23 and live in the UK. I do wall climbing, and started back on the wall after a month-long break. A new route had been set out and I tried besting it by raising my leg violently to get my foot on a high foot hold and... I kneed a bolt hole full whack with my right knee. I struck the kneecap about 7mm from the left edge of the kneecap.

For reference, a bolt hole looks like this:



http://www.dpmclimbing.com/sites/def...top%20bolt.png



The vertical piece of metal is what I kneed. I couldn't have kneed it any harder if I tried. It hurt.



I tried to continue climbing but quickly realised it would be too swollen and got down. I had to quit and limped home.

Here is a picture I found of my knee about 20 minutes after I did it:



Imgur: The most awesome images on the Internet



3 or 4 days after the initial impact, and it was clear I'd done some real damage. I was still limping and driving was very painful (holding my foot in the same position over the accelerator became so unbearable I had to pull over and take breaks every 20 minutes or so)



Essentially I thought it would be healed within a few weeks. I stayed off it but couldn't resist a climbing trip I'd previously planned. This made it worse.



I went to the doctors and she said it was likely ligament damage - possibly the medial meniscus one? She was just a GP though - she recommended the RICE routine I was already doing and left me to it.



I visited a physio but all he did was try and induce the pain, fail (as it was 99% healed at this stage), and rub ice then ultrasound it. I don't know what more he could have done.



A couple of months later, in January, I felt brave enough to try and climb again. Everything went fine, I experienced no pain while climbing at all. But then when I woke up the next day, my knee would be stiff and in pain, like it was in the first few weeks after I injured it. After 4 or 5 climbing sessions it was clear it was degrading so I stopped again.



What's been frustrating is during this entire period, it has been 99% healed, but any running, hard cycling, climbing, or certain other activities have degraded it again.



Last month I became determined to fix this once and for all. I went to the doctor again, who recommended I SLOWLY get back into exercise. So I've been doing just that, slowly been doing exercises...



Problem is this: what exercises should I do?



So far I've been doing controlled squats, without weight, and hoped to join a gym next week to start building it back up again. I've also bought some ankle weights so I can do some one-legged leg extensions while sitting on a chair, swinging my leg out in front of me. Is this a bad exercise? I've also been told to cycle but it's been raining a lot here so I've only got out a couple of time on the bike.



My job involves sitting at a desk all day and my commute is 1 hour long by car. I no longer experience pain when driving, or even tightness, so it has been healing, just not fully.



But last weekend I played squash, and ultimately ran around a lot and ended up kneeling to pick something up from under a sofa... one of these activities has degraded it again. I feel like one mistake and I'm back to that all familiar tightness in the joint and it's really frustrating. Should I fight through this?



The state of play currently is this: there's nothing I can't do on it (except kneeling flat, which hurts my leg muscles in both legs and causes pain afterwards). Nothing causes pain during or immediately after (except kneeling), but then some time later, usually the next day, it will be tight or stiff or painful. It usually subsides again but it accumulates



My questions are:



1) What exercises should I be doing?

2) Are there any recommended supplements I should be taking?

3) When I feel this tightness after putting my knee through its paces (I can't avoid running etc. forever), should I fight through it and continue my exercise regime?

4) Why hasn't it healed in EIGHT MONTHS?? I know I've done some one-off activities that could degrade it but they've been few and far between, with weeks of healing time in between

5) Should I keep doing Rest, Ice, Compression, Elevate? How often, which ones, and for how long?

6) How much longer should I expect this to take to heal?

7) Should I visit a new physio?

8) What if I get a real injury at some point in my life - will I never recover??



This is really getting to me now as I really miss climbing and just want to get back to normal. it's now summer again and people are inviting me mountain biking and running and stuff and I can't go because I know they cause my knee to flare up.



Feel free to ask any questions, sorry for how long this is but I wanted to cover everything.

Hi Kneebola - wow, great history - so much detail. I am sorry to hear that your recovery has been so prolonged and restrictive. I would recommend that you find a good sports physio that does more than rice and ultrasound. It sounds like you have a soft tissue injury that is obviously easily aggravated and there is some inflammation/swelling that cause it to stiffen with minimal aggravation. Meniscal injuries often swell easily. Bony injuries are often tender for a long time after the injury. You could see a specialist who will run a load of tests, then probably refer you to a good physio. Ultimately, this injury is still probably going to take some time to resolve - 8 months is a long time, but I've had injuries that take 12-18 months to settle down (knee, wrist ... but I am an old gal). I don't know that when you do activities that you are making it worse (ie more damage). My advice again - find a 'good' physio (one who knows knees and soft tissue and sports rehab), and slowly return to your activities, and continue with gym exercises. The good physio should help you return to your activities - and know where to refer you if you don't make an expected recovery. You are 23 and have an awful lot of living (and recreation) to get on with - I hope that this injury does not slow you down for much longer. All the best!

You must be so frustrated by all this!
My immediate reaction is that you don't really have a solid diagnosis re the original injury and after 8 months there has to be an element of chronic pain here, where at least some of the pain is being generated by your nervous system itself.
To deal with the first issue of diagnosis: I would suggest that what you did was to smack the knee cap into the bone of the joint surfaces behind. (No brainer from your photos and description!)That would give you a classic periostitis which is characterised by an "exquisite" pain - not an ache or a stabbing, but really a pain like no other! This would be on the assumption that you didn't crack the bone of the kneecap. Good way to do it is to whack the knee really hard or fall on it directly! It maybe worth getting an X ray to rule out a fracture, but also to see if there is any calcification under the periosteum (membrane covering the bone and very well supplied with blood and nerves!) If you didn't fracture, then you can get the situation where there is swelling under the periosteum, which in turn can turn into bone - this would show on a plain X ray.
I would expect the physio would have found any ligament damage etc with a full clinical exam. If not then you wouldn't be able to do half of what you are doing with ligament, meniscal damage etc. So I would rule those possibilities out.

The ongoing pain appears to be the real problem and this is either because of damage etc to the periosteum and/or the chronic pain. Simply, pain does not come from damaged tissues. Messages are sent to the brain that something is wrong and the brain decides what to do about it. In the first instance, it will give you pain as a warning that damage has occurred and to make you look after it! Interestingly, if there was a marked danger to you, as a whole, at the time of the injury, that you may fall off the wall because of the pain, then you wouldn't feel anything at that moment. Only when you are in a safe situation will the brain allow you some pain!
The problem is that the pain can persist even after the original injury has long since left the building! It has become almost a learned response. Your brain has learnt that putting the leg under load, or putting pressure on the front of the leg etc etc previously caused trouble. Even though everything is now OK the nervous system has become "nervous" about you getting back to full fitness and activities - so you still feel pain!

As to treatment: If there was no fracture and the periosteum is ok then I would treat the back of the kneecap with Interferential Therapy to make sure that there is no persistent, underlying inflammation. I would still do the same, but different frequencies if there was a fracture/peristeal problem. That gets the "passive" treatment sorted and after 35 years of working with IFT, I can tell you it works!
My personal maxim is "Heat on the body and ice in my gin". It is far too late for ice etc. Get a simple wheatbag if you need to.
The pain issue can be dealt with by thinking along the lines of - I have had an X ray and there is no longer any damage in my knee. Therefore, what I need to do is retrain my nervous, nervous system to realise that pain does not equal harm. ie hundreds of painfree movements in sitting and/or standing. I don't care how you move your knee as long as it is PAINFREE. Range doesn't matter - just get it moving. Don't go and do weights and heavily loaded exercise until you have complete full range, painfree movement. Then gradually increase the loading until you get full fitness back. The old adage of "do 80% of what you think you can do" works well here.
I have had patients in a far worse situation than yours and they recovered fully in a few weeks - BUT you need to get your head in the right place and I would suggest an X ray will allow you to do this by putting your last fears away.
Hope this rather lengthy reply helps, but you should and can be better!