Help! My knee problem.

Hi,

The area around an old knee injury has become inflamed and I am resting the knee until the inflammation goes away. However, I would love to be rid of this problem once and for all. The history of the problem is that when I was about 23 (I'm now 31), I damaged my patella retinaculum; I was working as a bicycle courier. One day, whilst working, I felt something give way in my left knee. Thinking it was no big deal I continued riding through the pain for a couple of days not realising the damage that I was doing to myself. I soon realised the damage I had done and stopped cycling soon after. I thought that if I just left the knee alone, it would heal itself.

After a few months, I got back on the bicycle and was soon in a lot of pain with my left knee. It felt like something had given way in my knee again and I realised that whatever the problem was, it had recurred. I went to a physiotherapist and they quickly diagnosed the problem as a torn patella retinaculum. My problem was that the retinaculum had not healed correctly and 'wasn't doing it's job properly'. Instead of acting like a sheet of film covering the whole kneecap and keeping the patella aligned, part of it had torn and it had healed in large clumps around the kneecap area. So, when I used the knee, the scar tissue would grate against the knee itself, thus causing pain. Anyway, the physiotherapist administered some electro therapy that helped to break down the scar tissue - I did this on 2/3 occasions. It was then a very lengthy process of cycling with a knee support and gradually building strength back into the leg. Thankfully the process basically worked but the problem is still there to a lesser degree.

Over the last few years, I have since cycled many thousands of miles. Over time, other knee and joint problems have arisen and I've dealt with them with appropriate stretching exercises. However, this particular problem doesn't seem to want to go away.

My body shape is that I am a bit knock-kneed and my left leg is slightly shorter than my right. So when I walk/cycle, there is extra stress on that inside area of my left knee. (Imagine facing my knee head on - the specific problem area is the bottom left of my kneecap – see photo). The black outline is the patella and the shaded area is the inflamed trouble area where the original injury occurred.

I’m currently applying various leg strengthening exercises to the problem area. However, whilst this might help, I still don’t feel that this will ultimately deal with the issue. Perhaps I might need to have more electro therapy on the area.

Also, might I need to have some surgery done to clear away some of the scar tissue?

Anyway, I’d really appreciate some advice. Thanks.

Hi

Getting the physio to do some mobilisations to your knee cap will help break down scarring. Also doing deep tissue massage around your knee cap and down the outside of your leg along what is called the iliotibial band (your physio will know what this is) you can also stretch this iliotibial band yourself to take some tension out of it. Taping your knee cap will also help reduce symptoms while you work on your strengthening

It is really important to get an appropriate strength program! You need to work on quads strength (thigh), core strength (pelvis and lower back) and butt strength (is the program you are doing addressing all of this???)

If all of these things have been addressed and you are still having problems then I'd look at xrays and MRI scans to see what is going on. If there is something requiring surgery then that may be the next step, however even if you do end up having surgery, your recovery would be a lot faster if you've done a lot of strengthening prior.

Check out my website if you are looking for an exercise program that will address all of this!!

Hello there,

you mentioned that you have a previous problem with the patella retinaculum.

Something that I would be concerned about is the tracking of your patella within the groove. I would theorize that your vastus lateralis is pulling the knee cap laterally while the vastus medialis .
Your problem MAY be a strength imbalance between the vastus lateralis (the lateral sweeping thigh muscle) and the teardrop muscle.

If you just stick to squatting and other bilateral exercises like leg press, hack squat etc., the lateralis muscle on each leg just keeps getting stronger and the medialis keep getting weaker and it will not help your condition. You have to incorporate more peripheral stabilization exercises into your leg program.

This can be corrected rather simply by incorporating unilateral, closed chain, fixed end exercises such as the quarter and half split-squat and lunge. Split squats are like lunges only you stay in the one position (don't move your feet).

Start with a very light barbell. Do not perform full range movements for the first 8 weeks and hold each position for a full 2 seconds on each repetition. Focussing on control and feel. You want to go to the point before the perceived onset of pain, and not get into the range of pain or stiffness (if present).

Coordinate this with you real life physio and see if it helps, slow and steady wins the race.

Hi, thanks for the responses.

Canuck, I presume you meant to finish your sentence with something like, "while the vastus medialis is not pulling the patella enough in the opposite direction"

I would agree with this because it seems to make most sense.

I would theorize that the reason for the imbalance is because the retinaculum is not sufficiently connecting all muscles over the patella.

I'll apply the tape so that it pulls the kneecap towards the area where the vastus medialis joins on to the patella.

So yes, I'll incorporate the suggested exercises. Thanks very much.

Quote:

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Originally Posted by flashingswords

Hi, thanks for the responses.

Canuck, I presume you meant to finish your sentence with something like, "while the vastus medialis is not pulling the patella enough in the opposite direction"

I would agree with this because it seems to make most sense.

I would theorize that the reason for the imbalance is because the retinaculum is not sufficiently connecting all muscles over the patella.

I'll apply the tape so that it pulls the kneecap towards the area where the vastus medialis joins on to the patella.

So yes, I'll incorporate the suggested exercises. Thanks very much.

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Hello,

Yes, sorry about that, that is basically what I meant. The idea is if you have been attempting to strengthening your quads you may be have been contributing strength imbalance. Thus, it may be beneficial to train the VMO (vastus medialis oblique), to regain that 'pull'.

I like the tape idea, because it may allow you to temporarily facilitate re-alignment of the patella within the patellar groove. I am assuming you already have experience with and are proficient at doing this yourself.

Hope it helps

I don't have actual experience of taping. However, it seems obvious to me that I'd have to tape the patella in such a way that 'persuades' the vastus medialis obliquus muscle onto it. That's why I said earlier 'tape the patella in the direction of the muscle'. See photo.

Hi there. I've been following a set of exercises that address the problem area for several weeks. I'm now able to cycle again (quite hard albeit with a knee support).

However, when I massage the problem area(see photo), it is still tender and sensitive. This therefore prompts me to conclude that the problem is a combination of scar tissue on the retinaculum and incorrect repair of the retinaculum, which when rubbing on the kneecap can cause inflammation.

I can't know this for sure but am reasonably confident this is the problem. Will this require surgery?

It's just that if the scar tissue needs to be broken down, I'm not confident that I will be able to do this of my own accord.

I think your original diagnosis was perhaps a little off. One would not really tear the patella retinaculum especially on the medial side when falling off a bike unless they also damaged some other structures.

I would think and MRI and an arthroscope are in order to take a look and have a general cleanup inside.
p.s. If taping is to be effective you must be able to demonstrate that on application of the tap that the pain is immediately reduced or removed. The way you image shows the tape being applied is not the correct way to tape to facilitate VMO activity if indeed you even require it.

Hi again. Since Dec I've continued to do all the strengthening exercises and I've definitely noticed a small difference. Perhaps what I've noticed most of all is the imbalance between the legs - the left leg being weaker than the right. (This is not hugely surprising given that the left leg is slightly shorter than the right, and that I am right handed - so I naturally distribute more weight to my right side)

I've started to massage the iliotibitial band and noticed that there is quite a lot of tenderness at the lower part of the vastus lateralis muscle. I was a bit surprised at this as I thought this muscle was overstrengthened and that this was the cause of the original problem (pulling the kneecap too much to the outside). Nonetheless, I suppose this weakness of the lower vastus lateralis contributes to the overall problem of the incorrect tracking of the kneecap.

Quote:

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Originally Posted by flashingswords

Hi again. Since Dec I've continued to do all the strengthening exercises and I've definitely noticed a small difference. Perhaps what I've noticed most of all is the imbalance between the legs - the left leg being weaker than the right. (This is not hugely surprising given that the left leg is slightly shorter than the right, and that I am right handed - so I naturally distribute more weight to my right side)

I've started to massage the iliotibitial band and noticed that there is quite a lot of tenderness at the lower part of the vastus lateralis muscle. I was a bit surprised at this as I thought this muscle was overstrengthened and that this was the cause of the original problem (pulling the kneecap too much to the outside). Nonetheless, I suppose this weakness of the lower vastus lateralis contributes to the overall problem of the incorrect tracking of the kneecap.

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Hello Flashingwords,

Hopefully you will continue to improve. This is a long term problem that you have had, and it is nice to know that at least you are heading in a positive direction.

In terms of the weakness in the left leg, it is natural that we have a weaker side. The key is working that weaker side up by challenging to improve to the stronger side. As opposed to working the weaker side, and making the stronger side settle. The number one factor of course being safety and quality of movement.

Please if you could list what your current routine is to give everyone an idea of what exactly your doing.

For example:

Wake
- Massage
Morning
- Cycling warm up
- Dynamic Stretching
- Resistance Training
Lunch
- Afternoon Cardio
Evening
- Static Stetching and massage

And additional therapies such as Ice/Heat, Electro, or what have you.

Hopefully, you are also continuing with your regular Physiotherapy treatment? The advice given on this forum is very limited, even with pictures and such, because there is so much wanting to be revealed through soft tissue massage, postural observation, amongst other assessments.

All the best.

Additionally I forgot to mention, is there any further asymmetry between the left and right side in terms of strength, flexibility, functional or dynamic strength/mobility?

I recently went to see a specialist about my knee.

I explained the full history to him (see above).

He diagnosed the problem as being 'jumper's knee' and that the problem was the patella tendon. He prescribed physiotherapy. I pressed him about the diagnosis and he seemed certain that the problem was the patella tendon. I suppose it explains the inflammation...tendons get tendinitis, right?

However, this seemed to ignore the retinaculum issue. I mean if the retinaculum is still incorrectly healed, then it could always tear again leaving me back at square one.

Also see if there is pronation of foot that is turning in of foot which could cause internal rotation of knee adding to the tendinitis.i feel that properly designed knee strap could be helpful to protect the knee and continue stretching and strengthening muscles around the knee.

I went out for a ride recently. I always wear a knee support on the affected knee.

I went really hard to order to induce the knee pain. There was a strong reaction along the side of the knee cap and where the vastus medialis attaches to the kneecap. If you look at my attached photo below, just imagine the knee joint moving on the bicycle and how the highlighted area would move along the side of the knee cap. That's where I felt the pain. The sensation was that there was load of tissue in there that was all messed up; it felt like scar tissue. This was my original diagnosis and so I'm certain that the specialist who recently saw my knee was wrong in his diagnosis of 'jumper's knee'.

On the plus side, I was able to put my knee through that and it was still strong enough to keep going without too much adverse reaction. However, obviously it's something I'd like to correct.