Baffling 8 month Grade 2 MCL sprain

About 8 months ago I suffered a grade 2 sprain of my MCL in my left knee, which has since been confirmed with an MRI scan, along with some minor fissuring of the patella. On the night of the injury, although in some pain, I was still able to play football, and it wasn´t until I was on the train home and then in bed that night that it really started to get painful. It didn´t swell up massively, but I became virtually unable to move it and could not sleep that night because of the pain.

At that point I got it x-rayed, but nothing showed up and over the coming 6 weeks or so I could feel improvement on it every day. After about 2 months I started playing the odd game of 5 a side football again as it was my weak leg which was injured so I could avoid using it and I only got a few twinges in it when I jogged about which weren´t too painful and when I had sprained my ankle ligaments I had been able to do this and it had not really affected it´s recovery. Over the next 3 months though, progress slowed to a stop, so about 5 months after the injury I eventually went to see a physio to see what was wrong.

At this point, in addition to playing football once a week I was walking about 45 minutes to work and back each day, which would be fine, but would make it ache a bit by the end. I was also still feeling twinges of pain whenever I went out at weekends and danced as drinking alcohol meant that I stopped being careful with it. For the rest of the time it didn´t really affect my daily life too much, but I could feel it almost all the time with a very mild pain. The physio told me that the lack of recovery was probably because when I walked my feet rolled in, putting extra strain on that ligament. This was also apparently associated with having a poor posture, with over developed hip flexors and very tight quads, which possibly had something to do with weight distribution.

I started doing exercises to correct this, along with stopping playing football, and a week later on my next visit to the physio she performed cross friction massage to the ligament as well. The following day after the massage I felt some improvement, and as I also became able to be careful with the knee when I went out, this improvement continued for another 6 weeks or so until I wasn´t really feeling it at all for hours at a time. I even played football again, in a tournament, and although I felt a bit of pain in it between games I was passing the ball with my left foot with no pain and the next day it didn´t feel any worse.

A week later though I left to go traveling around South America for 9 months and on my first weekend in Chile, I guess as I had grown complacent, I made it worse again. I am not sure how I did this as I couldn´t remember feeling twinges in it how I used to do, but on the Sunday morning I felt like it had been put back about a month or so. Now, after another 2 months it is still not back to how it was. I have been very careful at all points and haven´t played any football or done any running so I am really confused.

In addition to this it feels different to how it did before, in that now I feel it mostly when I am sat down for more than 10 minutes or so, when it begins to ache. If I keep my feet up then it feels better, but obviously this is not always possible, and I have had a few days where I barely walk on it at all and it still didn´t feel any better afterwards. I also saw a physio in Santiago Chile a few times who gave it ultrasound and electotherapy (possibly called something different – pads were attached to my knee and electricity pulsed through it), but it didn´t really have any effect. To make things even more confusing, 2 weeks ago I went on a 5 day trek on uneven ground up and down mountains with a heavy back pack on, walking for about 8 hours a day, and my knee felt absolutely fine! Even when we did stop to sit down it felt fine and I basically felt almost nothing from it the whole 5 days, but when I got back, within about 5 days it had gotten back to almost as bad as it had been before.

Athough there was some small improvement this was mostly been wiped out a few days ago either through having an overnight bus ride (so was unable to fully recline – lying down in bed is the only time that I can never feel it) or through trying for a couple of minutes to massage the ligament myself as this was the only thing that seems to have worked so far. I really don´t know what I should be doing anyway and can´t discuss it with anyone out here as it is fairly complicated and my Spanish is not that strong.

I am also a bit reluctant as performing assessments on it in the past has often made it feel worse. So to sum up, at the moment I can walk around and only feel it a little bit after a while (on the first day of my long walk I felt this same mild pain after a while and then it went sometime later), but when I sit down it starts to ache after about 10 minutes. This can sometimes be alleviated by extending my leg, but not always.

If anyone has any advice on what might be wrong and what I should be doing to help it or what I may be doing already to stop it getting better, or any thoughts on whether it may need an operation and if so whether I might be able to get on a waiting list while I am out here, I would massively appreciate it.

I don´t mind paying for this time either, or calling someone up from out here, I am just desperate to have it sorted as worrying about it is seriously affecting my trip.

Thanks a lot. Sam

Hope your having an awesome time in south america regardless. I'v got a physio buddy trekking around there right now - it's a shame he's going back to manchester in a few days cause I think he's not far from santiago.
Anyway - MCL strains shouldn't hurt in sitting... the ligament isn't under load so it should be feeling good. it may hurt because it's inflammed from chronic loading due to your overpronated feet - you never got orthotics to help with that did you? that may have been what it needed to prevent you from stressing the ligament while playing sport... I'm wondering wether you perhaps have a meniscal injury because of your knees ability to be fine with walking long distances and then worse after being in sustained flexion. - these usually will appear on MRI, though if it's quite minor then maybe not. Electrotherapies won't do much for it - avoid physios who will use that as their primary treatment. It's quite possible that both the meniscus and MCL are damanged.
I'd suggest taking it easy and waiting till you can see a good physio? maybe get someone to tape your arch of your foot to help with the pronation to help reduce the stress going through it. You are unlikely to hurt yourself more unless you have a traumatic injury or go for some massive hikes without good shoes to support the arch.
Good luck - hopefully someone else will have some other ideas also

Just wanted to say a big thank you to pudding bowl for taking the time to reply to my message. (I wasn`t really expecting any replies so haven`t checked for ages) I`m still having problems with my knee, but there has been some very gradual improvement. I think one of the big problems may have been that I let my quads in my left leg diminish somewhat so I am trying to exercise them every day now, and otherwise just waiting it out till I get back in June. Any suggestions for whether it`s worth trying to get on any waiting lists for an operation/another MRI etc?

Hi Sam, just read your post. MCL's are painful and they remain painful for a long time. It was funny but reading it I was thinking all this guys needs is some frictions to the ligament and low and behold that was a treatment that worked. From you recent observations the knee gets into trouble when sitting for long periods. This is in around the 90 degree flexion mark which is also specific to the medial meniscus at that range. The ligament itself communicated with the meniscus and different fibers of the MCL are under different amounts of tension depending on the position of the knee. This is a way that the brain helps us to understand joint position without having to look at where our limbs are all the time. Anyway the point being that the position of the knee is different in sitting to that when walking.

Yes I agree with pronation contributing to issues here but you were OK prior to your injury so let's not over analyze that. Orthotics are always useful in part. Connective tissue, especially degenerate tissue, does not like being help in the one place for a long period of time. Doing so leads to pain e.g. bend the finger back and hold it for a few seconds and it doesn't hurt. Hold it there for 5-10mins and it become really painful. I would get someone to assess the medial joint line to see if in fact the meniscus is irritated and if so it can be frictioned as well. They I would friction the MCL in the position in which you get the pain.

It's unlikely you'll need an op as I see dozens of presentations like yours every year and less than 1% need investigative surgery. Best of luck :)

agree with the above. friction in painful position. medial ligament also has a role in checking lateral rotation at the knee in 90 degrees knee flexion. I'd try some specific soft tissue mobilisation a la glenn hunter into lateral rotation at the knee in a flexed position, see what the response from this is, ie is it pain provocative, does it respond to some grade 3's into same.

Thanks again for the replies to my problem. Posting the thread in the first place was such a stab in the dark - I thought the main benefit of it would be some sort of release from writing it down. Not sure where I really am now as things are different depending on what I do each day, but I still think there is a gradual gradual improvement. I am focussing for the time being on developing my left quad, although any suggestions for new excercises that can be done on my own (I do have one of those blue elastic strap things) would be greatly appreciated. The most frustrating thing is just not being able to see a decent physio. I`ve been to see different people in Chile and Brazil, but no one seems to have a clue about frictioning. Anyone fluent Spanish speakers out there who might be able to give a description? They all just want to do the electrotherapies that I`ve been warned against and ultrasound, which I was told back in England also wasn`t effective. I`ll be in Lima in a week or so though so might have another crack then. When I get back I think I`ll make our like I`ve been travelling the world for a cure.

Oh yeah, just in reply to one of the things mentioned so far, I did get some orthotics before I went away and I`ve been wearing them all the time. Not sure if they really help or not, as I think I need a higher arch. As I understand it, most people who need orthotics have flat feet, but my feet aren`t flat, they just roll in. When I walk around now I tend to lift up the big toe on my left foot as I bring my foot down as I know from looking in the mirror that this stops it rolling in, but I don`t know if this might somehow be giving myself different problems.

I had no idea knees could be this complicated. Thanks again anyway, I really mean it.

Does anyone know if cross friction massage or deep tissue massage or whatever you want to call it is practiced in South or Central America? Just thinking about having another crack at finding a physio in either Quito or Bogota. Any suggestions appreciated

....don't suppose you'd consider your saphenous nerve. Sounds most unlike a pure MCL issue

SP

Saphenous nerve? That`s the first time I`ve heard of it. If it is damage to that, is it serious? Is there anything I can do in the 10 weeks (and counting) before I get home, and when I do get home is it just a physio I should see, or do you get specialists in this type of thing? Thanks for your suggestion anyway.

Now 7 weeks until I get back, I have just had a conversation with another person with knee problems which has worried me quite a lot. He said that after injuring his knee playing football, he had to wait 6 months for an operation and in that time the damage to the "shock absorbers" - he was Swedish, so we struggled to translate technical terms - got much worse and now, despite having had 2 operations on it and some sort of "tendon" removed from his thigh to help, it will never fully recover. I know all cases are different, but it was the similarity with getting pain after sitting down for long periods which concerned me most. This started happening with me when I first came away travelling 7 months ago and though it improved gradually, and in the end fairly substantially over the next 5 months or so there has been no real change over the last 2 months and it is still giving me some discomfort. I can only ask again, what can I do????? Or just as importantly, what shouldn`t I do/what might have I been doing that might have stopped it recovering or made it worse???? This has had such a massive effect on being away, I now can`t wait to get home just so I can get some proper answers, in a language I understand, and if necessary get on a waiting list for another MRI scan/operation. Any thoughts anyone might have would be massively appreciated.

Sam
Additional Comment I forgot:
Likewise any physio recommendations in California. Will be getting there in 3 weeks for the final leg of my trip.

Hi Sam, I'm pleased to have come across your thread as I have symptoms very similar to your own, so know that it's not just me.

Just to give you a brief history, I sprained my MCL rather badly around 1999/2000 over-training at squash. After seeing several physios not one of them ever cleared it up. Eventually, after a year or so it appeared to just sort itself out.

Now I'm 41 yrs and still playing squash at a high level. Since May 2009 I have had trouble with the MCL again on my left knee. This came on gradually whilst training last summer including on court work and running. I have seen two physios and have not helped my case I continued to play squash throughout the season until March this year. I found that I could play squash fine, once the MCL was warmed up there was no discomfort. I paid for it the next day though. I too would get the pain when having been sat for a while and then straightening the leg.

From March I have been working with the physio to rehabilate the knee by building up the muscles, which I was shown had somehow retarded. She also showed me how much movement there was in the knee due to the lack of muscle, this was causing the repeated strain of the MCL as the knee wobbled about when it shouldn't.

I can send you a list of strengthening exercises if you wish, that I can certainly say have improved my muscles considerably. I also had tight quads and with daily stretching this appears to have eased the condition as well.

I am still unable to run without aggrevating it and have recently done just that meaning that I'm having another short lay off. I will be doing some friction on it myself following the other recommendations, as I have in the past, just copying the physio. I have my own ultrasound machine and can confirm that this does not appear to help.

Coincidentally, or maybe not, I too pronate inwards and recently went to a podiatrist who recommended some slight orthotics to help but I'm still waiting for these. I requested a visit to one because I don't feel that I am walking on my left leg correctly compared to my right leg and have a little pain in my big toe. Perhaps this is why it still isn't sorted.

I hope this info is of some assistance, at least you know that you're not alone.

All the best, Mark

Thanks for that one mate. I've now been back in England for 2 and a half months now so have been seeing physios and have had another MRI which just showed there to be thickening of the ligament consistent with a chronic MCL sprain.

There has definitely been some improvement, and I'm doing strengthening exercises for the quads twice a day, cycling 8 miles a day and stretching hamstrings, calfves and quads daily too so I'm hopeful, but progress is still ridiculously slow.

I was recommended to start doing some running and other things to help get me back playing some sport, but when I attended an hour's returning to sport physio session I was set back a full week and a half, even though I didn't really feel any pain at the time. I even tried taking it even slower, starting off with 3 minutes of running/changing direction a lot which was fine, then upped it to 5 minutes the day before yesterday and yet that time it made it sore again (not as bad as after the hour session) and I'm still having more aching today than I did before the running.

The knee doesn't feel weak at all, and I'm told there's not a lot of laxity or whatever, but I can't understand why it still aches after sitting down for medium-long periods. I've found that when I do the 'wall sit' exercise it stops the pain for a bit, but the aching gets more annoying as the day goes on whatever I'm doing.

It's not really painful, but I'm just so desperate to get back to playing football it's killing me. The physio said it shouldn't be too much longer but I'm worried that the MRI missed something as sometimes when I do the wall sit exercise my knee cap hurts and today I've had some pain under the knee cap on the same side as the MCL, potentially in the miniscus area, when I walk which I can agitate a bit further by pushing/rubbing it hard. (Incidentally, to complete the picture, the aching I get when I sit down is just a general aching across the whole knee whereas when I get the odd twinge from stretching slightly awkwardly or when I tried a standing stretch for my hip flexors it's in the region of the MCL)

What's going on?!?!?!??!?! Should I avoid doing any running etc or is my physio right that this aching for days afterwards is helping it get stronger afterwards? Is it likely other things could be going on with my knee aside from the MCL and if so how can i get someone to believe me when it wasn't picked up on the MRI?

Any advice is greatly received, and yet again thank you for everyone who's taken the time to give me their advice so far.

Sam

Hey i put up thread yeasterday looking for info very similar to your complaint except mine is my ACl.
i have problems standing- which would make sense as its the opposite ligament to your injury.
I've got an MRI and the reckon its a grade 1 acl tear with a slight thickening.
I really feel i need an Arthroscopy as the pain i get is like someone throwing a doorstop into it.
We have a similar health system to Britain here in ireland- its called the HSE but its not as good as the NHS.
I've a consulatiion next month and i'm going to beg for a scope as that should find what the proplem is. Apparantly if its only a Partial Tear of a ligament it should only be tender for 5-6 months at then depending on the thickness left your knee shoudl be pretty good. Mine still aches & months later. I feel your pain though- it would drive you crazy!!!!!!!

:mad:

If your MCL merely aches in the same way that your muscles would after hard exercise then they're probably right. If it hurts though it's probably the body's way of telling you to stop doing what's causing it.

I'm now seeing a sports therapist that has worked with Sheff Utd football club & Sheff Eagles rugby club so she's seen this type of injury plenty of times.

My own MCL gets set back when I do any running, either treadmill or road. She's has told me not to do any running at all until it's 100% better. I am doing all of the things that you are doing and I do feel that I'm progressing but you're right it is slow and with patience it will get better so long as you don't aggravate it. That has been my problem, lack of patience and trying to get back to normal activities too quickly.

Good luck, Mark

Thanks a lot for that Mark. It's strange how much it can help just having contact with someone who'd going through the same thing. I don't talk about it to anyone really as I don't think they can really understand and I don't want to be complaining when I can still function well enough day to day but it does have such a big effect on my life. I think the lack of improvement is the hardest thing because it just means I'm ALWAYS worrying about what's going to happen, and if I wake up in a morning and it feels worse or the same as the day before I'm in such a foul mood pretty much all day.

Had a physio appointment this afternoon anyway where he tried some lazer thing on it which was new to me, but which I'm not holding out much hope for, so he's going to give me 3 more goes at that before then giving me my chance to convince a consultant to have a look inside, which might be difficult as nothing turned up on the MRI.

I've got 2 more weeks till my next appointment though now so till then I'm going to not do any running or anything whatsoever, stop doing the wall sits as they seemed to be giving me discomfort and hope with everything I've got that at some point I get the same small but day by day improvement I was getting a couple of weeks ago and then that it keeps on improving without the running etc to make it worse. I'll still be doing cycling every day and stretches for quads, hamstrings, calves and hip flexors, but if anyone else has any ideas whatsoever I'll listen to anything.

Hi sammo440 - just come across your post...

I was thinking saphenous nerve as well...i have helped a lot of chronic knee pain with a good L/S, hip and knee assessment.

Saphenous nerve (see here for a nice pic...http://www.karate.butsu.net/anatomy/827.gif) runs down the inside of the leg and very near the MCL with branches to the infrapatella area as well.

Feel between your VMO and adductors - is it more tender than the other side? If so, just try to massage it there and then see how your knee pain goes.

Also, don't forget to check your whole lower back.

See how you go...cheers.

Thanks for that. I'm having trouble finding the join between them, maybe as I had never heard of either muscle before you just said them. So the VMO is the muscle right above the knee on the inner side that bulges out a bit right? If so, where is the join between that and the adductor? I know I still have tenderness right on the jointline on the MCL because that's where the physio does frictions on it.
Additional Comment I forgot:
Ok, to satisfy overwhelming demand, or if no one believes that then just to give me something more productive to do than just mindless worrying, I've done a chronology of my injury from day 1 to now. It was supposed to make everything more simple but it's so long it might do the opposite. Any questions let me know. Enjoy!

<link rel="File-List" href="file:///C:%5CDOCUME%7E1%5CKATHER%7E1%5CLOCALS%7E1%5CTemp%5 Cmsohtml1%5C01%5Cclip_filelist.xml"><o:smarttagtyp e namespaceuri="urn:schemas-microsoft-com<img src=" http:="" www.physiobob.com="" forum="" images="" smilies="" redface.gif="" border="0" alt="" title="Embarrassment" smilieid="2" class="inlineimg"></o:smarttagtype> March 2009<o></o>
<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- Fell down in gap between train and platform, with right leg remaining on platform and left in the gap. Severe bang, but unsure with shock whether any twisting was involved. Felt sore and it didn’t just feel like a normal bang, but was able to play some part in football game I was on my way to. Put ice on immediately after getting home as could feel it begin to seize up.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->Woke up in night due to excruciating pain in knee, and any movement of the leg whatsoever from its nearly straight position was nearly impossible.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->Pain still very severe in the morning, but knee not that swollen.<o>:p></o>:p>
<!--[if !supportLists]-->· <!--[endif]-->Went to hospital next day for x-ray and was told that nothing was broken.<o></o>
<o></o>
March – April 2009<o></o>
<o></o>
<!--[if !supportLists]-->· - <!--[endif]-->Improvements felt day by day and after approximately 6 weeks I started playing occasional games of football. I did not feel any weakness in it, but felt regular sharp twinges of pain on inner side of knee and was careful not to kick or tackle with that leg. Knee would always ache more the day after a game, but none of the pain was sufficient in itself to make me not want to do it.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- Twinges would be felt a lot more when playing on uneven surfaces (i.e. grass rather than astro turf) so I only played once on that surface.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->Twinges would also be felt if I went out and drank as I would cease to be careful with it, especially when dancing.<o></o>
<o></o>
April – July 2009<o></o>
<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- Day by day improvement lasted about 8 weeks after the injury, then promptly stopped at a point where, as long as I was careful, I was able to play football without too much pain once a week (I used to play 4 times a week). I felt pain otherwise mostly when walking to work which I did each day (45 mins each way) and a few hours afterwards, then at a constant low level the rest of the time.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- After approximately 4 weeks of this I saw a physio who thought it was a MCL sprain but said it would be fully better after a couple more weeks. <o></o>
<!--[if !supportLists]-->· - I still did not feel any improvement however, and at the end of July saw a different physio. She agreed that it was an MCL sprain but thought the reason it wasn’t getting better was because of problems with my posture. She said that my knees and feet rolled in when I walked (but that I didn’t have flat feet) and there was too big a curvature in my back and so this put pressure on the damaged ligament stopping it healing. On my 2^nd appointment with her she performed cross-friction massage on it and for the first time in over 2 months I felt very small, but recognisable day by day improvement from the next day onwards.
<!--[if !supportLists]-->· <!--[endif]-->- By this point I had stopped playing football and only felt the associated twinges on the infrequent occasions that I got drunk and forgot about it.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- At this time I got orthotics for my shoes, and did a lot of work focussing on my posture and walking correctly.<o></o>
<o></o>
August – September 2009<o></o>
<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- An MRI scan at the beginning of August confirmed there was a recovering grade 2 MCL sprain with minor patella fissuring.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- Improvement continued with 2 more sessions of frictions to a point where I felt confident to return to playing football. I played in 2 games in mid-September where I felt some aching towards the end of the games, but had no adverse reaction later or the next day. <o></o>
<o></o>
Mid-September 2009<o></o>
<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- In the middle of September I went away to begin 9 months travelling around <st1>South America</st1>. Despite it feeling ok on the flight over I felt some pain in the 2 hour car journey after arrival where we were very cramped in. That night we went out to celebrate and I got very drunk. Although I danced I cannot remember doing anything specific to damage it but the next morning it ached significantly more. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- This aching did not go away and I remember thinking at the time with the associated pain it had set me back about a month. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- I tried to rest it as frequently as I could but in contrast with before this incident whenever I sat down normally the knee in general started to ache significantly and would increase the longer I was sat down. This was alleviated when I kept it up, but would only delay the aching somewhat.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- It was still (and has always been since the early stages) painless when I lay down in bed however.
<!--[if !supportLists]-->· <!--[endif]-->- I would also still get pain when walking around for any long periods.<o></o>
<!--[if !supportLists]-->· - <!--[endif]-->At this time I saw a physio in <st1></st1><st1><st1:city>Santiago</st1:city>, <st1:country-region>Chile</st1:country-region></st1> several times who used ultra-sound on it, but this had no effect.<o></o>
<o></o>
November 2009<o></o>
<o></o>
<!--[if !supportLists]-->· - <!--[endif]-->There was no improvement with this for approximately 6 weeks until I went to a national park on a 5 day walk. After some initial mild pain on the first day, this cleared and I hardly felt any problems with it at all despite walking on uneven ground for between 6 and 10 hours a day, even when I sat down at the end of the day (although I still kept my leg up).<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- Very soon after coming back from the national park however the pain returned to almost its previous level.<o></o>
<o></o>
November 2009 – May 2010<o></o>
<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- Problems remained the same, but improved very slightly, in such small increments that I was only able to judge that they had improved when I looked back as each month passed. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->I would have good days and bad days, but in approximately March, for the first time since September, I had some days where I was able to walk around and might be able to go half an hour without even feeling a slight injury. The ability to do this came and went over the following months, although I was never able to match improvements or deteriorations with what I was doing at the time. After sitting down for any period of time I would always feel it for a while after. <o></o>
<!--[if !supportLists]-->· - <!--[endif]-->Throughout this time I did not play football, do any running or do anything at any time which I could point to as being something I could avoid in future.
<!--[if !supportLists]-->· <!--[endif]-->- By the end of this I could sit in seats where my thighs were fully supported, with knees at right angles and feet resting gently on the floor for some time before the aching returned.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- This aching could be described as being similar to stiffness like sleeping overnight in an incredibly uncomfortable position, and even though this ceased when I stood up etc it would return immediately if I sat down again soon after. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- In addition to this I would still feel twinges in the inside of my knee with certain irregular movements of my body and legs, especially if I was kneeling down or on an uneven surface like a bed.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- In swimming pools I gently tried breast stroke occasionally and by the end could do it without pain for a short period if I didn’t kick strongly. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- I saw physios in<st1:country-region><st1>Colombia</st1></st1:country-region>, <st1:country-region><st1>Brazil</st1></st1:country-region> and <st1:country-region><st1>Mexico</st1></st1:country-region>, but all were equally ineffective.<o></o>
<o></o>
June – August 2010<o>

</o> <!--[if !supportLists]-->· - <!--[endif]-->Immediately on returning from <st1>South America</st1> I saw a doctor and got referred to a physio and another MRI scan. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- The 2^nd MRI scan showed thickening in the ligament consistent with a chronic grade 2 tear but nothing else. <o></o>
<!--[if !supportLists]-->· - <!--[endif]-->Physios performed friction massage on it and I started doing daily stretches on quads, calves, hamstrings and hip flexors as I was told that all were quite tight. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- I was also encouraged to up my activity to strengthen the ligament and so attended a return to sports physio session involving twisting and turning and some ball work.<o></o>
<!--[if !supportLists]-->· - <!--[endif]-->In doing this I felt next to no discomfort whatsoever whilst in action, even when twists and turns were involved, but the following day felt much more aching whilst sitting and slight twinges in the inner knee. This aching persisted for a week and a half after each of the 2 sessions, with no improvement from one day to the next until it finally began to settle down again to get back to its previous level.<o></o>
<!--[if !supportLists]-->· - <!--[endif]-->I have not been able to see if this improvement continues with no activity as there have only been 3 such occasions, and 2 of them were followed by the sports sessions<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- The third set-back came 2 weeks ago (early August) after I received further advice to continue trying to attempt a graded return to full on activity. I wanted to be careful so did 3 minutes of jogging (with changes of direction included) on a Sunday then did 5 minutes of the same 2 days later (without any real discomfort on either occasion).
<!--[if !supportLists]-->· <!--[endif]-->- The 3 minutes of jogging provoked absolutely no adverse reaction but when I did the 5 minutes of running this was followed by 2 weeks of nearly zero improvement and pain at new points in my knee that had previously not been a problem.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->To fully put this into context, the 5 minutes of jogging that I did was accompanied by a new set of exercises to strengthen my quads that my physio had asked me to start a couple of days earlier involving small squats against a wall, for 20 sets of 10 seconds, twice a day. On the day in question I felt some discomfort doing these exercises in the region of my kneecap. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->Discomfort with these exercises continued on the following days so I have since stopped doing them. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- The pain I have felt in the last 2 weeks has been characterised by the familiar aching after sitting for medium periods with occasional pain in the knee cap and in a specific point under the knee cap in a region I understand to be the meniscus. Pain behind the knee cap could not be provoked by prodding at any point on the knee but the meniscus one could, and more so by rubbing it.
<!--[if !supportLists]-->· <!--[endif]-->This has been different on different days with no recognisable pattern evident. On one day for instance I felt pain in the kneecap region on every step forward when I climbed stairs, but the next day this pain was only present when I was on my bike and pedalled too forcefully.<o></o>
<!--[if !supportLists]-->· <!--[endif]-->- The aching tends to get worse as the day goes on, especially as I am at my desk most the day. I am currently cycling to work and back each day (4 miles each way), do all the stretches mentioned previously every day and have over the last couple of days increased the hamstring ones to several times a day as I find this can alleviate aching for a while. The specific pain in kneecap and meniscus regions has died down over the last couple of days but is still present at a very low and intermittent level. <o></o>
<!--[if !supportLists]-->· <!--[endif]-->- The only times I can now guarantee being completely pain free are when I am lying down fully in bed and nearly all of the time when I am on my bike. I say nearly all the time as occasionally it still hurts seemingly within the knee behind the kneecap when I pedal particularly forcefully, as part of the ‘new’ pain in that area over the last couple of weeks. Certain types of seat are also good for it, although I cannot usually predict this, nor understand why it seems to ache more when I lie down but am not fully reclined, i.e. lying on bed but with pillows underneath my head so I can watch tv etc.
<!--[if !supportLists]-->· <!--[endif]-->- As an aside, after describing my symptoms to my physio the other day he started thinking that maybe there wasn’t anything wrong with the <st1:stockticker>MCL</st1:stockticker> any more. This does not appear to be correct though as I still definitely get pain in that specific region and there is significant sensitivity when cross-friction massage is carried out.

Anyone last till the end?
Additional Comment I forgot:
It seems like my last reply to alophysio has been deleted somewhere so just to make sure it's still out there -

Thanks for that. Do you have any tips for finding the region where there might be tenderness though? The VMO is the small muscle right above the knee on the inner side right? I think I'm just unsure where the adductor is and therefore where the join is between them.
Additional Comment I forgot:
It seems like my last reply to alophysio has been deleted somewhere so just to make sure it's still out there -

Thanks for that. Do you have any tips for finding the region where there might be tenderness though? The VMO is the small muscle right above the knee on the inner side right? I think I'm just unsure where the adductor is and therefore where the join is between them.

Hi - i made it but was speed reading!

The most common thought i had when reading your info was..."..but why is the pain there?"

In other words, has anyone looked to see why you might be loading up the MCL?

How are your muscles? Are they overactive in your hip flexors, TFL, Adductors, hams, quads etc during different positions/range of motion?

Have you been videoed or observed on a treadmill to see what your lower limb kinetic chain is doing?

Has your back been assessed - to me, it doesn't seem like anyone has checked your back and nerves.

I have had Gr III (full rupture) MCl as well as Gr I and II come back much quicker than you have - but i tend to look for why it gets stressed...obviously someone forcing your knee there is out of control (or falling down between the platform!).

I would try to find someone who can look at you *move* and try to rebalance your musculature - your "tight" quads are probably overactive etc hence overdeveloped...

Good luck :)

I agree with alophysio. A lot of time has been spent on your knee with little effect. That begs us to look elsewhere and especially at neurological structures. Once I even has what I swore was MCL/Meniscal type pain only to find that it was coming from my proximal tib/fib joint. I would look there and carefully work on the Lumbar spine, expecially when in pain as hitting (treating) the right spot at the right time should be able to provide instant relief.

Thanks so much for that. It seems to fit in with what the good physio I saw before I went away travelling said (who I have not been able to see since) in that my legs and feet pronate and also that I had very tight quads, hamstrings, and hip flexors. I kept up the stretches she gave me for a while, but I was always seeing other physios when I was away with different exercises and as it felt like a different injury as well I didn’t start them up again till I got home.

That means that problems here could still be the case, but for many weeks now I have been stretching every day, with 3 sets of 30 seconds for each one, and have recently upped them to more than once a day, and I am not seeing any improvement. (I only do 3 sets of 15 seconds on the quads as I find it requires a lot of effort to get and hold the required stretch).

Also, for the whole of the last year I have had insoles in my shoes and also been very focussed on walking evenly through the middle of my feet without rolling in. I will definitely get this checked but I believe that I have done this successfully as I still spend the majority of any time I spend walking around thinking about my knee and it is not something I ever have to correct when I think consciously about how I am walking. I know I am also supposed to walk straighter by using my stomach muscles more when I walk and which stretches my hip flexors but I still have to regularly correct this when I become aware of how I am walking naturally. I have never had any advice in changing my running style, which I have always believed to be quite awkward, although never experienced any pain with beforehand.

To answer the other questions, no I haven’t ever been assessed on a treadmill and no one has checked my back and nerves beyond the initial assessment that I needed to straighten my back more and tuck my stomach in so that the trunk was aligned. I have not had problems with any pain whatsoever in my back since I had the injury however.

The vast majority of the time I feel pain in my knee comes when I am sitting down so is this still consistent with overloading of the MCL? Could overactive muscles in that region cause the associated pain in other areas of my knee, and if so is that damage likely to permanently weaken different areas of the knee?

Just to confirm again where I am at right now, I get general aching across the whole knee region when sitting down, which can sometimes come on very quickly or sometimes take up to a maximum of an hour depending on the comfort of the seat, the time of day and whether I have been sitting down a lot earlier in the day (i.e. when at work, regular walks around to stretch my legs delay the aching by less and less when I return to sitting down as the day goes on). I also get variable twinges in the MCL which occur in certain specific situations like crouching down to sit on my heels or when I carried out the standing hip flexor stretch incorrectly and put strain on that ligament, but mostly unpredictably, like just from walking or sitting or other things I do countless times without feeling a twinge. Finally I get pain in different regions of the knee, such as particular points of (what seems to be) meniscus near the MCL and further down towards the tibia in the middle, around/underneath the patella, and in a particular region of what I think is the hamstring (behind the knee near the MCL where the ‘tendon’ can be easily felt by touch). Pain in these areas is mostly relatively new but it varies in terms of whether the pain is achy or sharp and appears to fade and return completely independent of pain in other regions or any activity that I may have done before hand.

Just as a final aside, if anyone in any country has the time and thinks it could be helpful I’d be more than happy to call to speak on the telephone. And if anyone has any advice for finding a physio in Manchester/London who might be able to help me ‘rebalance my musculature’ please let me know. I have seen so many bad ones now I’m not going to a new one till I know someone who’s recommended them.

Hi sammo440,

I have done courses with diane lee and LJ lee (who are unrelated) and i know they keep a register of people who have done their courses. check out Discover Physio - Diane Lee and LJ Lee and try to contact one of them - what you want to find out is who has done "The Series" - these are physios who are trained to think about the effects of seemingly different areas and how your neck and affect your knee with a logical explanation.

I have fixed many a sore knee with back treatment - i have fixed many a sore knee with knee treatment too!

Stretching for tight muscles is one thing but you can *feel* tight but actually be "overactive" which is a neurological thing, not a physical shortness of your muscles.

Anyway, i would be happy to put money on it NOT being your knee at this stage - please remember that it is very hard to diagnose and treat online - nothing replaces actually having a physical assessment - which is why i am skeptical of promised internet consultations!

Cheers

Thankyou Alophysio. I have contacted them to see if they know of anyone over here who has completed that program.

I fully understand the limitations of diagnosing and treating an injury online, and I will do everything I can to find someone who will look at it in the right way for a proper assessment but, on the basis that you're online assessment is correct, is there anything particularly I should be doing/not doing in the intervening time before I can find somebody?

I am assuming that I shouldn't do any running etc. and to keep up my stretches, but are there any muscle groups that I should also be trying to build and could it be beneficial/detrimental to do my stretches several times a day rather than just once? I remember the good physio I saw before I went away performed some deep massage of the quads and calves to loosen them up, so is this something that I can maybe even try myself or could I damage it more? And I have 2 final sessions booked with my current physio before he refers me to a consultant so is there anything I should ask him to do? As it stands he will just try some lazer treatment on it as a final approach to see if that works. And finally, is there any benefit in frictioning the ligament myself? I have watched my physio do it a few times and know the area around the joint which is tender, but I don't want to damage it further.

Sorry for the excessive length and volume of my posts by the way. I think about it near enough all the time, but I don't know anyone who I can talk to and would understand what I'm going through, including it would seem a large number of physios here, so I massively appreciate anyone listening to what I have to say. I can't bear to ask the question of whether or not it will ever fully/near-fully recover, but if it does then to say I owe you an even bigger thank you would be a massive understatement.

Hi Sammo440,

It is hard to recommend what you should or shouldn't be doing.

You may very well have a knee problem.

However, i would ask your physio to use the remaining 2 sessions to clear the L/S and hips and in particular the saphenous nerve, femoral nerve etc. Ignore the knee for the last 2 sessions.

If you keep doing the same thing getting the same results, how will continuing to do the same thing produce different results?

As for massaging and frictions etc...Personally, unless it is really obvious (and i haven't felt your knee, quads or calves), i wouldn't bother...you have tried stretching and massage before.

Ask your physios to "think bigger"...

Cheers

So, it's been another 2 months! Since I last wrote I've started weekly sessions at a new physio who is addressing my biomechanics issues. I'm doing a lot of work to lengthen my quads as she said that their shortness was causing my pelvis to tip forwards and back to arch. I'm also trying to strengthen my core stomach muscles and muscles at the top and outer sides of my quads, by the glutes.

I've definitely had some improvement since I started with her (after just getting over some quite bad back pain caused by using the wrong muscles to change my posture I think), so that now I can sit for longer periods without it aching and don't feel it as much when I'm walking around etc. I am going to continue with this, as she said it would take 4 to 6 months for the necessary changes I'm making to become automatic, but I've also got an appointment in December with a consultant, in case it has still not recovered by then. Because of how slow and inconsistent my progress has been (it is currently worse than it was last week for instance after spending about 9 hours sat around on my friend's sofa, only moving to go to the toilet, and I had a similar setback after dancing at a wedding) I am not expecting it to be fully recovered by December, and after something my physio said yesterday, I am beginning to think that it is not ligament damage at all.

She was treating the ligament by rubbing up the inside of my leg with lotion and rubbing specifically over the point of my knee which is the most sensitive to touch - on the inside, right on the joint line - and I commented that while the whole thing was painful, the pain in my inner thigh above my knee was more like a stretch and the pain on the particular point of my knee she rubbed was more like a burning pain. She said that a burning pain was more likely to be nerve related, and that there was a chance that some fibers from the saphenous nerve could have become entrapped in the scar tissue of the ligament (which has been confirmed to be slightly thickened from my last MRI).

The more I think about it the more it seems to fit. When I first started getting physio, approximately 3 months after I did the injury, there were 2 people who didn't believe I had injured the MCL because they couldn't find the point of the ligament which was particularly sensitive to the touch. Since coming back from travelling, this has very much not been the case and the region can be easily found which is tender.

The injury definitely changed when I first went away travelling, in Sep 2009, when I went out on my first weekend, got drunk and then woke up with pain again. I feel fairly sure that if there was a particularly bad fall or severe pain from the knee on the night I would have remembered it, and I remember even the next day thinking I'd only been set back a month or so at the time so it couldn't have been that bad. The injury changed though in that from that point on, sitting down would be incredibly uncomfortable unless my leg was stretched out, with pain coming generically from the knee area, so I always kept it up, and this could have affected it healing. It has also always been an anomaly that after 6 weeks of keeping my leg up all the time I went on 5 days intensive trekking (up to 10 hours walking a day, on very uneven ground) and didn't feel anything from my knee so I don't know if that could fit with a nerve related injury, but it certainly doesn't seem to fit with a ligament one.

A nerve related injury might also explain why I have never felt any weakness in the knee itself but have experienced pain in multiple different regions of my knee at different times over the last 6 months or so. This has died down recently, but it was when I did activity on it, such as a returning to sports physio class with twisting and turning involved, that it flared up, and the aching pain from my knee as a whole, became more regular.

Finally, just as an extra little anomaly, I had thought over the last few months that I was unable to sit back on my heals as when I did so I felt pain from the inside of my leg as I eased myself down, soon before I was fully resting on my heals. I still do get some pain as I do this, but it disappears when I continue to rest all my weight on it. My physio couldn't explain this so I just thought I'd put it out there.

Right, so if anyone is still reading and has any thoughts, please let me know!! I'd be extremely interested in any treatments that might be possible if it does seem like some nerve fibers may have become trapped. At the moment I'm feeling quite positive as it would mean my knee is actually strong in itself, and maybe there might be a quick solution which will have me playing football again, but if this is not the case and having a partially entrapped saphenous nerve is worse than a weak knee, I would definitely want to know.

Thanks, Sam

Sam, having had a very similar problem as yours including the hip alignment thing, I have recently found out that I have been misdiagnosed by a whole host of physios, sports therapists and a consultant.

I have seen another more experienced consultant who immediately diagnosed that in fact my MCL was not the problem, it was a small tear to the medial miniscus. Apart from the fact that he spotted the tear on an MRI (the same MRI that the first consultant viewed), he also stated that a tear or damage to the MCL would not produce the inflammation I was getting all over the knee. This is because the MCL runs down the outside of the knee joint and so the inflammation would be more localised if that were the problem area.

I have just had the arthroscopy surgery 10 days ago and watched it on the monitor where I could see the fraying of the medial meniscus. This was trimmed up. Unfortunately he also showed me where my articular cartiledge was worn away, probably through 30 yrs of squash and fitness training.

Hopefully though once everything heals I'll not be getting any of the pain and inflammation I've had for so long.

If any of this sounds familiar ask if your medial meniscus could be the cause. It may not show up on an MRI but I would certainly advise having an arthroscopy, particularly as it has been so long.

Regards, Mark

thanks for the update sammo440

An arthroscopy isn't what i would recommend. Persist with physio although i think 6 months is a bit long - however, i haven't seen you personally.

All the best - and keep us informed!

Cheers

Thanks for that. Yes, I'll keep trying with the physio. It should do me good anyway to get my posture sorted even if it's not having a direct effect on my knee. I don't think it's a meniscal thing as it doesn't get inflamed and the pain i get generally is now in the medial part of my knee. Do you think from what I've described though (and not that I'm taking this as a direct diagnosis, as I know it's impossible to do that without seeing it yourself) that it could be a partial entrapment of the saphenous nerve in the scar tissue or would I be experiencing other symptoms if that was the case?

I have a patient who is going through similar recovery Sammo. Without seeing you it is hard to advise but i'd agree with Alophysio and persist.

Wishing you a speedy recovery

Laura Jayne Physiotherapy

I've been meaning to come back to this for months, as I wanted to say thank you for everyone who read and replied to my thread. After almost 10,000 words on here, 15 different physios, about £1000, and 2 years, I am now back playing football, have no pain whatsoever in my knee, and although I think there will always be a bit of weakness in that ligament, I am so unbelievably happy and grateful to get where I am now.

The advice on here was really useful, especially when I was away travelling and couldn't speak to anyone about it properly, and it made such a difference just to feel that I was being listened to and to be reassured that my worst fears weren't accurate. I'm sure if I'd been able to see any of you you would have helped me recover, but in the end it was the 15th physio I came across (I got passed around a few different physios when I went to different practices, saw private and NHS physios in Manchester and London and saw a few different ones when I was travelling in Brazil, Chile and Colombia) who saw what it was that was stopping me recover and helped me through it.

Basically, my problem was in my posture. I may struggle to remember everything now, but I had over-active hip flexors and very shortened quads (I'm 6'3" and so the growth of my muscles probably didn't catch up properly with that of my bones) which meant that my hip was significantly tipped forwards, I gripped and held through my hip flexors and lower back rather than stomach and those muscles near my glut, and as I walked, rather than the pressure going through the centre of my leg, it went through the inner side and my feet rolled in, suggesting that I had flat feet, even though this wasn't the case.

The process of becoming aware of what muscles I used when I stood and walked was absolutely torturous, and changing it virtually impossible. I'm still very much in the process of changing these in-grained habits and becoming comfortable with them, but I'm at a point now where I've given my MCL enough of a break for it to recover. It wasn't without some pretty serious set-backs though, as I was trying so hard to change things that I didn't understand that I made the wrong changes, forcing movements with the wrong muscles, so that for about a month at the end of last year I suffered serious back-pain and developed a nerve problem in my left leg whereby I had pins and needles in it constantly. I nearly lost it at that point as my physio was telling me it was just because I was getting older and these things happen and I knew that wasn't the case, but thankfully my persistence, her patience and my eventually gaining the awareness I needed, paid off.

So again, thank you. A lot of your posts show that you were on the right lines, and I just wish one of the 14 other physios I saw beforehand had looked at the bigger picture of my whole posture etc rather than focussing purely on the knee.

Hey Sammo440 - that is great news!!

i think the lesson from this is that you should ALWAYS consider the big picture.

Those posture corrections shouldn't be painful - a useful test to see if you are doing it right is to ask the physio to do an "isometric muscle test" for your anterior deltoid or any other muscles you want to test - if the posture correction is good, you will be strong, if it is bad, you will be weaker than just standing there comfortably. This is the most simple test of whether something is effective or not and so many Physios don't use it or understand it!

All the best - remember to trust your instincts - so many of my patients tell me through their story what is wrong with them so if you feel like you aren't being listened to, tell them to listen to you!

Cheers and thanks so much for the update!

Hi.. Sammo440 i am from India .. after reading about ur ligament tear story i feel its a very similar one to mine .. i ad a ligament tear a year ago and still i have pain .. i cant stand continuously for more than 15 min and cant walk more. So i felt if u tel me hw u got the recovery it may help me . i know it is a very long back story of ures but hoping i may get some replies I am posting this. Thank you.