Years of knee trouble - do I need surgery?

Hi Jen,



Sounds like you have fun teaching…but end up sore as a result. Great that you are active though!



Some feedback with my physiotherapy hat on….



With you having fractured your leg many years ago, while the fracture healed, the ‘alignment’ through your lower limb has likely changed. Thus, the X-ray showing medial tibiofemoral compartment narrowing is likely evidence of this altered alignment. With the ‘altered alignment’ and plenty of moving around on it over the years, you may well have developed early wear of your knee cartilage. If you have twisted on your knee, your may have even developed a small tear in the cartilage or meniscus (shock absorbers). This may be the cause of serious clucking that you experience. If this is the case, performing knee stretches in a particular direction may well help to ‘iron out’ the worn cartilage. If you can work out what affects you more - getting up from a sitting position or standing for a length of time - this might indicate a direction preference for you to stretch your knee. If you can work this out, let me know and I may be able to direct you further.



With regard to arthroscopy - this may be useful. However, I have recently treated an 82 year old lady that had an extruded lateral knee meniscus. Her GP referred her to an orthopaedic surgeon for assessment. An arthroscopy was performed with some benefit with pain, but her normal knee range of motion into flexion was not significantly improved. We applied a mobilisation with movement technique to her right knee - me applying  some pressure to the side of her knee while she actively straightened her knee as far as possible. There was a single clunk and knee range of motion in flexion was near normal and she could complete a full revolution on the bike!



Regards, Neil

Hi Jen,



A couple of things a likely happening with your knee - change in the articular function (joint) of the knee and muscular control (especially the patella, knee cap).



Given your initial injury was 30 years ago, your leg and knee joint will have adapted. From what you describe, you may have a ‘articular block’ to knee extension (having your leg straight). This may be due to the remodelling of your knee over the years or an acute disruption of the cartilage and menisci. An exercise to try GENTLY… I mean GENTLY is to rest the heel of your right foot on a chair (make sure your balance is set), and try to straighten your knee as much as possible. Relax and repeat x10. Each repetition should  try to straighten the knee further… but remember to be GENTLE to begin with. This should make standing more tolerable. If it make sit worse, stop and I can talk you through another exercise.



To manage the quadriceps (muscle which controls the patella), cycling is a great exercise. Just cycle at a comfortable pace for 5-10 minute intervals. IF you can complete this 3-4 times per week would be a great start.



Let me know how you go!



Regards, Neil

I will give it a go, Neil.  I have a referral for an xray - do you think that would be useful? One Dr and my chiro think an ultrasound would be more useful, they think it is ligament damage. Any sideways movement hurts. It is taking a long time to feel any better.

Ok, I just tried that GENTLY and it hurt, so I only did it for a minute. The knee grated. I just want to know if it is a joint problem or a ligament problem and how to fix it. Should I get the xray and the ultrasound and see an osteopath or an orthopaedic surgeon? Or a physio? Jen

Hi Jen, Glad to hear you have tried the exercise. While doing it, did the knee hurt right from the time you started and get worse as you continued, or even a little better as you continued? And how did it feel afterwards? Much the same or worse. If the knee was much the same after giving the stretch a go, you are safe to keep trying. Often the first few attempts at completing these exercises can be sore.



With diagnostic imaging, I would have the X-ray and ultrasound completed. However, I would consult a physio once all imaging is completed. Physios tend to do hands on work and give appropriate exercises. Osteopaths and chiropractors tend to just just do hands on.



Depending on the result of the X-ray and ultrasound, your doctor may send you to an orthopaedic surgeon. They would likely order an MRI to further assess the injury to your knee. So let your doctor and physic direct you here.



Let me know how you go.



Regards, Neil

Hi Neil,   I haven't replied for so long, sorry. My knee has been gradually getting better, with some good days and bad days. One night it kept me awake for ages. I found my XRay form, had an Xray last Monday, made an appointment for this Thursday with the oprthopaedic specialist, and my knee has been so much better!  I am still going to see him, I would think an orthopaedic specialist (while being disappointed at probably not being offered surgery) would tell me if it really is ligament damage and have ideas on where to go from here.



The funny thing was the Xray man - he went out to view the films and came back in and said, “You did know that you broke your femur sometime in the past?” I should have acted shocked and said NO!



1 week till camp! Jen

Hi Jen,



Great to hear the knee is improving. Surgery should always be a last resort… I have seen many people that have had surgery as a first resort because there are signs that suggest the specific joint being attended to has some wear and tear. After surgery they have not been as improved as they would have expected… often because another body part/ joint contributes to that painful scenario. This is where accurate diagnosis and appropriate exercise prescription are so very important!



I assume that you are keeping active? Given the knee is improving, still be conscious of moving too much, especially twisting on it. Gradual and consistent improvement is best… relapses are not fun!



I like your sense of humour with the radiologist! I would have done a similar thing!! 



Regards, Neil

Hi Neil,



I saw the ortho today and he asked if anyone had detected a knee injury when I broke my femur. They didn't even look at my knee, they certainly didn't notice that I had broken my right big toe either! What you said earlier in this thread made sense - that the joint had become a little misaligned after that accident. I fell on the knee at Camp 2 years ago, an Xray last year showed osteoarthritis. He examined me, the fact that I cannot straighten my right leg indicates to him that I have some cartilage damage so it's off for an MRI - tomorrow!!!! I can't believe it - we have to drive 2 hours to Newcastle but I can get in tomorrow!!!!  I'm taking a sickie to get it done. It's expensive too - $200 and not claimable on medicare or a health fund as it's not going through as a work related injury. So back to see him on the 1st of December.



Camp is on Monday, so I will try not to injure it again. Outdoor Recreation Camp, near Karuah, with 39 Yr 10 students! It is fun. Will let you know how I get on. Jen

Hi Jen,



Unfortunately… getting a complete history of events (other places that hurt) and physical examination (knee and toe) when an injury occurs does not always happen. From a physiotherapist point of view, we are trained to assess and clear other areas that may contribute to the pain, but this doesn't always happen. I have been reading a spinal assessment book recently… it has a few important words… choose your clinician CAREFULLY (doctor, physic, chiro etc). I agree with this! I appreciate it when my patients ask me questions, so don't be afraid to ask for clarification of what is actually happening within your knee/ body!



Re your MRI… Sounds like a good idea. This will assess the degree of cartilage wear in your knee. $200 sounds cheap and getting in tomorrow is excellent as a private patient can wait a few weeks… strike while the iron is hot!



All the best with the camp!



Regards, Neil

Hi Neil,



well I survived camp - there was only one moment when i thought seriously about going home! But my knee is hurting like it did when i first injured it. It took 3 attempts to put my foot down to the floor this morning and take that first step.



I rang the specialist this morning to offer to come in if they had a cancellation (my appointment was next thurdsday) and the receptionist fit me in, so I saw the specialist today! I have degeneration, which he can't do anything about and two tears in my cartilage - one on the outer and one in the inner. AND an arthroscopy booked for the 6th of December! How's that for amazing! I've never been so excited to be going into surgery! I have some exercises to do before and after.



So that's cool, can't wait to stop grimacing in pain every time I stand up and to be able to walk properly. Thanks for your help. Jen

Hi Jen,



Good news that a tidy up (arthroscope) is a suitable option for you. In my experience, performing the prescribed exercise before and after surgery helps for a better outcome following surgery.



All the best for 6 December! A nice xmas present hey! I would be pleased to hear your recover story following surgery.



Regards, Neil

Hi June,



My name is Neil, I practice as a physiotherapist. I agree with your GP about when to have your knee replaced… aged 71 is still young! and if you can manage the pain this is great! Delay the initial knee replacement as long as possible, however if the ‘kicking the toes’ episodes start to become more frequent… one significant fall can be enough to really slow you down… a fractured hip can mean surgery whether you want it or not!!!



The life of a knee replacement if 15-20 years, so you can get a great lifespan out of the replacement. Everybody is different, but I am currently involved with a lady of 82 years who recently had her knee replaced for the first time… she is finding it hard going. I review with her for the first time following surgery (approx 6 weeks ago) this coming week. My point is there is an optimum time for the replacement surgery as younger bodies heal quicker (within reason)!



Regards, Neil

Hi Neil,

Yes I understand all that I volunteer with a senior ward at local hospital and see results of falls etc too often. When I feel it is right I will have knee surgery,having an incorrectabe bow in my leg will make the life of the replacement knee shorter than usual. Another reason I am waiting to have it done. i have private Health Insurance so I will make decision how to go a bit further down the track. Regards.

Hi Jen,



Overall, your arthroscope sounds like a success… except for the right foot pain!



Even though the exercises as prescribed by your physio may be sore, the straight leg raises are a good place to start… the longer you don't move that leg, the more you have to catch up on! My experience with this type of injury (including myself) is that not enough cycling for exercise and strengthening is done… The knee joint loves the cycling motion!



All the best over the festive season…



Regards, Neil

Hi Neil, how are you?



it's been three weeks now and I am still in pain, although my leg is bending much better. Not entirely straightening though. Going to the physio today. Still using a walking stick when I am out - for protection more than for anything else - Neil, from your experience, how long does it take to get over an arthroscopy???  I guess it depends on the amount of work done during surgery and how active I am afterward? I know he removed part of a bone and removed part of each cartilage so it wasn't all that small an op.



Several people have told me 6-8 weeks but that is the standad time to get over any operation. One nurse even told me that I should have gone for a replacement as that hurts the same!!!



I am so glad that it was done at the end of the school year so I have all holidays to get over it!



Hope your holidays have been fun and relaxing. Jen

Hi Jen,



I'm good thanks… Did you and your family have a nice xmas?



First point regarding your question re expected recovery time…. everybody and everyone is different! So timelines are always a guide only.



If a part of bone has been removed, you would likely be expecting 6-12 weeks of (semi) intensive rehabilitation. This means exercise every day to get the knee joint moving on its own, and in coordination with the ankle, hip and back. If you have good bend in the knee, the knee joint loves a cycling action… so jumping on a bike for 5-10-15 minutes every day is a must.



Where significant pain is continuing at your stage of rehab, I am often suspicious of a low back or sciatic nerve tension issue… Ask your physio about this.



Even though a total knee replacement is the same amount of ‘hurt’… you are probably too young for this surgery. Surgeons only offer it for over 55 years or where an alternative (such as an arthroscope) is not going to provide any help.



I admire your spirit in keeping up with your rehab… Keep it going!!!



Regards, Neil

Hi Neil,  it is 5 weeks today post surgery and I am still having pain. Though have stopped taking any painkillers most days so the pain isn't severe enough for Nurofen. I have been in the pool and that is fantastic - very little pain. And cycling for 5 minutes every day - I can put my foot as far forward in the pedal as possible and keep my foot on the pedal for the entire rotation.  I can sit comfortably on a normal chair and I think I ran a couple of steps yesterday when I was chasing a man who had forgotten his wallet, and lived to talk about it.



My friends assure me that at the 6 week mark the pain will significantly decrease so I am waiting for that moment is a week's time!!! This is the quietest school holidays I have ever had - not doing much each day. Am hoping to see the physio again next week when he returns from holidays.



Catch you! Jen

Hi Jen,



Overall your report sounds like you are progressing as expected. So well done on keeping up with the daily cycling (and other activities)!



I agree with your friends… the 6-8 week mark is when everything starts to settle more - especially pain. However, what is more important is your functional abilities - if you were able to run a few steps without a significant issue afterwards, you again sound like you are on track!



Where a bouts are you feeling the pain? And what has the physiotherapist been doing with you - massage, mobilisation, exercise prescription? Just interested to see if I can suggest something further for you.



Regards, Neil

Hi Neil,  I am racked with guilt! I haven't been doing any exercises for a few days. Not good. And it was feeling a bit better until I went to the Tuncurry Markets and hurt it on uneven ground.



I will do some straight leg raises tonight and 5 minutes on the bike. My physio is away for another week so any suggestions would be appreciated.  My physio was doing manipulation, tens machine, 5 minutes on some slidy machine. 



I went on holidays but we had to return because my 8 yr old child contracted a severe case of hand, foot and mouth. Wasn't pretty. Now hubby is crook with some stomach complaint - i think we all have a touch of this. Totally unrelated to health, our 20yr old car carked it and is going to apprentice mechanic heaven tomorrow!



Thanks in advance for any suggestions, Neil.   Jen

Hi Jen,



My best advice is to continue with the exercises your physio gave you - the straight leg raises and cycling.



What sort of footwear did you wear at the Tuncurry markets? Regardless of how physically fit you are or any injuries you have - walking on uneven ground in unsupportive shoes is hard work for your foot, ankle, knee, hip and back. So in your case with a recently operated on knee, the supporting muscles are still recovering and the walk on uneven ground would habe upset them a bit (even with supportive shoes)!! So my other suggestion is ALWAYS wear a supportive shoe when out and about!



Regards, Neil

Hi Neil,

I am having a rough time. My leg got worse last week. We were in Newcastle looking for a car, and went to two shopping centres and walked on the rock pools - I didn't hurt my leg but it just got sorer and sorer. On Sunday a friend suggested that I ring the specialist. I rang him on Monday and went in to see him. He said it wasn't any better than when he first saw me, which was a strange statement to make as I saw him on Day 10 and I can bend it a lot more since then. He asked me if I was still icing it, was I underdoing it, was I overdoing i? I asked him how I would know what I was supposed to do as there were no guidelines or hints or instructions for recovery from him or anyone else. Try looking up “surgery recovery” on the internet - nothing. At least this time he examined my leg properly, sent me off for a ?DVT ultrasound, started Celebrex, ice pack 3x/day, seeing him again on Friday. Possible MRI - though that doesn't excite me as I don't intend to have any more surgery, once is enough.

All I want to do is go back to work, students arrive next week and I want to be able to teach them properly. We have Conference this week. Saw my physio today and she gave me lots of exercises and instructions and advised me to start pushing movement more. That should help educe the swelling. The pool would be great but it's not swimming weather!

What do you think, Neil? I am praying that if I do all these exercises properly 3 times per day, by Friday it shojuld be better and I can avoid a MRI. Another artroscopy would be disasterous. Yes?   Jen

hey neil,  i can't swee what I am writing as this reply thing isn't working properly. Ramii is working on it.  So I am hoing this comes across.  I am still having trouble with my knee - it won't fully dstrigthen or bend. Had another MRI at Port Macquarie last night so need to go back to the specialist to see what is going on inside the knee. Is it true that some knee surgeries take 6 - 12 months to come good? I only had an arthroscopy - I thought that was minor, not like a knee replacement? wHAT DO YOU THINK?