Just What I Kneeded

What happens after a life-altering knee injury?

Rare bird

8 Comments

A few weeks back, I had X-rays taken of my knees and legs. Don’t worry; there have been no new symptoms or a worsening of symptoms. I’m still in a pretty good place. In fact, I’m doing the best I’ve been doing in the two years since surgery. I’m just trying to work out why I still have so much pain doing certain activities, especially since some of the activities cannot be avoided or are actually kind of important parts of life. I can’t avoid stairs all the time, nor can I (unfortunately) avoid vacuuming my living room.

Good news is that my knees look ok from a radiographic standpoint; there’s no compartmental arthritis that has caused joint space narrowing or anything like that. Not so good news is that I’ve been subconsciously favoring my “bad” leg for so long, there are radiographic changes in my right tibia. The doc pointed to the X-ray showing my legs side-by-side and showed me the difference, which was pretty easy to see.

The left leg is normal (an opaque, whitish color on the image). The right leg shows radiolucency (dark bone when it should be whitish).

The doc indicated this is because I’ve favored/protected it for so long because of the pain that the stresses aren’t enough to keep the normal metabolic process going. You need to stress a bone to make it strong. Mine looks weak on film.

I was surprised to see that there were radiographic changes; I wasn’t aware that was something that could happen in my case, though I guess it makes sense. I think it also validates that the knee hurts. Duh. My brain likes to protect the things that hurt, so my body adapts new ways of doing things. I’ve talked about the incorrect movement patterns and the way I walk with my foot curled in at length. None of it is something I consciously do. At least not anymore, if it ever was conscious.

Side note. After I heard this, I started doing research… as usual. According to the Department of Radiology at the University of Washington, a person must lose 30-50% of bone mass before it shows up on a plain X-ray. That sounds great. Just great.

After looking at the X-rays, I’m pretty much sitting there just staring at the doc. I wasn’t exactly sure what he was telling me. I mean, I understood his words, but I didn’t understand what it meant. He said “you’re only as strong as your weakest leg,” so we still need to work on that a bit. Build back the strength. But first, he wanted me to work on ROM… again.

I was measured at only four degrees off of extension and had full flexion, so it didn’t sound like much of a big deal to me. Regardless, I was told to do nothing but work on getting full extension back. I was given three stretching exercises to do five times a day for two weeks. I was also told to do no more walking than absolutely necessary; I could continue with the bike and swimming but had to limit walking. You know that means no more Challenge Route.

I was a stellar patient (I can’t often say that since I frequently take things into my own hands), and I walked back in to the clinic after two weeks of stretching and had regained full ROM. That it had been accomplished without an exacerbation of symptoms was great.

I was really taken by surprise with the next steps. I had to build strength, but first I had to be tested so they had a baseline. I didn’t realize right away that this meant testing with the big, scary machines that I’d always been told would hurt too much to use for my case. Holy chipotle.

I was tested on both legs doing both leg extensions (ouch!) and leg presses (not as much ouch). Turns out, I am exactly equally deficient in all four ways they tested. Seventeen percent across the board. I was told that’s pretty uncommon. Most people are deficient in one or two areas, but few are equally deficient across the board. I’m no longer surprised when I hear things like this. I can’t tell you how many times my doc or my PT has said I don’t follow the book or I’m not like most people in how I move/compensate/function. This latest rarity apparently makes me the “poster child for a deconditioned knee.”

All of that to say… I guess I’m back in PT. Sort of. I’ve been given two exercises to do at home that are intended to help build strength until I go in again in about four weeks. At that point, my strength will be tested again. Joy of joys.

I have so many questions right now. How can the strength test be accurate when it hurts so much to do leg extensions in the first place? How are two simple exercises with relatively low weights going to make up for a 17% deficit in four weeks? I wish I’d thought more quickly and had these answered while in the clinic. I think I was so floored by the fact that I had to do strength testing that I couldn’t think of much else.

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Author: Laura

I have a fern I named Frankenstein. I like leprechauns, practicing kung fu moves on my dining room furniture, and pretending that one day I will move to Fiji. I dislike my neighbors' kids, anything that is chartreuse, and Ben Roethlisberger.

8 thoughts on “Rare bird

  1. Those are valid questions…I also question why they don’t want you to walk. If you have bone loss, weight bearing activity (walking) can help stimulate bone growth. Reduced bone mass may also not be painful..Many people have osteoperosis (bone loss) and it is pain free. As for your pain, some of it may be coming from a sensitized nervous system…With any prolonged injury/surgical recovery this can happen..ask your pt about it.

    • I wondered about the walking, too. They did tell me to make sure I was standing on that leg when I was standing still (as in taking most of the weight off my “good” leg). But that confuses me, too, because it seems like I’d just be starting the same messed up process with my one good leg.

      I did look up the bone loss and read that it doesn’t typically cause pain, unless there’s a fracture. This makes sense to me because my leg doesn’t hurt at all. I think this was an incidental finding, but it points to the deconditioned knee theory.

      I was told, near the end of February, that the pain could be sensitization from the prolonged recovery. Since that time, I’ve seen two pain docs–one a Sports Med specialist in musculoskeletal pain and one a pain psychologist. Neither believed it was hypersensitivity, and neither offered any treatment options. The SM specialist wanted me to go to another OS for another eval to double-check that there is nothing structurally wrong. The pain psychologist was hesitant to even call it chronic pain and said that I was already doing everything she would tell a patient in my position to do. I’m not sure what else I can do to explore the possibility of central sensitization.

      I have a long list of questions for the next time that I go in to the clinic, and it grows every day.

      Thanks, as always, for your comment!

      • No worries

        Unfortunately a lot of “pain specialists” are not that versed in modern pain theory…I do not know if your guy is or not..It sounds like structurally you have been checked in and out. and with your history being like 4 years of surgeries and rehab your nervous system is going to be on alert..It just happens…The problem is people keep worrying that something else is wrong which keeps the nervous system ramped up which can feed into pain.

        I dont know that you are centrally sensitized, but if you were in my clinic I would treat you as if you were, which would not stop the strength program or anything else you are doing…I would educate you on how pain works, continue to advance activity as you tolerate, and keep you doing aerobic activity. You could also explore things that ramp down your nervous system such as relaxation breathing, diet, yoga, meditation…You might also look into graded motor imagery and mirror therapy. The goal in addition to getting your leg stronger, which I am sure it needs after 4 years of stuff, is reducing threat to our brain. All pain is from our brain and it has been hyped up about your leg for a long time…That doesnt go away overnight…The problem is when we in the medical profession keep it hyped up by telling you something else might be wrong. Nothing to treat the pain will interfere with treating your tissues.
        Here is a post i did about treating persistent pain last week, http://ascentpt.wordpress.com/2014/09/09/4-things-to-reduce-chronic-pain/

        The bone loss can come from disuse atrophy, just like your muscles, which also for me points to central changes. Your brain may be altered from not using the leg. A great study from a couple years ago put people in slings for one shoulder and within a couple of weeks brain scans started to change in the areas associated with the shoulder and enhanced the opposite side. The theory is that evolutionarily if we lose one limb the brain starts to make up for it by strengthening the connections in the other. Hopefully I am not adding to your confusion.

        Keith

        • No, this is good! It helps me think more clearly about my questions. But it also validates some of what I’m doing or have tried (I take two yoga classes a week, and my PT had me try mirror therapy earlier this year). I’d never heard of graded motor imagery, so that is now on my list to ask about when I go back in two weeks. My main concern right now is that I don’t know how to know or find out if someone is truly well suited to treat chronic pain. There seem to be so many possible treatment modalities, it’s hard to wade through everything and determine what’s best.

          Is there something special about diet (i.e. certain foods to eat or avoid)? Or is it more just to maintain a healthy diet?

          Thanks!

          • Ok good sounds like your PT knows about pain theory and sensitization but a lot of stuff is fairly new in the research and we are kind of experimenting with the best treatment methods….The thing with mirror therapy is it is a slow process and people who do it well usually start with graded motor imagery. It involves you first visualizing motions that are painful like you are doing them…Then doing reps with you unaffeccted side. Then mimicing the motion with your painful side. it is a slow process but does make changes..I think that is where people get hung up patients and doctors, not realizing the time it can take to desensitize the system and if something doesnt “work” in a couple weeks they move on. An analogy that i like to use is your nervous system may be turned up like your stereo and is blasting heavy metal at 10…you work on desensitizing it and it doesnt just go to 1 it may go to 8 or 9 for a bit, but if you keep going it will go to 6 or 7 and so on. noigroup.com is a good pain website run by the therapists who have done a lot of the research in Australia if you havent looked at it it can help.

            As far as diet yes eating healthy is the first step. There are foods like omega 6 and nightshades which can increase inflammation and omega 3 can reduce it. There are others which do the same. As far as calming the nerves they say things that contain tryptophan(Dark Chocolate :) ), vitamin k (spinach), , B vitamins, among others can calm the system. Caffeine and other stimulants like sweeteners ramp it up .I dont know how good the research is on that though.
            I think like with a lot of things you reduce processed sugar and flours, good fruits and veggies, healthy fats, and a bit of chocolate it cant hurt :)

            • Yep! The noigroup is what came up when I started looking up graded motor imagery. There is some really interesting reading about both that and mirror therapy.

              I know I can do better with my diet. That’s one thing I can and should control. I have no excuse not to; I’m just busy like everyone else and look for convenience. I’m going to do more research into foods that cause or help inflammation. Certainly can’t hurt to attack it from all sides. I think I’ll start with some chocolate research… :)

              Thank you SO much for your insight and information! I appreciate you taking the time to comment.

  2. your welcome..thanks for listening

  3. Pingback: Suck it up, Buttercup | Just What I Kneeded

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