It’s been nearly three months since I updated on the knee. It’s about time I bring y’all up to speed. Much has happened.
I wrote in September that I’d had an x-ray, been diagnosed with some bone loss and a “deconditioned” knee. Then I started another round of PT that began with regaining ROM followed by strength building. (This was a new doc and a new PT. I’d given up trying to get my surgeon to own that he’d fixed the cartilage problem as best as it’s ever going to be fixed–a good thing– but that there was something else that needed to be addressed. He just seemed to be focused on the cartilage.)
We started with single-leg extensions with a 5-lb ankle weight and single-leg press with 60 lbs. Those low weights were all I could do without eliciting significant pain, even though the strength test indicated I could do much more (but there was pain with the test). I worked up to 30 lbs on the leg extension and 90 lbs on the leg press in the first four weeks. I thought I was doing pretty well, despite increasing pain.
After the second round of strength testing (four weeks after starting the exercises), I was told that I should push harder to add weight and that I should push through the pain to do so. Ok. Bring it on!
In the next four weeks, I added another 60 lbs to the single-leg press (150 lbs total) and another 10 lbs to the single-leg extension (40 lbs total). At some point during this round, my knee started hurting when I was in the pool–even a simple flutter kick elicited pain. I’d never had much pain while in the pool, so I should have called it off at that point. But hindsight is 20/20, and I had a PT encouraging me to push through all the pain (suck it up!).
After the third round of strength testing showed that my numbers on BOTH legs were decreasing for the leg extension (because pain!), we decided it was time for another chat with the doc. I was, once again, not following the normal pattern of progression.
Doc said I was trying too hard to get the strength back (that’s going against what his PT said, but whatevs). I asked very specifically if we were sure that it’s the cartilage causing the problem. My thought has been for a very long time now that there is an issue with the patellar tendon; I’d even discussed it with my surgeon seven months ago, but he didn’t agree after a cursory exam. New doc said he would be disappointed if there was something else wrong with the knee (me, too!) but that he wanted to send me for an MRI to make sure since my last imaging studies (MRI, bone scan and CT arthrogram) were done 18 months ago.
New MRI taken a month ago showed a number of things. Cartilage fissures and subchondral cysts on the weight-bearing surface of the lateral tibial plateau were unchanged. There is a new fissure on the mid medial side of the lateral tibial plateau that is already more than 50%. There was a lot of info about the cartilage behind my kneecap–there’s thinning in a few areas under there, but largely unchanged since the last scan (all indications the graft is doing ok). There is arthrofibrosis or a joint body in the intracondylar notch near the tibial insertion of the ACL. There is scarring of the infrapatellar fat pad (Hoffa’s fat pad). And, wait for it… patellar tendinopathy.
I met with the doc after the MRI. I was concerned about the new cartilage fissure. I don’t think there’s pain from it because I couldn’t have said there was a new fissure or any other new problem on the lateral tibial plateau. But I was worried that there was a new fissure even though I’ve only been doing PT and low-impact activities for the last 18 months. He indicated that the degenerative process has started in the cartilage, and there’s just not a whole lot that can be done to stop it. I’m not going to make the problem worse, but I can hasten the process if I do high-impact activities like running. Good thing I’m not a runner.
We talked at length about the patellar tendon. He said it’s not an inflammatory problem (it’s a degenerative problem), but he thinks it’s worth pursuing PT geared specifically at addressing the tendon. He said surgery is not on the table because the degeneration is so widespread. If I were, say, a basketball player with a focal defect, he could go in and cut it out. The tendon would heal. I don’t have a focal spot that’s bad; it’s all bad. I’m glad we’re not talking about another surgery, but I’m not happy that there is such widespread damage in the tendon. I don’t want to dwell on it, but I wonder if the damage would be so bad if we’d addressed this specific issue when I first asked about it.
I’ll write more about what we’ll do for the patellar tendinopathy in another post.