conflicting MD opinions and unsatisfactory advice on deteriorating knee

[bumkneeChris]

Hello doctors,

I was referred to you via the StartingStrength subreddit and am very excited about the possibility of receiving your opinions.

To sum up, I am having significant knee pain with loss of ROM, I have received conflicting comments from doctors, and no one is offering me a solution other than "stop being active," which I don't want to accept unless I have gone down all other possible avenues first. My situation is complicated by the fact that I live overseas and cannot communicate well in the doctors' language. I know you probably cannot offer professional advice in this forum, but I was hoping you could at least offer some medical "meta-advice".

My Right knee is arthritic. Most of my life, I have had knee pain and dealt with it through strength-training. However, recently, the condition of the knee is exacerbated, and there are new symptoms that it is not clear to me stem from the arthritis. Especially, the posterolateral aspect of the Right knee has a pretty intense pinching sensation that accompanies any flexion of the joint. It is not a diffuse sensation, but focused on a very specific point in a ropy-feeling structure that looks from anatomy books to correspond to the biceps femoris tendon, although I don't know that's where it actually comes from.

The pinching sensation is the most annoying thing, but there are other new problems as well: for a while the knee was "locking" so that it would not extend to less than about 20 degrees, requiring me to limp until it unlocked again; the entire joint occasionally gets very stiff, preventing me from flexing past about 100 degrees at all and past about 50 degrees without pain.

I've been to 2 orthopedic doctors recently. One advised that removing the extensive bone spurs in my Right knee joint could improve my symptoms. The other, to whom I was referred for the surgery, declined to do any surgery and said there was nothing to be done and that the problem was with the knee's capsule. I can't talk easily with either or with other docs since they don't speak English and I don't speak their language.

I've stopped weight training because I can't squat down, and my personal goal is to get the knee back to the point that I can do a squat.

I'd love it if you could speculate on what might be going on and give advice on resources like websites/books/articles with in-depth information on the knee, its diagnosis and surgical treatment, etc. that might let me understand why, for example, the surgeon declines to do surgery.

I have results and images from diagnostic tests, and I can post those as well as more extensive history/description of the problem if you think it would be worthwhile.

Thanks so much for your consideration.

[Derek Miles]

Hello,
Could you give me a little more background on the development of symptoms and your training history? How often do these "very stiff" episodes happen? The more background information I have the easier it will be to help discern what can be done to help you out.

[bumkneeChris]

Hi Dr. Miles. I posted a reply with more background info, but I think it's hard to follow the chronology. Basically:

TRAINING:
before 2013 -> weight training but without barbell lifts for lower body (no squats/deadlifts)
2013-2014 -> intensive martial arts training without much weight training
after 2015 -> tried to change over to a squat/deadlift program, but was prevented by knee

KNEE:
before 2013 -> arthritis that didn't interfere with activity
2013-2014 -> a lot of various knee problems during martial arts training
after 2015 -> new knee problems interfering with squatting

[bumkneeChris]

Good afternoon, Dr. Miles, from the Pacific Rim. Thank you for your reply. I didn't post more history before because I was trying to keep the length of my post down. But since you asked, I will post a detailed history. Bolding included for ease of skimming...

I am a 42yo, 6', 260lbs WM with a long history of both knee problems and weight training. I am from the USA but am currently living in Japan.


PRIOR Hx 1990-2012:
Training 1990-2012:
high school & university: competitive swimmer.
1992-2009: intermittent weight-training without lower-/whole-body barbell lifts (e.g.: 1200lbs x 10 leg-press, but no squats); weight gain 185 -> 290 lbs.
2009: weight loss 290 -> 230 lbs.
2009-2012: combination of weight training, spinning, sprints, hiking, and CrossFit-style exercises like box jumps and kettle-bell swings but without barbell lifts.
Knee 1993-2012:
1993: complete dislocation of Right knee cap (subluxated patella) while rough-housing.
1994: Right knee swelled up to the point of immobility during a backpacking trip; after 1 day rest, swelling went down and trip was completed without further problem.
2002: Right knee osteoarthritis diagnosis.
2009-2012: consistent low-level, manageable knee pain (ache) centered in front, subjectively "under the patella".



PRIOR Hx 2012-2017:
Training 2012-2017:
2012: weight 210 lbs; backpacking through Asia.
2013: year-long, full-time martial arts course involving a lot of seiza and suwari-waza; did NOT do any weight training.
2014: repeated same martial arts course on a part-time basis; however, re-started weight training similar to 2009-2012.
2015: intermittent weight training only; tried adding squats to my routine in addition to leg press.
Dec'15-Jan'16: hired a well-credentialed personal trainer to teach me Olympic lifts and worked out daily at a CrossFit box; Right knee was entirely functional.
2016: weight 210 lbs; tried weight-training program based around squats and deadlifts, but actually didn't get to the gym very much during this year.
Knee 2012-2017:
2012: Both knees: "under patella achiness" when walking up stairs/uphill during backpacking trip.
2013-2015, during martial arts courses:

• (1) Both knees: constant general swelling, more or less;
• (2) Both knees: previous "under patella achiness" continued;
• (3) Both knees: painful, swollen, and eventually hardened patellar tendon across soft area between the knee cap and upper tibia; occasionally tender to pressure, but usually painful under tension while standing up;
• (4) Both knees: occasional pain/tenderness just above top of patella;
• (5) Both knees: inability to sit in "seiza" properly with butt touching heels; subjectively, not from quadriceps tightness but from "something" in the back of the knees that prevented them from flexing completely (felt like too much tissue to compress);
• (6) Right knee: in addition to (5), the posterolateral aspect of the Right knee had a consistent pinching sensation while sitting in seiza; not a diffuse sensation, but an extremely intense and localized sensation in an anatomical structure that feels ropy to touch and appears from anatomy illustrations to correspond in location to the Biceps femoris tendon.

During this time, I saw 5 doctors in Japan, none of whom gave me advice beyond "stop training". One gave me a shot of cortisone, which gave me limited relief for only one day.
2015-2016: Outside the gym, knees went back to 2009-2012 condition; in the gym, the pinching sensation described in (6) above continued during squats/leg press/kettle-bell swings, etc




CURRENT Hx 2017-2018:

(Jan 2016 - August 2018: weight gain 220 -> 260 lbs; mostly occurred in 2017.)

• April 2017 - February 2018: same martial arts course as above, but on weekends only; few days a week weight-training. Attempted to do squats/deadlifts program for lower body, but ended up doing leg press/deadlifts instead because while squatting Right knee would not compress as much as Left knee, resulting in a non-horizontal bar at the bottom of the lift and a decent amount of the "pinching" pain in the back of the Right knee; also, knee swelled up from doing aerobic work such as elliptical machine.
• March 2018 - June 2018: Tried to go to the gym a few times, but basically stopped training of any kind; "pinching" discomfort in the back of the Right knee (along the right side, but also in the middle, "internally") even while doing things like raising my foot to tie my shoe.
• April 2018: Saw a non-surgeon orthopedic doctor who took X-rays (SEE ATTACHED PHOTOS). I asked him if he thought surgical removal of the bone spurs would help (since they seem to correspond to locations where I have pain). He said yes and referred me an orthopedic surgeon.
• May 2018: orthopedic surgeon did an MRI and said that my meniscus and ligaments were all intact; he declined to do surgery, saying he didn't think there was any reason to remove the bone spurs and that there was nothing to be done. His only advice to me was that I needed to "stop being active" and that there was probably a problem with the "capsule."
• June 2018: knee started locking without warning. Usually while standing from a sitting position, but sometimes just while walking on a flat surface, it would suddenly catch in the back so that it would extend to only about 10-20 degrees of flexion, which meant I could only limp rather than walk properly. At first, I had to wait until it released on its own, but I eventually figured out that if I pressed my thumb into the soft part of the back of the knee and massaged intensely, I could make the knee release. The locking occured about 10-15 times per day and lasted for about 10 minutes or until I caused it to release. In addition to the locking, I started having increased swelling and pain while trying to flex the knee: any flexion beyond about 75-80 degrees was both difficult and painful. I was barely able to ride a bicycle at this time, and I started wearing compression sleeves to try to keep the swelling down.
• Late July: frequency of locking started to decrease, but I started having pain just from weight-bearing. Just standing or walking caused sharp pain. From late July to mid August, Right knee was visibly swollen almost constantly, and I had an almost constant limp from either a locked knee or weight-bearing pain.
• Late August: the locking and weight-bearing pain both spontaneously resolved.
• Since late August: swelling and stiffness in the Right knee, pain in the back of the knee with flexion, and the same pinching sensation in the back right side of the knee with any flexion or squatting motion. When I am not flexing the joint, there is dull aching in the back and along the right side. When I walk, sometimes it feels fine, but sometimes there is random pain in various places in the joint (front, side, back). The entire knee joint also seems to have gained in size. It is not soft and squishy all the time like it has fluid in it, but it is visibly larger than the left knee joint all the time.

OPQRST:

• Onset: see above History.
• Provocations: Pinching and back of knee pain: any flexion or squatting; bicycle riding; sometimes, standing, walking, or running; sitting "Indian style" creates aching on the outside of the Right knee. Occasionally at work, I have to stand constantly for a couple hours, and this usually makes the joint much stiffer for the rest of the day. Walking sometimes makes the knee stiffer when it's feeling good, but also sometimes when it's stiff, walking makes it looser.
• Palliation: Constricting wraps and icing the knee don't do anything to reduce swelling/size. Loxonin (a Japanese NSAID)+Tylenol helps with pain somewhat during the day. At night, Loxonin+ Eve(Japanese, ibuprofen/magnesium)+Tylenol+Loxonin medicated tape wrapped around the knee makes the knee looser in the morning on waking, but only sometimes; sometimes it does nothing. Self-massage around the posterolateral ropy anatomy (tendon?) sometimes relieves some aching pain (but not the pinching with flexion). I had one professional massage once, and the whole leg felt looser afterwards, but the improvement around the knee joint in particular was minimal if at all.
• Quality: Variously, sharp, aching, pinching, "compressing", stiffness.
• Radiation: ropy anatomy in the back/right of the Right knee, in the soft tissue of the back of the knee, occasionally in a few places on the front of the knee, especially just medial to the patella. Infrequently, there is some tenderness in the lower hamstrings or upper calf muscle.
• Severity: from 3 to 8 out of 10.
• Time: The swelling and stiffness are present almost constantly, but the severity changes. Bicycle riding is always uncomfortable now, but sometimes there is only the pinching sensation, while about 70% of the time there is the pinching plus pain that feels like it's from compressing something in the back of the knee (I assume this is from swelling). When this compressing pain is present, it usually feels stiff/difficult to bend at the same time. The stiffness gets severe enough to make peddling a bicycle difficult to do about 1-2 times per week. The stiffness usually changes overnight. Sometimes when I wake up in the morning, it's stiffer than the previous night and remains that way most of the day, but sometimes when I wake up in the morning, it feels much looser and then gets stiffer in the middle of the day.

Note on images: I have circled the places I was told by the doctor have bone spurs.

Note on patella: the "under patella achiness" is consistent bilaterally; it's worse while riding a bicycle or walking up stairs, but then goes away. I have lived with this since my 20s and it doesn't hinder my activity; I am concerned about the stiffness, pain, and pinching in the Right knee.

[Derek Miles]

Thank you for the thorough history. As it would be increasingly difficult to offer best advice via a forum I would recommend a formal consult with either Michael of myself with which to discuss your current issues. It is not uncommon to have some episodic stiffness in your knees with the "bone spurs" identified by your physician. That being said, there are certain ways with which to build more capacity in that tissue and work on decreasing the frequency with which you are experiencing symptoms. There are almost always training modalities that can be introduced to build more resiliency in tissue, it just ultimately comes down to a factor of time for the prognosis. As this has been going on for quite some time, it will likely be a series of small gains that will add up to giving you less stiffness and more strength. Sometimes this is achieved by loading through a tolerable range in the major exercises and sometimes it can be beneficial to approach the problem from other angles. Regardless, there are certainly ways with which to modify programming to construct an efficacious program that will get you towards where you want to be.