Chondromalacia Patella Grade 3. . .

[episodic]

Saw a sports med. ortho. Saved up to do it (my copay and coinsurance sucks). He diagnosed me with grade 3 chondromalacia patella - he joked and said it might even be 3.5

I also have a spur on the back of my heel that causes a popping sensation when I walk. He wasn't concerned about that as it does not hurt. He said it was insertional achilles tendionpathy - likely from when I was 350lbs. The spur was clearly visible on the xray. He did say it was small. He did say it could get worse in the future. It has never hurt me though. It is just annoying. Question for this one. Should I abandon my use of 0 drop shoes due to this? What are your thoughts?

My knees he didn't try to sell an arthroscopy - but he mentioned he does alot of them. He basically told me that knees have a shelf life, and that I'll know when it is time to get more done.

I told him about all the exercises I've been doing (squats, slantboard squats, knee raises, planks, bicycles, leg raises, etc - all of the rehab exercises you find. I do them all, almost daily. He told me that if I were the average couch potato with the knees I have, that I would most likely be in pain - and that my strong musculature is probably what is 'saving' me at the moment.

He did not discourage my marathon plans - he just said that he hoped that my knees didn't hit their limit before time.

All of this worries me as my insurance situation is always tenuous. I can't afford the 'good insurance' that my employers offer - so I get the higher deductable stuff - and well most of you older guys understand that makes you think about everything in a different way. He put no timeframe on the knee scope and clean out - there was no hard sale.

I already take fish oil, glucosamine msm choindroiten (I know I misspelled all of those).

Will this get better on it's own I'm wondering? Anything I can do to reverse some of the damage? I bought a patella strap - but it seems like it makes it worse when I run (or I might not understand how to use it right). He said it wasn't the running that did this to me btw - he blamed the decade that I was 300+ lbs - with a top weight of 350 pounds. (I weigh 170 now).


One thing he said confused me. I'm an avid bicyclist too. He mentioned that often the bike was harder on this than the running (I thought it was the dead opposite.) I mentioned that to him and he said because of the angle of my issue the bike would be harder on it. This actually rings semi true with me because my knees are sorer after a 20 mile bike ride than a 5 mile run (about the same time exercising).

What else can I do? Is the arthroscopy likely worth it? I really don't quite understand what the long term ramifications of having one done is.


tia....

 

[SociallyChallenged]

Your ortho is right. While bike riding, your knee is almost always in some knee flexion. When you're in the highest position of knee flexion, you're also firing your quad vigoriously. That causes compressive forces at the patellofemoral joint (not the true knee - tibiofemoral joint). Grade III chondromalacia is moderate to severe on the 4 point scale. You're doing everything right though with the supplements. If your diet looks good too, you're good to keep doing most everything you like. Something I wouldn't suggest is heavy weightlifting in a lot of knee flexion. This pretty much rules out weighted squats. Things like deadlift, body weight work, maybe even DB lunges are likely fine. You can continue with full range squats, but those will load the patellofemoral joint pretty much maximally. With your current diagnosis, not squatting heavy in this case is the correct answer.

Don't do the arthroscopy at this stage of the game. It's silly to get surgery when you're asymptomatic. It won't fix your knee - it may very well initiate chronic knee pain and it will be a several months for recovery. These are some of the problems that are associated with being obese for so long. Your joints take a real beating. I'm sorry that you're dealing with this now. I'd definitely wait - sometimes imaging can show things that may seem severe, but never actually progress into a problem.

 

[episodic]

Thanks. Any thoughts on the insertional achilles thing and 0 drop shoes (I've been using them for a while at 20-25 miles a week running).

Your ortho is right. While bike riding, your knee is almost always in some knee flexion. When you're in the highest position of knee flexion, you're also firing your quad vigoriously. That causes compressive forces at the patellofemoral joint (not the true knee - tibiofemoral joint). Grade III chondromalacia is moderate to severe on the 4 point scale. You're doing everything right though with the supplements. If your diet looks good too, you're good to keep doing most everything you like. Something I wouldn't suggest is heavy weightlifting in a lot of knee flexion. This pretty much rules out weighted squats. Things like deadlift, body weight work, maybe even DB lunges are likely fine. You can continue with full range squats, but those will load the patellofemoral joint pretty much maximally. With your current diagnosis, not squatting heavy in this case is the correct answer.

Don't do the arthroscopy at this stage of the game. It's silly to get surgery when you're asymptomatic. It won't fix your knee - it may very well initiate chronic knee pain and it will be a several months for recovery. These are some of the problems that are associated with being obese for so long. Your joints take a real beating. I'm sorry that you're dealing with this now. I'd definitely wait - sometimes imaging can show things that may seem severe, but never actually progress into a problem.

 

[SociallyChallenged]

Thanks. Any thoughts on the insertional achilles thing and 0 drop shoes (I've been using them for a while at 20-25 miles a week running).

I think zero drop shoes are excessive if you're running much mileage on asphalt or cement. They're fine if you've trained well for it and do a lot of running on grass or dirt. As it relates to your Achilles tendinopathy, I might get a running shoe with a very slight heel. That will reduce the range you utilize slightly and may offload the tendon at its extremes. That's just my personal opinion though.

 

[slush]

Don't do the arthroscopy at this stage of the game. It's silly to get surgery when you're asymptomatic. It won't fix your knee - it may very well initiate chronic knee pain and it will be a several months for recovery.

I was just diagnosed with Stage 4. After 5 appointments two MRI's and one with an arthrogram, the OS at the Mayo Clinic gave me the news yesterday. I'm 36 and pretty healthy and can't really pin a reason as to why this wear occured.

The advice that SC stated above is almost verbatim as to what my OS said. There isn't an effective treatment at this time, there are things like synvisc injections, but have a low success rate. OS basically said, get your legs strengthened, and refrain from activities that aggravate it.

Final step at some point will TKR, just not now.

 

[slush]

Oh yeah, and good luck.

 

[episodic]

I was just diagnosed with Stage 4. After 5 appointments two MRI's and one with an arthrogram, the OS at the Mayo Clinic gave me the news yesterday. I'm 36 and pretty healthy and can't really pin a reason as to why this wear occured.

The advice that SC stated above is almost verbatim as to what my OS said. There isn't an effective treatment at this time, there are things like synvisc injections, but have a low success rate. OS basically said, get your legs strengthened, and refrain from activities that aggravate it.

Final step at some point will TKR, just not now.

Are you in pain right now, etc? Or does it just swell sometimes? Did they give you a window of 'time' before the TKR? I'm really curious to know everything you were told as you probably went to a 'better' medical place than I did.

Did they tell you the same thing about cycling? Are you into running, etc? What are your plans moving forward? Would love to 'share notes' with you. Feel free to PM me, etc. I know some of this might be too personal for you - so I appreciate whatever you'd be willing to share. Thanks for your time.

 

[episodic]

Hey SociallyC-

quick question.

Am I likely to damage myself more continuing my current activity. I've been reading - and lots of what I've read totally concurs with what you said. What I am getting is differing opinions on activity. Some say 'charge ahead - make the best of what you have left' - some say 'be conservative, etc'.

I'd like to hear some 'what if you were me thoughts' - for instance - I'm progressing in running dramatically. I've actually came in third overall in several races as of late. I'm pushing into high 6 minute miles for 5 and 8k events. I finished a 10k in mid-fourties. I'm 'really enjoying running'.

What I'm struggling with is - should I stop racing? Should I just become 'the older guy' that jogs 30 minutes three times a week and hits the elliptical another couple of days. Those thoughts depress me very much. Of course it would depress me even more to be disabled.

I've made a remarkable change. I'm at sub 8% body fat, I've hit the weight room, ran up to 10 miles at a time so far, rode bikes over 100miles at a time, participated in sprint triathlons, etc. Is that over? Should I abandon being competative? Should I give up plans of marathoning? I just am unsure what to do with the info I have. And why on earth isn't there some cartliage replacement surgery they can do? Can't they move some from my ear to my knee or something new fangled (lol). . . I'd give up an ear to keep running

 

[episodic]

Also, are there any recommendations on a book that would give me tons of good information, excercises, techniques, etc for the best management of my condition.

 

[SociallyChallenged]

Hey SociallyC-

quick question.

Am I likely to damage myself more continuing my current activity. I've been reading - and lots of what I've read totally concurs with what you said. What I am getting is differing opinions on activity. Some say 'charge ahead - make the best of what you have left' - some say 'be conservative, etc'.

I'd like to hear some 'what if you were me thoughts' - for instance - I'm progressing in running dramatically. I've actually came in third overall in several races as of late. I'm pushing into high 6 minute miles for 5 and 8k events. I finished a 10k in mid-fourties. I'm 'really enjoying running'.

What I'm struggling with is - should I stop racing? Should I just become 'the older guy' that jogs 30 minutes three times a week and hits the elliptical another couple of days. Those thoughts depress me very much. Of course it would depress me even more to be disabled.

I've made a remarkable change. I'm at sub 8% body fat, I've hit the weight room, ran up to 10 miles at a time so far, rode bikes over 100miles at a time, participated in sprint triathlons, etc. Is that over? Should I abandon being competative? Should I give up plans of marathoning? I just am unsure what to do with the info I have. And why on earth isn't there some cartliage replacement surgery they can do? Can't they move some from my ear to my knee or something new fangled (lol). . . I'd give up an ear to keep running

Well, it's hard to say. There is research that shows being active is the best way to maintain function and joint space in individuals with signs of osteoarthritis (essentially where you heading with a Grade III chrondromalacia). However, excessive volume or intensity of loading can cause further degeneration. I don't have a research article that suggests either way for someone in your situation. Essentially, it's a decision that you'll have to make.

If I were you, I would probably not do heavy weightlifting in high degrees of knee flexion as I mentioned before. That's because it would be at an excessive intensity for loading the patellofemoral joint. In addition, I would probably stick to shorter events. That's not to say that you can't run/bike hard and bring your times down. However, minimizing the volume might be the difference between running the cartilage into the ground and not having to get a TKR in your lifetime.

Personally, I wouldn't pursue a marathon. That's just me though and I don't particularly like long distance running so it wouldn't be a hard decision.

You could supplement part of your training on the elliptical, as you said, as it may avoid very sharp increases in quad activity, which create sudden bursts of patellofemoral joint contact and pressure. I wouldn't say you don't have to compete, but my suggestion is to find something that you like that's a shorter distance - 5k, 10k, maybe even a half marathon. I just think that marathon training will do you in.

The medical world is still trying to find a good way to restore cartilage. Synvisc injections were mentioned earlier, but have pretty poor efficacies. Cortisone, prolotherapy, PRP are all ineffective at treating the pathology itself as well. The best intervention you can do it eat well, be moderately (but not excessively) active, take fish oil and glucosamine, and KEEP MOBILE. Making sure your quad and hip flexors are properly stretched is particularly importat.

In addition, you could see a physical therapist to assess the mobility of your patella itself. If it has limited joint mobility, that will load particular parts of the joint excessively, making things worse for you. That would probably be the best conservative action to take.

This is all my opinion, in this case, as there isn't a great guideline on how to approach these things as an active individual. I say take care, be cautious, make accommodations, but don't stop living your life.

 

[episodic]

Well, it's hard to say. There is research that shows being active is the best way to maintain function and joint space in individuals with signs of osteoarthritis (essentially where you heading with a Grade III chrondromalacia). However, excessive volume or intensity of loading can cause further degeneration. I don't have a research article that suggests either way for someone in your situation. Essentially, it's a decision that you'll have to make.

If I were you, I would probably not do heavy weightlifting in high degrees of knee flexion as I mentioned before. That's because it would be at an excessive intensity for loading the patellofemoral joint. In addition, I would probably stick to shorter events. That's not to say that you can't run/bike hard and bring your times down. However, minimizing the volume might be the difference between running the cartilage into the ground and not having to get a TKR in your lifetime.

Personally, I wouldn't pursue a marathon. That's just me though and I don't particularly like long distance running so it wouldn't be a hard decision.

You could supplement part of your training on the elliptical, as you said, as it may avoid very sharp increases in quad activity, which create sudden bursts of patellofemoral joint contact and pressure. I wouldn't say you don't have to compete, but my suggestion is to find something that you like that's a shorter distance - 5k, 10k, maybe even a half marathon. I just think that marathon training will do you in.

The medical world is still trying to find a good way to restore cartilage. Synvisc injections were mentioned earlier, but have pretty poor efficacies. Cortisone, prolotherapy, PRP are all ineffective at treating the pathology itself as well. The best intervention you can do it eat well, be moderately (but not excessively) active, take fish oil and glucosamine, and KEEP MOBILE. Making sure your quad and hip flexors are properly stretched is particularly importat.

In addition, you could see a physical therapist to assess the mobility of your patella itself. If it has limited joint mobility, that will load particular parts of the joint excessively, making things worse for you. That would probably be the best conservative action to take.

This is all my opinion, in this case, as there isn't a great guideline on how to approach these things as an active individual. I say take care, be cautious, make accommodations, but don't stop living your life.

Regarding weights, I've been getting more into kettlebells and the ideas of 'functional' strength. Squatting was always uncomfortable (I know why now), and I never pursued it maximally. I pretty much stopped progressing on squats when I reached my bodyweight on the bar. I do swings with a 1 pood kettlebell, and a few other exercises. I think I've seen that you are a fan of kettlebells before (correct me if I'm wrong). I'm taking squatting with a kettlebell of this size would not be the 'heavy lifting' you are talking about?

 

[slush]

Are you in pain right now, etc? Or does it just swell sometimes? Did they give you a window of 'time' before the TKR? I'm really curious to know everything you were told as you probably went to a 'better' medical place than I did.

Did they tell you the same thing about cycling? Are you into running, etc? What are your plans moving forward? Would love to 'share notes' with you. Feel free to PM me, etc. I know some of this might be too personal for you - so I appreciate whatever you'd be willing to share. Thanks for your time.

Epi,

My knee pain is pretty constant, up and down stairs is uncomfortable all the time, and painful most of the time. If I do any mid-distance walking, the swelling is very noticeable, or if I drive for a long period of time it swells, no tennis as that about kills me. If I stand up and put all my weight on the bad knee, it kills me as well.

The latest development is the general aching down the back of my knee and into my calf.

The OS said they could do the microfracturing surgery but in my case it wouldn't yield results, especially any that would be greater than what the surgery could cause.

He also mentioned the synvisc injections, but didn't think they would do anything either.

It all boiled down to two things; refrain from activities that cause pain (no more tennis, or at least play on clay courts), and to make sure I strengthen my legs, as it is the one thing most likely to lessen the pain and reduce further damage.

He gave me no definitive timeline on the TKR, I think it's one of those "lets try everything else first" type deals.

 

[SociallyChallenged]

Regarding weights, I've been getting more into kettlebells and the ideas of 'functional' strength. Squatting was always uncomfortable (I know why now), and I never pursued it maximally. I pretty much stopped progressing on squats when I reached my bodyweight on the bar. I do swings with a 1 pood kettlebell, and a few other exercises. I think I've seen that you are a fan of kettlebells before (correct me if I'm wrong). I'm taking squatting with a kettlebell of this size would not be the 'heavy lifting' you are talking about?

Kettlebell work, especially swings, power cleans, power snatches, etc are all good. Goblet squats with a 1 pood weight are probably ok, but could aggravate you. I'd probably bias more toward the other stuff, but the squats could be fine.