Eight Months of Patellar Pain

One day running my usual 10 to 15 miles a week I felt a sharp pain under the lower front part of my knee. It’s now been eight months, and I still have a little pain in my knee when I walk. I can actually hear a kind of slipping and popping in the knee socket when my left heel touches the ground. If I walk a lot and then sit, the knee gets stiff and sore. What can I do to get through this and back to running? I'm 6' 2", 200 lbs.

Tom Katevatis
Raleigh, NC

Instability of the fibular head is possible, but is usually caused by significant trauma, for example, a car accident; and there are usually other ligament injuries as well. A simple exam by an orthopedic surgeon can determine whether the head is subluxing (slipping). One treatment for this consists of fusing the head of the fibula to the adjacent tibia. This is a relatively short and predictable operation and should allow you to return to running. That said, I don't quite have a good explanation for why this has occurred in the first place, so upon examination you may find yourself with an altogether different diagnosis.

Klaud Miller, MD
Evanston, IL

What Are My Options For Osteochondritis?

I was recently diagnosed with osteochondritis dissecans (OCD) in my right knee. My doctor explained that this is essentially a piece of bone that has separated from the end of the bone. He recommends I have osteochondral allograft transplant surgery (OATS). I have already had meniscus surgery on this knee, about a year and a half ago. I'm wondering what the best course of action is at this point. I've been running for 22 years (I'm 52), and I can still jog slowly on a treadmill.

James Douglas
Round Rock, TX

There are many issues with osteochondritis, and the OATS procedure brings more into play. I assume that if allograft is anticipated there must be large OCD lesions, otherwise autograft tissue might be preferable. I would probably avoid surgery until you do not have other options. Patella-centering braces, NSAIDs, quadriceps strengthening exercises, and crosstraining would all likely be helpful. I would avoid stairs, hills, and the like and never train to excess. Some patients use injections of viscous material like Synvics.

In the right circumstances OATS is a good procedure. However, if the lesion is small with intact articular cartilage, the bone scan normal, and your symptoms minor, then the real value of the procedure is less evident.

Larry D. Hull, MD
Centralia, WA

In order to make an assessment I’d have to see your MRI as well as an A/P longstanding view of both lower extremities to determine the size of the OCD defect, your weight-bearing alignment, and associated intraarticular knee disease. My experience with allograft osteochondral grafting has been very encouraging. Results, at least in the short term, are excellent.

Rob Meislin, MD
New York, NY

Where the Tendon Meets the Hamstring, Chronic Pain

I have been a runner since 1972 and had never had hamstring issues until I combined yoga and running. I have practiced Ashtanga yoga for over 11 years.

I was injured doing yoga a decade ago, and I have never gotten over the injury. In yoga it is referred to as “sit bone” pain, but I believe it is essentially a high hamstring injury. I am 54 years old, weigh 112 lbs, and am 5 feet 6 inches.

I have rested, crosstrained, etc. I am able to run, but not at the intensity or duration I once did and during yoga I have to be very careful when doing anything involving the hamstrings, which in yoga is almost every asana. For running, it means no hills and no interval training. I have gone from 6:30 mile pace to 8:00 mile pace.
 
There have been times when even walking was difficult, and sitting at length (especially in a car) was very painful. Also, at the height of the pain, I could not even do 10 lbs on the curl machine.
 
My new yoga teacher has indicated it may involve the sacroiliac joint and the pelvis being "locked." I’m interested to know your thoughts on this and would really appreciate any suggestions to help me move beyond this injury.
 
Rita Andersen
Holyoke, MA

While high hamstring tendinopathy is most commonly seen in runners, it can occur with other activities. Runners tend to develop this problem after years of running. Tendinopathy describes chronic injury to the tendon as opposed to an acute strain. As a result, stride length will decrease due to a loss of flexibility. Strength deficits will also be present. Single leg exercises to address the strength and flexibility deficits are essential to recover from this problem; stopping the offending activities may be a necessary component of the recovery process. Running through the problem will result in exactly what you are describing: a significant decrease in speed.

The "sit bones" (otherwise known as the ischial tuberosities) are on the bottom rim of each side of the pelvis. The majority of the hamstring tendons originate here. Sitting on a hard surface or in the bucket seat of a car will put pressure on this site, causing pain.

The pelvic bones attach to the sacrum, creating the sacroiliac (SI) joints. Any abnormality in the lower back and pelvis will impact other structures in the area. Chronically irritated proximal hamstring tendons may cause irritation of the SI joints. Irritation of the sciatic nerve and hip flexors may occur in conjunction with hamstring tendinopathy. It is also possible an alignment issue in your pelvis or back was the cause of the hamstring problem. Each step that you take is the result of a chain of events; a problem with one link affects the entire chain.

You should seek evaluation by a sports medicine specialist to assess alignment, mobility, strength and flexibility. You may discuss treatments in addition to exercises, such as platelet rich plasma (PRP) injections. Recovery will be a slow process, especially since the problem has been present for more than a decade. Hang in there with the therapy and you will likely note improvement in your symptoms.
 
Cathy Fieseler, MD
Tyler, TX

Without actually examining you I believe this pain could be caused from small tears in your hamstring or connected tendons. Since your hamstring attaches via tendon tissue, it is possible that the tears have occurred at the junction of the tendon and the hamstring muscle. Sometimes during yoga, participants will overstretch the hamstring causing these small tears. This can be the source of your pain.

If the pain is a result of performing yoga exercises on a firm mat, it is possible that the pain is caused by a bruising. In either case, pain while sitting for a prolonged period in a chair or in a car can be bothersome. This injury will also likely bother you when running, especially on an incline.

I would recommend that you perform higher repetition (15 to 20 reps) leg curls with low resistance. The first intent of these exercises is to stretch the hamstrings and glutes and increase blood flow to these working muscles. The second goal is to increase the strength in these muscles.

Gradually increase the resistance you are using until it is challenging to perform 10 to 15 repetitions in your leg curl exercise. If you experience any pain during either exercise, it is likely that it will be experienced when the muscles are in a stretched position, so pause in a stretched position for two seconds. Let any pain be an indicator that you have stretched sufficiently for that particular repetition. Use your pain to let you know when you have stretched far enough—never try to continue stretching through the pain.

You can place warm, moist heat on your hamstring/buttock area prior to working out to promote blood flow to the areas. Daily contrasting applications of heat before (20 minutes) and ice after (20 to 30 minutes) workouts will help to promote recovery.

When you feel that you are ready to return to running, you should begin on a flat surface and at a comfortable speed. And whenever you perform any exercise or work in a standing or seated position, try to maintain a slight bend at your knees, as this will reduce stress on your hamstrings and connected tendons.

John Comereski, MD
Ithaca, NY

Even Cycling Can Trouble The ITB

As a runner, I’ve gone over 25 years logging about 15 miles a week without pain or injury. Recently I’ve started biking several times a week, and I was surprised when I began to develop pain in my right knee. I’ve always been under the impression that the impact forces due to running were the major culprit of knee pain, and that biking was in fact what a lot of injured runners wind up resorting to permanently after they “retire” from running due to knee pain. The onset of this pain has almost exactly coincided with my new biking habit. It is on the outside of my right knee, and so it feels a lot like iliotibial band syndrome. Can bicycling cause knee injury?
 
FrancIs Goodsell
New Lenox, IL

It’s important, first off, that you don’t go too long guessing at a diagnosis: If your problem hasn’t resolved after resting for a week or two, find a sports medicine professional for a thorough evaluation. Iliotibial band syndrome (ITBS) is most common among runners, but it can also occur in cyclists. Cycling might also exacerbate an underlying, mild ITBS condition. Whether or not your problem turns out to be ITBS, the first thing you should do is find a professional bike shop and have your bicycle evaluated for fit. If your frame is too big or too small, or your seat adjustment is incorrect for your body, it can increase the stress and strain on both of your knees, hips and back.

Once you are certain your bike fit is correct, you can minimize strain while riding if you avoid your big ring and stay in your saddle. When climbing hills, try spinning up rather than pushing a bigger gear. You will generate less force and will decrease the compressive load on your ITB at the knee.

As for recovery and future prevention, avoid running on a cambered surface (this doesn’t apply if you always run on a treadmill). Make sure you are wearing the right running shoes for your foot and running style, without excessive mileage. It is also very important to keep the ITB stretched from the hip to the knee. Stand with your left side about 12 to 18 inches away from a wall or other support, and cross your left foot in front of your right foot. Lean toward the wall, with your right arm straight up, pushing your right hip away, stretching your arm toward the wall, until you feel a stretch from the hip downward. Hold for 30 seconds and repeat on the other side.

Pain can be minimized with massage (manually or by rolling on your side on a styrofoam roll); icing, stretching and topical anti-inflammatories (ask your pharmacist about these). It can be helpful to strengthen the gluteal muscles, particularly the gluteus medius, which is primarily responsible for abduction (moving the leg laterally away from the body), and is important in controlling pelvic motion. This may, in turn, reduce the tension on the ITB from above. To strengthen hip abduction, while lying on your side with the affected leg up and weight applied to the ankle, slowly lift (abduct) the leg and slowly lower it.

John Cianca, MD
Houston, TX

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