Tripleshot Cycling

It's been quite the medical learning curve this year, attempting to win back a pair of knees damaged by some questionable judgment and overuse (see Jan 29 post "What not to do on Maui"). But at least I've got a better idea what's going on, thanks (and a tip of the helmet) to Steve the physio, who told me about the MRI cancellation list - the result w as I got the test in 3 weeks rather than as previously booked: April of next year!

As suspected, chondromalacia (kneecap cartilage injury) with bonus - torn meniscus (click, snap) and mild tendinosis. Damn. Following Rob Hasegawa's "time, love and tenderness" prescription, I'm not even doing the 10 minute bike commute to work - for the first time in decades, I'm taking the bus, since even low gear/high cadence cycling was causing knee flare-ups...

Now I'm looking for a surgical fix - are any of you docs/athletes out there able to recommend someone for arthroscopic surgery for the meniscus? Any "cancellation lists" out there for that? (I can handle the pain - I'm just worried about permanent damage to articular cartilage) And any tips on chondromalacia recovery, since that's usually a non-surgical thing.

Any and all suggestions gratefully received- I just want to get back in the pack
___________________________

Fairweather Mike (now willing to ride in any weather if knees get fixed)

Sounds like a tough row to hoe, Mike. Best wishes on getting back in the saddle.

Can't help you on the arthroscopy -- but I will suggest that a bum knee won't stop you from taking the bus to Spinnaker's tomorrow night.

Hi Mike. Tough luck with the knee. I had one of mine scoped by Cecil Caines in Surrey about 6 years ago. Works great now but I don't have any pull to dodge the waitlist. My experience though was that if you identify the surgeon the referral can happen faster.

Hey Mike,

I have a few suggestions but need a little more info. Give me a call at work during the day - 478-8590.

Steve

I'm sure Rob H, Steve, or the docs have told you this already, but I've heard of chondromalacia being a result of imbalances between quad muscles; one side too tight can cause knee cap tracking issues that causes the cartilage wear. I've also heard that the results of arthroscopic surgery are disputed by some, ie. results not that different from physiotherapy. I'm sure it depends on the issue. Maybe read this; the wikipedia entry quotes two studies questionning it's effectiveness. Note the line at the end that even a torn miniscus may not be especially well treated by it. (I'd also add that even statistical evidence shouldn't rule it out; you might have the injury that does need it, even if many others are not helped by it.)

http://en.wikipedia.org/wiki/Arthroscopy

Arthroscopic surgeries of the knee are done for many reasons, but the usefulness of surgery for treating osteoarthritis is doubtful. A double-blind placebo-controlled study on arthroscopic surgery for osteoarthritis of the knee was published in the New England Journal of Medicine in 2002.[9] In this three-group study, 180 military veterans with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement with lavage, or arthroscopic lavage alone without debridement (a procedure only imitating the surgical debridement, where superficial incisions to the skin were made to give the appearance that the debridement procedure had been performed). For two years after the surgeries, patients reported their pain levels and were evaluated for joint motion. Neither the patients nor the independent evaluators knew which patients had received which surgery (thus the "double blind" notation). The study reported, "At no point did either of the intervention groups report less pain or better function than the placebo group."[10] Because there is no confirmed benefit for these surgeries in cases of osteoarthritis of the knee, many payors are reluctant to reimburse surgeons and hospitals for what can be considered a procedure which seems to create the risks of surgery with questionable or no demonstrable benefit.[11] A 2008 study confirmed that there was no long-term benefit for chronic pain, above medication and physical therapy.[12] Since one of the main reasons for arthroscopy is to repair or trim a painful and torn or damaged meniscus, a recent study in the New England Journal of Medicine which shows that about 60% of these tears cause no pain and are found in asymptomatic subjects, may further call the rationale for this procedure into question.[13]

As an alternative, I'm a big fan of biomechanical assessments by physiotherapists to determine the underlying causes of injury. My son had an assessment last year when it was included in the fee for his metro soccer team. It consists of a careful viewing of how you move as you walk, run, do exercises like lunges, and strength and flexibility tests. With no help from us, they found all his previous injuries, and even predicted one.

The same issue, tight hip flexors, caused Osgood Schlatter’s (inflammation below the knee) that stopped his track and field one year, then was a contributing factor in a pelvis fracture two years later, and was the cause of a toe injury a year after that.

At the walk-in clinic they thought the toe injury was a bunion, and the family physician thought it was an impact injury. The physio pointed out that in his gait, he toed off differently on the side with the tight hip. He did two treatments to the hip, and sent him home with exercises. The pain was gone in a week. Meanwhile I had been scouring the internet for info on bunion surgery in young teens.

Each time, renewed attention to hip flexor flexibility cleared things up quickly. (The speed of our learning is another question…. )

Given that many of us are at an age where our posture and movement habits are well learned and not easily altered by ourselves, I’m going to have an assessment every year and pay attention to the advice. $60. Cheap, cheap, cheap.

Thanks to all of you who weighed on on this vexing subject (Lister, you duplicated several months of my research and poking around, with just one post)... the most encouraging, and challenging, notion is that this can be fixed through a combination of biomechanical detective work and the right exercise.

As a matter of interest, I have been seeing a bunch of folks including sports med doc (and triathlete) Paddy McCluskey - he prescribed some VMO (inner quad) and glute activation exercises. For people who literally sit on that muscle all day - attention all office and computer/tech workers - it can go dormant (no signal to the brain, and brain literally forgets its there, so no activation) with major consequences for the other muscles who take over its duties and throw the biomechanics of the leg out of whack. These exercises produced almost immediate and very welcome pain relief; the problem is that after a while the exercises seemed to irritate the patella and the pain returned. Now that I've dialled back absolutely everything except swimming (legs locked with foam pad to avoid knee movement), the low-level pain seems almost constant, with a measure of protective spasm in the patellar tendons and lower lateral quad. Hmmmm....

Steve the physio wonders if dialling back the muscle-balancing exercises has allowed the mistracking to return, with consequential pain and protective response from the muscles (i.e., deactivate to avoid stressing the painful area). This looks like a job for the full biomechanical clinic - Lister, I recall you talking about it at Galen's art reception earlier this year - what's the name of it again?

Hi Mike:

One of the great advantages of therapy-type solutions is you can feel in control of the outcome. 'Hope you get control soon!

The physio clinic my son and I went to is Lifemark at PISE (Camosun Interurban). We've seen several people there, including the head guy Stefan Fletcher. He speaks the most eloquently about the biomechanical approach, but the others there do the same stuff as far as I can tell. I thought I noticed a difference from other physios which seem to have focussed more on treating the injury than the cause. But I did note that Steve said this am that looking at the hip was his approach to knees, so it may be wider in the field than my experience. Or both Stefan and Steve are just good!

Stefan is also a very good soccer and rugby coach, so if you have any history in sports like that he may be able to recognize it. Another one to consider is Barb Biakoloz, (Carly's former tandem partner) a high level cyclist and physio who also does bike fitting.

Hello Mike, We met on Canada day and shared knee stories at the street BBQ. As mentioned I have my share of knee problems too. If and when you want a sedate ride, let me know, as we live really close by. No speed too slow, I assure you.

Pierre