knee stiffness and pain, x-ray shows moderate osteoarthritis

[tompaynter]

Hello all,

I have had reduced mobility and pain in my left knee for awhile now, made considerably worse by some conditioning movements I unwisely did about 2 months ago. I have mild pain now just sitting around sometimes, and cannot bend my knee past 90' or so without pain. Just had an x-ray which shows:

"THERE ARE MODERATE SEVERITY OSTEOARTHRITIC CHANGES, NO ACUTE BONY
ABNORMALITY IDENTIFIED. Standing AP and lateral, plus sunrise and tunnel views of the left
knee were obtained. There are moderate osteoarthritic changes
present with spurring of the intercondylar spines, articular margins,
and patellar osteophytes. There is moderate narrowing of the lateral
patellofemoral facet with prominent osteophytes noted on the sunrise
view. There is no evidence of intraarticular loose bodies or joint
effusion."

What's this mean for my training and future? Can range of motion be regained by the stress-recovery-adaptation cycle, i.e., by gently moving and working a little further into the restricted mobility range over time?

Thanks.

[Railbob1776]

I was diagnosed with OA in my right patella in November 2022, but I'm pretty sure it's in both knees. It's depressing. Arthritis is an incurable, degenerative, and progressive condition, ultimately requiring joint replacement surgery. My doc told me I would need surgery in 10-15 years, but who knows? Some days my knees are painful and burning and it feels like I could use the surgery now, and somedays I barely notice it and wonder if the diagnosis was accurate. Based on my research there is not much you can do about it. The stem cell and PRP injections haven't been the game changers people hoped they would.The goal is to slow the degeneration by getting to a healthy weight and staying active.

Staying active doesn't mean you should do dumb stuff but apparently the research has shown that pain associated with activity does not result in acceleration of the degeneration. I'm not sure how much I trust that conclusion. I just avoid stuff that makes my life worse or causes my knees to flare up for more than a day or two. Knee replacements last for 15-20 years so docs are wary about doing the surgery on anyone under 50 since there will likely be a messy revision required down the road but it appears that out of all the joints, the knee replacement technology is improving the quickest. I believe the last stat I saw was that 55% of the population will have some level of OA in the knees after age 55 so the knee surgery demand will hopefully spur innovation. I am going to put off surgery as long as possible to try and get the best technology but ultimately it comes down to pain and function. If the pain becomes too much to deal with day to day and I'm unable to complete daily tasks, it's time for surgery. Good luck.

[tompaynter]

Finally saw a physical therapist. She gave the usual PT prescription: activate my VMO with straight leg raises, standing on one foot, etc. Her thinking is that a stronger VMO will make my knee more stable, particularly in full extension; the stability will mean I don't aggravate the arthritis and inflammation, leading to less pain and stiffness. She also said I could gradually regain range of motion by bending my knee to where it starts to hurt and holding it there; over time I will be able to bend it further and further.

Without debating whether the VMO exists, I do tend not to develop quad size around my knees, particularly on the side that is now sore and stiff. Are her recommendations worthwhile at all or should I ignore them and get back to squatting? Let's break the recommendations down, for clarity:

1) "activating the VMO" by very light, isometric-type exercises
2) regaining mobility by just gradually bending my knee further and further.

Oh, she also suggested a steroid injection to get the inflammation down, so that I could do more strengthening and movement without pain.

3) steroid injection

What say y'all?

Thanks.

[Mark Rippetoe]

The Physical Therapist thinks squats don't activate the "VMO" even though the knee is extending concentrically under load. Fascinating.

[tompaynter]

The Physical Therapist thinks squats don't activate the "VMO" even though the knee is extending concentrically under load. Fascinating.

Her attitude about squats was more that I shouldn't do them because I am getting older and have arthritis and inflammation. Also she looked at the fact that my left quad isn't as developed around the knee as my right as evidence I guess that whatever I had been doing wasn't activating the VMO. I told her that I was squatting 350 for reps back in the fall. I think her logic in part is: 1) He was squatting; 2) his left VMO isn't developed; ergo 3) his squats weren't activating his left VMO. And maybe also 1) the pain is in his left knee, 2) the left VMO is less developed, ergo 3) activating the left VMO will help with the pain.

I am not defending her logic, just describing it.

My left knee had been getting stiffer and more painful over time even as I was squatting and deadlifting pretty successfully. I want to get back to training, but I would like to know if there are other things I should do to help with range of motion, pain, arthritis, etc.

[Will Morris]

Also she looked at the fact that my left quad isn't as developed around the knee as my right as evidence I guess that whatever I had been doing wasn't activating the VMO.

Complicate to validate. When you aren’t interested in actually understanding musculoskeletal and rehabilitative medicine, you just make shit up on the fly despite the fact what you are saying has been extensively shown to be horses$&@. There is no separate and distinct innervation for the obliquely pennated fibers of the VMO compared to the VML. It’s the same muscle, but with a slightly angulated orientation of the fibers. Also, on what planet and what variation of human physiology would allow for light isometric contractions to cause hypertrophy and strength improvements in a muscle that has not responded to heavier loaded movements.

Let me offer a competing theory: you have a slightly worse than mild meniscal pathology that is still causing episodic effusion in the knee and your “underdeveloped” quads on that side are the result of arthrogenic muscle inhibition.

I currently have a client who has “end stage knee osteoarthritis” and was indicated for immediate knee replacement. She opted to try a different approach, and she recently deadlifted 310 and squatted 235 to competition depth, currently plays multiple tennis matches per week, and has zero pain. But, then again, nobody ever assessed her VMO.

[Railbob1776]

Hey Will, do you offer remote consults? If so, how can someone schedule one? Do you have a website? Thanks.

[Will Morris]

Hey Will, do you offer remote consults? If so, how can someone schedule one? Do you have a website? Thanks.

I certainly do. You can reach me at William(dot)morris217(at)gmail(dot)com.

[tompaynter]

Complicate to validate. When you aren’t interested in actually understanding musculoskeletal and rehabilitative medicine, you just make shit up on the fly despite the fact what you are saying has been extensively shown to be horses$&@. There is no separate and distinct innervation for the obliquely pennated fibers of the VMO compared to the VML. It’s the same muscle, but with a slightly angulated orientation of the fibers. Also, on what planet and what variation of human physiology would allow for light isometric contractions to cause hypertrophy and strength improvements in a muscle that has not responded to heavier loaded movements.

Let me offer a competing theory: you have a slightly worse than mild meniscal pathology that is still causing episodic effusion in the knee and your “underdeveloped” quads on that side are the result of arthrogenic muscle inhibition.

I currently have a client who has “end stage knee osteoarthritis” and was indicated for immediate knee replacement. She opted to try a different approach, and she recently deadlifted 310 and squatted 235 to competition depth, currently plays multiple tennis matches per week, and has zero pain. But, then again, nobody ever assessed her VMO.

Is that really a competing theory though? Because it actually sounds consistent with her theory. It is true that the lower quad of my bad knee, particularly on the inside of the leg, is less developed than the other side. I think your mechanism fits within her claim that squats weren't activating the muscle: "due to worse than mild meniscal pathology that is still causing episodic effusion in the knee, you have arthrogenic muscle inhibition that prevents your quads from developing around your knee on that side in response to the heavy squats you were doing."

I am also extremely skeptical that light isometric contractions will do anything. But I had been doing the program, yet even before I aggravated my knee and got the arthritis diagnosis, I had been experiencing increasing stiffness and pain on that side. So I am not sure that just going back to the program is the answer.

I just saw a white-haired grandmother go into a full butt to heels squat, hang out there for two minutes putting on a grandchild's jacket, and then stand up out of the squat. I don't think I could have done that at 20, and I certainly couldn't have done that last fall despite squatting ~350 for reps. There's room for improvement in my knee mobility and strength, despite doing the program.

The point of this isn't to quibble but to learn if there's things I should do beyond the program to improve my knee mobility/strength/function/stability, reduce pain, etc. (or shouldn't do--I'd rather not waste time with the PT's recommendations if they are pointless). I have an appointment with a sports medicine doctor, but I welcome other input.

[Will Morris]

No sir, it is a completely different mechanism. Her mechanism would posit that a squat isn’t effectively activating a small region of the vastus medialis, whereas, arthrogenic muscle inhibition is a central nervous system mediated process.

Her hypothesis suggests that light isometric movements are going to preferentially activate the VMO to somehow “wake it up”, whereas there is no true physiological argument to be made for this, that I am aware of.

Doing the program for someone of your age and training history is radically different than someone who is new to strength development. What was your program like when you stopped? How did you modify your program as you became stronger? That’s the key to this, because most of the injuries you see in the clinic are from improper programming more so than true injuries. That’s why someone with end stage knee osteoarthritis can hit lifetime PRs on her major lifts with no pain, and others are relegated to doing straight leg raises on a PTs plinth. Maybe you should consider leveraging the services of someone like Rori Alter or John Petrizzo, as I am quite certain they can provide a far more valuable service than your outpatient PT.