Need some advice about knee pain

[ca1]

I've used the search and read all the relevant threads on patellofemoral pain, chondromalacia, etc… so I've tried to cover all the bases here. I'm not trying to get a diagnosis or treatment, but since you've had several knee procedures, I'd like to get some advice on whether this fits the criteria for involving an OS. Also, I realize that sometimes our knees hurt, but this has been progressing for four months, and I have a hard time believing that the chondral defect is causing all of this since everything else is normal or that a debridement would fix it.

- Age, Gender, current training status 33 Male 6', started with starting strength 11/2011. Did GOMAD and went from about 140 to 175 lbs. Never lifted previously. Began 5/3/1 in November and was doing fine. Have not squatted since 1/7 at 270, last deadlift was 1/11 340.
- Chief Complaint Pain behind patella with acute knee angle. Stiffness and some swelling of the knee.
- Narrative describing the mechanism of injury: Right knee began feeling "off" in early January. I laid off of squatting, deadlifting, and hill sprints (done on press/bench days). I had also been doing lunges on squat days, but cut those out too. The first thing to feel bad was some vague medial patellofemoral soreness. No swelling at this point. Began ibuprofen 2400mg/day for two weeks. No improvement. Saw sports medicine doc at the beginning of February and he suggested switching to aleve 880mg/day for a week or two. He mentioned that it's either not an inflammatory process or that it's in non-vascular tissue. Came back in 2 weeks after no improvement. Did an MRI and was referred to PT. MRI found a 7mm grade 4 chondral defect on lateral patellar cartilage with subchondral marrow edema. Trochlear, medial, and lateral cartilage all normal. Menisci were normal. Tendons and ligaments were all normal. At some point prior to the MRI, I had started noticing swelling and stiffness in my knee, mainly at night. It was not helped by ice, NSAIDs, or elevation.

Began PT 2/21. PT did some manual therapy on my distal quad tendon that was very painful but relieved most of the pain immediately. At that point I was able to do bodyweight squats again relatively pain free. I was told to keep doing bodyweight squats, which felt fine for the most part as long as I kept my shins as vertical as possible.

After a few visits with no further progress we decided that PT wasn't working, and I was referred to an OS in the practice. He seemed reputable since he's worked with some pros and the local university, but he's not a knee specialist. Saw him on 3/26 and he suggested an arthroscopy "to confirm the MRI" and possibly do a debridement to clean up the edges of the defect. I understand that doctors can't make guarantees, but he wouldn't say much about whether I'd be able to return to lifting (or any activity) or at what level. To his credit, he said that a year of squatting wouldn't cause this and that it had likely developed for several years. Patellar tracking is normal according to PT and OS.

- Pain Never got worse than a 4/10, but swelling and stiffness are causing ROM restriction, which is the most annoying
- Describe the pain deep, sharp, and localized.
- What makes it better? Unknown. I've tried RICE, taping, arch supports. Nothing seems to help.
- What makes it worse? Stairs, walking on uneven surfaces, weight-bearing under flexion.
- How do your symptoms behave throughout the day? Best in the morning, worst at night.

- Signs and Symptoms Stiff and swollen at night. Swelling never fully goes away, but is usually mostly better in the morning. Some days are better than others, usually correlated with less activity and avoiding stairs. Bodyweight squats are usually ok for low reps, but I get pain behind the patella when trying to squat even with low weights. I walk very slowly now and take stairs 1 at a time. Knee gives out once or twice a day, usually if I take too long a stride or am on uneven ground.

Other background info: I now realize I had been letting my knees go too far forward at the bottom of my squats and tried a wider stance and keeping my shins more vertical. I have a history of crepitus in both knees. Got caught up in the extreme sports craze of the 90s. Logged a few thousand miles running in high school and college. Taken together, all of my symptoms sound to me iike osteoarthritis, but the OS disagreed. I've laid off of all but routine daily activities for my legs, but the symptoms have only gotten worse.


Questions:
1. Would you recommend the arthroscopy and/or finding a second opinion?
2. Is there any lower body training I can do in the meantime since I can't squat/deadlift pain-free?

[Mark Rippetoe]

I think you have a lunge/running injury that will heal if you start back squatting with correct form. If the pain goes over a 6 we'll have to reconsider, but right now training is the best way to force the issue -- it either heals or it gets worse. I would certainly try this for a month before I let anyone scope the knee. Never again do any unilateral leg work or any knee extensions. Were you doing leg extensions too? By any chance?

Any thoughts on why the pain is medial with a lateral chondral defect?

[ca1]

I appreciate you taking the time to read the long post, and I realized I forgot to say thanks.

I'll start squatting again and see where it goes. Do you recommend I start out light and do a linear progression or at some percent of where I was at back in December?

Early on before I did much research, I tried doing leg extensions for a day or two just to see if it'd help, but it seemed to just aggravate it, so I stopped. I had also tried doing good mornings and SLDLs to work the hamstrings since I've always had tight hamstrings and I'd read that it could help with knee pain, but after a couple weeks of no improvement (didn't make it worse though), I stopped that too.

As for the medial pain with a lateral defect, I think it could either be two separate issues, one being the injury you suggested, or maybe just referred pain.

[Mark Rippetoe]

Just start back with a weight you can tolerate, USE PERFECT FORM, and go up from there.

[heints25]

My experience: http://startingstrength.com/resource...ad.php?t=28043

I had the surgery 11 months ago, and am finally nearing the end of the rehab. My right quad is still significantly smaller compared to the left from being on crutches for 3 months. Squat isn't quite where it was prior to surgery, but deadlift has passed. Rehab is a bitch. It is long, but my knee is much improved. Only thing that bothers it now is cold/wet weather. Living in MN doesn't help that much...I will be able to resume sports this summer, if that ever happens.

My only advice would be to find an ortho who specializes in this. This might help: http://www.carticel.com/patients/surgeon-locator.aspx

Oh, and long distance running is not good for it. My ortho told me about some pretty compelling research he read on how bad marathon running is for your knees (I know, surprise, surprise). The study was on ultra-maration runners. It takes 6 months for the body to recover from an event like that. But, most run several in a year.