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Knee Advice
Old 05-18-2009, 10:22 AM   #1
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Knee Advice

I injured my left knee about 30 years ago, in twisting type skiing injury 25 years ago. It hasn't given me any trouble at all, even on a marathon. Starting a month or two ago, I get pain after running or after bending it significantly.

I can get it checked out when I get back from the trip, but for now I'd like some general guidance. The three questions are:

1. It hurts to bend it a lot. For example, if I kneel and sit back on my heels. Should I do gentle stretching (that is, bend it) or not?

2. Should I give it as much rest as possible or do some walking and even running?

3. Are my running days over?

Thanks.
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Old 05-18-2009, 10:52 AM   #2
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I had a similar twisting injury about three years ago on the left knee and it has never really been right afterwards. Like you I was an avid runner having run four marathons when younger. Now if I cross my left leg over my right, the knee starts to hurt. Fast walking and it starts to hurt. Slow running and it will swell a little. If I rest it the pain goes away until the next time I try and run. If there is no swelling I would try some light walking and see if it aggravates. Your probably better served resting the knee for several weeks. My MRI showed nothing seriously wrong and the orthopedic is inclined to leave it alone. I need to get a second opinion some day. I hope you are able to run again, I really miss that.
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Old 05-18-2009, 11:09 AM   #3
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Al,
Rest it. See the doctor. Discuss advantages of Physical Therapy. I have an old hiking injury that flared up. I thought I might have arthritis. Turns out the joint was fine, but I had a large cramp in a muscle that was pulling the knee cap out of alignment -- and that's what hurt.

Six weeks of physical therapy with daily stretching/strengthening exerices. Did a six mile walk two weeks ago. No pain in my knees, but my ankles were complaining a bit.

Plan a six mile hike this week.

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Old 05-18-2009, 11:10 AM   #4
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1. It hurts to bend it a lot. For example, if I kneel and sit back on my heels. Should I do gentle stretching (that is, bend it) or not?
Reminds me of the Groucho Marx routine "Doctor, it hurts when I do this."

That squatting position is one of the worst for putting pressure on knee injuries-- you're maxing the flexion of everything you have left in the joint. You probably injured your knee recently (or just hit the low-level alarm on its worn-down cartilage) and your body is telling you that it needs some recovery/physical therapy. You might have compounded the damage of the previous injury or this is is a totally new problem. Hard to tell.

So yes, gentle stretching to warm up the muscles, but not so aggressively that you're stretching the ligaments & tendons. (You want tight ligaments & tendons so that the parts don't wobble around while you're walking/running.) Instead of static/passive stretches, try dynamic stretches of the activity you're doing-- walking before running, or using your wobble board. If you really want to get into the medical/physical details read Thomas Kurz' "Stretching Scientifically".

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2. Should I give it as much rest as possible or do some walking and even running?
Keep moving. Your quadriceps atrophy extremely quickly if you don't exercise the joint, and things will just get weaker & stiffer. You might benefit from 600-800 mg of ibuprofen before exercising (I use 800 mg because I'm 185 pounds). You won't feel the warning pain but you'll also minimize the swelling. There's no reason to run 10Ks or marathons, but low-impact activity should keep you in shape while healing.

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3. Are my running days over?
Hard question to answer. Groucho would say "Then don't do that anymore!" Some people are built to run and have perfect form all their life. Others wear out. Do you need to keep pounding your feet on the ground and risk total knee replacement in your 70s? Or could you happily spend the rest of your life at moderate low-impact walking & biking?

An additional approach would be to add more knee exercises to your routine and see how your knees respond. I personally loathe these two exercises-- if you're not already doing them then they will challenge your quads & joint strength.
- Work up to 2-3 sets of 15x squats (with or without light weights) on a slow down four-count (femurs parallel to the ground) and a two-count pop up. Single-leg squats without weights are more challenging than double-leg squats with weight-- the idea is to practice control/stability along with building muscle.
- Hold your arms straight in front of you and slowly lunge to a full extension (front knee directly over ankle). Once extended & stable, twist your arms/torso as if you're moving a volleyball from your left side to your right side and back in front. Slowly come up and walk forward to lunge the other leg. Move the beach ball again. 12 steps out and 12 steps back. Three sets. For variety, twist the volleyball back over your shoulders instead of side to side. Going slow and maintaining full stability/control is more important than speed.

When you're feeling strong at those levels then do the second exercise by staying in the lunge as you move forward-- keeping your head at the same height all the way through. Again the challenge is tracking your knees straight ahead instead of wobbling or weaving along the line.

There's also jumping rope on a bouncy surface like a mat or the grass, especially hopping on one foot. But personally I think it gets pretty boring after 5-10 minutes.

At physical therapy I also learned about balancing on one foot on wobble boards or thick foam mats. For extra fun the PT staff would have us toss medicine balls around while standing in that position.

Or you could just do more surfing...
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Old 05-18-2009, 03:54 PM   #5
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I think you should have an evaluation by an orthopedic surgeon before I did anything including excercise. I went through this two years ago because of artheritis. My knee was never bothered by my golf swing but I couldn't walk from the green to the cart. Had an evaluation and he showed me how the knee had detiorated in the joint. Had full knee replacement 30 days later. Eight weeks later I was back on the golf course and have never been sorry. Very painful the first two weeks after surgery and the recovery, exercises, home health care gets old quickly. However, glad I had it done and glad it's over.
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Old 05-18-2009, 04:03 PM   #6
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Great advice from Nords on the ibuprofen and the gentle stretches also ice and rest are usually a good idea until you see an Orthopedist.
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Old 05-18-2009, 07:40 PM   #7
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1. Nords is right about squats. They're knee killers. After knee surgery for bone chips, my doc said I could do anything but squats.

2. I would definitely give it some rest from running. And ice it if its swollen.

3. Your running days may or may not be over. Get it checked by an orthopedic and see what the doc says.

Good luck!
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Old 05-18-2009, 07:50 PM   #8
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I have no medical training past undergrad premed from the previous century. Do not take anything I say as informed medical advice.
I'm a veteran of a childhood knee injury and surgery in the bad old days (the 1960's). Now I go to an orthopedist every five years or so (usually because of a reinjury), and request a prescription for physical therapy.
Every time I go, the orthopedist takes an x-ray, and says I need knee replacement "when I'm ready", but the PT has so far always managed to help me rehabilitate my more aged knees. This has been going on for almost 25 years.
A good therapist can tell if your muscles are in balance, and if not, how to fix them. Just having huge quads is not enough (they know NOW) - you have to have things in balance.
Do not try this at home - get thee to a good PT, IMHO.
I personally have decided to put off knee replacement as long as possible. My orthopedist (I chose him because a physician I respect chose him for HER knee) told me they last only 10 years or so in a younger active person, and then the revision is never as good as the original, so that gives me maybe 20 years, then what? Also I was told I should not run on a replacement knee (just as I'm not supposed to run on my worn original equipment).
Also my orthopedist said that, as I have heard from people here in town with failed knee replacements, he (and other orthos I know) only does revisions on knees he personally has installed. He's going to retire in 5 years or so. So where would that leave me? When I pointed that out to him, he said there were others in his practice that would help me out. Hah!
I agree with previous posters on the ibuprofen, gentle stretches, ice and rest until you can see a PT.
Remember, I have no medical training.
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Old 05-18-2009, 11:44 PM   #9
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Holy Cow Nords, 600-800 Mg of Ibuprofen? Maybe you submariners have stomachs of steel in addition to b---s of steel. I have done 400-600mg 3 times a day for a few days on occasion, due to (you got it) hurting myself while exercising. When I hurt myself sufficiently thru exercise to require that much ibuprofen, I can bet my next paycheck on having stomach problems requiring a few days to a week of tagamet/zantac or a course of Prilosec, and not lose my paycheck.

Does the pre-exercise ibuprofen at that dosage help prevent pain only during exercise or does it keep the exercise from causing pain at all?

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Old 05-19-2009, 04:41 AM   #10
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T-Al - those exercises described by Nords are killers! I just saw my PT doc yesterday and he's ordered another month of PT before I go to agility class. Umm, I can't do those - the single leg squats are really killers - also need to make sure knee never goes beyond plane formed by ankle and knee as seen from the front. Squats (not all the way down) are OK, the leg extension weight machine (open chained movement) is a killer on the knees - I can only go up 60 degrees and it still hurts - don't know if I'll ever get full leg extension on the weight machine. Also the squats could be done against the wall (we called them burpees) or with a stability ball against the wall.

The key thing they've told me in PT is if it hurts, don't do it - now, hurt is a relative term - it is a sharp pain which gets worse or is movement specific, then stop. If it is a general ache and seems to get better with movement, then OK.

Muscle atrophy occurs amazingly fast - need to keep the quad moving and the strength as balanced as possible. Balance exercises are paramount for healthy knees as well - standing on the pads and doing various leg movements with one leg as well as jumping on a trampoline with only one leg will definitely help you.

Running - good question - I've just started re-jogging - I'm using the podrunner intervals couch to 5K program - it's good, but I'll say I don't know if I'll ever feel as comfortable as I was before - it just takes time.

Other ideas - my Dad has knee issues (surgery this Wed for meniscus repair and Baker's cyst) - can't bend his knee, although he's quite a bit more sedentary than you. Arthritis? Although your description sounds like the pain is movement or position induced.

Go see a PT - they can help with the biomechanical aspects - then if that doesn't work an orthopod may be needed. Lastly, the body does heal itself well (we are interesting self-healing/correcting organisms). Ligaments and tendons are the second slowest biological materials to heal (nerves the slowest). So patience may be the order of the day/month/year.
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Old 05-20-2009, 12:36 AM   #11
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Holy Cow Nords, 600-800 Mg of Ibuprofen?
Well, I was never a picky eater, even before I joined the Navy.

Apparently ibuprofen is dosed by weight. I'm 180 pounds now, and my orthopedic surgeon said that at my weight the ibuprofen's anti-inflammatory properties don't even start until 600 mg-- and are considered effective at 800 mg. (He was clicking away at a PDA calculator as he spoke.) So I could probably have pain relief at a lower dosage but it wouldn't stop the body's swelling reflex. The stiffness that comes from the swelling is definitely counterproductive to 540-degree hook kicks. When I'm hurting I tend to guard the joint, which only makes my form (and the strain on the joint) even worse. It's a vicious death spiral.

Ibuprofen can eat away at the stomach's lining, so I only take it after a meal and I wash it down with a couple cups (literally 24 oz) of water. I don't take less than 800 mg at a time, and I try not to dose 800 mg more than three times a day.* I don't use any other medications. The stronger & more stable my knees get, the less I need ibuprofen.

The orthopod also said that he recommends over two dozen anti-inflammatory & pain-relieving medicines, some over-the-counter and many prescription. He starts with the easiest (ibuprofen) and works his way up to the addictive stuff until the patient finds something that does the job without too many side effects. He said everyone's different. For example, I don't seem to get any benefit from naprosen but its label warnings scare me. He's had others go through the entire list until by the time they're getting relief there's a very real issue with addiction. But I'd quit taekwondo before that point. I already know a 3rd dan black belt who's facing hip-replacement surgery in his 40s.

Swelling is a body's healing reflex. These days it's not automatically considered bad, but if left unchecked the body will begin the swelling reflex with progressively less exertion. So the best approach is to use the anti-inflammatory before the body realizes that it needs to swell up something, and to keep taking the medication until the body decides it's done trying to swell up.

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Does the pre-exercise ibuprofen at that dosage help prevent pain only during exercise or does it keep the exercise from causing pain at all?
Yes and mostly. I take 800 mg after dinner before heading to taekwondo. Most nights there's no pain afterward but if it's been a session of 100 hook kicks then I'll feel it in my "worse" knee by the time I'm finished showering. In that case as soon as I've eaten the next morning I'll take another 800 mg. I do this routine 2-3x/week. If I'm more active during the day (yardwork, heavy lifting, surfing, a tournament) then I may take three 800-mg doses a day for 2-3 days.

Two years ago when my knees were weak & injured I'd start swelling up after just the warmups or a couple squats, and even with ibuprofen it would take a week for the swelling to stop. Today my knees are a lot stronger (even though I still have no ACLs), I have full flex down to squatting on my heels, and my knees rarely swell up. If I pay attention to the ibuprofen beforehand then they don't swell up at all.

There are solutions, but only a doctor can safely guide the search.
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Old 05-20-2009, 12:41 AM   #12
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Thanks. I think I have my answer...eat first, drink lots. This is not something I have been doing...its more often on an empty stomach. Might try that next time I'm doing speedwork.

Thx for the explanation.

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Old 05-28-2009, 12:31 PM   #13
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Before you spend alot of $$ or surgey, read this - http://www.medscape.com/viewarticle/478840

It is mostly about the back but the knee is also referenced. Dr John Sarno's view into why we get pain is worth learing about. Get his book. I treated my back pain using his methods.
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Old 06-02-2009, 05:51 PM   #14
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Just got back from our trip, and the knee is a little bit better now.

I'm curious about this: It hurts worst when I've been driving or sitting for a few hours with my knee comfortably bent, then straighten it out to walk. What's going on, are there adhesions that get formed while it's sitting in one position?
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Old 06-02-2009, 05:59 PM   #15
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I'm curious about this: It hurts worst when I've been driving or sitting for a few hours with my knee comfortably bent, then straighten it out to walk. What's going on, are there adhesions that get formed while it's sitting in one position?
Al, I know this is going to come as a big shock, but consider for a moment it may be simply due to the fact you're getting old. Happens to the best of us...
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Old 06-02-2009, 06:03 PM   #16
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Just got back from our trip, and the knee is a little bit better now.

I'm curious about this: It hurts worst when I've been driving or sitting for a few hours with my knee comfortably bent, then straighten it out to walk. What's going on, are there adhesions that get formed while it's sitting in one position?
Too soon for adhesion, Al, most likely. Any irritated or inflaimed area tends to collect fluid and swell a bit; the fluid makes things swollen and uncomfortable. That's why elevation is often recommended. In your case, the relative lack of lots of movement, dependent position and prolonged non-use probably are just gunking things up a bit. Just my guess.
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Old 06-02-2009, 06:58 PM   #17
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Al, I know this is going to come as a big shock, but consider for a moment it may be simply due to the fact you're getting old. Happens to the best of us...
Nah, if it was due to getting older, then he would utter a couple of expletives under his breath while trying to straighten out his knee...

Not that I would know anything about that, of course!
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Old 06-02-2009, 11:31 PM   #18
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I'm curious about this: It hurts worst when I've been driving or sitting for a few hours with my knee comfortably bent, then straighten it out to walk. What's going on, are there adhesions that get formed while it's sitting in one position?
I stiffen up like that all the time. The first step is the worst, especially the morning after taekwondo. It seems to happen less often if I've been exercising and surfing.

But I like Rich's explanation a heckuva lot better than "incipient arthritis".

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Nah, if it was due to getting older, then he would utter a couple of expletives under his breath while trying to straighten out his knee...
Not that I would know anything about that, of course!
Nah, you're supposed to let out an involuntary groan or a grunt!
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Old 06-03-2009, 09:43 PM   #19
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Just got back from our trip, and the knee is a little bit better now.

I'm curious about this: It hurts worst when I've been driving or sitting for a few hours with my knee comfortably bent, then straighten it out to walk. What's going on, are there adhesions that get formed while it's sitting in one position?

Most likely patellofemoral syndrome, if the pain is in the front of the knee (or feels like it is under the kneecap). There is a low level load (joint reaction force between the patella and femur) that after prolonged knee flexion can result in this type of pain.

The patella sits in a groove of the femur. It glides back and forth like a train on a track. When structures attached to the patella (usually on the lateral, or outside part) get tight, they tilt the patella and pull it slightly out of alignment. Sitting for a long time with it out of alignment like that only increases the joint reaction force farther.

It may very well get better now that you aren't driving so much. If it doesn't improve, you may want to get a referral to a PT who can do patellar mobilizations, teach you stretches for the tight areas, work on the alignment, try some taping techniques, and/or specific strengthening of the medial (inner) quad (vastus medialis).

Of course, if the pain is deep in the joint, it could be good old arthritis or a meniscal issue, among others.

Hope you enjoyed your anatomy and biomechanics lesson!
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Old 08-26-2009, 02:21 PM   #20
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Update: It's pretty much all better now. Good prediction, SG. I gradually started running again a month after it started bothering me, and was careful to warm up gradually.

I ran three miles on pavement last Sunday, and didn't have any pain (although I did take two ibuprofens after the run).
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