nagging knee injury - sports/physio types need advice

Ok so i'm a long time reader, sometimes poster. This is a bit of a long post, but I thought the details are important.

Long and short - I have constant pain in my RIGHT knee. All day, only stops when I stop.

What I need to know is where/how do I repair this? Start with family doctor? Skip and straight to physio?

Here's the details:

Patient - male 41, as active as a small business owner, sole bread winner with two kids under six can be. Weekly bike, weekly ski (tour or whistler) former marathon runner. Occupation: General Contractor - lots of time driving, talking on phone. No tool time anymore, business is too busy. Runner/biker/skier/climber/former mountaineer from early teens to present. Always maintained a respectable level of fitness.

History - this all starts 10 years ago:

1) I crashed my DH bike, mangled my LEFT ankle. Did not seek medical attention. Ankle like a ballon, took an uncharacteristically long time to heal. I suspect there was ligament damage. Very easy to re-injure now. If I mis-step while trail running I still get a 7/10 pain shot in the ankle. Had a serious re-injury last summer that I should have milked the recovery longer but didn't. My ankle looks "weak" slopes to the inside of my stance compared to right ankle.

2) 2002: tried to run a sub 3hr marathon (second that year). Did lots of track work without really know what I was doing. End result - ended up hobbling across the finish line in 3:20 with massive disfunction of my RIGHT knee. Physio says its a super tight ligament that runs from my butt to past my knee (IT Band). I was given rubber ball and tube exercises to stretch the ligament. Seemed to work. I rested a couple of years (read: kids came along). But still ran trails with a semi-serious intent to get into ultra long running.

3) Dirty duo 2009. I do the ride portion no problem. The run kills my knee again. I'm 20k in and hobbled at the right knee. Finish race limping across the line.

- bit of a rest, still maintaining fitness (Read: 2-3-4 runs per week with weekly milage in the 50k range)

4) FALL 2010. I run from Cypress to Porto Cove. 8hr run, lots of elevation gains and drops. Was doing awesome until the 6hr mark then the RIGHT knee again. Basically the same as above, little more intense. Limp into the car.

5) Winter 2010. I go to one physio appointment complaining about my RIGHT knee. She checks me out and basically says "sure that knee is weak/fucked up, but so is your left ankle - maybe even more so". This is news to me, I didn't really give that original injury a second thought. Gives me exercises which I do with ok persistence.

5) Spring 2011. I can ride a bike with a bit of pain. I can ski but feel it all day. I can't run. 10 k and the knee is saying no. I give up and focus on family and work.

6) I'm loosing fitness at a scary rate.

7) Yesterday and all last winter: putting on my LEFT ski boot is very painful. I have to do it in one fast push. Feels like I'm hyperextending the ankle but once I'm in the boot - I'm fine.

The end.

So this is the advice I'm looking for: I want to run again. I'm loosing fitness fast because I can't just jump out the door and get a work-out. Fellow runners know what I'm talking about - no fuss, no muss. Watch and shoes and a water bottle - done.

Where do I start? I'm uncomfortable with physio because I feel like I need empirical evidence of the damage - both ankle and knee before I can trust their program. Also hate that it will take a really long time to repair damage (but I can get over that).

Go see my MD? Get xrays and then to physio? What would you sport injury pros do?

Thanks.

You need to go straight to a sports med doctor. Get a referral from your family doctor ASAP.

In the meantime, maybe look into swimming to stay in shape?

If you're in North Van, I found Dr. Bovard to be very thorough.

^^^^

Sports Med Doctor is definatly the way to go.

I found physio was a waste of time/money for my seperated shoulders.

Also start from the ground up. Insoles then ankle support go a long way. A messed up ankle or knee can easily travel to your back and then its game over.

Thanks, I didn't really think of the Sports MD route. I guess that's the way to go. I think physio can help me, but I really need to know what's wrong before I spent the cash.

Go see Paolo at Salus physio. You may have to wait a bit to get in, but hes a good man. Do not skeptical hippo on this physio recommendation, he is REALLY good.

In the meantime, if it is tendon related, simmer the fuck down for a bit. Lots of ibuprofen, like 800mg 4 times a day for 5 days. Work on your mobility, probably lots of stuff relating to your hip flexors and hamstrings. For some good mobility stuff check out www.mobilitywod.com (inb4 someone says I crossfit, I don't.)

Other than that?

Stretch. Ice. Foam Roll. Standard recommendations. In 6 months, even if the knee is still fucked, other stuff will be better, and you will be a more mobile and better athlete because of it.

1. As the others have already said - go to a specialist right away.

2. If you love running (and assuming that you are allowed to continue running after having been to the specialist) try and get a coach who may teach you a thing or two, same goes for biking. It may well be that the muscles, tendons nd ligaments are too tight, or that the angle of your knee is not good = if the knee is not positioned properly between the hip joint and the ankle it might lead to a misplacement and pain (in the long run).

3. Get the ankle injury checked as well, it might be that you are slowly destroying yourself. Two years ago I badly sprained the muscle that pulls up the foot. The muscle originates in the knee area, and a result was that I could not hike, run or sit on a floor comfortably. I had to take time off for about 6 months. And sometimes it still hurts. The older you get the harder the recovery if not done properly.

4. Recover and take it easy. Swimming is an option. Exercises for mobility and soft muscles and tendonds/ligaments are definitely a must-do, imho. Ever thought about joining a yoga class?

I found a lot of useful info in this little gem:

Bisio, Tom: A Tooth from the Tiger's Mouth: How to Treat Your Injuries with Powerful Healing Secrets of the Great Chinese Warrior

Link here.

Good luck!

the human body is a pretty amazing machine, a relatively simple system of pullies and levers capable of astonishing feats. but when the machine isn't functioning properly, when things are out or balance of alignment, the whole system suffers. it could very well be that the problems with your left ankle are causing the issues with your right knee.

a good physio will be able to help and the a good physio should do a few key things when dealing with a patient.

1. assess the injury, let you know what the problem is
2. they should prescribe a course of action and give you a predicted outcome.
3. they should re-assess you periodically to see if you're on track with getting better and if you're not then they shoud re-diagnose you as they've either done it incorrectly in the first place or they've given you the wrong course of action. this thrid step is the most critical one.

of course, this is all dependent on the patient sticking to the rehab program.

the high volume of running you're trying to do is undoubtedly playing a part as welldue to the amount of unbalanced stress you're placing on your body. if fitness is really important to you right now you may simply have to back off on the volume of training you're trying to do. you could try slowly increasing the intensity of your workouts to help maintain your fitness or you could look at trying other activities at higher intenstiy levels as well as ways to boost your fitness.

whatever you do you have to consider the whole body as a system. this includes managing any injuries you have along with the total volume and type of training you're doing. good luck and hopefully it goes well for you.

ps - also sent you a pm

I had a similar issue with my ankle - got it whacked hard playing soccer. It nagged me all season, swelling after every practice or game. I lucked out in seeing a good physio who quickly diagnosed the problem and got me back to normal. In my case, the initial injury caused me to "adjust" to avoid pain, throwing my lower leg and ankle out of balance. I was compensating incorrectly and weakening muscles that were necessary for proper balance and strength. I couldn't stand on the one foot with any decent balance. Anyway, a few weeks of the prescribed daily exercises got me back to normal.

Get your knee checked out at a sports medicine clinic. If you go through your doctor, tell them you're an athlete - a marathon runner and ski racer; it sometimes helps get you into a better clinic.

what exactly is the question? At the least you need MRI of the bone and soft tissue. After obtaining an actual diagnosis, proceed… but no one is going to diagnose anything in this setting without images. Anyone that says otherwise is lying.

Anyway, one relevant aspect that you told us is that you're in _constant _pain. That's generally something intra-articular, such as a torn meniscus. Other kinds of pain, i.e. only going downstairs, occasional shooting pain, worse in the evening, worse in the morning, etc etc… mean other things.

Regardless, an anatomic diagnosis is needed, because if something is torn, physio will not do anything and you're wasting your money and hurting yourself.

also not to be a dickhead, but why are you hobbling across finish-lines? What is this? Braveheart? Are you fighting for the freedom of the western world? Don't hurt yourself.

what exactly is the question? At the least you need MRI of the bone and soft tissue. After obtaining an actual diagnosis, proceed… but no one is going to diagnose anything in this setting without images. Anyone that says otherwise is lying. Regardless, an anatomic diagnosis is needed, because if something is torn, physio will not do anything and you're wasting your money and hurting yourself.

Boom right on the money. If you dont have an MRI and proper diagnosis of your knee, physio wont do a damn thing. I had the same thing, was told by lawyers to goto physio, went once, sat around as he bent my knee, said ya knees arent supposed to do this you need to get an MRI and come back.

Regardless, an anatomic diagnosis is needed, because if something is torn, physio will not do anything and you're wasting your money and hurting yourself.

Agree 1000%. There are good physios and OK physios, but from the OP's description he needs to go straight to a sports med doctor and get checked out first. Then try physio under the course of plan suggested by the sports med doc.

And yes, I've gone through this personally with a nagging knee issue.

I used to be an adventurer like you, until I took an arrow in the knee

Running is very high impact on your knees. Find an alternate source of exercise for now and seek physiotherapy until you can get a referal to a sports medicine doc. Personally had good results with UBC sports medicine clinic.

I developed Patellofemoral Pain Syndrome on my right knee from DH riding alot with my right leg back/left leg forward. I know a few others who have had this problem from mtb

alternating your stance while not easy helped quite a bit.