Arthroscopy?

[westtexas]

Hi all!

I haven't been on much lately because I haven't ridden my bike in over 2 months now. I was having some problems with my knee and went to see an orthopod who diagnosed me with a tight IT band, a luxating patella, and weakness in my VMO. It only affects my left side and we've been over my bike fit a million times to make sure it's not the source of my issue. But riding is painful for me now and so I'm staying off the bike (probably why I've been getting a bunch of colds and feeling blue lately) for now.

Today I went back to my doc after 3 weeks of PT and he was not happy with the results. Although my patella is more mobile now and my IT band is nicely stretching, my VMO is not responding/getting stronger. We're giving it another 3 weeks of targeted VMO exercises in PT 3x/week, but if it's not better then, he wants to do a lateral release arthroscopically.

I was wondering if any of you ladies had ever had an arthroscopic surgery done before? I've done it/seen it done in animals before, but not in people. He says that the main problem is the extreme swelling after surgery. I only ask because I live alone in a third floor apartment and I have no family/friends here who could help me out. Is this something where I could manage on my own or do I need to start planning to fly my mom out to come help me out? How about going back to work right away? What's the pain like afterward? I'm pretty much a huge wimp so I am dreading this if it has to be done.

Thanks in advance for any insight!

[Kathi]

Three years ago I had an ortho who recommended lateral release surgery. I postponed it until after the ski season. So glad I did, the problem was in my hip, actually my left SI joint, not my knee. Since then I've had 2 pt's tell me that lateral release surgery isn't always successful. I've also been told by my PT's that most knee problems come from the hips, not the knee. I know this isn't much help but I suggest you think very carefully before having surgery.

[Kiwi Stoker]

My sister had keyhole knee surgery this year. They normally have an icepack on your knee as soon as you are out of surgery and tell you to keep on icing it regulary.

The main issue is crutches and getting around. You probably can do this yourself BUT you have to be ultra prepared.

Cook and freeze a whole heap of meals- you won't want to be cooking and trying to crutch around.

Ask someone to fill a thermos with hot water everyday- you cannot carry a hot drink on crutches.

Wear a sling bag around your neck to carry things. My sister didn't and carried things in her teeth!

Have a mobile phone nearby or in your sling bag ALWAYS.

Get a plastic stool to sit on in the shower.

Clean the house before surgery.

Look into getting groceries delivered to your door. Well actually you kitchen bench would be better.

You probably need someone with you for the first day after discahrge, however if you do get your mom out, a week would be best at least.

[pll]

I hope Knotted will read your post, but without any expertise in the area, I wonder what causes the problem only on your left side, and if you can correct/compensate whatever asymmetry is the root cause, then the muscles will be better behaved.

[Possegal]

I've had a lateral release done. I am definitely much better off since my surgery. I had it done a year after I had a patella dislocation and prior to the surgery I couldn't comfortably walk up and down steps and I could only run 1/16th of a mile and even then it hurt. I had been in PT nearly that whole year.

I will say though, that the PT who had worked on me both post injury and then post surgery, said that I was the only successful lateral release she and the other PTs there had worked on. She said most others saw no real change after their surgery.

That is purely anecdotal though, but thought it worth mentioning. I'm glad that I didn't talk to her prior to the surgery, or I may not have had it. And I'm glad I did have it as it is really much better. The surgeon said my patella was textbook for a tracking abnormality.

That's a mixed bag of info and probably didn't help you much. :) I did have a friend from HS that had one and she was much better after it too. I remember doing some internet searching and finding all sorts of people with bad stories. Then I was reminded that the people with the good stories were out doing things on their new happy knees. :)

I woke up with the giant ice pack on the knee, but I never needed crutches after the surgery. I got around pretty well from the day after onward. My sister came with me and stayed for about 36 hrs, but then I was on my own and it was no problem. For me I compared it a lot to the original injury and the injury was so much worse. That may have given me a different perspective to it. PT after the injury was really rough, after the surgery it wasn't.

Pain - I didn't have much pain at all. I think I took the pain pills the first 24 hrs but then didn't bother. I went out to lunch with my niece and sister on Sunday afternoon (and the surgery was Friday morning). I'm trying to remember how long I was off work (this was a while ago) and I'm thinking I took a week off. Then the first week or so back at work, well I wasn't running down the hallways :) and I did wear sweats most of the time for ease of putting them on. But again, no crutches, at all. Did the Dr tell you that you'd need them? I remember asking mine if I should bring them (had a pair from the ER when I dislocated) and he was all - oh no, you won't need that. He told me to NOT immobilize it and to NOT stop from putting my weight on it. So like I said, I was very mobile very soon after the surgery.

Just my experience, but I did have the exact surgery you are talking about.

[soprano]

Get a second opinion from a doctor who does not have a financial stake in your potential surgery.

I would absolutely fly my mom out. (Well, not my mom specifically because we don't get along, but you get the picture.)

Untill you get good with crutches, to get up stairs, turn around, sit down and scoot yourself up. Does this surgery require general anesthesia? Three flights of stairs is going to suck. Would you consider staying with a friend that night? My husband had two orthopedic surgeries a few years ago, and both times getting him up 2 steps and as far as the couch was quite an ordeal. I can't lift him, so he almost spent a night on the kitchen floor!

[Sky King]

My lateral release was done in 1998 and I have never regretted it. I will say that my knee is really ugly though. I have a big dimple on the top outside of my knee where the ligament is attached. While he was at it the ortho "roughed" up areas of bone to stimulate the area.
I do not have regular pain
My knee still sounds horrible and it really "clunks" but it has be almost 12 years.
My knee does swell often, especially after long rides and long hikes or backpacking.
I am not as flexible as I should be
I avoid activity that involves side to side movements (soccer, volleyball)
I do not run, EVER
I do not jump, Ever
This is my left side, which is basically a mess but as PT isn't an option I do stretch and am bartering some yoga with a friend.

Good luck, I had stairs and did spend the first two nights on the couch but then was able to handle the stairs. See if your insurance will cover "home health" type stuff for the first couple days.
I was always able to put weight on my knee, just not full weight for the first week.

[ehirsch83]

I did about 4 years ago. I was able to get around on crutches starting the next day, granted I lived in an apartment building with an elevator though.

Stairs will be a challenge until you get used to them :(

One more thing, I know you have been over your fit- but have you had your cleats gone over by a professional fitter?(someone who is a certified fitter)

[OakLeaf]

One more thing, I know you have been over your fit- but have you had your cleats gone over by a professional fitter?(someone who is a certified fitter)

Or your crankarm length? And did the PT assess your feet (which can be a source of all kinds of knee trouble) and/or hips?

It hardly sounds to me like three weeks of PT is enough to decide that you aren't getting stronger. Does the PT think you won't continue to get stronger enough to resolve the issues?

[Wahine]

You've seen a few posts already about the success of a lateral release. In my 17 years (OMG, how is it that long since I graduated!!!!:eek::eek:) experience as a PT, I have not seen a successful lateral release, except in those cases where recurrent patellar dislocations (much more serious than a subluxation) is an issue. I think that Possegal falls into that category.

Hips have a huge part to play in these problems as mentioned by Kathi. Often there is a lack of flexibility in the hips (usually they don't turn out well) and/or a lack of strength (of the muscles that turn the hips out. There can also be a problem with the feet. If you have very flat arches that will cause bad things to happen at the patella. So be sure to have your PT look at your hips and feet.

Treatments that can be very effective:
1) Manual treatments to release the quads, IT band complex, tensor fascia lata, gluteus medius and minimus. Including trigger point dry needling.
2) Exercises to increase hip external rotation and gluteus maximus strength
3) Exercises to increase the medial longitudinal arch height and control in the foot and/or foot beds to support the arch
4) Bike fitting and analysis of pedaling technique!!


3 weeks is definitely not enough time in PT to decide if conservative (ie non-surgical) treatment can be effective. If it was me, I'd go through at least 3 months of PT before making that decision.

I hope that helps.

Sincerely,
Your friendly neighborhood PT, triathlon coach, personal trainer person.

Cassie

[Wahine]

Here are some links to tests that I use on runners to see what their stabiliaztion strength in the pelvis and hip area is like. They can give you some great ideas for places besides your VMO where you can work on strengthening.

Single leg mini-squat (http://youtu.be/4WWqHYpL5Ks)
Supine Bridge (http://youtu.be/0qyuiAyrlRo)
Front plank (http://youtu.be/Xwd_RR8Myq8)
Side plank (http://youtu.be/eLPoJpXmTyQ)

Hope that helps.

[Blueberry]

Thanks, Wahine! I expect I'll find those useful (along with the rest of your youtube channel). No wonder my IT Rollering hurt - I wasn't taking enough weight off!

[westtexas]

Thanks all for the support and advice. I've already done ~6 weeks of PT prior to this at 3x/week and am still experiencing pain. We're doing lots of IT band stretches and have been doing most of the exercises suggested as well (plus laser therapy). I don't have access to a certified bike fitter out here, but the guy who fit me was a racer and very experienced cyclist. I have high arches in my feet and I know that my hip muscles are weak. I'm all lateral thigh muscles and nothing else.

The reason my doctor is already talking about surgery is because I am about to go off my parents' insurance (really good, no deductible, etc.) and onto my own insurance (bare minimum as I have no money and my job doesn't help pay and this is now a pre-existing condition). I trust my doctor to make the right decision - he was highly recommended by a close cyclist friend and he was trying to avoid surgery until I told him about my insurance situation. My patella is pretty rotated, but the groove of my bones is good, so my doctor thinks that with increased VMO strength we have a good chance of avoiding surgery. I'm just a researcher - I like to know about all possibilities, just in case.

In addition to PT 3x/week a friend of mine that I work with used to play collegiate level basketball and she is going to take me as a guest to the Y to use the machines there the other days of the week (I know nothing about gym equipment, I generally hate those places). My right side is >50% stronger than my left according to my evaluations, which is probably why I haven't had a problem yet on that side. I've always been inflexible/weak on the left as long as I can remember.

Thanks all for the replies. I really appreciate the insight and things to consider. I am going to ride today for the first time 2 months to see how my knee behaves (on the order of the PT). But it will just be a short out and back so hopefully it will go well. I didn't experience any pain last time until the next day, so I won't know until tomorrow if things are ok.

[Wahine]

Other things to explore if you haven't alreday is McConnell taping for the knee. Your PT can show you how to do it. I tape my patients and leave the tape on for up to 2 days to allow the tape to help stretch out the soft tissue that affect the patellar alignment. I also teach patient how to do the taping prior to activity to minimize pain during the activity.

Yoga is very helpful too.

And don't forget to look into trigger point dry needling (http://www.kinetacore.com/physical-therapy/Find-a-Therapist-TDN-IMT/page62.html) if you can. It has helped me a great deal with my own chronic patellar pain (related to thigh and hip issues).

I feel like I'm bombarding you with stuff, but really it would be so great if you could find a solution without surgery being necessary.

Good luck.

[westtexas]

I feel like I'm bombarding you with stuff, but really it would be so great if you could find a solution without surgery being necessary.

You are definitely not bombarding me! I appreciate everything. We have been taping my knee the McConnell way and with physio tape and I leave it on until they change it at PT.

Today on my ride I unclipped the right pedal and tried to pedal with just my left. The motion was not smooth, but I definitely felt my medial muscles working hard! I did 11 miles total at a very easy pace (I'm out of shape anyway) and so far so good.