I have painful/weak knees - which practitioner is best to see?

Question

I have had this issue for over 4 years now and in that time seen many practitioners including GPs, Physiotherapists and Physical therapists. All been insightful but unsuccessful.

I am at a loss and don't know which practitioner to see next, any advice would be great.

More information about my knees: The physiotherapist used the umbrella term "Runners knee", it certainly helps describe the symptoms I am experiencing but is perhaps a bit vague. I would say a definite weakness there when exerting myself, and eventually pain / inflammation afterwards. To me it feels like a cartilage issue. I have tried supplements including: Bone broth, Glucosamine and chondroitin but still no difference. My knee condition became much worse after repeated exercise on my bicycle, eventually I just couldn't ride it any more.

Answer 1

Please Note: This is not a diagnosis, it is being provided to help you and a health care professional understand possible causes of your condition. You must see a local professional for an evaluation and orthopedic testing.

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Runners Knee is also known as "Patellofemoral Pain Syndrome (PFPS)" which essential describes the symptoms not the cause of the problem.

So you basically were given a term to describe what you already knew (not exactly useful). I’m surprised further testing was not done.

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Chondromalacia Patella

From the limited information I have it sounds like Chondromalacia Patella.
Which is the combination of patellar tracking issues and deterioration of articular cartilage on the posterior surface of the patella.

I would have to perform special orthopedic tests to narrow down the cause.

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Essentially the information below is what your PT should be looking for to rule in / out this diagnosis (normally the information below isn’t given to patients but it sounds like you’ve been getting nowhere with this -- hopefully this gives your PT a direction to figure out what is going on).

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Clinical Picture

• Generally there is a gradual onset of diffuse aching pain over the anterior or anteromedial aspect of the knee.

• There may or may not be inflammatory signs.

• There is often crepitus (cracking) as the knee moves thru its ROM

• There is an exacerbation of pain with activities such as squatting, kneeling, and ascending stairs.

• There is what is referred to as a positive movie sign – that means that refers to seating in a movie – fair amount of flexion – will get achy in the ant/medial knee to the extent where you have to change position or shake out the knee – patient may also have a feeling of the knee catching or giving way.

• Typically see mechanical causes of this pathology – will affect not only tracking but also the contact surface areas of the PF jt

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Etiology – Mechanical Causes

1. Genu Valgum (means knee) – where we are going to see an increase in the valgus vector at the knee- which is going to affect tracking.
2. Femoral Anteversion
3. Excessive Internal Femoral Rotation- alters the Q angle which increases the lateral stresses.
4. Patella Alta – if the length of the patellar tendon exceeds the top to bottom displacement of the patella by 15% or 1 cm
5. Laxity of medial capsular retinaculum
6. Tightness of the lateral retinaculum
7. Acute or chronic patellar subluxations
8. Pronation of the foot
9. External Tibial Torsion
10. Weakness of the VMO

This pathology – referred from the floor up – or from the hip down

Usually there is something going on above or below the joint – results in this pathology – must find what is causing this to be successful

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Treatment

• If you understand the cause you will be able to effectively plan the intervention

• There are things you can’t fix- structural deformities – if it involves structures that displace the patella laterally

• The follow will also alter patellar tracking. Excessive pronation of the foot, weakness of VMO, tightness of lateral retinaculum or ITB (ober , patellar tilt test) , weakness of frontal plane hip muscles

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Misc Notes

• Terminal Extension Exercises - Don’t strengthen the VMO
• Open Kinetic Chain (OKC) – the literature says the OKC ex from a position of 90-45 degrees of flexion is the safe arc in terms of joint reaction forces to do open chain work
• Close Kinetic Chain (CKC) - that arc of safe movement – is from 0-60 degrees of knee flexion

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What Professional(s) to See

An outpatient physical therapist should be able to narrow this down. As far as Musculoskeletal related issues the leading experts in this field are orthopedic surgeons (with physical therapists being #2).

Professional Bias
However be aware just like a PT will advocate therapeutic exercise - a surgeon will tend to lean toward surgery.

Also see DoctorWhom's post below as he has provided some great insight that should help guide you what to do next.

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Sources
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095938/ http://www.jospt.org/doi/pdf/10.2519/jospt.2010.0302?code=jospt-site

Answer 2

In addition to the above answer that provides guidance on some things to take into consideration when discussing this with your doctor/therapist, I will recommend how to approach seeking the right provider.

First, you've seen "GPs, Physiotherapists and Physical therapists" - but have you seen an orthopedic surgeon or non-surgical orthopedic physician? This is a situation where a specialist examination and imaging (perhaps even an MRI but at least Xrays) probably should be done. It is not always clear when to send a patient straight to PT for eval/treatment versus sending them to an orthopedic surgeon/nonsurgical specialist first, but in this case since the previous did not yield sufficient results, I'd recommend going that route.

Seeing an ortho surgeon doesn't mean you're saying you want surgery. They are the best experts for evaluating what is wrong and determining what options for treatment you have. They often work with Physical Therapist experts to determine course of therapy in non-surgical management.

When you go:

Write down and bring with you a concise, clear timeline of events - onset, past injuries, symptoms - and a list of what makes it worse/better. Bring any imaging or results you've had done before, then they can decide if they want to start from scratch or build on the tests/evaluations done before.