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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.

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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.


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.


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.


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).


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

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


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


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

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.


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

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  • Amazing answer, thank you @Mike-DHSc! I always am thrilled to see professionals join in. A couple quick things: (1) make sure to a little more clearly specify that this is not a diagnosis, this is information to take into consideration when asking his providers. This site tends to be picky about avoiding diagnosis, for a bunch of reasons (not unique to your answer). (2) You might get asked for references. Reading this it's obvious your background, but people reading may want to know more. If you provide a couple links, it will help meet guidelines :) This brings up a discussion I'm going to - – DoctorWhom Sep 5 '17 at 3:36
  • - open in Meta regarding professionals and citing references. I think some professionals have gotten frustrated by the citation/diagnosis thing and drifted away. I did too, since how do you cite your years of education/training/practice? But I think there are some ways we can make it easier to give links to the guidelines etc that underlie practice of medicine/PT/etc, to encourage more to participate long term... If I can get a good response to the meta, we could make it part of the faq for answering questions. /end ramble – – DoctorWhom Sep 5 '17 at 3:36
  • Also, you didn't quite answer which provider to see next, which would help your answer to be more guidance than diagnosis/mgmt leaning. I will add another answer for that purpose. Usually we try to have the answerer edit it to add that if it was omitted. In this case it's probably fine to leave it this way. – DoctorWhom Sep 5 '17 at 3:42
  • @DoctorWho thank you for the kind words – they are very much appreciated! (1) Sorry about that. I will edit my post to clearly state it is not a Diagnosis. (2) Understood. One issue - these are my own personal notes. I wouldn’t normally share them but I know how frustrating it can be spending years trying to figure out what is wrong. I added NIH and JOSPT sources either way. – Mike-DHSc Sep 5 '17 at 9:09
  • Guys, don't beat yourself up over what you didn't provide! This is actually the most amount of useful information I have received in a while, so thank you so much for that. I will take this with me when I see a professional. I will take on the advice of DoctorWhom and see a non-surgical orthopedic physician. Hopefully I can get to the bottom of this. From what you describe I can comfortably say I have crepitus kness, a slight increase in the valgus vector (my knees poke out when I bend them) but am not sure of the rest. Hopefully the specialist will know more! Thanks again. – Chris Rogers Sep 5 '17 at 22:46
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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.

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  • +1 - This is all excellent information - Will reference this in my post as I did not address who to see. – Mike-DHSc Sep 5 '17 at 9:13
  • Thank you DoctorWhom. If I could mark 2 answers as correct I would! But I chose Mikes because of his very descriptive diagnosis and strategies that I should be looking out for when seeing a professional. However, I will be taking your advice to see a nonsurgical orthopedic physician, so thank you for that. – Chris Rogers Sep 5 '17 at 22:51

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