Ideas for how to deal with long term knee pain and inflammation?

December 4, 2014 4:50 PM

I've had a year of knee pain and I'm looking for any ideas or advice about what I can try myself or bring up with my doctors to fix it.

Last January I hurt my knee, and it's been bothering me ever since. I've seen two doctors, three orthopedists, and two physical therapists, and we can't seem to figure out exactly what is wrong and how to fix it. Theories have included IT band syndrome, patellar tendonitis, a kneecap tracking problem, or Patellofemoral pain syndrome. You are not my doctor or physical therapists, but they are both running out of ideas, and I would appreciate any ideas or advice to bring to them at my next appointment.

The current best guess from my physical therapist is that my kneecap is pulling to the right because of a tight IT band and because my inner quad muscle isn't strong enough. At the moment, I'm using a knee brace to try to keep my kneecap from sliding to the right. I spent three months with the physical therapist working on strengthening the quad muscle and loosening the IT band, and I saw some improvement, but now that has stalled.

My physical therapist is now at a loss and doesn't really know what to try next or what might be causing the pain. Additional points:
* I'm taking diclofenac (an anti-inflammatory), which helps, but never gets me completely pain free. I also take tramadol and tylenol.
* I hurt myself running around exercising, but there wasn't any obvious moment of pain/tearing/etc. I've had an x-ray and MRI that showed nothing structurally wrong with my knee.
* Stretching/exercising that I do for physical therapy generally feels ok. I'm often in more pain lying down in bed or on the couch or standing with weight on my knee than I am doing a slow walk on a treadmill.
* One of the orthopedic doctors that I saw said I could consider doing the injection with hyaluronic acid (chicken shots). My physical therapist doesn't think that osteoarthritis is the problem since movement doesn't hurt, and I usually end up feeling better after my physical therapy sessions.
* In the past, I would have localized pain in various spots (outer edge/IT band area, below the knee cap, above the knee), but now it is just general pain all over.
* My physical therapist has also tried combo ultrasound and electrical stimulation, dry needling for trigger points, and graston scraping on the IT band. The doctor has done a cortisone shot in the IT band area.
* The only exercising that I'm doing at the moment is physical therapy (warm up, knee and leg stretches, leg exercising, balance, and core stuff).
* There is no catching/clicking/grinding/popping/etc. from walking around or my PT exercises.
* My knee feels much better in a bent position. I often cannot try to sleep or lie down with the leg flat and fully extended.
* I'm gradually getting less and less relief from the medication that I'm on and the physical therapy doesn't seem to be helping as much over time.

Any ideas about what could be causing long term knee pain and inflammation and how I might be able to fix it? Is there anything I should bring up with my orthopedic doctor or physical therapist that we might be missing?

posted by crocodiletsunami to Health & Fitness (16 answers total)

Definitely a longshot, but do you have any of the other symptoms associated with Reiter's syndrome? Have you had a basic workup for rheumatoid arthritis? Do you have any other health problems?
posted by telegraph at 4:57 PM on December 4, 2014

I know someone who had similar knee pain, and it turned out to be referred pain from a dental problem that was not at all felt in the tooth. A root canal solved it.
posted by Bentobox Humperdinck at 4:59 PM on December 4, 2014

Response by poster: One other thing that I forgot to mention. I'll sometimes notice that my injured knee is colder than my other knee. Any idea what might cause that?

Also, I've done lots of foam rolling on the IT band area.

And I saw a rheumatologist who did not think that was related to arthritis in any way.
posted by crocodiletsunami at 4:59 PM on December 4, 2014

Not to send you down a rabbit hole of mistrust, but there are lots of opportunities for error with any scan. Just because that particular MRI (i.e. that particular angle, machine, technician, radiologist, on that day) didn't pick up any soft tissue damage doesn't mean it's not there. I guess I would probably at least ask for a second MRI if a follow-up wasn't done. If feasible, actually, I would try to find a place that can offer diagnostic ultrasound* for MSK issues - it may be better than MRI, though accuracy is very practitioner-dependent, so would look for recommendations.

(*diagnostic US is different from therapeutic US)
posted by cotton dress sock at 5:25 PM on December 4, 2014

(Sorry, third link should be this, also should have said 'ultrasound may be better than MRI for some conditions' because it's not true for all.)
posted by cotton dress sock at 5:33 PM on December 4, 2014

Ha, until I saw your second posting, I was about to suggest foam rolling on the IT band area. Make sure you're doing it all the way from just-above-knee to the actual hip bone (i.e. do your butt, too), and do it not just on the side of the thigh, but also rotate just a bit to the inner and outer faces (I can clarify if that's not clear, but it should be, given that there's only one possible axis of rotation).

I have the exact same problem. I fixed it by practicing trikonasana, the famous "triangle pose". If you don't have yoga experience, you need to work with a teacher, though. Done right, trikonasana will fix this. Done wrong, though, you can hurt yourself. I recommend Iyengar system teachers (they're all over) who stress proper alignment, and who will show you how to get the benefits of the pose even if you're not totally flexible, by using a block on the floor to "make your arm longer". They'll also have you do things with your leading leg that will really make this pose effective (pulling your kneecap up as you reach down).

I realize I"m just a random internet dude, and that it takes time/effort to learn a yoga pose, and easy answers seem suspicious. But this really is a magic fix. Good luck!
posted by Quisp Lover at 6:10 PM on December 4, 2014 [2 favorites]

Oh, and best explanation I ever got was that I have naturally loose knees, which result in tendonitis as the tendons are forced to cope with greater motion than they're intended to. Bracing is NOT the answer, as you're surely realizing.

Ice helps some, with the aching, but it's not a cure.
posted by Quisp Lover at 6:13 PM on December 4, 2014

Sorry, yet one more follow-up. When I said "it you don't have yoga experience, you need to work with a teacher," I meant to start. Once you're established, you can practice it daily - or every other day - on your own. Periodically (every couple months) return to a teacher, though, to ensure bad alignment habits haven't snuck in. The curative power is all in the pose's alignment...and a nice firm, but not over-done, retraction of the knee cap (an Iyengar teacher can explain better than I can here).
posted by Quisp Lover at 6:34 PM on December 4, 2014

If you are of a mind to consider going the injection route, you might consider looking into stem cell injections. They are your own stem cells, and that form of treatment is becoming quite common, along with PRP and prolotherapy, especially for knees but also other joints. Although, as far as I know, it is still not covered by insurance.
posted by vignettist at 6:44 PM on December 4, 2014

Seconding yoga, though only if you can get the inflammation down. I've had good luck with alignment/posture correction, including rolfing and special insoles from my PT.
posted by susanvance at 7:19 PM on December 4, 2014

Check out Do it yourself joint pain relief

It's a form of trigger point therapy that has helped me and my parents with various issues. The instructor has a series of videos on pain in pretty much any joint in the body. Check it out.
posted by GregorWill at 8:05 PM on December 4, 2014

When doctors can't find out what the problem is (which is very common) there are only two possibilities:

a) There is an illness or condition that is there, but they are not finding.

b) The pain is caused by overall misuse of form.

In my own case of severe knee pain the answer was A. The doctors couldn't find anything wrong with my knee so they kept telling me to get therapy (because I was obviously CRAZY for feeling intense pain when there was nothing physically wrong, right?). Luckily the pain was much too intense for me to ignore so I just kept going to doctors, until I found one that would listen. It took him a while to find the problem, but it turned out to be cancer. A malignant tumor which could barely be seen via the MRI was in the synovium of my knee. Despite the fact that Synovial Sarcoma is one of the slowest moving cancers (It's possible to have it for years because the tumor can grow so slowly), it has a pretty low prognosis because Doctors almost never look for it so they don't find it in time. I'm lucky that I didn't listen and kept looking for a doctor who would take me seriously. I had to get a couple of surgeries and rounds of treatment, but once the tumor was gone so was the pain.

I'm not telling you this to make you think you might have something serious because the type of cancer I had tends to hit younger people (I was in college) and rarely older types. I'm only mentioning this because it's really common for doctors to equate "I can't find anything wrong." to "There is nothing wrong." But these are not the same things. If you have pain there is absolutely something wrong even if it's most likely the case that it's something small. Even small things will develop into large things over time if they are not fixed. A person who has a habit of leaning slightly forward while walking will have no pain for the first 25-35 years of their life, but then suddenly they'll start feeling pain. They go to the doctor and are told x-rays show heel spurs. Those heel spurs slowly developed over time as the constant shifting forward of the weight has over-tightened the tendon on the bottom of the foot causing painful bone growth on the heel. However the doctor is not likely to tell you this because they are trained to spot a problem and give a quick solution to it. So they might sell you orthotics, which will help, but they won't correct the underlying problem so you will have to use the orthodics indefinitely and keep having them replaced. In this case the bone deformation and pain is caused by misuse which has repurcusions over time and if you injure yourself it's often due to the misuse making you susceptible to the injury in the first place.

I suggest: Do not ignore the pain no matter what doctors might tell you. Doctors are well-meaning and smart, but they are not smarter than millions of years of evolution. Pain is your body's alarm system. It's your body's way of telling you "Hey buddy- pay attention to this... something's not right here." If you are under the age of 30 ask to be checked for the possibility of joint cancer (EXTREMELY unlikely, but better safe than sorry.)

When you get the clear medically the only other possible issue is that this is a matter of misuse of body that finally caught up with you when you got hurt. I recommend this DVD: (or it might be available somewhere free online). It's a bit boring, but very educational in terms of misuse. There's also "Alexander Technique" which is also great for misuse injuries and pain, but unless you have the money to take private lessons with a good teacher at least once or twice a week you may not benefit. It's worth the money if you can afford a good instructor though.

Rolfing aka Structural Integration may also be something to look into.

Yoga is great- but I would recommend taking a private lesson at least once every 2 weeks with a good yoga teacher because it will only help misuse issues if someone is around to point them out to you. For example- If you tend to supinate (distribute your weight mostly on the outside of your feet) you will tend to also supinate a bit while you're doing the yoga poses. So you are still misusing your body, just doing so in different poses. Having a good instructor watch you alone during a whole hour will allow them to really see the subtle things you might be doing wrong and you can take that knowledge with you in your group classes.
posted by rancher at 9:14 PM on December 4, 2014 [3 favorites]

I like rancher's options A and B regarding unexplained pain. I got option B.

I get right knee pain from time to time which is caused solely by a dysfunction in the left hip causing screwed up movement patterns. My knee is just the pain victim, there's nothing wrong with it. My physio explained that the knee is often the victim of hip, ankle, and other problems.

Just reading your problem description, you have knee pain when your hip is in extension (standing up or lying down). Forget your knee for a second, have you ever thought about why you are having pain when your hip is in extension? You might want to discuss your hips with doctors and physio.

In terms of what you can do to DIY, I am taking pilates and I prefer it to yoga as part of a rehab program. It is easier to hurt yourself in yoga. I would also suggest progressing the exercise program to a functional program guided by an educated trainer (in Canada we have kinesiologists) to build strength. As much as I advocate for physio, it's not a great long-term solution for things when you are getting limited results. A functional program will add glute work which might help you. You can also use heat and cold to manage symptoms and pain.

Keep at it and try to keep moving. There is a certain truth to pain being in the head as well. I started a new job when I was in a painful spot and being busy really helped to distract me and turn pain down a couple of notches. An exciting non-rehab project can help too.

Good luck.
posted by crazycanuck at 10:03 PM on December 4, 2014 [2 favorites]

My aunt had severe knee pain that went away when she had her hip replaced. Her hip didn't actually hurt much at all until right before it had to be replaced--it was new pain in that joint that caused her doctors to look there finally.
posted by xyzzy at 11:38 PM on December 4, 2014

I hurt my knee running on a treadmill in 2012 and it has never been the same since. My PT (also friends who are PTs) have diagnosed it as patellofemoral pain syndrome. It doesn't sound unlike what you have. I also had a hard time saying where the pain was... I think it was more because the pain is inside/under my kneecap, so there's no focal spot to point at and say "it hurts here". I would get the same idle pain sitting with my knee straight, but I would also sometimes get stabbing pains when going up stairs or getting out of a chair.

As I've never been able to get myself fully healed up, I don't have a ton of good advice regarding that. But for pain management, I would throw your brace right in the garbage and go straight to taping. I used this Leukotape stuff and it worked better than anything else. I had to shave my knee which looked kind of silly, but hey, them's the breaks.

The only other suggestions that I can give you are to stretch your IT band, stretch your groin, make sure your glutes are equally strong (and if not, work the weak one), and do squats and lunges (making sure your form is flawless). It probably couldn't hurt to get good orthopedic inserts in your regular shoes.

Good luck. I know how much it sucks.
posted by JimBJ9 at 7:19 AM on December 5, 2014

Really sorry to keep reappearing like this. Like I said, i experienced exactly the same knee issue (worse than you; I was nearly screaming in pain walking down steps), and fixed it, but it was nearly twenty years ago, so my memory was a little cloudy. I realized I'd forgotten a whole aspect.

Before I resorted to yoga, I went to a sports orthopedist. He told me that normally he'd advise strengthening the quad, but that since my quad was obviously strong, I might work with the other half of the leg mechanics equation and loosen my hamstrings.

If you don't have particularly weak quads (are they at all muscly or merely stick-like?), I would bet a good sum of money that you have very tight hamstrings, as I did. I did gentle (no straining, no bouncing....very slow and gentle and careful) hamstring stretches for a minute or two several times per day. My knees felt a LOT better within a couple weeks - surprisingly so. Trikonasana (triangle pose) was something I did AFTER that, to complete the healing.

With hamstring stretches (as with trikonasana), it's important to inner-rotate the legs a little (to ensure your kneecaps are facing perfectly frontward, rather than bowing outward), make sure your legs aren't the least bit bent at the knee (concentrate on firming and opening the area of the BACKS of the knees to ensure this), and that you're flexing/lifting the kneecaps upward (sounds difficult, and it'll take practice and a certain amount of physical conviction, but I promise it's possible) during the hamstring stretch.

Also, rancher is correct that you need to pay attention to foot dynamics (and working with an Iyengar teacher is the best way for learning about this), but I doubt you supinate. You likely place weight on the inner side of your feet, and either have (or one day may develop) weak arches from this. You won't fix it with the hamstring stretches, but you will with proper practice of trikonasana. And that, too, will help finish off the last traces of the knee problem.

Finally, I'd like to remind you this is entirely a mechanical problem. Your kneecap travels too easily/loosely, thereby over-stretching tendons. It's doubtful you can fix it with stuff like injections and stuff, except maybe to help with the pain. Again, I found ice helps considerably.
posted by Quisp Lover at 8:24 AM on December 5, 2014