Knees – not just getting old? #27 – Last entry (for now), including summary

A couple of days after posting my previous blog , I spoke to John about the possibility of him measuring me up for my insoles, as it seemed they now needed replacing (see blog #26).  He felt it would be best for him to pass on doing this, as it’s a little outside his realm of experience and his qualifications.  So I contacted the company that make the insoles I have worn for the last 6 1/2 years, to see who they might recommend instead.  They put me onto a highly qualified orthotics practitioner they have worked closely with for the last 2 years or so, to jointly develop a new kind of long-lasting insole which that practitioner has designed.  I saw this other person a few days ago, on 26 April, and the appointment ended up going in what I would describe as an unexpected direction, though a highly positive one.  But that is another story…

Looking back at the work that physio John and I have done together since I first came to see him in late October 2016,  it has been highly fruitful, to say the least.  When we started treatment at that time, running or playing table tennis – even for just a few minutes – made my left knee joint quite sore, the knee would get quite stiff when I sat down even for short periods, and my walking gait had somehow developed a strange limp on that leg, one that was most pronounced when walking downhill.  In effect I was unable to run, and I was especially worried that I might have to abandon running permanently.

From the first session John and I had together, my objectives for our work included eventually being able to resume running again, to my usual distance of 4 miles and to be done once every 3 days, and to be able to play table tennis – all with no soreness issues either during or after a run / table tennis – and to be able to walk without any limp, including up- and downhill as well as on the flat.  We have more than achieved these targets, and I am 100% satisfied with the outcomes.

Along the way during the treatment period, I had 8 sessions with John.  We covered and addressed a wide range of potential causes of the knee joint issues that I had been suffering from since before first seeing him.  With hindsight, it is now clear that many of these potential causes were making at least some contribution to the knee problems, so it was down to much more than there being just a single thing behind it.  Had any of these causes not been addressed, I don’t think I would have been successful in the attempt to resume running again.

In summary of all of my previous blog pages #01 through #26, the things we/I did as part of our work together, and as a result of it, include the following:

  • A] John carried out various “range of motion” checks, on each leg for comparison, as well as other checks.  We did this in various of our sessions, and the results indicated eventual improvements and progress along the way.  Examining me freshly was invaluable in assessing direction of travel, expected durations of recovery, and so on.
  • B] I bought a MOTI foam roller, to replace an inferior one I had previously bought from a high street “chain” sports store.
  • C] We looked at my posture for sitting at the computer, in some depth.  John showed me how to sit properly, and once he had arranged my posture so it was “correct”, he photographed the result.  This photo became a benchmark I could refer to in other tasks we carried out, and as I sat working at the computer at home.  I even used this photo to measure the angle of my upper legs from the horizontal, using nothing more sophisticated than Microsoft Word and some simple geometry.
  • D] I undertook doing a major overhaul of my home computer workstation setup, where I have been making a living as a freelance Microsoft Excel spreadsheet developer for the last 18 months.  We both strongly suspected that this setup was a major culprit in my knee issues, which had only started up since I began working from home and sitting at it for a total of the usual sorts of working hours each day, sometimes more hours than that, etc.  Before that switch to home working, I had been running the same 4 miles every 3 days for some 14 years, with no problems of any kind – so even though we did not discount the usual things like poor running form etc as possible reasons for these knee issues showing up after all that time, we were on the lookout for other causes as well.  Altogether, the overhaul to my home workstation involved:
    • i) a shift from not having enough room to stretch out both legs underneath the desk and thus sitting at it at a “skewed” angle, to clearing away some IT equipment that had been stored under the desk, by adding strength to an existing shelf found out of the way and under the desk, making more room on that shelf, and putting the IT equipment on it;
    • ii) lowering the height of the desk so it was closer to a standard desk height in most offices;
    • iii) adding a “top of desk extension” so there was now enough desk “depth” and room to rest my elbows on it while using the computer keyboard (resting the elbows is an approach that was a completely new experience for me);
    • iv) replacing the old chair I had originally had leg extensions made up for – to accommodate my previous sitting position, which was quite high – with a spare chair from John’s  MOTI treatment room that he offered to sell to me, a chair which:
      • a} has more “depth” front to back and so provides better support for my long legs;
      • b} is of a more standard height as in most offices, and which;
      • c} when sat in properly following all these changes to the workstation setup – including v) below – results in my lower arms naturally resting in the perfect horizontal position, while I work;
    • v) adding a towel folded into 8 layers to the chair, positioned so the pelvis ends up a bit higher than the knees.
  • E] We took film of my walking and running gaits in the MOTI store – in more than 1 of our various sessions – and we worked on improving my general posture for both walking and running.
  • F] We fixed some ankle turn-in on the affected left leg, which had showed up on the films of me running.  In the end this appears to mostly have been from using running shoes that were quite worn out, as they were over 5 years old.  I bought a new pair at MOTI, and when we filmed me running in those, the ankle turn-in was gone.
  • G] John showed me various exercises, including some to target the glute muscles and get them working more properly.  I have incorporated all of these as shown, into my usual daily routine of morning exercises, and am still doing them today.
  • H] When the knee did not seem to be responding much to our early work from the first few weeks of treatment, I saw my GP.  To his credit, was willing to send me for an x-ray on the knee.  When this eventually did not show anything abnormal, my GP did not hesitate to send me for an MRC scan on it as well.  This proved to be very helpful in my treatment work with John, and it also demonstrated that it is possible for the NHS and a private practitioner to co-operate and work together to the benefit of the patient.
  • I] Between the x-ray and the MRI scan as outlined in the previous item, a “breakthrough” event took place in early December 2016 (see blog #14), after which the limp I had had when walking, which was most apparent when walking downhill , completely disappeared.  Although John and I were left a bit puzzled as to just what had taken place, and why, it was very good news, and as well as never seeing the limp again since then, the knee has also been improving ever since.  When the MRI scan results finally came in and I next saw John, he gave me new exercises to target the smaller joint on the outside of the knee, the “tibiofibular joint”, an area the scan had indicated was involved in the ongoing issues.  The scan suggested the main joint was more or less fine, despite showing what John and I felt were typical signs of me now being over 60 years old.  He felt I should have a good chance to make a recovery that might mean I could eventually get back to some amount of full running again, something my GP had also said after he saw the scan results.
  • J] In the first session with John after the “breakthrough” event as outlined in the previous item above, but still some time before the MRI scan results had arrived as also described in the previous item, John found a further possible cause of the knee issues – some tensions to the left of the joints in the lower spine.  He took a “before” photo of my back that showed my upper body was leaning to the right by a significant amount (around 1.5 inches at the neck), then he got me on the treatment couch and worked out these tensions, and then he took an “after” photo, which showed that I was now standing straight.  He was convinced this and the resulting “lockup” of several of the joints of the lower spine, was also a major contributor to my knee issues.  The knee did improve after his work manipulating the lower back, confirming what he had said.  That work also resulted in my upper body becoming more “evenly” aligned – joints were “popping” evenly on the left and right sides when I did the usual morning stretches and exercises, and so on.  Over the weeks following his manipulation work, I took 2 further photos of my back at home, using a delayed 10 second timer on my camera so I could get into position.  After using the computer to make adjustments to these photos to correct for perspective, they confirmed what I had been feeling – I was still standing up straight, so John’s work seemed to have “stuck” and was permanent.  A recent view of my back has also confirmed that it is still straight.
  • K] After the session outlined in the previous item above, we had a further, “penultimate” one on  02 Jan 2017, in which we had a review of all work so far, John re-checked for range of motion, and so on.  The MRI scan results were not in yet, but it seemed a good idea to take a fresh look at everything we had undertaken, up to that point.  As a result of these fresh checks, John carried out further manipulations on the remainder of my spine, all the way from the lowest joints he had addressed in the previous session, to the neck at the top.  There were no further significant tensions that he felt might be causing or contributing to the knee issues, but he did find some other, more minor tight spots, which he was able to “undo”.
  • L] By the time of our final session together, which was on 20 Feb 2017, the MRI scan results had arrived.  We discussed the results, John repeated the checks from 7 weeks ago, he showed me a new exercise for the “tibiofibular joint” as indicated by the scan, and we talked about recovery and about the physiology of the leg joint in general, and about my affected joint.  John felt I could start experimenting with short distances of running, keeping a close eye on how this felt, both during and afterwards, backing off if there were any issues, etc.
  • M] For a few weeks after that final session, I was reluctant to push the knee and so kept away from any running, just tried a little jogging for a few hundred yards now and then, which seemed fine.  I was going on instinct, and eventually took a proper run around the end of March.  By then the joint had gradually improved enough that there were no problems on that run, and since then I have been able to quickly get the distance all the way back up to my previous 4 miles on any given run.  I have lost a fair bit of runner’s conditioning, but it looks like this may return relatively quickly as well, perhaps due to me having continued the usual morning exercises throughout the treatment period in my work with John, as well as having kept playing at least some table tennis for most of that period, recently adding more of this , and averaging more duration in each table tennis session recently as well.

So that’s really about it in terms of my work with John.  I would highly recommend him, based on everything we have done together over the last 6 months.  He has succeeded in helping me to get back to running again, and the things he and I have done as outlined above, mean I have a good chance of being able to keep running for some time to come.

Calf problems from posture: #04 Twenty six days to twenty six miles

Twenty six days to go and it hasn’t escaped my attention that there is one day left for every mile I will have to run. I feel that this is somehow apt – the marathon is not only run over the 26 miles on the day, but over the many more miles run over the days and months leading up to it. This miniature mountain of time and distance (and hills) already covered is what makes my sensations heighten as the event draws nearer – I have put in so much effort to get this far that I don’t want to miss out due to injury or illness at this late point.
The exercises John has recommended have adjusted my posture to the point that the right calf is much less problematic, although this adjustment does seem to have ignited soreness in the left achilles. I am working on my gait to push right through to the toes on the trailing leg, increasing speed and reducing effort in the legs. This weekend will be my last truly long run before the marathon. As long as that goes well it will be all about keeping the legs ticking over for a few weeks and giving absolutely everything on the big day.

To see Tim’s personal blog see: http://edenprojectmarathon.blogspot.co.uk/2015/01/twenty-six-days-to-twenty-six-miles.html

Calf problems from posture: #03 Whales and Marlins

I feel it is no coincidence that this Christmas I was given two books which are undoubtedly related: Hemingway’s ‘The Old Man and the Sea’, and Melville’s ‘Moby Dick’. Both describe the immense efforts of people to overcome multifarious obstacles in order to capture a monster far bigger than themselves (although I haven’t read Moby Dick yet). It may be over-dramatic, but in some way this is how the marathon has become for me. Particularly since the calf problems, it has been a daily struggle to stay on top and build the mileage back up enough to make the marathon plausible. I put in calf-strengthening exercises daily, I now also slot in postural exercises and some ‘neural flossing’ as recommended by John. I am careful to warm up and down thoroughly around each run. I run three times per week, unsure each time whether the calf will fail again, but monitoring and adapting my runs accordingly. Add to this that I will not be satisfied purely with finishing the marathon, but I would like to run a reasonable time. My running is currently limited not by my fitness but by the leg, which sometimes does not allow me to run further. This is concerning given that my longest mileage since the injury is 15 miles. Still, I believe that my approach is giving me the best chance possible. It combines patience, determination, and discipline. Keep doing the exercises even though you may be bored. Keep training even though the weather may be terrible. Keep believing even though other people may not hide their doubt. There is never a guarantee of success, but you can always put in your best effort possible.

BEFORE:

AFTER:

Calf problems from posture: #02 A two pillow sleeper

On my second appointment with John, he once again demonstrated to me the flaws in my posture. With me standing casually, a quick profile photo showed that my pelvis and nose stuck out in front of the rest of my body. I am curving my lower spine backwards and then my neck and head are pushing too far forwards from my shoulders (see photo); as John rightly pointed out, I am a two-pillow sleeper. These extra curves in my skeletal frame mean that the nerves strung over that frame have further to travel than they should, and therefore have less give in them. My first prescription was to sort out my posture during the many hours I use a computer (at the office and particularly when using my laptop at home, for which my posture is really pretty terrible).


Following this, we tried some little hops as if skipping, first on both legs then switching to one leg, showing that this was much worse on my right side. Similarly, when balancing on one leg, I would lean my upper body much further to the side on the right leg than when balancing on the left. It seems I am literally a lazy arse, at least on the right side, where the upper glute muscles do not want to work to keep me balanced. Prescription two was the sitting-to-standing posture exercise from the physiotherapy.co.uk website to wake these muscles up. You or I may well ask what all this has to do with my calf injury? I believe John’s answer might be that you treat the body and not the symptoms of injury, and the rest follows…there is a logic to this, and as a scientist I see that you can only test this theory by following the advice, so fingers crossed and here goes…

Knees – not just getting old? #26 – Running again!

Wed 19 Apr 2017

It’s been a full 8 weeks since I last updated these blog pages.  For the first few weeks of that period, I still did not try any proper running, just added a bit of jogging in now and then when out walking, always for quite short distances.  These experiments went fine, with no ill effects, but my instincts were still saying to hold off for a bit, so that’s what I did.

During that first month or so of these past 8 weeks, which ran up to the last week of March, I was very busy finishing off a work project that took up a lot of extra time, and I was reluctant to put any extra demands on the body, beyond my usual daily exercises, the walks of around 1.5 miles on most days after having lunch, and fitting in some table tennis, though not as much as normally.

During this time, the knee still seemed to be improving slowly.  It was not at full strength yet, but was heading in that direction.  Walking felt fine and, as had been the case since the breakthrough events of early December (see blog #14), there continued to be no difference between walking on flat elevations, and walking down- or uphill.  As in the recent past before this, the main times I noticed much of anything at all, was when doing squats as part of my daily exercise routines, and also as before, at night I could not use one of my normal sleeping positions on my left side, because the weight of the other, OK leg on top of the affected one, continued to make the knee a bit sore.

I carried on doing the new exercise John had showed me in session 8 (see blog #24), to loosen up the smaller joint between the tibia and the fibula, the “tibiofibular” joint.  I have been doing this one at the start of my morning routine of foam rolling and various exercises, which now includes a few things added over the last several months, to target the various causes of the knee issues.

I have noticed one odd thing while doing this new exercise to loosen the tibiofibular joint.  The back of the top of the fibula bone on the affected left leg, seems to have a really pronounced “knobby” bit, which is not present in the same place on the other leg.  I can only surmise that this is a long-standing difference that was never noticed before I started doing this exercise, as it seems to be very hard bone that I can feel.

I have also added one new exercise in, taken from a web video by a runner, “lunges”, which is helping to give more strength to both knees.

A few days before the end of March, the work project was coming to a close, and I felt freed up to put more focus onto the knee, and on fitness and exercising in general.  I first tried a slightly longer bit of jogging while walking to an evening meet-up with friends in central Bristol.  This felt fine, both during it and afterwards.  I probably jogged a total of 1/8 to 1/4 of a mile.

Even after this, I was overcautious about trying out any proper running.  But I did begin to play table tennis for longer periods of time in a given session, and I also added more sessions each week.  These changes did not result in any noticeable issues.  There were none of the sorenesses afterwards, such as on the day after table tennis, which had been so prevalent just a few months ago.

Around this time I began to notice that I was occasionally having pains in the neck area again, on the left side as before.  Historically this has always been due to my left leg being shorter than the other one (see blog #01), and usually it has meant that either the insoles I wear on the footwear of the affected left leg were wearing down, or the shoes themselves were wearing down, or even, as after the first year of using 8mm insoles in 2010, that the leg length discrepancy had changed further.  For the last 5 1/2 years I have worn 11mm insoles, and that seems to have been correct since then, although as various pairs of shoes would wear out / down, I have tended to add a few layers of black tape to the insole, to correct for shoe wear etc.

In my 8 sessions with John starting in late October 2016, we have made all sorts of adjustments that could potentially also be having an effect on the neck.  The most notable of these is some work John did in session 6 on 19 Dec 2016 (see blog #16), to free up some tensions to the left of the lower spine joints which were giving the upper body a “lean” to the right, when viewed from behind (see photos in blog #16 for specifics).

I began to wonder whether the prolonged period of over 4 months during which I had done virtually no running at all, might also be having an impact on the leg length discrepancy – could it be changing further?

Eventually I decided that one simple way to test this idea, would be to try out some proper running at last.  Having put it off for quite some time, I dressed in the usual running gear one day in early April, did the usual foam rolling, stretching and other run-prep exercises, and headed off down my street to see what it felt like.  I was prepared for any possibility.  If, for example, there was to be any sign of similar issues while running as I had suffered in previous attempts in late November of 2016 and before,  I was clear I would have to stop, and probably just walk back home from there.

The first few hundred yards felt just fine.  I was going fairly slowly, more of a jog than a run, but everything was working correctly.  My running posture was naturally quite good, and my affected leg’s stride appeared even in terms of the foot pointing forwards (no “turn-out” for example).  I carried on from there.

It was surprisingly easy to do this.  I think my discipline about all the other exercising, and playing more table tennis (including a 3-hour session a few days before this), meant that my general level of fitness had not dropped all that far back from when I had last been running 4 miles every 3 days (up to late September 2016).  Either way, I was encouraged by this, and kept going on my usual route.

I paid special attention to any differences in how it felt to run down- and uphill, compared to running on the flat.  There were none of these at all, which I took to be a very good sign.  This was a world apart from the issues I had been having before the breakthrough events of early December 2016 (see blog #14), before which I would always be running with a noticeable limp on any downhill sections, for example.

I ended up doing the entire previous normal distance of 4 miles on this first run.  Then, after a hot bath and another foam roll to cool down, I did not have any of the kinds of soreness that runs or jogs of any distance at all, had been giving in the Autumn months of 2016.

The day after this first run, I was also not sore at all.  The knee felt like it had done some proper work, but that was a different kind of feeling to any soreness.  In fact, the whole body felt that way to some degree.  The 2nd day after the run I was especially tired, and my hamstrings were fairly sore, despite having rolled them out properly before and after that run.  I have heard that sometimes it’s not the 1st day after physical exertion that you feel it, but the 2nd.  This was an example of that.  But even then, the knee was not sore in the way it had been getting, before the work I did with John in our various sessions as from late October 2016.

Doing one run was one thing.  Would there be any adverse effects if I took another one?  I waited until 4 days after the first one to try again, an extra day beyond what I usually would leave between runs.  The 2nd run felt quite different, but not in any adverse way.  It just seemed more difficult overall, and my legs just felt like they had lead weights in them.  Still, it was fairly easily able to do the usual distance that time as well.

As with the first run, there was no soreness during or afterwards this time, neither on the 1st or the 2nd day after.  I also did not feel any more tired on the 2nd day than the 1st afterwards.

I played table tennis in between these 2 runs, and it was also fine.

Since then I have done a total of 5 runs.  The body is returning to full conditioning slowly as a result of this, and there appear to be no issues.

Between runs 3 and 4, I had a major house clean over about 3 days, the middle of which included hoovering the house from top to bottom and then using one of those steam cleaning machines to clean the carpets – something I do each spring.  I was quite tired for the 2 days after the carpet cleaning day, and there was some soreness in the knee joint, which first appeared the day after that cleaning and then gradually subsided over the day or so after that.  I was down on my knees quite a lot doing the carpets, in all sorts of body positions I normally don’t adopt, so this was understandable.  I delayed run 4 for an extra day beyond when I would have otherwise done it, meaning runs 3 and 4 were a total of 5 days apart.  If the soreness from carpet cleaning had not improved, I would have waited longer – but early on during the day on which I later took run 4, a short walk showed that the knee was no longer sore at all, and my walking was full of vigour once again, so I was confident enough to have a go at that run, which went fine – no soreness either during or after.

I took run 5 this past Monday, and it felt really good.  I am still going slower than before all these troubles from the past year, but that is to be expected.  As I never push this anyway, it’s not an issue.  It might take some time to get back to the same level of conditioning as before – and it might not even happen.  Either way, I am very pleased to be able to run at all, with no apparent adverse effects.  I must keep an eye on things, as it’s not certain I can continue like this, but for now it looks very hopeful.

The pains in the neck have remained.  Today I got out some spare insoles and measured them up, then phoned the orthotics firm who made them for me, to ask them a couple of technical questions.  I also bought a big bag of plastic spacers that carpenters use to level up furniture and cabinet installations, and something hard and flat to put over the tops of these spacers.  The point of getting hold of these things is so that they can be used to have my leg length discrepancy re-checked, which I strongly suspect now needs to be done.

The orthotics firm told me one thing I had not known – the insoles tend to be good for 6 to 12 months only.  Mine are over 5 years old.  Once I knew this, I compared the thicknesses of the spare ones that I have never used yet, against a couple of the ones in my current sets of footwear.  Sure enough, the ones from my footwear have compressed a bit and are no long giving the full compensating thickness I require, assuming there have been no changes to my physiology that has resulted in a further shift to the difference between the length of each leg as I stand upright.

It is possible that the knee joint issues have had an impact on the leg discrepancy, but I suspect it’s unlikely.  The alignment of the main joint in that knee may now be slightly different to before I starting having all these knee issues around a year ago (something my instincts are saying, based partly on how it feels to do even normal walking), and even though the MRI scan had some comments about “patchy subchromal marrow changes” to the main joint, John and I think this is probably typical of a 60-year-old man, and that, had they also scanned the other, OK knee, the same thing might have showed up on that one.  Aside from this, the scan they did on the affected knee showed nothing of particular note in the main joint, only some degeneration to the outer joint where the tibia and fibula meet, the “tibiofibular” joint.  If that’s all that’s different in comparison to the other knee, I doubt it has led to the overall leg length discrepancy having changed.

The only way to find out for sure is to measure this.  Now that I have the tools to do that – the plastic spacers etc mentioned above – I want to ask John whether he can carry out these checks.  It will involve measuring up to see whether, using various thicknesses of extra height added under the affected left foot while standing barefoot, the pelvis is level, until the correct spacers give a level result.  I know this is what is now required, because it’s what the therapist who originally diagnosed the discrepancy did, when he first found it 6 1/2 years ago.  That therapist no longer takes private patients, and even if he did, given the history of the sessions I have recently had with John, and given John’s expertise in all his work to date, I prefer him to do this, if he is able.

As well as this checking, I will need to have a check done while wearing each pair of current footwear, to see whether the insole worn in the left shoe of each pair, is resulting in the pelvis being level and, if not, how far off this is.  My suspicion is that I probably need new insoles made up, just because the current ones are so old and they have suffered some compression in their own right, as the suppliers have suggested by their comments to me today.

Even if I just need the same sizes again, the suppliers require a request be made to them by my physiotherapist, so I would ask John to do one for me, following this checking.

To summarise all the above, I am extremely pleased to have been able to start running again.  Although I am still very cautious about it, there don’t seem to be any problems arising.  I now need to address the neck pains that have returned, which is usually due to the insoles I use – to compensate for the affected left leg being shorter than the other one when I am in a standing position – and/or the footwear itself, having worn out.  This means I need to be re-measured for insoles, and probably then have new ones made up, even if the discrepancy is unchanged.  I will ask John whether he can do this measuring.

 

 

 

Knees – not just getting old? #25 – After session 8 with John

Wed 22 Feb 2017

I have been doing the new exercises John showed me in session 8 last Monday, for the small tibia/fibula joint on the outside of the knee – the “proximal tibiofibular joint” – using the heel of my palm as John demonstrated, doing this to each leg, partly for comparison.

Even after I work it a bit, the affected leg does clearly feel like it is still harder right there at the top of the back of the fibula bone, compared to the same location on the other leg.

Since our session 8 two days ago, I have also noticed that when I bend the knee, I can often still feel some tightness below the joint, in that muscle area where the leg coloured up in early December (see blog #14).

Rereading the blog #19 notes from our session 7 appointment on 02 Jan, it seems that John did a bit of work on the area right around this same tibiofibular joint, at that time.  When he repeated the range of motion checks in that session, the range had improved as a result of his work.

The main difference in how we have viewed that area since session 7, is that the MRI scan has clarified that there are particular issues in that location, and this has brought both John’s and my own focus more to bear on it, both during and after session 8.

I played table tennis yesterday evening, for around an hour in total.  Although I was playing quite badly by my usual standards – probably from tiredness due to lack of sleep – I did notice that the knee was not giving any indication of me being on the verge of any pain or soreness, at any point.  However, I think this might be inconclusive, because my general level of play was way off where it usually is, and I don’t think I was really pushing myself physically, as far as I would normally be doing.

It is still too early to make any definitive judgements, but taking all the above into account, my feeling at this point is that, assuming a recovery is possible, there is some way to go, before the proximal tibiofibular joint will consistently seem to feel the same as on the other leg.

This all raises the following questions, some of which I can answer myself right now, with others needing either more time, or some comment from John.  I have marked each item as appropriate, in the () at the start of each question :

  • (NEEDS MORE TIME)  Did the work John carried out on the proximal tibiofibular joint area in session 7 on 02 Jan, to free up some tightness in that area, result in only a temporary improvement to that tightness?  If so, this might be simply because it is necessary to work that area more regularly – which I am now doing, using the new exercises John showed me.
  • (ME)  Am I doing those exercises properly, for this proximal tibiofibular joint?  I am fairly confident that I am.
  • (JOHN)  Is this tightness and hardness which we found in the proximal tibiofibular joint in session 8 this last Monday, consistent with the details about it having “degenerative change”, from the MRI report?  Or are these perhaps two different sets of characteristics, related but distinct from each other?
  • (JOHN)  Does the answer to the previous question, have any bearing on what I need to do regarding recovery?
  • (JOHN)  I am still a bit puzzled by the hardness aspect of this small joint.  Is there a possibility that the joint has become “stuck together / fused”?  If that was the case, would the MRI report have described it in a different way to how they have done, or would that still fall within their description as given in the report from 26 Jan?  Their wordings are as follows, from two sections of the report:

… patchy subchondral marrow changes involving the …. [and] lateral tibial plateau and proximal tibiofibular joint, with associated cartilage fissuring, consistent with degenerative change…

…Conclusion: Degenerative medial and lateral compartment chondropathy slightly more pronounced laterally, with further degenerative changes in the proximal tibiofibular joint.

  • (JOHN)  Based on our work in session 8, on the MRI report,  and on developments since then as outlined above in this blog page, am I right to think that recovery of this proximal tibiofibular joint, is still not a foregone conclusion?  In other words, could this still go either way – recovery / no recovery ?

John’s answer to the final question will not necessarily change how I approach taking things from here, but it will be helpful to know what he thinks at this stage.

 

 

Knees – not just getting old? #24 – Session 8 with John – Mon 20 Feb 2017

We began this session by John taking a close look at the MRI scan report details, which we discussed.  Here they are again, from previous blog #22, this time with [only] slightly better resolution:

Nelson - 26 Jan 2017 MRI scan NHS report - description - sized up

The key bits of info from this are:

  • The main cartilages, menisci, kneecap, and joint, are all in reasonably good shape.
  • My bones may be showing a little sign of getting porous – hardly surprising for a 60-year-old – but it is not serious at this point, and is unlikely to be the cause of the various issues I have been afflicted with in the left knee area.  I commented to John that, had they done a scan on my other, more healthy knee, it might have shown the same signs of getting porous – which he agreed with.
  • There is some degeneration/pathology of the smaller joint between the tibia and the fibula (“proximal tibiofibular joint”), which is located where these bones meet each other on the outside of the main knee joint, and just below it – the exact area where I have had pain, tightness, and so on.

John had not considered this smaller joint as a candidate for having anything up with it, as this is normally a fairly rare thing to come across – but if this is indeed something that has been a contributing factor, then it would explain quite well, why some ongoing problems have persisted up to now, since we have only really uncovered it properly at this stage.  Either way, it gave us something new to look into and to work on, in this session 8.

We began that by a fresh examination/checkup, with John getting me onto the treatment couch and repeating some range of motion tests as he had done in previous sessions, to judge whether there had been any change to affected left leg since then.  Although it was still not as good as in the other healthy leg, John felt that the range of motion was much better than it had been when we last tried this.  I agreed, based on how it felt as he moved each leg and took me through the same “resistance” tests in various directions, as we had done previously.

John then did some probing around this tibiofibular joint, comparing how easy it was to move it a little, vs the other healthy leg.  As he did this, both he and I could feel some stiffness / hardness in that area of the affected left joint.  There was no pain as John did this, which we both took as a good sign.

I was particularly aware of how “hard” this area felt – I had not expected hardness, and John was also a bit surprised to find it.  He did some further work on the area to try and free it up a bit, and then we repeated the range of motion checks.  There was a noticeable improvement, and as far as I could tell, the affected leg was now much closer to having exactly the same range of motion as the other leg.

We then discussed the strange colouring up of the muscle on the outside of my lower leg below the affected knee joint, a spot that had looked a little like a bruise, and which had appeared briefly at the start of the “breakthrough” events from early December (see blog #14) – events which had ended up being a transition from limping noticeably when walking downhill, to having virtually no limp at all.  We talked about how this might be related to the various nerves that run down through the area we had just been working on, and to the lower IT Band etc.  The exact nature of what had taken place in these breakthrough events, had never been clear to either John or to my GP, with whom I had discussed this when he phoned me last week to go through the results of the MRI scan.

John found some diagrams online showing how the tibia and fibula fit together to form this smaller joint, and how the various nerves are situated there.  Although we were not able to shed any further light on just what was going on with the breakthrough events, it was good to consider the nerves and their location in relation to this joint.  John felt that it might have something to do with the peroneal nerve in particular.

Despite still being a bit in the dark about what was up in early December with this, it was clear that we had found some tightness and “hardness” in the tibiofibular joint which had escaped both John’s and my attention, until now.

John showed me how I can work this area myself, to help loosen it up.   Here is a diagram John passed me a link to, on which I have added a blue circle to show where this tibiofibular joint is located.

Knee joint diagram incl peroneal nerve - incl blue circle croped

The diagram is for a right leg, but I can easily work with this for consideration of my affected left leg, because the diagram shows what I would see in a mirror for the left one, if I had x-ray vision etc.

John’s recommended exercises for this joint involve pushing the fibula – the smaller “outside” bone – forwards from behind, at around the red spot on the diagram (below and to the left of the blue circle), and then releasing to let that bone return back again.  He said that doing the motion in a forward direction is partly akin to how it should work normally, when either walking or running for example.  I got him to show me how to do this while I stood and put my leg onto a chair.  As well as him repeating, as a demonstration, what he had done on the treatment couch, I also then tried it, using a couple of techniques he showed me that require both hands – the left to do the pushing, and the right to hold the main knee joint relatively still.

This is always to be done gently I must add – the aim is to loosen the joint up again, after it seems to have been stiff and hard for some time.  It is probably best done while on the floor or sitting on a chair, with no weight bearing on the leg.  I will be including these exercises in my usual daily routines, going forward from here.

John also advised me to slightly modify the ankle exercise I have been doing for a few weeks now, which should also be targeting roughly this same area of the knee joint.  Instead of bringing each foot up diagonally to the “upwards and outwards” position, he said it is better to “rotate” or “swivel” it into this position, from the other position of “downwards and inwards”.  I will be sure to modify how I am doing this exercise, along these lines.

John’s suggestion regarding returning to some running, was to build up slowly and see how it goes each time, and not to just assume I will be increasing distance each time – to always assess as I go along, in other words.  This is exactly what I had already expected that I must now do.

His overall assessment of the state of the joint, is that it is indeed much improved since I first came to see him last October, and that it should be OK to now try adding some light jogs into walking, etc.  He again mentioned the NHS “Couch to 5k” plan for getting in shape – which I had briefly looked at a few weeks ago.  It is a simple and gradual increase within a set amount of overall exercise time, of the percentage during which you are jogging or running, with walking making up the rest.  My picture of how this recovery might need to be addressed, is very much along these lines.

That was about it for this session, which I suspect – and hope – will be the last one I need for awhile.  As I left to make my way home, my instincts were telling me that, in this tibiofibular joint, we may have found a “final” piece of the puzzle.

By the time I got home around lunchtime after the appointment – which was a trip made by car – I had decided to try out my usual lunchtime walk of around 1.5 miles, after eating.  I had already been noticing that the leg was feeling a bit more strong and “steady”, and perhaps a bit more similar to the other, OK leg.

Before taking the walk, I first did one quick experiment which gave an interesting and encouraging result: I bent both knees down and squatted to the floor, but with my knees not touching the floor, and just held that position for a minute or so – this is the sort of pose that people in India and Asia spend a lot of time in, which John has said is one reason why they tend to have healthier knees that we do in the West.

Before today, this sort of squatting would fairly quickly have started to hurt the affected left knee joint a bit, feeling too tight especially on the outside area, right around this tibiofibular joint.  Today, after our session 8, it didn’t hurt at all, and it didn’t feel too tight either.

I then took my walk, which felt good – it felt similar to recent ones, but in general I think my steps onto the affected left leg were less tentative than recently, more solid.

This walk includes one short but steep downhill section which, going back a few weeks, was always my litmus test of whether there had been any change to the noticeable limp I had suffered from until the breakthrough events of early December (see blog #14).  Although I have not been limping at all when walking this section lately, I had still been finding that there was a trace of pain, as though I was on the verge of the joint hurting, especially in that outside area of the knee.  On this occasion however, there was nothing like that at all – as I did this steep downhill bit, my step, gait and general feeling in the left leg and knee joint, was exactly identical to that of the other, healthy leg.

This is the first time in probably nearly a year, that I can truly say that my walking gait seems to be fully “symmetrical” on the left and right legs, both when walking on the flat, as well as up- and downhill.  I will be keeping a close watch on whether this continues, as I walk over the next few days.

I feel quite hopeful from all these developments of today.  It looks like we may have found the cause of the residual issues that have persisted since both those early December “breakthrough” events, and since John was able to loosen up some lower spine tensions in our session 6 on 19 December (see blog #16) – tensions which, for many years, were making me lean over to the right a bit in my upper body.  In addition to those sources of trouble, I may simply have also been suffering from some built-up tensions / hardness in this smaller joint on the outside of the left knee area.  These may have at least partly been brought about by the other sources, remaining there unaddressed, until now.

Speaking of the work John did on my lower spine in session 6, I have concluded that those tensions probably played a fairly significant role in me ending up with the various knee troubles that I first came to John with, last autumn.  I believe they combined with the various difficulties I was having around the waist and rib areas on the same side of the body (see blog #02), to give me the knee problems which, before they all started up around a year ago, I had never suffered from before, as a runner for over 14 years.

Once again, I want to praise John’s work on this.  I have not been a straightforward patient by any means, but he really knows what he is doing, and I believe that his knowledge and experience have enabled him to eventually pinpoint, treat and recommend things I can do myself going forward to address, all the various causes of the troubles I have been having.  I feel that without his help, I might never have been able to get to the bottom of these issues.

My GP has also been extremely helpful by having no hesitation in ordering an MRI scan on the knee, once the apparently OK results of an initial x-ray had come in, something which had left him, John and me a bit puzzled as to what might be going on.  In this instance, it has been a good mix of both private and NHS diagnosis and treatment.

My mission now is to see how it goes, from day to day and exercise session to session.  From here on, I will report in with further blog pages from time to time, even if I don’t need to see John for any further sessions for the time being.

 

 

 

 

Knees – not just getting old? #23 – Before Session 8 with John

I have been meaning to arrange to see John again but have been quite busy.  Also I was expecting to have a call from my GP to discuss the results of the MRI scan.  He ended up phoning me today, a week earlier than planned, and we talked about what the scan suggests.

His assessment of the MRI report is that my condition is the result of wear and tear, some of which perhaps goes back a few years – but that, because the menisci, main cartilages,  and other main parts of the knee joint are relatively OK and it is only some of the “lesser” parts of the joint that are showing signs of degeneration, in principle it should be possible for me to effect at least a partial recovery to being able to run again.

I have now booked to see John for what will be our 8th session, on Mon 20 Feb.  In this session, I would like us to do the following:

1] Go through and discuss these 5 questions:

  • Does the MRI report “explain” / make sense of, all the symptoms I have had with the knee? Is it “in line” with them?
  • Could a person who has suffered a trauma event, end up with a similar pathology as in this MRI report? Could I have actually suffered a minor  trauma event when – after doing foam rolling following the first run I took in late September at the time I first started to foam roll – the knee joint gave a good loud crack as I swiveled the leg into position while sitting on the floor (with no weight on the leg, and while all the muscles were relaxed)?  If this was in fact a trauma event, could it have led to the pathology as described in this MRI report?  Or are the deteails as in the report, much more likely to be the result of all the wear and tear, and the other “misalignment” issues including lower back area tensions, ITB getting tighter as a result etc, going back several months in the medium term, and in the long term, overall since starting to run 15 years ago?
  • Does anything in this report explain the issues with the lower IT Band having gotten coloured up in early December?  Does the report make any sense of the “breakthrough” events around that time (see blog #14), after which the previous pronounced limping on that leg when walking downhill, quickly improved?  Keeping in mind that whenever foam rolling, nowadays I never find any more muscle tension in that lower ITB than in the other, healthy leg, can the report explain why I can still feel what seems like extra tightness/tension in the lower ITB when I bend the knee?  Does the report suggest that the sciatic nerve might be involved in that feeling of tightness, rather than just the ITB muscles themselves?
  • Does the report suggest permanent damage? Am I likely to be able to recover from this, enough to eventually start running again?  If so, what exercises should I start off with now, to begin to strengthen the whole knee joint, which is still weak?  What exercises should I do to target the specific areas affected as described in the report?  If running again at all is an unrealistic expectation, what exercises should I do to aid whatever recovery should be possible?
  • My instincts over the last few weeks have been that, if I am able to recover and eventually run again, I must make a deliberate and gradual return to this, beginning only by introducing targeted exercises to help the knee to get stronger, and then slowly starting to do some light jogging etc – similar to the “couch to 5k” NHS approach.  I am clear this will need me to pay close attention to how the knee is feeling – before, during and after any running etc – and I will most likely have to be flexible about recovery, and about my expectations.  Keeping in mind that this will be a slow return in any case, does John think I can get back to my previous usual 4 miles of distance every 3 days?  Or is that perhaps too often, and/or too far as a distance, based on what is in this MRI report?

2] Have John check out how the knee is now, and then show me any extra exercises he recommends I do, to take it forward from here.

3] Possibly have a brief spell of jogging on the treadmill and film this from the back, to see whether there is any sign of the previous hip drop that was present before the “breakthrough” events of early December (see blog #14), and before John’s work on the lower back area in our Session 6 on 19 Dec (see blog #16).

Incidentally, I am still standing up straight following that Session 6 work, and in particular I notice that, for example when doing my usual stretches and exercises each day, the joints on the left and right sides of the upper body, continue to “pop” at the same time as each other on both sides – something that they always did “offset” before that (one side after the other), and which had been going on that way for such a long time, that I thought it was just how I am built.  It’s clearly not, and was down to those lower back tensions which John was able to address in Session 6.

I have a friend from table tennis, who is experiencing similar knee troubles to myself.  He also runs, so may have a corresponding set of exercise “circumstances” to me.  Also, when he stands up straight he leans over to one side, very similar to what I used to do before Session 6.  In his case it is more pronounced than me though.  I have recommended John to him.

Knees – not just getting old? #22 – MRI scan result: report

07 Feb 2017

I phoned my NHS health clinic today, and they told me the scan results were in, from my 26 Jan appointment.  I picked them up, and now have their report, which I will discuss with John.  Here is an image of the specifics in the report:

Nelson - 26 Jan 2017 MRI scan NHS report - description

In short, it seems the meniscus are OK, but some other things I have never heard of, are showing “degenerative change”.  I don’t really know where the various muscles and so on are located, or whether this is permanent damage or it will heal up.  I need some input from John on this.

 

Knees – not just getting old? #21 – Before MRI scan

Mon 23 Jan 2017

Since my last blog post on Fri 06 Jan, the knee has improved only slightly.  For much of the time it is still tight in the joint, and it also seems tight around the lower IT Band area when I bend it – even if bending with no weight, i.e. lifting the leg up and bending at the knee.  The rest of the time, it is a bit better than this, but still has what feels like tightness in both of those places.

Lately I have begun to think that the “tightness” in the lower IT Band is not to the ITB muscle itself, but maybe just the sciatic nerve.  Whenever I foam roll, which is 2 or 3 times a day, that lower ITB is no tighter than on the other, healthy leg.

On once occasion I tried a foam roll on the ground and  with the affected knee joint bent, to see whether the ITB would seem to be tight – but this proved to be pretty much impossible to do properly, so I did not get a definitive result from it.

Whatever is up with the ITB, it feels like borderline pain that is sharper than in the knee joint itself.  I can even feel this borderline pain in the ITB if I press on that area with my fingers while the leg is straight and the muscles are not being worked.  This is partly why I suspect it is more to do with the sciatic nerve, than the muscles in that area.  The joint mainly feels tight around the outside, as it has done for some time.

I have done John’s new recommended ankle exercises every day since my last post on 06 Jan.  I cannot tell whether there are having any effect, but am doing them anyway.  If they are working to help the joint stay loose, I think it is only by a little.

I have done no running for 2 months now.  Since my last post on 06 Jan, I have played some table tennis.  This sometimes seems to leave the joint worse off the next day (tighter), but not always – and it does not seem to be related to the length of time I play, more to whether I hold back a bit when going for shots, or take them fully committed.  Unlike the more severe troubles I was having before early December, the joint is not sore on the day after table tennis.

When I bend the knee, even without putting weight on it, it still does not “pop” as much as the other, healthy knee joint.  When it hardly pops at all, these are times when the joint is always tighter.  When I have been working at the computer and get up, I often get a small pop from bending the knee, and the joint and ITB feel a bit less tight.  On days when I am not at the computer and do not do any sitting of that sort, the joint pops less, and is a bit tighter in general.  I find this to be a strange observation, but that’s what’s going on.  Maybe it tells us something about what’s wrong with the knee.

I have been walking most days, for around 1.5 miles or so usually.  Walking down a slope no longer results in that “goofy” gait, and there is no specific pain in the knee joint now, when on a downward slope   – but overall, I am still favouring the affected knee a bit when I walk, and I can almost always feel that something in the joint is not right, as I take each step.  I would not want to do any amount of running or even jogging on it, at this time.

I still cannot use my preferred sleeping position when on my left side.  It continues to give the same pain to the knee joint as it has done since early October last year.

I am having the MRI scan this Thursday 26 Jan.  I have spoken to a technician there, and they have told me that the area the scan will cover should include about a third of the way down the lower leg from the knee joint itself, and a third of the way up the upper leg from the joint.

With the lower IT Band clearly playing some sort of a role in the current state of the knee joint – even if it is just the part of the sciatic nerve that goes across the ITB – I am wondering whether it would be a good idea to ask the technician to aim the MRI scan down a bit lower, so it still includes the whole of the knee joint itself, but also picks up more of the lower ITB.

That is a question I would like to hear from John on, before the appointment for the scan on Thursday.

Thu 26 Jan 2017

The scan took place today.  There were no issues with how the scanning process went.  They told me the results should be with my GP in about 2 weeks.

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