Monthly Archives: February 2017

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.