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Knees – not just getting old? #28 – postscript A: other treatment, workstation revisit

It’s been nearly 3 months since my “final” blog re Physio John’s treatment. Since then I have been seeing an orthotics specialist.  As well as giving me further specific exercises to do to help re-train both my running and walking gaits, he has had me gradually reduce the height of the insole worn in my left shoe for the past 6½ years, down from 11-12 mm to a current height of just 3mm, and which in a few more days can be reduced down to nothing!  This has been aided by learning to use my glutes and piriformis muscles much more properly, and getting them firing better.

There have been almost no “transition” issues as the insole heights were reduced – none in the neck area , where I had a lot of pains for years (before starting to wear the original insoles in 2010), and just some soreness in a muscle in the middle of the shoulder blade of the opposite arm, which might not even have been related to the insoles reductions, as it could have just been that I pulled something. In any case, that has cleared up now also.

Over the course of appointments spaced about 1 month apart, the orthotics specialist has gradually concluded that even though I was turning out to be a model patient, and we were making big advances towards much better walking and running posture, I might still have to wear an orthotic insole. Whereas “normal” insoles are “even” from the left to the right side as you look from behind , orthotic insoles are slanted, either one way or the other.  In my case this needs to have the extra height on the inside of the foot – near the arch etc – and reducing down to nothing on the outside.  I had been wondering several months ago about whether something like this might be needed, when I was having the more serious issues at that time with the knee.  The orthotics specialist made up a “quick and dirty” jury-rigged orthotic lift for me, which I have worn in all footwear since the first week in June, changing it over from one left shoe to another as I did varying activities etc.

On the plus side, both my walking and running gaits have ended up with a much longer stride than before. They were each always unnaturally short, and I didn’t know why until now.  I just wasn’t using my body’s equipment properly.  After resuming full running a few months ago, with the improved techniques and gait, I found that the time it was taking to run the same 4-mile course, came down from about 40 min to just 36 min on the last run taken, which was around the middle of June.

On the minus side, after that last run, I developed some soreness again in the affected knee later that evening, but it felt a bit different to previously – not as severe as when I had been having major troubles in the Autumn of 2016, which had led me to start seeing Physio John, but serious enough that I realised I would have to stop running again, for an unknown period.

Since then, based on both my own instinct and on the orthotics specialist’s advice, I have only mixed in a few very short runs of 1 min or less, while taking walks.  Even so, over the past few weeks, as well as some pain in the tib-fib joint on the outside of the knee, the main joint feels like it is not quite properly lined up, and that joint can also sometimes give a little pain.  When playing table tennis, which I have continued with the whole time, I am unable to give 100% when going after a shot that requires a full stretch onto that left knee.  Another thing I’ve noticed is that while laying on the couch, such as after a day’s normal activity, if I rest that leg with the knee bent upwards and the foot on the couch, even after a few minutes, the whole knee joint is a little stiff when I next straighten the leg out again.

After that final run, when I next saw the orthotics specialist on 19 June, he concluded that I will definitely need to wear an orthotic insole. In that session he took some film on his mobile phone, of me walking across the floor of his treatment room.  He found that looking from the front as I walked toward him, my knees stay straight as I walk, but from the back, my legs are rotating – both of them.  His conclusion is that this rotation, together with the likelihood that the affected knee has some permanent damage, is why I am having further issues, despite the fact that my walking and running techniques had recently been much more “correct”.  He took imprints of both feet and ordered the orthotic lifts, and I am now waiting for those to arrive with him from the manufacturer – the same firm who had made the original, “unslanted” insoles I had been wearing previously.  His assessment is that wearing an orthotic lift on both feet will gradually help with re-training the body to use my long limbs more naturally and efficiently, without any of the observed, unnecessary rotations to either leg.  Until that has taken place, I will continue to do no further running of any significant distances at all, just a few yards here and there when walking.  This transition to phase out the current rotations, could take some time – so I am being fairly patient.  It’s also not clear whether I will ever be able to resume running the same distance as before.  I must be prepared for any outcome on that.

 

One other development of note has come from the work done with the orthotics specialist, something worth sharing in this blog. In his treatment room/office, he sits on an unusual-looking “sit-to-stand saddle stool”, the kind of stool used in places like hair salons, for example.  He recommended I get one of these – they are dirt cheap on Amazon – to see whether it would help with sitting properly more of the time, as well as not putting the glutes and piriformis to sleep as much as sitting on a conventional chair does.

I bought one of these saddle stools in mid May – the same model he has in his office – and gave it a proper tryout for around 6 weeks. While it was indeed clearly much better for the various muscles on my backside, I did get very sore where the bones of the hip stick downwards – the same place where cyclists get sore, from sitting on their bike saddles.  Also I found that sitting on the stool seemed to aggravate some residual muscle sorenesses I have continued to have up in the rib area on the same left side of the body on which I have had the knee issues (see blog #01).

I did like using this new stool, and as predicted, due to simple physics, they naturally move you into good back posture. But after a couple of weeks to see whether my “underside” would toughen up and I would be able to get used to sitting on it at my home workstation for a total of the typical hours in a working week etc, I had to admit to myself that this was not happening, and that it was just too painful.  So I tried adding a layer of 1-inch foam rubber, of which I had some left over from an unrelated DIY task done in the house.  That helped quite a bit at first, but within a few more weeks, the foam had squashed down, as it was not designed for seating or furniture.

I then tried using proper foam for cushions – 2 inches thickness in total, and much stiffer material that wears out much slower. For this, I had a professional upholsterer add the foam over the top of the existing saddle shape, then finish it off with the same sort of layer of PVC as the stool originally came with, over that foam.  While this felt a bit better at first, after a few days the hip bones that protrude downwards were still getting quite sore, and the aggravation to the rib muscles was still happening.

Here are pics of the various stages of trials of the saddle stool, as described above:

      

Having been through all the above experiments, the continuing pains etc led me to decide it was time to give up on the saddle stool approach altogether. Instead I returned to using the “deep” chair I had bought from Physio John late last year, which was a spare one from his treatment room in the MOTI store.  Sitting on this chair, with an added towel folded into 8 layers as John has recommended (something that helps keep the pelvis a bit higher than the knees as you sit), did not hurt the “underneath” protruding hip bones like the saddle stool did, and the soreness in the rib area was also not bothered as much.  But as I had always found, my glutes get fairly sore after even just ½ an hour on the chair, and also my right hip joint gets sore.  These issues had been what motivated me to try the saddle stool – but compared to the troubles I had with the stool, it turns out that the chair issues are the lesser of 2 sets of evils.

To come up with the best compromise that seemed possible, using all the knowledge gained from trying various things re sitting, and based on what the orthotics specialist and Physio John have each told me, in place of a folded towel – which offers only a little cushioning – I worked out a design for a cushion to use together with John’s chair, one that as it turns out, works reasonably well. It’s made of 2-inch stiff cushion foam, is a square 360mm x 360mm when seen from the top, and starting halfway along it from the back to the front, I had the foam cut at a diagonal angle, so it slopes down to nothing at the knees.

Below is a scan of the drawing I initially made up of this shape, which is intended to provide the required extra height for the hips so that they are a bit higher than the knees, and to do this in a way that should feel comfortable and natural, as you sit on it.  In the past I have tried thicker foam, but it just squashes around too much, so 2 inches seems about right.

Using some excellent cutting machinery in their factory, the foam people were able to produce some pieces to the specification in this drawing.  I then took those to the same upholsterer who did the saddle stool work, along with some nice fabric I had picked out for covers. I had 2 cushions made up, one in green for use at home, and a black one to take out to the workplace.

After trying out the green cushion for a few hours, it was clear it helped with the sore backside, and to some extent, with the sore right hip joint. But one thing I noticed was that with the extra height I was now sitting at above the chair seat, a bony bit of my spine that had previously been lined up with the foam in the chair’s curved backrest, was now up against the top edge of the backrest, where there was no foam.  This was making it sore.

I took a closer look at the backrest on the chair, and immediately worked out what to do about this. The height of the backrest needed to be raised up by at least 1 inch.  As well as taking care of this new pain in the spine, I realised that if I raised it a little more, the whole backrest might then work more as intended by the chair’s original design, but for a person like me who has a longer than average torso.  It occurred that I could add a 3rd screw halfway between the existing 2 on each side of the backrest, then move the backrest up by one “set” of these screws, in effect adding around  2 inches to the height of the whole backrest, relative to the seat itself.

I carried out these modifications to the chair, and was even able to get the lowermost pair of screws – one on each side – to get a proper hold in the wood in the very bottom part of the backrest. The end result of this was that as well as being exactly the correct height for me, the backrest was now fastened even more strongly to the rest of the chair, than it originally had been.

The final tweak of note that I have made to the workstation setup in the last few months, was to the height of the desk. I had already raised it a little when trying out the saddle stool for a few weeks, and as it turned out, that height was still correct for sitting on John’s chair again, with the new green cushion.

Below are some pics of John’s chair, showing these mods and the new cushion, as compared to how it looked before they were made. In each pair as aligned, the left pics show the original chair design, and of me sitting on a towel folded into 8 layers as advised by John, for the extra pelvis height – and the right pics show the modified chair, and me sitting on the new cushion with the slanted bit to get my knees lower than the pelvis.

 

    

Finally, here are shots of the modified chair and new green cushion:

 

Sitting on this for the last few days has been much better for the parts of the hip bones that protrude “underneath”, and the rib area soreness has improved also.  Although my glutes are still getting sore, it’s not a bad as with no cushion, and the right hip joint soreness is also reduced, though still there.

I am open to suggestions from anyone reading this, about how this setup might be improved further, to both retain a structural design that will promote sitting properly – as this seems to do – but which might further reduce the sore glutes and right hip joint.  This is the best I have been able to come up with, at this point.

 

How to become a blogger for AAA Physio

  1. Write First Blog Post and email to John Stephenson PHYSIO
  2. You will need to come up with a blogger name- you could use your real name or a creative username. This will also need to be in the email you send to John.
  3. John will then set you up a bloggers account, and email you back with details of how to access this account. Your first blog will have been posted for you by AAA Physio Support.
  4. You are now able to log in, have a look around! (You are also able to change the automatically generated password given to you)
  5. All blog posts from that point forward can be written and posted by you directly onto the website (no need to get it done in one go –  there is a ‘save as draft’ function!). You are also able (and encouraged) to include photos in your posts.
  6. John or AAA Physio support are always on hand if you experience any technical difficulties with the blog.
  7. Write away!

Here is the blog to give you ideas for your own posts! http://www.physiotherapy.co.uk/blog/

Dr Mark Porter: Stiff knees may be a sign of arthritis, but exercise can help

Here is a link to a very interesting article by Dr Mark Porter on how physiotherapy and exercise can reduce the affects of arthritis…

https://www.thetimes.co.uk/article/dr-mark-porter-stiff-knees-may-not-be-a-sign-of-arthritis-just-that-you-need-to-do-some-exercise-xzj9fkvn3

cycling-bicycle-riding-sport-38296 small

For those with arthritis here’s a useful link to Arthritis Research UK for some excersises to help manage knee pain…

http://www.arthritisresearchuk.org/arthritis-information/conditions/osteoarthritis-of-the-knee/knee-pain-exercises.aspx

London Marathon Success!

We would like to congratulate all runners who took part in the London marathon on 23rd of April. A special congratulations to Annie and Rob Dixon who completed the marathon in 3:58:12 and 2:51:43 and also to Richard Edwards in 5:02:00 (who was still looking full of energy despite already completing 25 miles!) and all of whom completed it with no injuries!

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http://www.marathonfoto.com/Catalog/List/285322548?PIN=V54972&LastName=EDWARDS

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: #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.