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Knee discomfort under knee cap, low vitamin D, wearing patella straps. Do I have significant cartilage damage?

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Practicing since : 1985
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I’d like to describe the condition of my knees and ask you some questions.

The symptoms: Knee discomfort in general but mostly in the area under the knee cap (the area the doctor hits to test your reflexes). When extending my left knee after having it bent, I get some slight grinding in the knee. In the right knee, though, I get quite a bit of grinding and sometimes it hurts. Two years ago, my knees were great and I was playing basketball twice a week. Now I can’t do much other than walking and very light strengthening exercises (e.g., straight leg raises with ankle weights while lying down). I have seen orthopedists, podiatrists, rheumatologists, and physical therapists. The consensus is that my knee caps don’t glide right because I have weak quads and tight muscles in my legs. Also note that as of last December, I had low vitamin D levels (22 ng/ml). I’ve been taking a 5000 unit pill daily and am now at a normal level though. Also, I’m 32 and relatively lean (5’5”, 140).

The good news: After many years of bad orthotics, last week I got new orthotics from my podiatrist and they feel great. I can tell there’s MUCH less pressure on my knees and I feel better balanced than I ever have before. My knees caps (especially the right) still grind though and extending the right after having it bent causes discomfort. I’m not in constant pain, though. It’s just occasional movements that cause discomfort. My podiatrist showed me that the different orthotics I’ve worn over the past 5 years (I brought them all to show him) did not fit my feet well and may have actually done more harm than good. Note also that I wear patella straps for walking.

My questions:

A) Does it sound like I have significant cartilage damage, especially in the right knee? With these new orthotics and strengthening and stretching exercises, what’s the best case scenario? I know that wouldn’t make the cartilage come back but am wondering if I can get to a point where I can play sports again? Will my right knee always hurt upon extension after being bent? I’d love to be able to play basketball again but don’t know if that’s completely unrealistic.

B) Will I need microfracture surgery if I want to get to a good level of athleticism or could there be a lot of improvement just from the orthotics and exercises?

C) Can I do lying leg raises *daily* to strengthen my quads or do my muscles need a day off in between to grow? I use only a 1 lb weight on each ankle but work the quads *very* hard (holding the leg in the air for many sets with reps varied from 5 to 90 seconds).

D) In my lifetime, do you think there will ever be cartilage restoration options that don’t have as brutal a recovery period as microfracture surgery (either a gentler surgery or a nonsurgical approach)?

Thanks for all your feedback!

Posted Tue, 22 May 2012 in Lupus
Answered by Dr. Praveen Jadhav 22 hours later

Thanks for your query.

It would be important to know how was the wearing off of cartilage diagnosed. Was it with an x ray? If indeed the cartilages are damaged, then the diagnosis of your condition is osteoarthritis. However, at 32, it's too early to have primary osteoarthritis. In case the cartilages are damaged, there ought to be some reason (at 32) why this has happened i.e. you have secondary osteoarthritis.

The obvious reason why you may be getting knee pain is due to your previous history of Crohn’s disease. Inflammatory bowel disease can cause arthritis, involving knees and later spine. This can happen even if the bowel disease is in remission.

So obviously, the first step is to rule out bowel disease as the cause of our problem. Rheumatologists do it by examination - depending on whether there is inflammation of the synovial membrane of your knees (which is quite possible in your case), presence of high sedimentation rate or high C reactive protein and range of movements of your knees.

Coming to your specific questions,
a. X rays of knees can tell if there is significant cartilage damage. If there is no significant cartilage damage, you can surely get back to your athletic ways, but only with specific treatment of the underlying condition.

b. Reaching a diagnosis and getting a specific treatment is most important than orthotics or exercise. Rheumatologists should be of help in getting to a diagnosis. If your diagnosis turns out to what I presume, there will be no much role for surgery, but an important role for medications like suplasalazine.

c. You can do daily exercises without any harm.

d. Cartilage restoration should be thought of only when you prove that the cartilages are damaged. Unfortunately, if they are damaged, then surgery will be the only option.

Hope your questions are answered.
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