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Knee pain, weak quads. Orthotics haven't helped. Knee clicks. Why is this happening?

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Orthopaedic Surgeon
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I've had knee pain for about 1 1/2 years. My doctors have told me it's because I have weak quads and my knee caps don't glide correctly and my feet are in a bad position when I walk. I've tried a variety of orthotics that haven't helped. 1 1/2 weeks ago, I got a new pair of orthotics. Initially, they were helping a lot. The podiatrist showed me that they fit my feet better than the other ones. (Unlike with the old ones, there is no space between the feet and the orthotics with these new ones.) I felt better balanced and it felt like there was much less pressure on my knees. That was how the first few days went. Now for the last 3 days, my knees have felt awful. My left knee cap appears to be clicking or rubbing something the wrong way and I have discomfort on the inner parts of both knees. The discomfort is not in the leg muscles but is actually in the knee joints. Is this just temporary or is there a problem with how these orthotics are working for me?
Posted Tue, 22 May 2012 in Osteoporosis
Answered by Dr. Atul Wankhede 26 hours later
Thanks for posting your query.

You seem to be suffering from a condition called as tight lateral retinaculum of knee. The lateral support of your Patella is unusually tighter than the medial one, causing a bio-mechanical mal-alignment of your extensor (quadriceps) mechanism. That's why you have that pain in knee and until you correct the deformity, it won't go.

Managing conservatively works for individuals with minor deformity and very little quadriceps weakness. Conservative treatment includes-

1.mechanical support by brace/ orthotics-which doesn't seem to work for you,
2.preventing overuse-by lifestyle modification,
3.releasing tight structures-by XXXXXXX frictional massage,
4.improving muscle balance-by selective muscles strengthening,
5.relieving local inflammation/painkillers-for temporary use, and finally
6.artificial lubrication-injecting synthetic fluid similar to what natural knee makes.

Since orthotics have not worked for you and knee symptoms are flaring up, I suggest you consider visiting your physical therapist soon. Most of the aforesaid options will be readily available there.

For any reason if conservative treatment does not work out, do not worry. A small surgery where in the surgeon carefully and partially releases the tight retinaculum and balances the opposite lax retinaculum by tightening it. This automatically improves the quadriceps function and in turn eliminates the cause of pain. (Besides this, there various other surgeries like Maquet, Elmslie-Trillat etc-for further reading on internet).

Hope this answer was informative. If you need more help understanding the condition, feel free to ask more. I'm available for follow up.
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Follow-up: Knee pain, weak quads. Orthotics haven't helped. Knee clicks. Why is this happening? 13 days later
I have developed patellofemoral pain syndrome in both knees in the past year and a half. The condition out of nowhere got substantially worse in the past few works in my left knee. I’d like to give my history below and ask a few questions.

Until about 3 weeks ago, the left knee was minimally affected, while the right knee was worse. Still the symptoms were not severe. I had x-rays done in January and they showed a very good amount of space between the bones. I did get some grinding at times when extending the knees, though. My left had been in pretty good shape, though. I could even do one-legged body weight squats on it. Then, about 3 weeks ago, I tried my new orthotics and my left knee coincidentally began to deteriorate. I actually feel much better balanced in these knew orthotics and they feel very comfortable on my feet, though. The podiatrist who made them showed how they fit my feet much better than my previous orthotics. However, about a week after I started wearing them, it felt like something was moving in my left knee incorrectly when I walked. It feels like something is rubbing against something on every step I take, and occasionally there’s a significant click or pop. Could I have gone from having good cartilage (based on the January x-rays) to bone on bone in some part of the left knee and that’s what the rubbing is? Or maybe a piece of bone chipped off and is rubbing against something? The discomfort is pretty bad when walking, and this came out of nowhere. Yesterday, I went back to wearing my old orthotics but the left knee doesn’t feel any better.

I saw an orthopedist yesterday, but I don’t think I did a good job of explaining how sudden the deterioration in the left knee has been. Note that he moved my knees in a bunch of ways. There wasn’t any pain but there was grinding and occasional popping. He said I have patellofemoral pain syndrome. He ordered an MRI to be done but I’m really worried and was wondering if you had any insights you could offer while I anxiously wait for the MRI. Note that he said my knee caps track pretty well when I bend and extend my knees and said my walking posture (bare foot – no orthotics) was not that bad. I’m not overweight. I’m 5’5” and about 135. Two years ago I was in very good shape and able to play basketball twice a week with no problems.
Answered by Dr. Atul Wankhede 5 hours later
Thanks for writing back.

Glad to hear the tracking is good on examination. Nevertheless if the friction is felt while walking there is good possibility that its Patellofemoral syndrome.
In my opinion get the MRI done at earliest to rule out any XXXXXXX Derangement of knee.

Meanwhile use orthotics that are most comfortable.
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Follow-up: Knee pain, weak quads. Orthotics haven't helped. Knee clicks. Why is this happening? 9 days later
Hi Dr. Wankhede,

I have the MRI report for my right knee from the radiologist. I'd like to tell you what it says and ask you if you can tell me what it means in plain English and what to do about it.

At the summary part of the report it says:
1. Menisci, cruciate and collateral ligaments appeared intact.
2. Focal area of chondral edema, mild chondral loss and also marrow edema and subcortical cysts in the median ridge of the patella.
3. Very mild degree of chondral loss in the anterior femoral trochlear grove.
4. Anomalous appearing slip of the medial head of the gastrocnemius muscle extending along the lateral margin of the popliteal vessels.

In the detailed part of the report, it also mentioned the following:
1. The marrow edema and subcortical cysts are around 7mm in cephalocaudal extent around 5mm in AP dimension and 3-4mm in depth.
2. There was a small joint effusion.
3. The slip did not extend to the popliteal vessels.

I know the orthopedist said that he would consider hyaluronic acid shots but wanted to see the MRI results first.
Answered by Dr. Atul Wankhede 55 minutes later
Thanks for posting your MRI report.

The first part shows you have normal ligaments and cushioning is intact, so nothing to worry there (we did not suspect that since beginning).

The second part is the one that we suspected. Due to biomechanical mal alignement, the inner part of your Patella (knee cap) has been and still is rubbing against the Trochlear groove of Femur. That has resulted in loss of cartilage on Patellar surface, and even caused small cysts (collection of fluids in small pockets under the bone) about 7x5mm. Also there is fluid collection XXXXXXX inside the core (marrow) of Patella. These are all necessarily friction effects.

The third part describes that Trochlear groove where the Patella articulates also has undergone friction changes, less severe than Patella but on the same track to same fate as later.

Don't worry about the last part, that's an incidental finding.

The treatment that I told you in my first response wont help anymore. You may still try preventing overuse by lifestyle modification, releasing tight structures by XXXXXXX frictional massage, improving muscle balance by selective muscles strengthening and painkillers for sometime, but I suggest you go for some definitive treatment soon.

Definitive treatment is surgically correcting the mal-alignment, removing the dead cartilage/cysts/marrow oedema, and making drill holes under the bone (that enhances growth of new cartilage). We now have provisions of cartilage harvesting and implantation too, do inquire about that as well. These all surgeries are done arthroscopically (pin hole surgery) and on day care basis. All this must be followed with physiotherapy and cartilage growth enhancing medications.

I hope this answer helped you understand the situation and you take all necessary steps to correct it.
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Follow-up: Knee pain, weak quads. Orthotics haven't helped. Knee clicks. Why is this happening? 38 minutes later
Thanks; I have a few more questions.
A) Are you talking about microfracture surgery when you mention drilling holes under the bones? I've read about athletes who have had that and the recovery phase and time period looks rough.
B) Is there any chance this is nutrition related? I became a vegan about 2 1/2 to 3 years ago and about a year 1 to 1 1/2 years later began having these knee problems. I've had routine blood-testing, which has always been normal, with the one exception that last December my vitamin D levels were low. In December, the numbers were
"Vitamin D, 25-OH,D3: n 12"
"Vitamin D, 25-Hydroxy: n 22"
"Vitamin D, 25-OH, D2: n 10"
I've taken a supplement and gotten the level up to normal now. (The doctor didn't say the exact level but just said it was normal.)
C) Do you think a less invasive approach - like hyaluronic acid shots - won't help?
D) Is there any chance I might need surgery just to correct alignment without needing the microfracture technique? The technique sounds intimidating.
Answered by Dr. Atul Wankhede 19 minutes later
Yes it is sort of microfractures that raise the blood supply locally, bring the cartilage precursor cells to affected site. Indeed the recovery period is long but it pays off well.

I don't think this is nutrition related and your Vit D3 is insignificant in this case.

Hyaluronic jabs like SynVisc One are good options only in early phases, but there is a fair possibility of you recovering with its help (since your's is a slightly advanced phase). It helps recovering a lesion, but wont prevent new one's from developing. (just imagine a nail stuck in a tyre, you might fill in air after the puncture but it will keep re-puncturing unless you remove the nail). In short you still need the definitive mal-alignment and later or in same sitting needs palliative microfractures/hyaluronic acid therapy. And believe me, its a minor procedure with absolutely nothing to get intimidated with.

Good luck.
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Follow-up: Knee pain, weak quads. Orthotics haven't helped. Knee clicks. Why is this happening? 40 minutes later
OK, thank you so much! I appreciate all your help.
Answered by Dr. Atul Wankhede 18 hours later
You are most welcome sir
Above answer was peer-reviewed by
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