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Ultrasound guided fine needling of the knee
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Having suffered what I can only describe as 'tennis elbow' type symptoms in both knees since VLM this year my consultant has said its tendonitis from overtarining and not resting after long periods of heavy training and arranged having it treated by ultrasound guided fine needling. I understand that a Radiologist will first apply a local anaesthetic to numb the affected area and then use ultrasound to guide the fine needle to puncture the tendons multiple times.The goal of this is to cause some minor bleeding which in turn stimulates and encourages healing properties in the site ,enhancing recovery.Physio follows this 7-10 days after.
They say most patients experience improvement of symptoms within 2-3 weeks.If this doesnt work my consultant says he will have to repaet the procedure with surgery.I have beeen told to rest in the meantime-even avoid walking swimming and cycling so my fitness such as it is will disappear
Has anyone experienced this type of treatment before?Its not mentioned in running injury sites.What were your experiences?Was it successful?I can run at all without discomfort sometimes pain so am pinning my hopes in a successful outcome as you would expect.
Thanks
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Need to establish why your tendon is going splat and then get it stronger a la physio....
HW
HW
The suggestion of surgery seems completely insane considering the short time you've had the problem. That should be an absolute last resort.
All the treatment you are getting smacks off treating the symptoms and not the cause. It's far more likely that your problems are caused by something biomechanical than the vageries of "overtraining". What's to stop it coming back if the cause is still there or are you just going to accept having to train far less?
Did the physio do a thorough gait analysis whilst you were running? Did the physio diagnose a cause other than overtraining? Did the physio check strength / flexibility etc? How many visits to the physio took place before this course of action was suggested?
I'm not claiming the needling won't work (I think there's also something called galvanic needling) but something smells fishy here.
Moraghan thanks for your robust concern- I saw 3 physios before I saw my GP and to be fair they all had a go at looking at the cause ranging from lower back and core weakness to muscle imbalance and tightness in the legs but none could resolve the symptoms.So I went to my GP who after XRays said I had arthritis ,accept I was getting old and take antinflams when needed but this again didnt deal with the symptoms.By the way I am not going to accept I am getting old I have more marathons and running to do!
Then I got referred to an Orthopaedic Consultant who said I was suffering from tendonitis and referred me for the needling procedure which is ongoing. He did not say my running days are over just that I need to sort out the symptoms and rest after intense periods of training. He felt 2400 miles for me last year quite a lot for a 50 yr old .I wasnt convinced though that years mileage was about7/800 miles above previous years averages.
I go for physio on Tuesday for the knee thats been done and have the other one needled on Weds and then physio for that.I will be asking why it started in the first place and how to stop it happening again then.I see my Consultant early Dec and I surgery will be the last resort especially as I dont intend missing my skiing after Xmas.Trouble is until the symptoms are resolved I really dont want to risk running which seems to particularly aggravate them and I dont enjoy running in continuous discomfort.
So I will hang in there thanks Heavyweaponry and see what next week brings and will go to NY and try to enjoy the marathon as a spectator
Best of luck mate.
Definitely ask about the cause and don't get fobbed off by overtraining etc. Too much symptoms, symptoms, symptoms etc to date by the sounds of it.
Ok , for Moraghan and anyone else interested, I saw the phsyio today. He agreed with the Consultant's diagnosis of patella tendonosis and discounted the possibility of any tears etc. He said that it was a condition that can heal completely but that it could take many months but was initially thinking that he could get me running for next years VLM.I wasnt so sure that this was a good idea and said I would be happy with an Autumn marathon-Liverpool?New York?Both-maybe not?He told me its the condition the Man U player Owen Hargreaves suffers from so it can be a nightmare to treat and totally shake off.
Anyway he said that it would be necessary to get back to basics to aid recovery and prevent future reoccurrance -get me into a regular and planned stretching regime,build up muscle strength and balance in legs back etc and look at running form and shoes.Stage 1 is stretching ,so I now have a regime to follow everyday and I return in 2 weeks for him to measure any improvement in flexibility .
Worrying was him identifying that my left leg is about 5-10 mm shorter than the left so he advised that will have to be addressed.
On a positive note I can go back to the gym or swim provided I dont exercise in pain and avoid impacting the knees so no running yet.
And thats another phsio who hasnt ruled out me running again in the near future.
Tomorrow I get my left knee fine needled-hope it goes to plan.To be honest I dont see any real improvement at the moment though I am told the theory is that the kneedling causes the established inflamation to be replaced with new inflamation which is more easy to clear or heal.
Did he watch you run? If so, in your case how does the muscle tightness and weakness manifest itself in gait problems which cause the knee pain? Which areas are tight or weak?
Have you come away with a clear idea as to what is causing the pain?
Btw - I've had patella tendonitis for a while now and my physio allows me to carry on training with pain being my only limiter. My knees are improving whilst I run, although the healing process obviously has a longer time line this way.
...be very careful about even worrying about leg length differences - most people have them, very few of them give any symptoms at all, especially if you have a sedentary job.
Think Moraghan's advise is spot on, but as with him, you need to establish if you have a reactive or degenerative tendonopathy. They need to b e looked at differently. Degenerative can be run on with very little detrimental effects....
HW
HW - any chance you could explain the difference in terms of symptoms / prognosis between a reactive and degenerative please?
Thanks.
Here goes....
Reactive tendons are generally younger who have had an acute overloading issue.
The degenerative type can be older with acute overload or younger with chronic overload. Biggest give away is a big lumpy (painful) tendon.
Reactive needs to be less painful before loading starts and is a definate limiter. Degen's generally start stiff/painful, then improve with loading and feel OK at the end....
HW
Heavy weaponry -there was no mention of either and I have no idea as to which applies to me although its fair to say both knees feel as though there are lumps or knots just where the tendon join the patella so maybe its degen?.Thats why I wondered if there was a tear .Dont know if that helps.
As regards the leg length Ive managed this long so will continue to do so
Moraghan-no he didnt watch me run-thats probably next time.At the mo all he wants me to do is stretch ,he hasnt explained the mechanism of how tightnness and imbalance causes the problem.What is your physios approach? I would happily run through it but my attempts in the Summer resulted in me coming to the view that running up to 8 miles in pain or discomfort with no respite and no sight of improvement wasnt a good idea.Some days the knees were so tender I couldnt run at all.
Thanks for you interest
I would have thought any physio's approach should start with watching you run, from there identify any biomechanical issues (preferably with you using a video of your running to demonstrate it) and then assess what is causing the issues (tightness, weakness in glutes / feet, poor alignment when running, "scar" tissue, knee cap mobility, tight ITB etc). That's what mine did.
If your physio didn't do it the first time (and also video it so he could show you what's happening) then I suspect he won't do it the second time. If he doesn't I suspect you need a new physio otherwise he's going to go through a standardised list of fixes and charge you for it.
These will probably be:
Soleus stretch, ITB stretch (which you should really be foam rolling not stretching), 1 legged incline squats etc.
Honestly, if he can't give you an accurate description of the cause which you can understand and are satisfied with you may as well treat yourself over the internet.
From your symptoms described and the treatment you have a degenerative tendinopathy. What that means is the collagen in your tendons has changed and can no longer heal effectively. The needling causing a reaction in the tendon to stimulate the healing process. The research shows that you need to progressively load your tendon in the correct way to stimulate collagen change. This will not happen over night. You should expect a 3-6 month recovery.
Yes the stretches can be important but the loading is more important. There is good evidence to show that an eccentric loading program works in both achilles and patella tendinopathy. The exercises may and probably will cause pain and this is ok as it is causing a reaction in the tendon.
You definitely need to have your running assessed to identify any potential overloading problems. When returning to running this needs to be a gradual process with adequate rest. You will probably need to incorporate some specific control and loading work into your training long term to help prevent recurrence.
I had my left knee needled today and it was far more painful than the right. Maybe no pain no gain eh? Pretty sore now but I am being optimistic.
I recognise that I may have to look to another Physio at some stage but I feel I should follow their advice at least til I see the consultant again early Dec .
The radiologist said I have to be patient but I will be pretty fed if I am not back running by January
Anyway I am off to NY to watch a marathon I should be running in
More to follow
I tried the protocol below for around 3 months and found some minor improvement:
Eccentric exercise protocol
However, my tendinitis was too far gone for it to be able to get me back to running.
I haven't run since Berlin 2006 and have tried just about everything in the medical text books:
I also did quite a lot of other stuff (stretching, other excentric exercises) but I can't remember them too well. Everything was supervised by a doctor specialising in sport / traumatic injuries.
The only treatment that had a significant positive effect was the EPI, I went two months without pain after a course of 4 sessions. I started training again but the pain came back once I got back up to 3x45 minute jogging a week. I then suffered a fall, banged the tendon and have been limping around ever since. The growth hormone injections have had a significant negative effect, I wouldn't recommend them based on my experience.
I'm waiting for a date for an operation (or maybe another course of EPI) but I don't hold out too much hope. Success rates for the operation are difficult to pin down but somewhere in the 25-75% range. That is the main reason why I didn't consider surgery until the injury started affecting my day to day life (outside of running).
I think my main recommendation after 4 years of being a medical guinea pig would be to put yourself in the hands of a doctor that has a background in sport and this type of injury. They should be able to recommend a physio with the correct knowledge / equipment to get you up and running unless your case is particularly chronic (like mine).
Take on board that if degeneration of the tendon is underway, there is no quick fix. Be patient.
And as Moraghan said, once you have fixed the symptoms, you must find and correct the cause of the injury to prevent reoccurrence.
The eccentric protocol suggested by Metoikos looks pretty good, although I would argue that you have to increase the load up to heavy weights (still gradually) as 3-5 times your body weight load goes through your patella tendon when you are running. Your physiotherapist should take you through a eccentric protocol as there is very good evidence to show this works and it should be considered as standard clinical practice. Your physio may also address areas of muscle imbalance, alignment and core control which will assist with your recovery.
With the squats and especially the single leg squat you need to ensure your have the correct alignment to ensure the correct loading pattern through the tendon. Also if your alignment is poor you risk injuring other areas such as your hip or lower back.
You can start the protocol immediately. As a general guideline your pain with the exercise should not increase more than 4/10 (1 pretty much no pain, 10 worst imaginable pain).
Metoikos has obviously been through it all and surgery should definitely always be a last resort.
Thanks Grizzla and Metoikos. Metoikos your experiences add to my pessimism . I cant say I notice major improvement at present although I suspect both knees are less painful or less subject to the dull ache that was there a week or so ago.I am still concious of a 'lumpy feeling' below the knee cap and if i slide my knee caps down pain is present.
I see my physio on Tuesday what questions should I ask him? I did suffer achillees tendonitis a couple of years ago and that gave the impression of there being a lump in the tendon as I have know with my knees.Rest didnt seem to work so I tried eccentric stretches and ran through it . Is that along the lines of what you are doing now Moraghan? I am interested by the fact that you are still running. Naturally I dont want to ignore my consultants advice to rest but if theres another way I would consider it at some stage.This is very frustrating to say the least.
are you stretching or strengthening eccentrically a la achilles?
what is your time expectation of when you'll be fixed or just feel less pain?
what's the cause, and not the diagnosis?
HW
I'm not a doctor/physio and so what I say may not be 100% accurate (beware internet diagnosis!) but my understanding is that by the time you reach the degenerative stage, a sheath has grown around the tendon that prevents it from regenerating and, because the tendon cannot regenerate, it starts to break down internally (for me this differentiates a degenerative condition from HW's 'reactive' tendon which is simply an inflammation without the hardening).
Following on from this, the objective of the 'needles' treatment you had is to breach the hardened sheath that has grown around the tendon and allow the tendon inside to regenerate. I think that it is normal that the 'lumpy bit' (sheath) around the tendon remains even after treatment as you have simply had some holes punched in it and have not had it removed.
Again, my understanding is that the lumpy bit/sheath will only be removed if you have surgery. The operation consists of 'shaving' the tendon to remove the sheath in order to allow the tendon to regenerate without the constraint of the sheath around it. The first doc I went to see also spoke about drilling 3 holes in the patella to promote regeneration above the damaged bit but I don't know if this is standard practice.
I think I'd agree with Moraghan in that, if the pain is manageable and the injury doesn't get worse, I would keep on training. In any case I would definitely keep on doing the eccentric protocol or exercises to strengthen the quads / upper leg.
Good luck with the physio.Meto....not sure about your synopsis! Don't think it really matters really.
Operations don't return normal people to normal function, even though they may be classed as successful! Don't worry about the lumpy bit. It may or may not go, depending on chronicit...
2old, you do NOT need to stretch. You have an over stretched tendon which has broken down. Stretching (unless very controlled and not grossly done) will just restretch the stretch.....much better to eccentrically (and now maybe even concentrically) load and strengthen.
Must nail him/her down for a cause. If this is a simple over use (ie reactive) then with time it will settle and don't load aggressively. Your tightness is because of something....
HW
Heavyweaponry- thanks I think you may have hit on something. I ran VLM this April but had all but given up being able to do so because of these symptoms la t January.incidentally I had pulled a calf muscle in December .In February I went skiing at St Anton and did some pretty full on stuff and at the end of that week my knees felt great and symptom free enough to do a 20 mile run a week afte wards-the longest run for a couple of months. Symptoms started to return as i trained (40-50 miles per week)for the marathon but not enough to to make me want to stop.I couldnt understand what had happened to make such a difference.As I see it maybeskiing mimics the eccentric exercises recommended.However whilst that may be the treatment I need ,as you say it does not address the cause .Any idea what the other underlying causes of this are then I could start looking into it further and focussing my questions to my physio.
Also what is concentric loading and how do I do it?
Top 5 causes - excluding foot and shoe type/position/control and training type
1.Stiff thoracic spine
2. Unstable lumbar spine
3. Poor glut control
4. Internally rotating femur
5. Dodgy patellofemoral mechanics a la all of the above
Concentric is the opposite of eccentric and maybe,just maybe this should also be incorporated into your rehab, especially if it feels more insertional (ie at the bone junction)
HW
Haha HW! My laymans descriptive powers are obviously woeful!
I'm pretty sure the chronification process (inflammation > hardening > breakdown) is in the right ballpark though as it has been described to me by 3 different doctors.
Got back from the docs this morning. He offered me the chance to operate as things have not improved after the growth hormone injections. I will be going under the knife on 1st Dec. Procedure consists of shaving the patella and making some longitudinal incisions in the tendon. 2-3 weeks on crutches then rehab. Probability of success around 70%.
Do ask the doc what the return to functionality like, not just the %age success.
A successful op may not mean a return to full function.
Sorry to be a misery guts!
HW
Meto- the op is very soon- are going to go for it?You says it been offered but not that youve agreed.How do they define success?Full pre injury recovery or beter than you are now?Running again by January!!!Good luck anyway.
I did some eccentric stuff yesterday and think it might have helped my left knee a bit so I will do some more later today and see what happens.Right knee still cr*p. Got to be patient