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  1. #1
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    Extremely bad case of PF Syndrome

    Howdy,

    I've been struggling with Patellar Femoral Pain Syndrome for over a year now, and consequently off the bike for about a year! As you all could probably imagine, it sucks. It really sucks. I went from being an avid mountain biker and bicycle commuter to a depressed, car driving, ass-hole. I've been doing physical therapy for the past nine months, I've done accupuncture, rested and took anti-inflamitory drugs for over two months, had cortisone injections, had an MRI, had custom orthotics made, custom bicycle fitting, shims put under my cleats, rolled my IT band with a foam roller and I still can't ride my bike! The injury gradually got worse as I continued to ride last year and finally cut my cycling career short after a century ride just destroyed it. I haven't ridden my bike more than a few hundred feet in several months. I'm only nineteen and invested so much into cycling. It's just heartbreaking. Now even cross-country skiing's hurting it. I've seen several different doctors and the story's always the same. "I'll have you back on the bike within a month!" Bull****. Is anyone else outthere struggling with patellor femoral pain to this extent? Has anyone on this forum had a "lateral release" surgery? Somebody give me hope, please!

    DistantFellow

  2. #2
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    Well patella femoral syndrom can be caused by lots of things. Do you know what the cause is in your case?

    I don't have it near as bad as you but in my case it seems to be muscle imbalance. I have been strengthening my vastus medialis and this has been working. To strengthen this I have done some physical therapy but I was able to give this muscle a huge workout by just lowering my seat about 2". After every ride that muscle is sore with a good workout and my patella is hurting less and less.

  3. #3
    Forgiven
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    Seek out a good Osteopath (A Dr. with a D.O. after their name) that specialize in manipulation. Function follows Form. I agree with presslab that something seems to be out of balance. In the meantime quality deep tissue massage, proper stretching and Physical Therapy are probably your best alternatives. How about a swimming pool for that aerobic fix? At, the very least you'll feel better. Healing does happen. Keep seaching and don't give up.

  4. #4
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    DistantFellow: I hear your pain, and "heartbreaking" is a great description. Sounds like you have done everyone you ought to. I had PF Syndrome in my twenties and it turned into arthritis.

    I did a year of PT, orthortics, professional fit, muscle balance issues, the whole nine yards. Unfortunately, I think some people just have bad knees. PT's will help address muscle imbalance & stretching issues, etc, but usually if PT is going to work, there is noticeable progress fairly early. If you don't see it, they probably aren't addressing the real problem, whatever that may be. The frustrating thing is that I have ridden with people who never stretch, have weak hamstrings (thus ham-quad imbalance), don't pay attention to bike fit, and they still ride pain free. I finally quit PT after a year, and eventually got back on my bike, but it wasn't easy.

    I have had a Lateral Release, and it did no good for me. By the way, I have never heard of someone who had a Lateral Release for PF syndrome who considered it a real success.

    Since you have done so much physical therapy, and all the other basic things, ask your doctor about Synvisc shots. It doesn't work for everyone, but was a real savior for me and enabled me to ride pain free for several years. It is not a pain killer-anti-inflamatory but rather actually addresses mechanical issues (lubrication) in your knees, although even the experts don't understand exactly how. You get a series of 3 shots 3 weeks apart, and it usually lasts for 6 - 9 months. You owe it to yourself to check it out.

    I do think the roller is helpful as is stretching in general and VMO strengthening, but I have seen enough people with weak VMO muscles and poor flexibility ride to know that there is something more involved.

    Good luck and healing vibes your way. I know how much it sucks to be off the bike, and all the more so at 19.

  5. #5
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    I feel your pain, literally. While not PF, my knee pain was so bad that I resorted to a scope two days ago. It got so bad that it hurt to even walk around or sit, much less do any sort of exercise. I tried ALL of the things that you did and some worked better than others, but none of them got at the root. Even though my MRI was deemed "clean", there were things that needed fixing.

    I agree with the others so far. It sounds as though something is out of balance. Best of luck with everything. I really feel for you!

  6. #6
    meh... whatever
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    the cause of most patellofemoral pain syndrome (pps) is multifactorial and generally cant be isolated to just one cause. im assuming that since you have had an mri done that they have ruled out chondromalacia?

    there are so many causes of pps that simply getting a lateral release may not be the answer. often times a lateral release will result in more damage than good, because 1. it is not needed; and/or 2. the proper post op p.t. is not done. please, please, please be very careful before you get a lateral release as you can end up with far more problems than you do now. the lateral release should only be done if the patella is mistracking or is abnormally tilted due to tight strictures on the outside of the knee cap.

    i dont have time at the moment to go into it more in depth, but i have a few questions for you and ill check back later.

    • which knee is affected?
    • where in the knee does the pain originate (front, side (l or r?), rear)?
    • where does it radiate?
    • what alleviates it?
    • does the pain intensify when yo descend steep hills or steps?
    • does prolonged sitting aggravate it?
    • do you have any type of foot pathology? (over/under pronation or flat feet, etc.)
    • have you done i.t. band stretches (not just the roller)?
    • tried strengthening your quads?
    • what kind of p.t. have you done so far?
    "The meaning of life is to find your gift. The purpose of life is to give it away."

  7. #7
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    Spine?

    Quote Originally Posted by DistantFellow
    Howdy,

    I've been struggling with Patellar Femoral Pain Syndrome for over a year now, and consequently off the bike for about a year! As you all could probably imagine, it sucks. It really sucks. I went from being an avid mountain biker and bicycle commuter to a depressed, car driving, ass-hole. I've been doing physical therapy for the past nine months, I've done accupuncture, rested and took anti-inflamitory drugs for over two months, had cortisone injections, had an MRI, had custom orthotics made, custom bicycle fitting, shims put under my cleats, rolled my IT band with a foam roller and I still can't ride my bike! The injury gradually got worse as I continued to ride last year and finally cut my cycling career short after a century ride just destroyed it. I haven't ridden my bike more than a few hundred feet in several months. I'm only nineteen and invested so much into cycling. It's just heartbreaking. Now even cross-country skiing's hurting it. I've seen several different doctors and the story's always the same. "I'll have you back on the bike within a month!" Bull****. Is anyone else outthere struggling with patellor femoral pain to this extent? Has anyone on this forum had a "lateral release" surgery? Somebody give me hope, please!

    DistantFellow
    Did your PT ever take a good look at your spine?
    This is where many of our "sports med" PT's fail. Not all injuries are actually coming from the knees. Many spinal issues, such as an L5S1 instability can present itself as a facilitated segment and cause imbalances (weakness vs tension) at distal muscle groups, especially longer muscles that are multi joint as occurs around the knee.
    If there hasn't been anybody to perform a good assessment to your spine, I would start there. Ask around and find, not only somebody who knows sprorts med, but is also a certified manual therapist as well. I end up seeing many pateints similar to yourself that other PT's, Doctors, and Trainers can't get better.
    Sometimes though, we have to admit with PatellarFemoral Syndrome (PFS) that there isn't anything that we can treat to get you better.
    It is getting to the point where some insurances are not paying for the treatment of PFS because statistically the medical community does not prove through research that we can make a cost effective difference in the patient's sx's.
    We (PT's, Ortho Surgeons, and Sports Med Fellows) had a conference last year and discussed this exact topic for two days straight.

    Good Luck
    BoiseBoy

  8. #8
    meh... whatever
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    Quote Originally Posted by BoiseBoy
    Many spinal issues, such as an L5S1 instability can present itself as a facilitated segment and cause imbalances (weakness vs tension) at distal muscle groups, especially longer muscles that are multi joint as occurs around the knee.
    interesting. i would really be interested in seeing some research corroborating this, especially in relation to pps (patellofemoral pain syndrome) since pps is relational to the travel (or mistravel) of the patella for various reasons. not saying that no research or hypotheses exists (there may be a plethora of it) but just saying that ive seen nothing in any peer review journal linking lower vertebral junction instability in and of itself with pps, and would be greatly interested in any cited correlation. (be it objective or subjective)

    since a facilitated segment is when a specific spinal cord segment's stimulus threshold has been reduced resulting in that segment of the cord to be highly excitable, meaning that smaller stimuli triggers excessive impulse firing in the segment, im not quite clear on how that factors in either. of course, the spinal cord is not segmented, but we view it as such to denote which areas of entrance/exit nerves are affected. so looking at the l5s1 as a segment and considering instability at this juncture im somewhat curious about this.

    generally an L5S1 instability will cause pain via disc herniation affecting the sciatic nerve, which will cause pain to radiate down the leg including medial and lateral knee pain, which can be confused with pps and even itbs (iliotibial band syndrome). but the spine is a structural support so how would an instability at a vertebral junction result in a muscular imbalance causing mistracking of the patella and thus pps??? generally it is the other way around, isnt it? muscular imbalance/strain/injury CAUSES spinal instability (esp. at l5s1).

    if the l5s1 instability were serious enough to inhibit neuromuscular impulse transmission resulting in an imbalance of the upper and lower posterior chain then there would certainly be accompanying pain in the lower back and/or legs rather than localized/isolated knee pain. how could pain resultant from pinched sciatic nerves be localized to strictly the knee(s)? how could the instability/rupture cause pain specific to the knee and the knee alone without affecting some of the rest of the leg and/or the lower back???

    there doesnt seem to be any other radiating or chronic/acute pain and @ 19 one assumes he would have mentioned any accompanying pain since most late teens are generally systemically pain free. (its bad to assume in medicine, so op please correct here if that is not the case and you have other pain in the legs or lower back)

    i could see a relation to pps in, perhaps, piriformis syndrome, since its etiology is muscular imbalance and often mimics l5s1 instability/rupture; but l5s1 instability in and of itself? of course, if the l5s1 instability is muscular in etiology (i.e. lumbosacral muscular strain) there could be distal muscular ramifications but then the cause would be the lumbosacral muscular strain rather than the resulting vertebral instability. conversely, the body's attempt at counter balancing a lumbrosacral strain could result in distal tension and imbalance as well, but again the root is the mitigating factors relational to the vertebral instability rather than the vertebral instability itself. so perhaps im not clear on exactly what youre saying, but im just unclear on how instability at the l5s1 junction (in and of itself) could be considered a viable etiology for localized pps.


    Quote Originally Posted by BoiseBoy
    Sometimes though, we have to admit with PatellarFemoral Syndrome (PFS) that there isn't anything that we can treat to get you better.
    true and sad that sometimes it cant even be traced to a specific or even indirect etiology. the knee (among many things in the human body) still holds an infinite plethora of mysteries.
    "The meaning of life is to find your gift. The purpose of life is to give it away."

  9. #9
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    Pfs

    Quote Originally Posted by monogod
    interesting. i would really be interested in seeing some research corroborating this, especially in relation to pps (patellofemoral pain syndrome) since pps is relational to the travel (or mistravel) of the patella for various reasons.

    PatelloFemoral Syndrome is a garbage term that we use for Anterior Knee Pain often around the Patellar. It will often involve the Patella, but does not have to.
    not saying that no research or hypotheses exists (there may be a plethora of it) but just saying that ive seen nothing in any peer review journal linking lower vertebral junction instability in and of itself with pps, and would be greatly interested in any cited correlation. (be it objective or subjective)

    since a facilitated segment is when a specific spinal cord segment's stimulus threshold has been reduced resulting in that segment of the cord to be highly excitable, meaning that smaller stimuli triggers excessive impulse firing in the segment, im not quite clear on how that factors in either. of course, the spinal cord is not segmented, but we view it as such to denote which areas of entrance/exit nerves are affected. so looking at the l5s1 as a segment and considering instability at this juncture im somewhat curious about this.

    Another way to look at a Facilitated Segment is from the idea that segmental hypermobility/instability will give abnormal segmental imput. This input will create such things as referred segmental pain, tenderness, and hypertonicity of some key muscles of that segmental level. Yes, this constant attack of afferent stimuli will lead to a segmental excitation which will actually lower the resistance of the synapse and facilitate the neurotransmissions. In the end this process creates an exaggerated response from both the cognitive and the effernt systems served by that particular segment.

    The cognitive responses are not sexy, but the Efferent responses are what we are actually looking at in this discussion. Extrafusally, there are an increased number of motor units contracting while at rest (hypertonicity) of a segmental spinal muscle in that Myotme or in a key muscle of the pattern. You can actually feel this. This is precisely why people with L5 instabilities have "bursitis" of the hip at the Greater Trochanter. It is not truly Bursitis, it is just the fact that your Hip Abductors are in a state of hypertonicity and are constantly pulling on their insertion which is at the GT. The Chronic Hamstring pain at the Ischial Tub "bursitis", Piriformis in the Butt, and the Levators are the same way. This is why nearly all females working at a desk job will tell you that they carry all of their stress throught their neck and shoulders. You can stretch and massage the muscles all you want, but until you change posture and stabilize that segment they will not get better.
    With the Extrafusal response, you also get increased resistance to stretch which will seem to the untrained as if it is a tight muscle, but truly is not.

    Intrafusally, you can get a decreases length to the spindle and with the increases sensativity of the flower spray organs can lead to increased resistance to rapic stretch. This process will predispose the Antagonist muscle groups to tearing during explosive movements. (We are looking at this theory when it comes to chronic hamstring injuries).


    generally an L5S1 instability will cause pain via disc herniation affecting the sciatic nerve, which will cause pain to radiate down the leg including medial and lateral knee pain, which can be confused with pps and even itbs (iliotibial band syndrome). but the spine is a structural support so how would an instability at a vertebral junction result in a muscular imbalance causing mistracking of the patella and thus pps??? generally it is the other way around, isnt it? muscular imbalance/strain/injury CAUSES spinal instability (esp. at l5s1).

    Lower Lumbar instabilities will often mimic that of a PosteriorLatera disc herniation with some distinctions. Often the instability will feel better and have minimial leg sx's with sitting as the Thoracolumbar fascia tightens up to support the spine. The PLL will also tighten in a seated position (remember it travels, but does not connect between L3 and S1). Generally speaking, the PL HNP will have increased sx's with forward bending and/or sitting. Conversely instabilities will be more painful in standing as they will lose a good amount of their inert stabillity.

    What many of us have to realize is that in the absence of significant recent trauma, we must look at microtrauma. Microtrauma can be a middle aged person who played football in highschool, a bad driver who was involved in several MVA's years ago, or a person who has a significant postural dysfunction. All of these microtraumas can lead to degredation of the segments and their stabilty systems. When this happens it causes muscular imbalances as noted earlier. These imbalances will often be caused by the instabilities and lead to other dysfunctions at other areas of the body.
    Ever wonder why Plantar Fasciitis is so hard to treat? Quite often it is not even plantar fasciitis, but referred pain from an L5 instability.
    The posterior Tib is a key muscle that will show up weak and have dysfunction leading to increased pronation. I have better luck treating the spine then I do placing athletes into orthotics for their pronation and shin splint issues.



    if the l5s1 instability were serious enough to inhibit neuromuscular impulse transmission resulting in an imbalance of the upper and lower posterior chain then there would certainly be accompanying pain in the lower back and/or legs rather than localized/isolated knee pain. how could pain resultant from pinched sciatic nerves be localized to strictly the knee(s)? how could the instability/rupture cause pain specific to the knee and the knee alone without affecting some of the rest of the leg and/or the lower back???

    Again, you need to think of microtrauma such as in postural dysfunctions. The process can take decades to progress and all of a sudden a seemingly amount of normal stress can bring about the sx's. The process can often proceed for quite a long time without it being heard.

    Think of this example: We had a pitcher who was having significant Anterior shoulder pain, torn laburm right? MRI was normal for it and Biceps pathology. What we found when we looked closer is that he had a significant forward head posture which facilitated his C2 segment. This process caused his Levator to become hypertonus lifting the scapular of his throwing shoulder. This elevation tended to put the Biceps on slack and cause slapping of the Biceps and Anterior shoulder pain. He did not respond to typical Rotator Cuff exercises such as the Throwers Ten. He finally recovered after working on his posture and stabilized his C2 segment.

    In regards to the knee, the following pattern is often seen in the lower body: With lower segmental instabilities you can also test and see weak hip External Rotators and Post Tibialis. These weakness will cause secondary issues at the hips, knees, and the feet and later lead to PFS.
    You seemed to be well versed so I won't have to go into how PFS may be associated with increased foot pronation, tibial torsion or Femoral Anteversion. Again, without a congenital defect or trauma you have to ask yourself why these structures are symptomatic now.
    These thoughts and theories may not anser your questions, but I hope that they will open a window for you.


    there doesnt seem to be any other radiating or chronic/acute pain and @ 19 one assumes he would have mentioned any accompanying pain since most late teens are generally systemically pain free. (its bad to assume in medicine, so op please correct here if that is not the case and you have other pain in the legs or lower back)

    i could see a relation to pps in, perhaps, piriformis syndrome, since its etiology is muscular imbalance and often mimics l5s1 instability/rupture; but l5s1 instability in and of itself? of course, if the l5s1 instability is muscular in etiology (i.e. lumbosacral muscular strain) there could be distal muscular ramifications but then the cause would be the lumbosacral muscular strain rather than the resulting vertebral instability. conversely, the body's attempt at counter balancing a lumbrosacral strain could result in distal tension and imbalance as well, but again the root is the mitigating factors relational to the vertebral instability rather than the vertebral instability itself. so perhaps im not clear on exactly what youre saying, but im just unclear on how instability at the l5s1 junction (in and of itself) could be considered a viable etiology for localized pps.



    true and sad that sometimes it cant even be traced to a specific or even indirect etiology. the knee (among many things in the human body) still holds an infinite plethora of mysteries.
    I apologise, I got a bit long winded, make that quite long winded with my response. It happens that way when you are trying to throw out technical information to somebody who has a good base of knowledge.
    I think that you should be able to see my angle. We can often treat the "strain" or "pull" with what we do on a regular basis, but for those that don't respond to typical treatments we must dig deeper. This is often the first thing that I think of in trained athletes that all of a sudden come down with something that does not always make sense (sans trauma). It will often help to explain why somebody was injured this time when they had done the same thing a thousand times before that, what was differnt? Possibly the cumulative effect of microtraumas on the spine?

    I am by no means the ultimate expert in this area, but I have a rather good working knowledge of it and it seems to answer a lot of questions and heal a lot of people that have failed other avenues of treatment.

    As far as research, I have an incredible pile of paper that if you want I can email to you if you want to PM me. That way we won't make this any longe than it has already turned into. I have not come across any specific literature regarding PFS and the facilitated segment, but if you have an understanding of the concepts you will see its relevence.
    BoiseBoy

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