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I have a recurring knee problem for 12 years that I have been unable to get a proper diagnosis for. I would be grateful for any advice or opinions.

I am a 45 year old male. I exercise 4-5 times per week, with either a stair-climbing machine or jogging on a treadmill for 30 mins followed by a 30 mins light weights workout. I stretch for about 10 mins before and after. The symptoms begin to occur approx 14 hours after a workout - so if I workout in the morning, I get the symptoms in the late evening, and if I work out in the afternoon (which is more usual) I get the symptoms in the middle of the night (it wakes me up). I don't have any pain or other symptoms during workouts. If I stop jogging/stairs (sometimes I go through periods of swimming instead) it never occurs.

The problem occurs on either one of my knees, but never both at the same time. It occurs approximately twice per month, and has been this way for 12 years.

The symptoms are slight swelling of, and pain in, the lateral collateral ligament, OR the quadriceps tendon, but never both at the same time. The affected area is also hotter than the surrounding tissues. It is painful to the touch as well as during extension of the knee joint under strain.

I have found that if I begin taking NSAIDs (I normally use ibuprofen 400mg every 6-7 hours acetaminophen 1000mg every 4-6 hours) when the symptoms begin, then the symptoms persist for about 18-24 hours without getting much worse, then wear off over the next 12-24 hours.

If I take no medication, the symptoms get progressively worse over the next 18-24 hours and then wear off over the following 24-48 hours. At their height, the symptoms are painful to the point of making me limp when walking, or to climb stairs with just one leg (if you know what I mean), and to cause me a little difficulty sleeping. So it's annoying but not debilitating.

Applying an ice pack to the area has no lasting effect on the duration of the symptoms.

Since it takes at least 3-4 days to get a non-urgent doctors appointment where I live, I have only ever been able to describe the symptoms to a doctor - the most common "diagosis" being tendonitis or synovitis with the advice to just take iboprofen and rest when it occurs. I cannot afford to see a specialist or physiotherapist privately.

If I take a half dose of ibuprofen (200mg) about an hour before my workout, then the problem does not occur - at least so far. I have been doing this for about three months on the advice of an unqualified friend. On the one hand I am happy to have "solved" the problem, but on the other hand I don't like the idea that it could be masking something.

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mmm... how have you exactly pinpointed it to the LCL or the quad tendon? What docs have you seen and what have they said? When you say you stretch before, what kind of stretching? And it occurs exactly the same way on both knees?? –  JohnP Jul 11 '12 at 15:39
    
Do you warm up before stretching? –  dotjoe Jul 11 '12 at 16:05
    
@JohnP I have seen a General Practitioner at our local practice several times and they told me (based on what I told them and where I pointed to). It occurs exactly the same in both knees, though never (yet) at the same time. I use a stretching "machine" (not sure what to call it, it uses your own bodyweight) and also I stretch by crouching down, and also by standing and pulling one foot up behind. –  P Sellaz Jul 11 '12 at 19:01
    
@dotjoe I usually walk for 5 mins just before my workout, not sure if that counts as a warm up ? –  P Sellaz Jul 11 '12 at 19:02
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3 Answers

up vote 5 down vote accepted

Since the symptoms respond to NSAIDs, the injury is likely inflammation related. That's why tendinitis or synovitis is usually the diagnosis. Without allowing the tendinitis to fully heal, it can reoccur frequently. However, since I'm not a doctor I will limit my answer to the exercise related portion.

Stair climbing, treadmills, jogging all produce a fair amount of stress on your knee. If I were to rate them from least stress to highest stress it would be: stair climbing, treadmill (assume walking), jogging. If you put the treadmill on an incline, it will reduce the stress on the knee.

Could it be stretching?

Connective tissue (tendons and ligaments) don't stretch, or aren't supposed to. Improper stretching by pushing past pain can cause injury and inflammation to the connective tissue. I'm assuming though that because you have been doing this for years, and the problem only happens twice a month, it's probably not stretching.

Could it be a muscle imbalance?

Your routine doesn't really give your knees a break, and it's also quadriceps dominant. Conditioning is good, but does not have to take the form of jogging/running/or climbing. Another potential problem is that your hamstrings are likely under-developed, meaning there is a muscle imbalance between the quadriceps and hamstrings. The presence of a muscle imbalance like that can also cause stress to the connective tissue pulling it towards the stronger muscle.

I'm assuming by the selection of exercises you are currently doing, that weightlifting isn't something that interests you. To that end, I'm going to suggest some body weight exercises for you to do:

  • Body weight squats. NOTE: I didn't listen to the guy all the way through, regardless of what he says, you want to go as deep as possible. That's what activates the glutes and the hamstrings.
  • Lunges. Focus on activating the hamstrings.

Start slow. If your hamstrings truly are out of balance, you will have a really bad case of DOMS until you get used to it. You might want to start out on the first day just doing 1 each of those two exercises. The next time you do them, do one more. And one more. Until you get to around 150 for the week (that's the equivalent of doing them 75 times a day for two days. 75 reps can be 5 sets of 15). How you divide up the work is up to you.

In the beginning you might start out with the squats and lunges every time you exercise. After a while you will probably get too tired to do them every day. That's when you can alternate your running/stairs exercise with the body weight exercise.

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Thank you very much for this. +1. I don't stretch past the point of (much) pain, but if I had to guess, I think that stretching seems to help. There was a phase when I did 15-20 mins stretching before a workout and afterwards which /seemed/ to help (the problem occurred a bit less frequently) but it didn't stop altogether so I went back to my old regime. –  P Sellaz Jul 11 '12 at 19:05
    
I'm going to try the exercises you suggest ! Would you also think it's an idea to do a week of swimming and a week of stairs/jogging ? –  P Sellaz Jul 11 '12 at 19:06
    
One more thing. Not sure if it is relevant. I used to do heavy-ish weight training when I was much younger (late teens, early 20s). I had very strong legs - I could push out the leg-extension machine on a full stack relatively easily, and also the leg curl (not so easily). I don't use either these days because I fear it will upset my knees. But I do use these new machines that work the inner and outer aductor muscles, and I can push those out on the max weight on both machines fairly easily (15 reps on max, 3 sets) –  P Sellaz Jul 11 '12 at 19:10
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An issue with machines is they usually isolate muscles without activating any appropriate stabilising muscles, so working the aductor muscles could contribute to the problem as well. Generally it seems it's best to use isolation machine exercises for rehab purposes, but not general strengthening. –  Robin Ashe Jul 11 '12 at 20:25
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Reducing the stress on your knees will only help them. Swimming is an excellent way to stay in shape. If you do want to get in to weightlifting, I recommend using the free weights with compound exercises like squat, deadlift, bench press, and overhead press. These help exercise the whole body most efficiently, while keeping all the muscles in proper balance. Theoretically you could do the same with machines, but your workouts will be much longer and you will need to use a whole lot more machines to do the same work. –  Berin Loritsch Jul 12 '12 at 12:34
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I realize I'm joining the party a bit late, but I do have one suggestion for a lateral collateral ligament stretch. I used to have pain in my knees when I ran coming from the lateral collateral ligament but I got lucky and found a good stretch for it.

This may be too simple of a solution, but its worth a shot because I have no problems with that ligament anymore.

Sit down on the ground, with your back off the ground and your legs on the ground straight in front of you (~90 degree angle). Bend and point your feet/toes as far forward as you can; this should start to make the ligament bulge out a little. Now try and bend your torso as far as you can toward your toes; this will amplify the stretch. If you don't know what I mean by bending your torso, just try and touch your toes with your hands while your feet/toes are bent forward. It does the same thing, but if you reach with your hands it'll stretch your calves as well as the ligament instead of just the ligament.

If you lean towards your left foot when bending your torso, you should feel the left ligament stretch more. If you lean towards your right foot when bending your torso, you should feel the right ligament stretch more.

If this is confusing, let me know and I can make a youtube video or something.

I hope this helps!

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-1. The primary function of ligaments is to connect bone to bone. The LAST thing you want to be doing is stretching ligaments. They are like the springs in click pens, once you stretch them out, they don't go back to the tightness they were before. If you stretch out the ligaments in the knee, the only thing you are doing is creating an unstable knee joint. Most likely, you had a tight/irritated IT band as the bend and reach to the opposite foot is one IT band stretch. –  JohnP Aug 27 '12 at 19:59
    
My apologies, I'm not extremely knowledgeable on human anatomy/physiology. I thought I'd located the correct piece that was giving me trouble. Anyhow, the "irritation" I experienced was coming pretty much from the exact area that the LCL ligament is at, and that stretch I described relieved the irritation, so I felt like I should share that bit of knowledge; I realize now that it is not the LCL. A small portion of the posts above dealt with stretching so I thought this may have been relevant. –  Andrew Gabriel Aug 27 '12 at 20:21
    
It is relevant, I just didn't want people thinking that stretching out their ligaments was a good idea. :D –  JohnP Aug 27 '12 at 20:25
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Ok, this is in response to your comment, but it needs to be an answer. Comment blockquoted below:

I use a stretching "machine" (not sure what to call it, it uses your own bodyweight) and also I stretch by crouching down, and also by standing and pulling one foot up behind

Don't do that. At least not before you workout. There are two main types of stretching that should be used by most people, static and dynamic. (There are others, such as PNF, ballistic and others, but these two are sufficient for most people).

Dynamic is motion based, you start with motions that mimic what you are going to do, and go from small to large in amplitude. So, leg swings, knee lifts, arm swings, etc. For jogging, I'd simply walk for 5-10 minutes at an increasing pace, until at the end of that 5-10 minutes you are at your goal pace for the rest of the workout. For the stairs, leg swings and knee lifts.

Static stretching is the typical "bend and pull" or "reach and hold" kind of stuff. This should never be done as a warmup, only done afterwards on warm muscles. It's easy to strain, tear, avulse and otherwise harm muscles and tendons if you do static stretching on cold muscles.

Ballistic stretching - This is the "bounce bounce bounce" type of stretching people used to do all the time. Don't do this either. There are specific instances where it is useful, but these are very sports specific and should only be done under the guidance of a knowledgeable coach/trainer.

As far as the "machine", I would have to see a picture of it and how it's constructed before I passed judgement. I've seen a ton in my time in martial arts, and many don't support the legs/knee area correctly to promote the correct stretch, plus many don't use the machines correctly. In any case, it's also nothing you should be doing beforehand. If there isn't movement involved, don't do it to start.

It's very possible that your stretches beforehand are causing or contributing to the intermittent knee pain.

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Thanks, that's really interesting.+1. I mentioned in my comment to the other answer that I had an inkling my stretching regime was helping, but it was not conclusive. Also, when the problem first began 12 years ago, I hardly stretched at all, and it occurred a bit more frequently back then. So again I assumed that my stretching may have been helping. But I am well aware of "assumption being the mother of all f***ups" so I'll certainly take heed of what you have said. I also wonder if you saw my other comment about my leg strength and had anything to say about that ? –  P Sellaz Jul 11 '12 at 19:47
    
@PSellaz - No, not really. Robin covered it quite nicely. Any imbalance can contribute to pain, so if you are working ad/abductors and not quads/hams, you could be contributing. Also, stair running can be incredibly hard on the knees if done improperly, I wouldn't recommend it unless you need it for a specific purpose, and general fitness doesn't count. :p –  JohnP Jul 11 '12 at 20:49
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