ario's digital detritus - Tendonosis: the bane of my knee's existence

Yesterday, I went to a knee specialist at Stanford Medical Center to get a second opinion on the knee pain I've been experiencing ever since the marathon last year. The pain I experience is only felt during the following activities:

-- Going up or down stairs
-- Running
-- Uphill cycling
-- Sitting in a cramped space for a long time (i.e. my commute)

The first doc I saw back in December diagnosed my problem as patellar tendinitis with chondromalacia. The typical treatment for this diagnosis is physical therapy, which I went through for 6 weeks, but it didn't help. I didn't have too much confidence in this guy, so hence seeking out the 2nd opinion.

Since January, I stopped running altogether, but as a substitute, I started doing the Stronglifts 5x5 workout which is centered around one main exercise: heavy squats. I worked my way up to squatting 145 lbs, but as the weight increased with my workouts, the knee pain became worse... and now I know why.

What I have is not tendinitis... but TENDONOSIS, which is much more severe. Here's a good definition...

Tendonosis is characterized by degeneration of the collagen fibers in the tendon (the fibers that provide the tensile strength), tendon weakness, abnormal growth of unhealthy blood vessels through the tendon, and most importantly no inflammatory cells. Basically the nice straight strong fibers of collagen become a tangled mess of strings with little pockets of "jelly" and small weak blood vessels.

Here's what that that looks like up close (compared to healthy tendon on the left)...



and here's another comparison. In an MRI, that black gap you see should really be white...



Up until very recently, doctors all over the world have been mistreating this condition by dealing with it as if it were an inflammation based disorder. The key difference with tendonosis is that there is no inflammation.

In reality, this is not a condition caused by faulty physiology... the main culprit is that of ignorance, and more importantly, hubris.

Ever since the marathon, I continued to run, sit in awkward ways at the computer, put loads of pressure on the knee while going uphill on my bike or carrying a heavy backpack up the hills of San Francisco.

None of these things on their own caused this problem... but taken in aggregate, they all did their part. Each time I felt the pain, I just pushed through it thinking like with fatigue or muscle soreness, that the extra exertion would cause me to get stronger. Tendons don't work like that. Sure, a little bit of stress is good for tendons, but by ignoring the pain over a long period of time, my body's natural response to repair the area with inflammation shut itself off. Apparently, if an area is consistently aggravated like this and the inflammation isn't allowed to do the repair, it gives up, leaving you with permanent damage.

So, what now?

The doctor is recommending surgery under general anesthesia where they will open up the knee, remove the "jelly-like" dead bits of tendon, cut up the blood vessels in the area to increase blood flow, and stitch me back up. This will have me on crutches for 6 weeks with lots of physical therapy. If all goes well, I'd be able to run again in 6-9 months. If that wasn't enough... the bigger catch is that this procedure only has a 75-85% success rate and of the people who have it done, only 50% get to the level they were at before the onset of symptoms.

Here's a little diagram depicting what the surgery does...



So upon receiving this news, I told the doc I'd think about it (which really meant, I'd internet research the hell out of it). Here's what I've found...

-- This page gives an excellent description of the problem along with instruction on what can be done at home to help repair the tendon. It boils down to avoiding activity that puts excess stress on the knee, lots of ice, and massage. The latter is particularly interesting because the theory is that massage can irritate the tendon just enough to cause the body to repair it naturally. I'm going to try these tips out for a month and then make my decision about the surgery.

-- Another treatment option is prolotherapy, but it doesn't sound like it has much medical community backing.

A few other resources:

http://www.kneeclinic.info/problems_overuse.php
http://www.webmd.com/a-to-z-guides/tendon-injury-tendinopathy-home-treatment
http://www.bmj.com/cgi/eletters/324/7338/626#20629
http://www.sportsinjuryclinic.net/cybertherapist/front/knee/indexjumpersknee.html

Some explanation around eccentric exercises for rehab here...



Aside from the personal angle in all this, I find it fascinating that it's only been in the last few years that medical community has caught on to the root causes behind this condition. There's still a lot to research as well, particularly when it comes to treatment...

Numerous conservative treatments have been and are being used to treat patellar tendinopathy; however, few therapies have undergone randomized prospective, placebo-controlled trials, and such studies are urgently needed.

Some relevant clips from YouTubes...

Here's where the pain is located...

Example of an eccentric loading exercise for rehab...

If anyone else has any insights or advice about this, I'm all ears! Knees suck!