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Chronic tibial tuberosity pain for 1.5 years, no history of Osgood.

Question: Chronic tibial tuberosity pain for 1.5 years, no history of Osgood.

Hi there, this is basically my last resort before I consider something like prolotherapy or even surgery.

I used to be a competitive Olympic weightlifter but had to stop because of a chronic tibial tuberosity pain on my left knee. It is now in danger of affecting my future career as I have to take certain fitness tests for this job, but simply cannot train adequately without pain and can't get my conditioning up to snuff.

It is only my left tibial tuberosity, and I did not have Osgood as an adolescent (I was quite active then). To be noted, I broke my left foot at 18 years old (three metatarsals) and had no knee pain before then, so it is my belief that over-pronation and subsequent poor bio-mechanics/knee tracking during exercises such as a squat/deadlift/etc eventually caused this problem.

I first felt this tibial tuberosity pain in May of 2011. I had some general patellar tendinitis (or osis) before this but it was a very minor discomfort, and never caused me to alter training or see a specialist. I remember one specific rep on the split jerk exercise, however, where I felt a twinge at the tibial tuberosity, like something tugged at it, and since then, I've had a tibial tuberosity pain that has not gone away. I even took three months completely off from leg work last year, and the pain came back and tenderness on the tibial tuberosity remained.

I've had an X-ray, which showed nothing. I've had an MRI which said not much at all either: "IMPRESSION: 1. Grade 2 chondral thinning of the posterior lateral tibial plateau with underlying bone marrow reactive change." I am getting a repeat MRI in 2-3 weeks.

I have seen two physical therapists (currently seeing one of them), and one orthopedist (seeing him as well). The first physical therapist said it was tender because my pes anserine/VMO were weak so she had me do exercises for those areas, and also said my lateral quad and rectus femoris were really balled up and had deep tissue massage done on it every session. This didn't really work for me after 3-4 weeks and the pain was still bad.

I then took three months off, and I saw my second physical therapist. He said basically jumper's knee/patellar tendinopathy, and did some Graston on the patellar tendon, had me do some decline single-leg eccentric squats (3x15 in the morning, 3x15 at night) adding weight every time. This seemed to work at first and I thought I was all cleared up, then I had a prolonged rest over the holidays (lots of sitting in the car as it was a road trip), and the pain came back. I tried doing the single-leg eccentric squats again but it did not work. I realize pain during the squats is a good thing, but before I was getting pain under the knee cap (not on the TT) and would actually feel better the next day. This time when I came back to the squats however, the pain was on the tibial tuberosity and not under the knee cap, and the pain was worse and worse. It's been a week since I last tried it and I still feel tenderness on the tibial tuberosity, even when I slightly push on the area.

So this is where I'm at currently. I saw my ortho again (fourth time) recently and he wants me to annoy it for 2-3 weeks, and then come in for an MRI at their place of business. I am going to see my physical therapist again in 1.5 weeks (he described my problem as acute-on-chronic). My ortho also referred me for an appointment with the chiropractor of an NFL team to see what he can do.

Is surgery or prolotherapy my only option at this point? It's starting to seem that way. Thanks for reading all this... I wanted to be as in-depth as possible so I realize all this text may be a bit of annoyance.

Answer:

You need a full biomechanical eval looking at all your lower extremity joints, ROM, muscle strength, posture and functional movement. If your left foot pronated, does it still? Does your left knee adduct w/squats? Do you have pelvis/SIJ pain/dysfunction? The pes anserine is a group of three tendons that attach medially and below the TT, what you are calling TT might be pes anserine tendon pain. VMO weakness/inhibition can be from damaged knee structures or it also can be inhibited by the position of your femur/knee - knee adduction will internally rotate the femur which is not the ideal position for VMO function. Some things to look at are: do you have weak hip rotators and glutes and is your ankle inverters weak (tibialis posterior, big toe extensors, toe flexors). As mentioned a therapist needs to do a joint by joint eval looking for hyper mobility.

Answer:

I have Osgood Schlatter and have frequent bouts of TT pain and patellar tendinopathy. I treat it with NSAIDs (Meloxicam or Indomethacin) and a small strip (3") of Kinesio Tape at 75-100% stretch right over the TT. I find the Kinesio Tape works better than a chopat. I will sometimes apply a patellar tracking stabilization taping to make sure the patellar tracks correctly as well.

Answer:

I stay away from NSAID's/ice, that does some good for the first 2-3 days of pain but this is a chronic injury for me, so I stay way from that stuff. I've tried KT tape but the pain is still there, and it doesn't really treat the issue.

Answer:

Good post, I am actually seeing the Chicago Bears/Cubs chiropractor. On my first session he pointed out a lot of stuff. He said my left hip external rotation was crazy good (or rather, too much rotation), and my left hip internal rotation was terrible, and basically said my VMO and hip adductors were completely shut off. Why that would cause the tibial tuberosity pain I'm not sure. Also, it's not pes anserine tendon pain, I've had that before (for like 2 days). It is straight on the TT, where the patellar tendon connects. He also said my lateral quad/rectus femoris needed some ART, as well as my calf and hip rotator.

Answer:

I agree. In my experience, a lot of patellar tendinitis (in the absence of Osgood Schlatter) or patellofemoral pain can be traced back to weak quads or quad imbalance. There are also a number of core and/or lower extremity muscle agonist/antagonist imbalances or overcompensations by synergistic muscles that may cause a slight change in your biomechanics that could lead to the condition you are experiencing. It's a matter of rooting them all out and addressing each of them.

And don't forget the value of eccentric exercises for patellar tendinitis.