THE CLINIC

Patellofemoral Syndrome: When to Operate

I am 47 years old and have been running for 30 years, competitively in high school and college, and 10K to marathon as an adult. My weight ranges from 130 to 136 lbs. and I am 5' 6". In April of last year I developed lateral knee pain and in June I was diagnosed with patellofemoral syndrome. The pain is directly on the site of the lateral retinaculum. I was in physical therapy twice a week in the summer, with persistent—but not worsening—pain. I continued to train for and race a half-marathon that September.

By December I had reduced mileage to 15 to 20 miles a week, without hard runs. I had an adjustment to my custom orthotics in June and again in October.

By this January, I was diagnosed with “atypical” PFS and sent for an MRI. That revealed a "small joint effusion” and “thin medial plica,” with a “small, septated popliteal cyst.” My patella is “laterally tilted” and “slightly laterally subluxed,” and there is “moderate to marked” thinning and irregularity of the patellar cartilage, “esp[ecially] along the lateral facet.” There are “broad areas of subchondral bone marrow edema” The patellar retinacula are intact, as are my cruciate ligaments, quadriceps, and patellar tendons. They found no meniscal tears.

I have had two orthopedic surgical opinions since, and both say I am an ideal candidate for a lateral release of the retinaculum. Self-research on this arthoscopic procedure does not reveal favorable results to a pain-free return to running. I have taken the past six weeks to evaluate things and during that time, the knee pain has grown worse. Stairs are now a problem; cycling and most exercise machines create the pain. When I do weight-bearing things like spinning class I now have discomfort along the left patella tendon.

The surgeons are optimistic but runners I have spoken to are not. The research indicates that certain ideal conditions need to be present in the injured knee for this surgery to be effective and not make things worse. Is surgery my only option? What happens if I push myself to run and pass on the surgery. Am I creating more problems?

Claire Anniston
Reno, NV

There are innumerable names for problems related to the patella. The basic problem is a loss of the normal muscle balance that controls the patella. This goes under multiple names. The most common is patellar malalignment syndrome or patellar maltracking syndrome. It has also been called an excessive lateral pressure syndrome. It is commonly known as"chondromalacia" in the lay press but that is inaccurate. Chondromalacia is a pathological finding of wear and tear of the articular cartilage and is not a specific diagnosis. Something causes chondromalacia. Chondromalacia is
not the problem, it is the result of the problem.

The MRI absolutely confirms your diagnosis. You have subluxation and tilt of the patella which has resulted in excessive pressure on the lateral facet of the patella and has caused premature wear of the articular cartilage. Whether this has crossed the magic line to be called osteoarthritis of the patellofemoral joint or not is probably irrelevant. You have pain and a degenerative process. The initial treatment for this is anti-inflammatory medication, ice, and straight leg raising exercises in an attempt to improve
the balance of forces on the patella. A cortisone injection or even a series of hyaluronic acid injections would also be reasonable if one felt that this was truly arthritis. A brace can sometimes improve symptoms but is much less predictable. If nonsurgical care fails, then a subcutaneous lateral release is ordinarily the next step.

However, there is significant disagreement among orthopedic surgeons. While
the subcutaneous lateral release would be successful in improving the alignment of the patella, it would also have absolutely no effect on the degenerative changes. It is unclear how much the degenerative changes are contributing to your current symptoms.

You could have perfectly normal x-rays after surgery and still have little if any improvement in your pain. Because of the degenerative changes, some orthopedic surgeons would advocate a tibial tubercle elevation, which has the capability of addressing the degenerative changes because it not only realigns the patella to take pressure off the lateral side, it also redistributes the forces proximal and distal to try to relieve some of the pressure on the "worn" area.

Therefore, while you are a candidate for subcutaneous lateral release, in my opinion, you are definitely not an "ideal" candidate. To a certain extent, it gets into philosophies. The arthroscopic subcutaneous lateral release is an outpatient procedure with a very low risk of complications when done properly but there is no question that the tibial tubercle elevation would have a greater chance of symptomatic improvement. However, the tibial tubercle elevation is an open procedure, requires several weeks in a cast, has a higher risk of infection, and the recovery time is longer.

In my opinion, running is not dangerous but certainly may be painful. You can rely upon the intensity of your symptoms. However, I am also not sure that any surgery, including the tibial tubercle elevation, would allow you to return to significant running. Under any circumstances, I would definitely avoid hills and StairMasters as much as possible because going up and down stairs and going up and down hills definitely aggravates patellofemoral pain.

G. Klaud Miller, MD
Evanston, IL

Is Menopause to Blame for Compromised Running Performance?

Have there been any studies on the effects of menopause and running? I started having hot flashes when I was 40. Previous to that, I loved running in hot weather; the hotter the better. But after that, when it was hot and the stress of being on the starting line would bring on a hot flash, I really wilted because I had no way to dissipate the heat. My race times suffered. Now, some of my younger friends are starting and wondering if there's something they should do or could do. Does running help you through menopause? Make the symptoms worse? Are there any supplements or nutritional changes that would help? What about soy products?

Vera Abercrombie
Meadville, PA

This question has been examined in a number of studies over the years. The overall consensus is that age, not menopause, is largely responsible for the changes seen in running endurance and speed. That being said, some of the symptoms of menopause, such as hot flashes and sleep deprivation, can impact running performance. A 1997 study published in Runner's World offered the following conclusions:

• More women in this sample perceive changes in their running to be related to age than to menopause.
• The most common change in running for women of menopausal age was a decrease in training pace.
• Most women reported that running affects menopause in a positive way, despite negative changes in running.
• The women runners in this sample reported being postmenopausal at an age earlier than the national average.
• More participants use HRT than the national average.
• The midlife women reported more negative than positive changes affecting their running.
• Weight maintenance was reported by those women who run the fastest and the most miles.
• Weight gain was fairly typical for women in this sample, even with regular exercise.
• The women in this sample continue to run and compete well beyond menopause.

I generally agree with these, as this is consistent with what I have seen in my own practice. Menopause and its symptoms are tremendously varied and each individual is affected differently. Interestingly, most studies indicate that running is a wonderful treatment for menopausal symptoms, as exercise has been shown to dramatically reduce hot flashes and mood changes. My guess is that your symptoms may be even worse without your running...so keep it up!

Ron Eaker, MD
Augusta, GA

Menopause has not been related in severity of symptoms or the timing of its onset
to running. Certain specific considerations include, has the runner stopped having
periods for more than six months, and has she had her thyroid checked? Soy supplements have not been shown to help hot flashes. As long as other risk factors are not present (smoking, stroke, heart disease), it can be very beneficial to use short-term hormone replacement therapy (HRT) at as low a dose as possible to alleviate the symptoms.

Hot flashes are probably worse or more common in runners with a leaner body and lower BMI. This is because adipose tissue (fat) is a source of estrogen production in larger women.

Lynn Pitson
Salisbury, NC

Treating Toe Pain, Kill the Nerve?

I have tried ice, pads, and double doses of o.t.c. pain killers. Nothing relieves the pain between my third and fourth toes. Please help, I’ve been in agony for 18 months!

Calvin Moriarty
Edmonton, NJ

You may have metatarsalgia, which mimics Morton's neuroma. This condition is caused by a metatarsal head which is a little lower than the other four heads and receives more "banging" when running. A true Morton's neuroma is painful with tight shoes and relief is obtained almost immediately by removing the shoe and rubbing the affected area. If your shoes are not tight, think metatarsalgia. If the forefoot is tight, get a wider pair of shoes. A good pair of orthotics may help. A cortisone injection may help. A precise diagnosis will help the most.

George Tsatsos, DPM
Elmhurst, IL

If you have pain between the third and fourth toes, you most likely have a Morton's neuroma. This is swelling or scarring of the nerve. Symptoms can be cramping, burning, and/or feeling like an ice pick is being pushed between the toes. Usually, relief is obtained by removing the shoe and massaging the area. In addition to metatarsalgia, other possible diagnoses include a bursitis, capsulitis, ganglion cyst, or even a stress fracture. After 18 months, this should be looked at by a podiatrist or foot and ankle orthopedist.

The neuroma diagnosis is confirmed by pinching the space between the third and fourth toes while squeezing the foot from side to side. If your symptoms are reproduced, that pretty much confirms it. It can be further confirmed by ultrasound or MRI, but MRI is unnecessary in my opinion.

Treatment after this long is usually by cortisone injection to reduce the size and scarring of the nerve. If you get some relief from the first, then we may do up to three injections in the same area. We then try to prolong that relief with an orthotic to lessen the pinching of that nerve. However, orthotics do not always work to help neuromas. If the cortisone shot(s) do not help, then I have used 4% dehydrated alcohol injections to chemically kill the nerve. This is a great way to treat this without the disability of surgery. Surgery should be the last resort to treat a painful neuroma.

Gene Mirkin, DPM, FACFAS, FACFAOM
Kensington, MD

Pelvic Joint Inflammation: Patient Q & A

I am 50 years old and have been running for 30 years at approximately 9- to 10-minute mile pace. I am also a triathlete. I hired a coach to help me with speedwork, and after working out with him for five months I could hardly walk. This was in May of 2008. I can't even describe the pain. My adductors were weak and would spasm. I could not lift my legs to get dressed. I thought I had a stress fracture in my groin. I had an MRI of my hips and pelvis in October of 2008, and it read as normal.

Throughout all of this I could still swim and ride my bike. In December I sought out an orthopedic surgeon specializing in sports medicine who, after examining me and looking at my MRI, told me I had osteitis pubis.

I was sent to PT for core strengthening. Will I ever get better, will I ever really run again? Can I be fast again, or is this going to be a chronic injury?

Christine Black
Fort Pierce, FL

The first few questions right off the top of my head are:

1. What special training did this coach have you do?
I would do a mile warm up, stretch, do 6 x 100m strides and then many drills involving 100's, 200's, 300's, 400's, some 800's, and a lot of hill repeats. There were many days when driving home after the workouts I could not lift my leg to push in the clutch. I would lay down and be unable to move. Within a month I was slower in my long runs, but setting PRs in his drills.

2. Did the MRI show pubic symphysis inflammation?
Yes.

3. Do you experience any pain with kicking during your swims, particularly with a frog kick?
Yes, I do experience pain if I kick aggressively. Before my diagnosis, I had also tried water jogging, which caused almost as much pain as running.

4. Do you have any pain/problems with coming out of the saddle for sprint/uphill pedaling?
I never have to get out of the saddle for hills. I have a compact crank and am able to spin. A couple of weeks ago I did try a hard gear on purpose, and stood going up a hill. I did not have pain, but it just wasn't efficient.

Something else to consider: in March of 2008 I also got a new bike, custom. It had a very uncomfortable lightweight carbon saddle, and I would tend to ride with my pelvis tilted to put most of my weight on my pubic symphysis. Last June I had a bike fit at Boulder Center of Sports Medicine and found that the seat ought to be raised almost two inches.

Also of note, I do not have any problem with StairMaster.

Maribeth Salge, PT
Rockledge, FL

Answers in italics by Christine Black

I think you may have at least two different things going on, but without actually doing a hands-on exam, it's a bit difficult to know for sure. Did a portion of your drills included high-impact, single leg or split leg landings? These can cause pretty significant shear forces on the pubic symphysis.

Another issue with high amounts of forceful hip flexion is anterior capsular or tendon impingement, especially as the muscles fatigue and the normal joint mechanics alter in response.

Additional considerations include:

When you say you couldn't lift your leg, was it due to muscle failure or due to pain? If the latter, was the pain over the pubic symphysis or more in the direction of the hip capsule?

Did your pain worsen or change when you got the uncomfortable saddle or did things stay pretty much the same as after the training? Were you still in as much pain as when you were doing the training with the coach?

Which StairMaster do you use, the one with pedals or the one also known as the Step Mill? There is an interesting biomechanical difference here that may be telling.

Maribeth Salge, PT
Rockledge, FL

A therapist or physician who is knowledgeable in gait analysis may offer some
assistance here.

In runners a proposed mechanism that makes sense to me is cumulative trauma
stress incurred during the up and down and/or side to side pelvic motion that occurs with running. Some studies suggest that excessive arm swinging in running may contribute to excessive pelvic sway.

The standard treatment, as in most overuse injuries, involves rest from aggravating activities followed by a graded return to sport. The problem with osteitis pubis is that this rehab program may require up to a year of time. I am not clear as to when you actually stopped running, but keep this time frame in mind.

The literature suggests that in compliant patients with chronic osteitis pubis, prognosis is good, but a considerable degree of patience is required. I see a few patients a year with chronic osteitis pubis, and unfortunately most are lost to follow up. I have had very good success treating the subacute cases with relative rest, NSAIDs, and a series of cortisone injections. The injections have been very helpful for diagnosis and treatment, and are relatively easy to perform in the office. This is followed by a period of PT to assist with pelvic stability.

I know of no cases that have gone to any surgery.

Robert Scott MD
San Diego, CA

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