Knee issue for the past two years

Discussion in 'Health & Fitness' started by Brett, Apr 6, 2014.

  1. Brett

    Brett Semi-Pro

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    I am 26 years old and I play tennis, lift weights and run. In January 2012 I originally started my right knee problem when I was doing standing lunges. I was holding a heavy amount of weight and immediately felt pain in my right knee after one repetition.

    The next month in February I scheduled a doctor's visit with an orthopedic doctor. The X-Rays came back negative. I believe he thought it was patellofemoral syndrome and he couldn't really recreate the pain in my knee when he examined me. That's because it was only coming up a few times when I did leg workouts and every time playing tennis. He ended up giving me a cortizone shot to the knee and I started a week or so prescription of Meloxicam. The next month in March I had a MRI done and it came back negative. The rest of the year I wasn't experiencing any more pain from my knee and kept playing tennis probably due to the cortizone shot until the end of December. I felt a sharp pain in the same knee just from walking on the treadmill out of no where. In April of 2013 I started going to physical therapy for my knee for roughly 2-3 weeks with three visits because I didn't have a lot of visits left due to having to go to PT for another problem. Throughout the summer I still continued to play tennis but my knee issue was still there. I stopped playing in about August 2013 and decided to pick up my racquet for the first time in March of this year. Immediately my knee pain came back playing tennis.

    Now my knee pain has never really come up at all when I go running. I have continued to run for the past 2 years and my knee pain only comes up in tennis and sometimes lifting legs. I can definitely tell my right knee is weaker than my left knee for these past two years. It never hurts just walking and when the pain was around I could feel it more walking down stairs than up stairs. I continued to lift weights on my legs and it would come back sometimes when I did lunges and just holding a dumbbell doing squats.

    In March of this year I started doing PT exercises (my brother is a PT) at night for 45 minutes and stuck with that for two weeks every night. I stopped doing lunges completely. I tried playing tennis again a week or so ago and the pain still came back. The only thing that makes me hesitate in thinking it's patellofemoral syndrome is that it doesn't hurt just sitting for a long period of time like people that have patellofemoral complain about? Could it be a slight meniscus tear that didn't show up on MRI two years ago?

    Now I'm at a lost in what to do. Part of me wonders if I should go to a different doctor (didn't really love the first one) and send my MRI/X Ray records from two years ago down to him. The other part of me says to just keep doing PT exercises at home for a longer period of time. I haven't been icing it everyday and figured maybe I could stick to doing that as well. Should I get another steroid shot to the knee? I'm sure that would last a long time again but I get scared because I feel like it's just a band-aid and not fixing the problem. Plus people warn against it?

    I'm just beyond frustrated. I'm upset this hasn't fixed itself and it's been two years. The one thing I love to do is play tennis and that's mainly the biggest time it starts hurting. Again, it doesn't hurt just doing normal day to day activities but I have been able to tell for the past two years that my right knee just feels weak compared to my left one. It's always been difficult to pinpoint exactly where the knee pain is when it comes but it usually is at the top of the knee or in the front of the knee. Last time I played tennis I was able to pinpoint it exactly on more at the top part of the knee. It hurt when I tried flexing my knee doing a quad stretch and the closer I got bringing my heel to my butt. It has never been on the back of the knee or the bottom of the knee.

    Any help would be appreciated for recommendations on what to do...
     
    Last edited: Apr 6, 2014
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  2. spun_out

    spun_out Rookie

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    Does your knee hurt also when it is the trailing leg on a lunge?
     
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  3. Chas Tennis

    Chas Tennis Hall of Fame

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    Do you have the written copies of your MRI and X-Ray examinations?

    MRI's are evaluated by a specialist and sometimes they may mention things in the written report that are not pursued at the time of injury. For example, when I had a torn meniscus, the serious patellofemoral conditions were hardly discussed.

    I believe that this applies to me. The recommended stretch improved my patellofemoral pain and I can see that my rectus femorus muscles are tight and short. My heels only reaches to many inches from my butt. I'm not young.
    https://www.mrtherapy.com/articles/article3.html

    The NCBI website is a good place to research for sports injuries. Free full research reports (pmc).
    http://www.ncbi.nlm.nih.gov/pmc/?term=knee+pain

    This is not exactly your injury but it illustrates the subtle problems that may be hard to diagnose without a very experienced Dr. I guess this party had a lose ligament or other tissue in his knee.
    http://asmiforum.proboards.com/thread/2050/help-solve-problem-sharp-pain

    Patellofemoral pain.
    http://www.aafp.org/afp/2007/0115/p194.html

    Miscellaneous injury information including knee injuries.
    http://www.hopkinsortho.org/conditions_diseases.html

    Your knee only has a few structures in it. Study ligaments, tendons, articular cartilage, meniscus cartilage. Pinched nerve above the knee
    somewhere. Research nerve maps to see which nerve might be pinched in the back or elsewhere to cause your knee pain.

    Your lifting injury might have caused damage somehow to your articular cartilage to either your knee joint or the patellofemoral joint. Understand these two joints. Also, the two different knee cartilages and their locations, meniscus & articular. A certain range of angle for knee bend puts a lot of pressure stress on the articular cartilage areas of the patellofemoral joint.

    Google images of the knee and try to locate the pain as best your can.

    Use Google Images http://www.google.com/imghp Search: knee pain
    https://www.google.com/search?site=...s=50000...0...1.1.39.img..0.9.630.y3Oi48f7rU4

    Youtubes on the anatomy and injuries of the knee can be very informative.

    Talk to your friends who have had knee injuries and find some recommended Drs.
     
    Last edited: Apr 8, 2014
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  4. tennis_tater

    tennis_tater Semi-Pro

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    Seems to me that getting an evaluation and recommendation from your PT brother would be the easiest thing to do.
     
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  5. Alexrb

    Alexrb Rookie

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    Sounds like you could have ***** lunge form. Glad you stopped, but maybe you need to rest it longer?
     
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  6. tennisenthusiast

    tennisenthusiast Hall of Fame

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    Totally agree and I hope he did not charge you for those sessions! :)
     
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  7. Chas Tennis

    Chas Tennis Hall of Fame

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    He went to his brother already and is still looking for a diagnosis. He may not have the most common injury, that we could guess and likely(?) be correct.

    Physical therapist are medically trained but not for injury diagnoses. I've got some better information from a physical therapist than from a Dr on one issue. I sometimes find good information myself.

    But for my next injury I'm seeing a Dr for a diagnosis. The chances of an accurate diagnosis are better.
     
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  8. tennisenthusiast

    tennisenthusiast Hall of Fame

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    Unfortunately doctors cannot diagnose musculoskeletal issues. Even MRIs, X-rays cannot reliably diagnose these issues.
     
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  9. Chas Tennis

    Chas Tennis Hall of Fame

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    I don't know the rate of false positives or false negatives from the various techniques. My meniscus tears did not show up for certain on the MRIs but the very slight shading were just 'consistent with a meniscus tear'.

    I would rate a well qualified Dr using imaging or other advanced techniques as much, much more reliable than all other ways. Those who are not medically trained for diagnosis and do not use imaging or other advanced diagnostic techniques including internet searchers like myself, physical therapists, chiropracters, etc, are not going to be reliable especially for anything unusual. If fact, this OP is dealing with something unusual. You also have had a lot of posts on injuries.

    I do pretty well on injuries that I have had or in guessing that very common injuries (common tennis injuries) are probably what is wrong. It is those other things that I've never thought of that I will always miss. Not long ago even Drs were missing Lyme disease, bacteria that caused stomach ulcers, etc.

    Doing things for an injury without a diagnosis might turn out OK or of limited additional damage in many cases. But in some cases, even through a Dr, proceeding without a diagnosis can lead to chronic conditions.

    A lot of Tennis Elbow becomes chronic because people continue to play tennis. Even a very short time can be important. Buy a brace and see how you do and you may have lost your one chance to heal optimally and develop chronic TE. Maybe it limits itself or maybe it just gets worse until you are forced to stop. Stop stressing for 3 months(?) and healing can be much better.
     
    Last edited: Apr 9, 2014
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  10. RogueFLIP

    RogueFLIP Semi-Pro

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    Chronic condition like yours for sure you've got some unresolved soft tissue restrictions in your leg. Might not even be near your knee.

    Did your physical therapist brother actually palpate you or just told you to do some exercises?

    Suggest you find a way either yourself or someone else to find and break up the tight tissues....massage, trigger point therapy, foam roller, myofascial release.
     
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  11. RogueFLIP

    RogueFLIP Semi-Pro

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    Currently all physical therapy students graduate with a Doctorate of Physical Therapy (DPT). Four years of pretty intensive education and clinical training.

    Part of that training is the ability to assess and diagnosis injuries, especially in the musculoskeletal system. Curriculum courses include classes in differential diagnosis.

    Currently 48 out of 50 states in the US allow for some form of direct access to physical therapy. This means that the consumer is allowed to see a PT without the need of a referral of a physician.

    Which means the PT field has shown that they have obtained the education, training and skills necessary to diagnosis injuries.


    Many of the patients that I treat come into the clinic without a prescription. I can diagnosis and treat them. Many doctors (orthopedics included) often write prescriptions that just say "Physical therapy" on them. Which means they leave it up to my training to figure out what's going on. And if someone presents with something beyond my abilities or scope of practice, I refer out to the appropriate medical resource.

    When I do get a prescription of the area injured it's not the be all end all. It's just a starting point.
    At my old job, I got 30 minutes 1 on 1 allotted to perform my evaluation. Clinics vary. At my current job, I get 1 hour. I doubt if you went to your doctor for a common tennis injury you'd get that much time. Plus, I can start treatment, show them things to do at home. Pretty good bang for your buck I think.

    I hope this clears up any misconception of what physical therapists can do.
     
    Last edited: Apr 10, 2014
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  12. RogueFLIP

    RogueFLIP Semi-Pro

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    While imaging is of course a useful tool, it still is just part of the puzzle. 1) only of the symptomatic region (hopefully) 2) 2 dimensional picture of a 3 dimensional object 3) rates of false positive/false negatives as you mentioned

    One shouldn't rely on imaging to form a diagnosis. It can confirm or rule out what you suspect may be an issue from probably the most important aspect IMO, the physical exam.
     
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  13. RogueFLIP

    RogueFLIP Semi-Pro

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    Don't get so hung up on finding a "diagnosis". It's just a label.

    The problem with labels is it leads to what I like to call "cookbook" therapy.

    You've been diagnosed with label "X".
    I'm got an MRI that's consistent with label "X".
    So I'm going to treat you with recipe "A" which peer-reviewed research says is the best way to treat you.

    What are you going to say when the patient isn't better?


    Think of it this way: Shoot a paintball onto a canvas. It makes a certain splash pattern. Shoot another paintball from the same gun at the same distance, same velocity. Different splash pattern.

    But bc it's paint on a canvas, it'll get the same "label". And thus, the same recipe to treat it. Might work.....but might not.
     
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  14. Chas Tennis

    Chas Tennis Hall of Fame

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    Are physical therapists trained to fully diagnose medical conditions?

    Is it more accurate to say that they are trained to evaluate but not fully diagnose some medical conditions?

    In CA, the law says that physical therapists can't diagnose. For other states?

    There is no doubt that many physical therapist sometimes do better that Drs in understanding an injury or some aspect of it, I've experienced that myself. I'm sure also many times a physical therapist has a correct diagnosis that the Dr had not found.

    With MRIs, along with false positives and false negatives there are many accurate or informative findings. There are evaluations of how well the MRIs do for specific injuries. For example, Google: MRI false positive labrum tear

    My Dr ordered an X Ray for my recent right knee injury ("R" on X-ray.). For the first time the spacing of the bones was not even, usually an indication of arthritis. See 2013 spacing on the right knee, medial side (inner) - compare to corresponding spacing in the 2012 X ray. I got physical therapy for specific exercises that I could do to strengthen my legs that would be less irritating for arthritis. I compared my new 2013 X Ray to the 2012 X Ray and could see the change in the spacing on my right knee. If the next injury has an X-ray with less spacing I may make some decisions about playing tennis.

    2012 - More or less even as in other earlier X rays.
    [​IMG]

    2013 - See right knee marked "R". There is some uneveness and the medial side is closer compared to the 2012 X ray.
    [​IMG]

    General discussion of knee imaging.
    http://www.kneeguru.co.uk/KNEEnotes...imaging-and-x-rays-patellofemoral-pain-part-6
     
    Last edited: Apr 11, 2014
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  15. NMTennis

    NMTennis New User

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    Perhaps there is something to your lunge technique.

    I was told to never let the knee go in front of the toes, and since I have changed my lunge technique, this seems to put a lot less stress on the knee and I haven't had pain/discomfort...You want to go more up and down, not forward with the knee...

    Any thoughts?
     
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  16. Chas Tennis

    Chas Tennis Hall of Fame

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    Not very sure of this so research it. The patellofemoral joint pressure goes though a peak over a particular angular range of knee flexion. That range is somewhat in the middle of flexing the knee. Probably patellofemoral damage might be more likely over this range. (?) Search internet for details, I've seen a detailed paper.

    The physical therapy I just took was aimed at posture strengthening among other things of the gluteus medius (small muscle) for better knee joint alignment during motion. Clamshells, and related exercises, etc.

    More to your question, the physical therapy emphasized using the gluteus maximus (large muscle) and reducing the quad participation, for example, when doing squats. I had more weight on my heels and became more conscious of using my butt muscles. This brought the knees back somewhat from over the toes. I try now to incorporate this glute emphasis more in my tennis ready position.

    My Dr had told me to exercise my legs by not bending my knees. !! That had been during my first visit perhaps from the acute injury. (?) This exercise issue is why I requested physical therapy - to find exercises that would be optimal for arthritis. A week after seeing my Dr the knee seemed to suddenly return to feeling normal. Did something reposition in the joint?

    The physical therapist said that I could exercise and bend my knees. I like the physical therapist's approach of emphasizing the butt muscles for extending the knees under load, like squatting. I'll discuss this conflict about bending the knee for exercise with my Dr on the next visit.
     
    Last edited: Apr 11, 2014
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  17. RogueFLIP

    RogueFLIP Semi-Pro

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    Physical therapists currently are educated at the doctorate level and receive extensive education and clinical training in the examination, evaluation, diagnosis, prognosis, and intervention of patient/clients with functional limitations, impairments and disabilities. Physical therapists are qualified to recognize when a patient presents with signs and symptoms inconsistent or outside the scope and expertise of the physical therapist and when the patient should be referred to a physician. APTA's Guide of Professional Conduct advocates that physical therapists should assist patients in receiving appropriate medical care when the physical therapist's examination and evaluation reveals signs and symptoms inconsistent with a condition that can be appropriately treated with physical therapy or needs a physician's care and expertise.

    Essentially, as long as it falls within our scope of practice, yes we can diagnose.

    Your knee issue from the tennis court? Yeah we can diagnose that.

    Your venereal disease? No we cannot diagnose that.

    It varies state by state. But just because the law in some states says we aren't allowed to diagnose, that doesn't mean we aren't trained to diagnose. Again as long as it falls under our scope of practice. I hope you understand the difference as I believe that was the crux of your misconception.


    I'm not saying that we can do things better than doctors. I just wanted to educate you and others on what PT's are capable of doing.

    And in general, PT's tend to have more time for a more thorough physical examination that can further solidify a diagnosis.
     
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  18. RogueFLIP

    RogueFLIP Semi-Pro

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    Regarding your X-rays, I believe there was a thread where PostureGuy posted an image of a client's knee x-rays where there was no space due to OA, injury, whatever vs following the Egoscue program, a year later the knee spacing had be restored to normal.

    My approach would be similar in trying to restore postural balance in the system, but also finding and releasing any soft tissue restrictions that may be contributing to the compressive forces at the knee in the first place.
     
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  19. Brett

    Brett Semi-Pro

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    Well I haven't been doing lunges anymore but I'm pretty sure it was hurting both on the trailing part and the one that was taking the forward motion. Again that pain would only come a few times when I kept lifting weights in the past two years.

    I have been doing physical therapy exercises at home on my own for literally 45 minutes to an hour every night and icing it for 20 minutes. It's so annoying...I just want to be better.
     
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  20. Egoista

    Egoista Professional

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    stop doing the leg exercises for a while
     
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  21. spun_out

    spun_out Rookie

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    This is the stretch that miraculously cured my nagging knee problem:

    1) find a table or counter, put your hands on it to brace yourself.
    2) place one foot behind another as if you are doing a lunge or calf stretch; the distance between the feet should be short.
    3) put your weight on the back leg and stretch.
    4) key here is to put weights such that you are not stretching the calf but the front of the lower leg; when I first did it, I felt a burning sensation as if the muscle going to cramp; try to hold it as long as possible.
     
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  22. Brett

    Brett Semi-Pro

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    Wow, this one really helped you? You don't contribute it to anything else? Do you know specifically what the problem was with your knee?

    I have been doing one exercise at night where I sit on the ground. I keep my left knee bent (the unaffected knee) and then keep my right leg straight on the ground. I push the bottom of my knee cap on my right leg towards the ground and hold it for a few seconds...this sounds about the same stretch and working the same idea correct?

    Just wanted to see if I could replace yours for it everyday?
     
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  23. spun_out

    spun_out Rookie

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    I was originally diagnosed with left quad tendonitis where inner top of my knee cap hurt after adding more knee bend on serve. It quickly spread to inner upper calf and back of the knee, and then to the right leg. The condition lasted, with varying degree of pain, for over a year (I had PT for the first two months, and it made it worse).

    I am not sure I am understanding the exercise you are doing correctly, but doesn't it stretch the back of your knee? The one I described stretches the front of your shin (dorsiflex muscle?). In my case, the muscle burned a lot when stretching but there was no pain after I stopped. The stretch basically resolved the problem in both knees within a week. If it doesn't hurt, then try it for a week and see if you experience a noticeable change.
     
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  24. Brett

    Brett Semi-Pro

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    Thanks! When I do it though it seems to stretch more of my quad muscle and or my knee...I almost imaging trying to "pop" my knee out when I do the stretch. Is this not correct on how to do it?
     
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  25. moonballs

    moonballs Hall of Fame

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    Thanks for sharing. I just tried the pose. To stretch the front of the shin of the front leg, do you need to put more weight in its heel, almost lift the toe? Is the back leg supposed to be neutral?
     
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  26. spun_out

    spun_out Rookie

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    Brett and moonballs,

    Maybe I didn't describe the exercise well. Let me try again.

    Take a short stride lunge (or more accurately, split squat) pose (feet 1-2 ft apart). Lean forward and put your hands on a counter or table for balance. You are trying to stretch the front of the lower leg (shin muscles) of the back leg in the split squat. Move the knee of the back leg down toward the ground so that your lower leg becomes closer to parallel to the ground. This means that the heel of your back leg will come off the ground. You should feel a stretch in the front of the lower leg. The stretch is felt as a burning sensation for me. For me, it helps when I move the knee down and in (so if you are trying to stretch the right leg, move the right knee toward your left).

    I hope this helps.
     
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  27. Chas Tennis

    Chas Tennis Hall of Fame

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    Last edited: Apr 29, 2014
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  28. moonballs

    moonballs Hall of Fame

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    #28
  29. spun_out

    spun_out Rookie

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    Yes, it's like that, except for you don't point your foot behind you with the top of your foot touching the ground. In the stretch I am describing, the bottom of the foot (mostly toes, with heel elevated) should be touching the ground. This means that the foot will still be pointing forward.
     
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  30. Brett

    Brett Semi-Pro

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    Well again, for the past 2 months I have been doing PT exercises and stretches at my home for 45 minutes to an hour every night. For the past 3 weeks, I have started to ice my bad knee for 20 minutes every night.

    For the first time about three weeks ago, I noticed a little bit of pain now in my good knee (left knee). I was doing standing wall squats for therapy but then also noticed it just doing ab crunches on a ball in the gym. This past Friday I felt more pain in my good knee (left knee) holding weights and just sitting down/standing up with 50 lb dumbbells in my hands.

    I started then wondering if it could be my tennis shoes or my running shoes? I have had my running shoes for three years now and they are getting pretty worn down completely on the bottom. I tried to get new ones a few months ago but couldn't find any I like. I run about 7-8 miles a week. Then I started wondering if it could also be my tennis shoes that I play tennis in since I also wear the tennis shoes lifting weights. And the pain only comes playing tennis and in the gym. So last night I tried playing tennis again and played in my running shoes.

    Same results. Extreme pain in my bad knee but the good news was my left knee was fine. The pain came more during the match and it hurts when I bring my heel to my butt (quad stretch motion).

    I have never been more frustrated.
     
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  31. tennisfreak

    tennisfreak Semi-Pro

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    You should replace your running shoes every 300-500 miles. If you run 7-8 miles a week, you should replace them at minimum once a year. You're still wearing shoes that you should have replaced 2 years ago.

    Not only that, you decided to play tennis in those running shoes. All that shock that should be getting absorbed by your shoes are getting absorbed by your body, including your bad knees.

    Something tells me your tennis shoes are also way overdue for replacement. Do yourself a favor and get some new tennis shoes and running shoes.

    It's much easier to replace your shoes than your knees.
     
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  32. Brett

    Brett Semi-Pro

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    Thanks for the reply! I actually just played tennis in my running shoes for only one time this past Wednesday. Just to test and see if it was my tennis shoes for sure or not. I still had pain so that tells me it's not just from my tennis shoes.

    And my tennis shoes are fine. I just started playing in these new ones in August 2013 and took a couple months off so they are pretty brand new. Do you think it could be my running shoes and the pain is being worsened by my running even though I don't have pain during my runs? My running shoes are pretty torn apart at the bottom...I know I have been stupid for not replacing them.
     
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  33. Chas Tennis

    Chas Tennis Hall of Fame

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    Do runners develop a running posture? Some muscles are too tight or short, etc. Do distance runners have reduced leg flexibility?

    Once I used running shoes with a wider flared sole than at the shoe. Playing platform tennis, they flipped my ankle to the side hard a few times. I had never had that problem before or since with tennis shoes while playing platform tennis. I decided to always use tennis shoes for tennis or platform tennis.
     
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  34. JonC

    JonC Banned

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    I did 15 minutes of PT stretching and exercises 4 times a day for two months , plus ASTYM, and it did nothing for my knee. I went barefoot for 3 weeks and my knee is 70% healed and I'm having some pain-free matches. Read up on the damage that modern shoes and arch supports are causing.
     
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