A pain that brought me to my knees

IN the last few weeks, I have got to know my knees much better. My new-found knowledge has raised my awe and respect for this part of my body as well as saddened me greatly.

The knee is truly a magnificent structure. It’s a hinge joint between the femur (thigh bone) and the tibia (shin bone) that allows us to bend and straighten our legs. It usually does the job quietly and so well that we take it for granted and easily overlook its value and importance. That is, until something goes wrong. That something can be the meniscus.

This is fibrocartilage, a special type of water-filled and collagen-rich cartilage, between the tibia and femur that acts like a shock absorber or cushion that distributes load and provides stability within the knee joint. There are two C-shaped menisci in each knee. The medial meniscus is on the inner side of the knee joint and the lateral one is on the outer side.

I gleaned this anatomical lesson because one of my menisci has been injured. The term used is “tear”. Such tears are typically categorised as traumatic or degenerative. Traumatic or acute tears are sudden injuries often caused by the sudden twisting or pivoting of the knee that can happen during, say, an extreme sport, and are more common among younger people. Degenerative tears occur because of wear and tear and, yes, are more common with older folk.

The meniscus is anchored to the tibia and when it becomes detached, it’s called a meniscus root tear. Interestingly, this type of tear is actually very common but remained undiagnosed until fairly recently, when it came to be called a “silent epidemic”.

As the Mayo Clinic’s Dr Aaron J. Krych explained, “Meniscus root tears were like a silent epidemic. Patients were presenting with pain, but we didn’t recognise what was happening. Ten or 15 years ago or more, we couldn’t explain the patient’s symptoms, and often they were thought to have a low pain threshold, as the X-rays only showed mild changes.”

When the root becomes torn, it causes significant pain, affects knee movement and can lead to the rapid development of osteoarthritis.

And that, my dear reader, is my meniscus injury: a degenerative root tear. Mine started with an ache behind the left knee a few months ago. Then when I tried to squat down fully, there was sharp and severe pain.

I experienced a similar pain when I tried to cross my left ankle over my right thigh. But apart from these movements, I could walk, stand and even run without any difficulty or pain.

I have always been active. In my teenage years, I played a lot of badminton and squash and took up running and yoga in my 20s. As I got older, I thought I was doing all the right things to keep myself healthy and flexible, including kickboxing and Latin dancing. Even when Covid-19 confined us, I found my exercise gurus on YouTube and followed them quite diligently.

I did high-intensity interval training (HIIT) workouts with ease.

After retirement, I decided to look for less strenuous and more age-appropriate exercises that were low impact and would improve my flexibility. I could do lunges and squats that are supposed to be good for my leg muscles, the quadriceps, hamstrings, and glutes. I did these for years and never had any pain.

Then a year ago, I took up interval walking training (IWT) that had been developed by Japanese researchers who reported that this exercise was an ideal and safe way for older people to stay fit. I really liked it and wrote about it, declaring that I was “Walking to save my life” as that June 26, 2024, column was headlined (online at bit.ly/star_auntywalk).

I would typically walk for 30 minutes and finish off with stretches, squats, and lunges. I felt good, my knees didn’t hurt. Perhaps I should have stopped at that and not pushed harder.

A few months back, I decided to increase the walk to an hour and I would stride up and down an inclined walkway to add a bit of a cardio workout. Again, there was no immediate pain but looking back, this could have been what finally did my meniscus in. It was probably already under stress and such hard pounding, even though I wasn’t running, could have been the last straw.

The area behind my left knee began to hurt more and became increasingly stiff. I thought it was muscle strain and even the two GPs that I saw thought so too, and gave me painkillers and told me to rest.

My condition didn’t improve but did not worsen either.

Then came the moment that left me no doubt there was something seriously wrong. I had parked my car to go to the shops. I took a low step up and my left leg seized up in pain so excruciating, I nearly collapsed. All I could do was freeze and wait desperately for the pain to subside. I still am unclear about what I did to cause the severe pain.

But other patients had similar experiences. As Dr Krych reported, “Out of seemingly nowhere, individuals can have acute knee symptoms despite participating in only low-impact activities”. In one case, a 47-year-old woman was suddenly hit by pain that she rated as a nine out of 10 while walking in a parking lot.

I finally saw an orthopaedic surgeon who ordered an X-ray and an MRI scan. I have a condition called genu varum. It’s the fancy term for bow legs that occurs when the tibia turns inward instead of aligning with the femur and causes the knees to turn outward. My genu varum isn’t severe but it means the off-alignment would have resulted in uneven weight distribution on my medial meniscus.

The MRI showed I had a root tear and there are signs of osteoarthritis which is not unexpected at my age. But darn it, in the United States, studies show that the vast majority of patients with root tears are white females, usually aged 45 to 65, and who are often overweight, have a sedentary lifestyle, and may have varus knee alignment.

OK, I am in the right age bracket and have varus knees but what the heck, I am not white, overweight, and sedentary!

As it turned out, I had been doing all the wrong things to keep supple. How absolutely devastating! The surgeon said lunges are bad and squatting down should be avoided. She told me she never squats and she looks like she is only in her 40s. She even demonstrated how one should position oneself to reach a low drawer or pick up something from the floor.

Now that I had the diagnosis, what was the treatment? I could choose a conservative approach which was physiotherapy (PT) and anti-inflammatory drugs, surgery to suture back the torn meniscus to the tibia, and at the extreme end, a total knee replacement (TKR).

My doctor said I am not in such a bad state that I am a candidate for TKR so my choice is really between PT and root repair surgery. But both approaches mean it will take a long time for the meniscus to heal. And it may not heal properly because a lot will depend on the condition of the meniscus and my bones. My varus knees will also be a factor.

Surgery would require wearing a brace for at least six weeks and keeping weight off the leg. There will be a lot of discomfort and even pain and I would need many weeks, even months of PT. Later on, I would need hyaluronic acid injections.

While many orthopaedic surgeons believe surgery is the only way to treat a root tear, others are now more cautious because two recent studies have shown that patients with degenerative root tears and possible osteoarthritis don’t seem to benefit significantly from the surgery.

I am still mulling over my options and plan to discuss my case further with my doctor. Whatever I choose, there will be no quick, easy fixes and I will have to make lifestyle changes. What also worries me is that even if I can fix my left leg, is there a ticking time bomb in my currently good right leg?

Growing old is really a pain.

The views expressed here are entirely the writer’s own.