Doctors Advise invited.. Both leg knees, ankle Pain..Chondromalacia patella

Hello Sir,

I am a male of 34 years, I have experienced with a pain in my right leg knee / ankle pulling pain since last two years.. also sever pain on left knee " Tibal collateral ligament" area started since last month.

AUGUST 03RD 2011- 1st visit to Hospital

Suspecting nerve related issue,  I have approached neurology dept and have taken following tests as per Neurologist advise in the month of August 2011.

HAMEMATOLOGY
INVESTIGATION: EST (WESTERGREN)
RESULT : Half Hour Reading :- ---- One Hour Reading : 13
REFERENCE : Male <15MM/hr, Female : <20mm/hr
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INVESTIGATION : GLUCOSE-RANDOM
RESULT : 118 mg/dl
REFERENCE RANGE : 80-120 mg/dl
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INVESTIGATION :TSH
RESULT :1.88 mlu/L
REFERENCE RANGE : 0.465-4.68 mIU/L

NERVE STUDY

Motor Conduction studies of posterior tibal and Common peroneal nerve
nerves were done on both the sides
Sensory conduction studies of Sural nerves were done on both the sides.

FINDINGS:
1. Latency, amplitude and NCV of bilateral Posterior tibial CMAPs were normal.
2. Decreased amplitude and NCV of bilateral Common peroneal CMAPs
3. Sural SNAP were not obtained on both sides.

IMPRESSION:
Electrophysiologically there are evidences of mild peripheral neuropathy in both the lower limbs,
   -sendory than motor,
   -axonal and demyelinating types.

Based on the above, Doctor has advised to take Tablets of
MECONERV FORTE (MECOBALAMINE BET) for 60 nos.
TRYOTIMER 10MG 50 NOS.  

I have completed above medication, even during medication the pain was continued up to November 11.. then after there was no much pain till Feb month..

Since the pain started again from Feb 21012, i again approached the same doctor, he referred for ORTHOPEDIC opinion.

FEB 24TH 2012- 2nd Visit to Hospital.

I REPRODUCE THE COMPLETE MEDICAL REPORT as BELOW.
I have seen this gentleman with complaints of pain in the right knee. he has evidence of patellofemoral arthritis both knees.

I have advised:
1. x-ray both knees, AP view and lateral view
I have reviewed Mr. -----------, 34 years
X-ray of the knees-normal.
He is not hypertensive.

I have advised:
1, Blood test-Serum Uric acid
2. Then review.

CLINICAL CHEMISTRY
URIC ACID( Method uricase / POD) Result : 5.9, Units mg/dl, Reference Range : Male :4-8.5mg/dl Female : 2.7-7.2 mg/dl.

FEB 25TH 2012
I have seen this gentleman with complaints of paid in both knees and pain in the right ankle and the cuff muscle.
Crepitus on the movements of knees and ankle.
X ray of both knees AP and lateral is normal.
Spine is normal.
Pull pain in the right leg.
Poly Arthropathy,
Internal derangement of the right knee
Varicose veins
Disc Bulge of listhesis L3 causing canal stenosis.
No Back pain.

I have advised:
1. MRI of the right knee.
2.Blood test : ESR, rhematoid factor, CRP and ASO titre
3. Then review

MARCH 09 2012

I have seen the MRI of Mr.------- who has evidence of sever pateall chondropathy.

MRI of RIGHT KNEE REPORT
Sequences : Coronal PD, FatSat, Sagittal PD, PDFat Sat, Axial PD Fat Sat.

Tibiofemoral joint space and articular cartilage appear normal. Distal femur and proximal tibia appear normal.

Thinning and superficial fissuring of articular cartilage is observed in median ridge of patella. No evidence of subchondral marrow edema.

The patellar tendon and Hoffa's fat pad are normal. The medial and lateral patella retinacula are normal.

The anterior and posterior cruciate ligaments are normal. No definite tear / buckling is seen.

The medial and lateral collateral ligament complexes are normal. Poplitieus tendon appears normal.

The medial and lateral meniscus are normal with no definite tear seen.

No significant joint effusion / synovitis is present.

The popliteal vessels are normal.

IMPRESSION:
Focal thinning and superficial fissuring of articular cartilage in median ridge of patella- Chondromalacia patella ( Grade II)

MICROBIOLOGY-SEROLOGY RESULTS.

ANTISTREPTOLYSIN TITRE, RESULT : 52 , UNITS IU/ml, Reference Ranage : Aduct
C REACTIVE PROTEIN, RESULT :5.0, UNITS : mgs/l, Reference :
RHEMATOID FACTOR, RESULT : 8.6 UNITS : IU/ml, Reference .

I have advised:
1.Arthroscopy, arthroscopic abrasive arthroplasty, arthroscopic patellaplasty
2. It will be cost Rs...... for the surgery
3.Room rent, food and medicines extra
4.Please admit on full payment
5. Since he has got not much pain only sensation he is advised -
   a. Tab. Dolo 650-60 Nos.. one tab. twice daily after food
   b. Tab Ranitidine-60 Nos... one tab. twice daily one hour before food
   c.Volini gel for external use, wait for half an hour and then warm water bath twice a day.
NEED AN EXPERT OPINION ON THE ABOVE..

I WOULD BE GREAT FULL, IF ANYONE CAN SPARE THEIR TIME  AND REVIEW THE ABOVE CASE AND PROVIDE YOUR INPUTS..
I HAVE BEEN TAKING ABOVE DOLO 650, Ranitidine, Volini gel two times since last week... but i feel there are increase of pain in both leg knee joints / right ankle.

Here i would like to know,
1. Whether, the increase of pain is due to medication and symptom of recovery??? or the pain getting increased in general.
2. Whether its  nerve related disease / or orthopedic disease?
3. How can we control this disease?
4. Whether it can be cured with the medication (or) only cured with surgery?
5. Any other information related to the above , which useful to me for recovery!

Thanks in advance, your valuable TIME / OPINION shall helpful in leading my life.

Thanks and regards
G.R. Prasad

[S. Kaul, MD]

Hey Prasad!

1. Increase in pain is neither due to medications nor a symptom of recovery.
2. Without a detailed description and a clinical evaluation it would be difficult to say. It could be either or both.
3. Well, without a detailed clinical evaluation/ detailed reports and images it would be difficult to determine the cause of the issue here or suggest an appropriate management plan.
4. With the report mentioned I am not sure if an arthoscopic surgery would be the best approach at this time, without an initial trial of conservative management for chondromalacia patellae; though medication would not ‘cure’ this.
5. I did not see a spinal/ ankle imaging and it may be premature to comment on the situation. I would suggest seeking a second opinion with another orthopedician with the MRI report and images and other tests performed so far, before taking a decision regarding the management plan.
Hope this is helpful.

Take care!