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ADVICE ON KNEE PROBLEM

 Poster: A snowHead
Poster: A snowHead
I did a ski course on a Glacier in early November and had pain in the knee and it was swollen every day .I used an ice pack and Nurofen in the evening to reduce pain swelling.
Back in the UK I had the knee X rayed and it turns out that one side is Mall tracking and on the the other side of the knee the cartilage has completely gone and I also have
artheritis in it! The consultant Surgeon said that the Malltracking can be fixed with physio but the cartilage/arthritis can only be helped not fixed and that eventually (when it
becomes too painful) I will need a partial knee replacement . They also told me one leg is slightly longer than the other so over the years all the pressure has mainly gone through
the bad knee . My physio has given me about 40 mins of daily exercises to do to strengthen the knee and supporting muscles which I have been doing for the past 3 weeks.
The swelling is now down and I have almost normal movement . I mountain bike 3-4 times a week and am generally in good condition for a 53 year old.I am planning to ski again next week but will take it easy and not do more than 1-2 hours (or less if any pain) and see what happens .

I am getting conflicting advice about when and how much skiing I can do in the future . From "take up cross country instead" to "just ski until the pain is too much and then
get a partial knee replacement" so would be very grateful if anyone who has had a similar problem , or is a knee specialist who skis , can share their experience or thoughts
with me . Good news stories particularly welcome !

thanks
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brnttptr, sounds a familiar story (about conflicting advice) my consultant said take up cross country my Physio says I should be fine to ski just need a hinged brace. I am not skiing until April so I have time to decide whether I go for the hinged brace Physio is suggesting or a ski mojo. If you want to read about my injuries etc, search under my name.
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I have a similar issues (for about 10 years) with my left knee and, other than a knee replacement, all I can do is manage the problems. Instability, swelling, pain...... I have resorted to co-codimol, naproxin (Anti-inflamitory), tube grip, neoprene knee supports, basic hinged knee brace etc...
After months of waiting I had a scan and that identified what the real issues were. Then, 2 knee operations (cartilage and chondroplasty) rehab excercise, physio, acupuncture, cortisone injection.

Definitely affected the skiing as any fitness went out the window as the required exercise caused the same issues. The consultant suggested it would not be wise to 'over do' things and when I suggested skiing it brought a smile to his face!

After all of this, when they finally said that's all they could do, I was still only able ski for a few hours even with the drugs and basic supports. If I pushed it for longer I would struggle for days. 3 years ago I heard about the Ski Mojo. Since I have used it I have been able to ski longer and do not have the fallout following the day on the slopes.

I can wholeheartedly recommend the Ski Mojo. For me, this is the one thing that has enabled to continue to enjoy skiing.
Also see this thread..

http://snowheads.com/ski-forum/viewtopic.php?t=105219&highlight=
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brnttptr, I do know what Mall tracking is, but I have osteoarthritis in both knees which has been very painful at times. Oddly this is the inner compartment of both knees. However, after a few years of exercise, particularly very high loads on an almost straight knee, the pain has eased and I am now able to do the really hard things like walk up and down stairs using alternate legs.

I use industrial strength knee braces all the time skiing to maintain the lateral straightness of knee. I only manage about 6 hours skiing most days and cover 50 - 60 km. I do restrict myself to only a couple big mogul runs a day and call it a day as soon as I start feeling any pain. This stops the inflammation before it becomes a problem and think this is very important. As soon as the knee starts swelling I have gone too far and the rest of the holiday is ruined.

brnttptr, May I suggest that you choose a skiing resort where it can be fairly easy to get back to should the knee start playing up. I have got the bus back on quite a few occasions.
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'Mal' not 'Mall' I think... Sounds exciting

Maltracking refers to several different conditions when the patella does not remain within the central groove of the femur (thigh bone). This includes ELPS (excessive lateral pressure syndrome) or LPCS (lateral patellar compression syndrome), patella tilt, subluxation and dislocation. The kneecap most commonly tends to tilt and glide towards the outside of the knee (subluxation). The patella may slip outwards and stay there, in which case the knee will lock and you will not be able to straighten it. Most of the time patella will reduce itself spontaneously, if you manage to relax a bit, but sometimes this memorable experience will require manual reduction by yourself, another person or a casualty officer in the A&E department. In most cases of recurrent patella dislocation several anatomical conditions are frequently seen: relatively flat patella, patella alta (high-riding patella), shallow femoral trochlea, femoral torsion, loose medial structures, general joint laxity, etc.
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Thanks very much for all the replies so far ! Sounds like the Ski Mojo is definitely worth looking at . JohnE very impressed you can do so much skiing and a couple of mogul runs a day with osteoarthritis in both knees ! Amazing! that's given me much more hope and inspiration to get back on the slopes.
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I've not had knee problems, but had major hip problems that were eventually fixed by surgery (resurfacing). I skied for a few years with arthritis that I developed at an early age (mid-30s), I think a lot of my experience might be relevant. My experience / tips are:

. Do lots of physio, religiously. Do it every day (or whatever the physiotherapist advises).

. Cycling was good for me; running was a complete no-no due to the impact, I imagine similar applies to knee problems.

. I took ibuprofen and later diclofenac (get advice from doctor or pharmacist if taking the latter, you can buy over the counter now but in rare cases it can cause internal bleeding if used a lot). I would take these at the slightest twinge, don't wait for pain. The anti-inflamatory effect it the main thing here. You can also combine with non-NSAID drugs (e.g. paracetamol) for maximum effect; again don't take advice from the internets, talk to a pharmacist about this. I heard a lot of cr@p from people about drugs masking the pain and making it more likely that you will cause injury. Well, yes of course they mask the pain and yes, I'm know doing impact sports on arthritic joints does cause harm... You can lessen the harm with appropriate drugs.

. Try to plan skiing to avoid walking too far in boots if possible. If you do have a walk to the lifts etc then either get "cat track" rubber thingies for your boot soles or wear trainers that you can then put in a rucksack when skiing. Walking in ski boots was a real problem for me, carrying trainers in a rucksack is a bit of a pain in the neck but worth it, especially at the end of a day. You may even be able to leave them at a base station somewhere.

. Avoid skiing hard on hard pack or ice; the vibrations from trying to hold an edge on very hard snow were the worst thing for my hip. In fact I tended to avoid skiing hard at all, just take it easy when ever possible.

. Skiing in poor vis was also really hard on my hip, not sure why exactly, probably because it was hard to anticipate terrain so my legs just had to work a lot harder.

. Bearing in mind the last 2 points it may be that on some days it's just not worth pushing on. The first time I ditched a day's skiing through pain I was gutted, it was chucking it down with snow and I was in an off piste group with a guide, we were skiing 20-30cm deep powder but over hard bumps and although it's what I wanted to do it was agony. I went back to my hotel room after lunch and was very down. It turned out to be a good move, I rested, took diclofenac and paracetamol and the next day was great. It was a bluebird powder day, the snow was deep enough to cover all the bumps and ice completely and the vis was about 100 miles. I think it was the best day's skiing I ever had, if I'd pushed on the day before I might not have got out of bed that next day.

Good luck with it!
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Thanks Sah very much for the tips . Very good point about the anti-inflamtories which I will follow (I tried to wait until the pain was very high before which was clearly a big mistake !) Enjoy your skiing this season and thanks again!
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brnttptr, also worth remembering to use ice - PLUS the anti-inflammatories - if your knees are feeling hot and puffy (mine get like that after a hard day's skiing). For a week's skiing you could usefully keep yourself dosed up permanently!
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brnttptr wrote:
Thanks Sah very much for the tips . Very good point about the anti-inflamtories which I will follow (I tried to wait until the pain was very high before which was clearly a big mistake !) Enjoy your skiing this season and thanks again!


Yep, I did the same initially, until my physio told me off. One other tip which made a huge difference (probably more than any other, so I should have remembered this!), if at all possible get physio with hydrotherapy (I think it may now also be called aqua therapy), this is basically physio in a warm swimming pool. Normal swimming will also be good for knees as it is 100% non-load bearing (for hips there are some thought that swimming is not so good because it reduces joint stability - not sure if there's much truth in that though).

If you are by any chance remotely close the the Reading / Wokingham area please PM me and I'll give you details of very good physio/hydrotherapist.
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for both hips and (especially) knees breast-stoke is sometimes not advisable. As ever, need advice from a clued-up physio.
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My ski physio told me that swimming was not useful for rehab, although good for CV of course - time better spent in the gym rather than the pool. you need to be able to load bear to ski so my rehab was heavily focussed on that.

Totally agree on taking anti inflammatories as a matter of course while skiing - I went through a shedload last week as well as gel and freeze-spray ... but I did ski 4-5 hours a day for 7 days, pretty hard and fast for me (and I was only meant to be doing green runs Embarassed )
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pam w wrote:
for both hips and (especially) knees breast-stoke is sometimes not advisable. As ever, need advice from a clued-up physio.


Ah, yes, that sounds like the advice I was given come to think of it. My physio tried to teach me the butterfly stroke... with rather 'limited' success; I could do the stroke but only if I kept my head under water, so not ideal for anything more than a width.

Ice also good advice of course... sadly for hips that doesn't really help (that is to say, it didn't help me, others may have more success) but for knees I suspect it will be very helpful indeed. I did use ice, but only for gin & tonic, probably not advisable to mix that with pills but I did anyway.
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brnttptr,

If the maltracking has lead to wear then physiotherapy can help to reduce the excess load on the worn area. You can then maintain the improved tracking by staying strong and keeping up with the exercises. add them to your weekly routine.

You will then find that if you remain active and keep in good shape that the knee will, overall , be better off than if you stopped exercise. however your knee will have a threshold beyond which it will flare up ( swell and become painful).

You need to learn where that threshold is, the better you do the less likely will you need surgery.If it does flare the better you manage it , and the quicker you get on top of it, the less likely will you need surgery.Use ice, anti- inflammatory tablets if you tolerate them.

You may have to experiment with skiing for less hours per day. Have a rest day on day 3 , when you are most fatigued. Be careful at end of the day when the form slips because of fatigue.

You do not need to give up any thing if you can get the knee to tolerate it.

Your biggest obstacle is the swelling, which "melts" muscle away.

Your physio program should be done at a level of effort that does not cause significant pain.

If you still cant ski, i would then offer you surgery

Jonathan Bell
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Quote:

Your biggest obstacle is the swelling, which "melts" muscle away

Jonathan Bell, could you expand on this? My knees are, like the rest of me, 66 years old but generally are pretty well OK, and no worse now than they were 30 years ago. A hard day's skiing can make them swell up - hot enough to feel through the salopettes. But that used to happen 30 years ago, too, and I am a better skier these days. I use ice (topically and in the gin) and ibuprofen and take it easy for a bit.

Do you mean that the swelling interferes with the effectiveness of your muscles? Or that it causes long term positive damage. If the latter I should probably try to avoid the kind of days which end with puffy knees. They are not painful, exactly, though the range of movement is obviously limited.

I have been doing the usual exercises, and will continue to do so, and as I ski quite a lot, and not usually for very long and hectic days, my muscles are normally well able to cope.
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Jonathan thank you very much for your comments particularly about the swelling and finding the threshold which are extremely important and I will follow.
Luckily I work , for myself, in the Alps in the Winter ( 5 mins from ski resort) and am able to ski every morning before work for an hour or two and as a result ski 90-100 days a season (mostly short days)
and only ski longer when friends come out ..........so regulating my skiing will be easy.

You might be interested to know that the Ski Physios/Osteopaths out here in the Tyrol are much keener on using Quark (German name for Ricotta cheese) on a swollen knee than ice . They say it has an active ingredient which draws out the heat !!! I have used it and it did seem to work . Buy from any supermarket and apply for 30 mins.

Do you have any view on using a Ski MoJo ??
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brnttptr wrote:


Do you have any view on using a Ski MoJo ??


I had some concerns when Ski MoJo was marketed as a device to allow you to ski all day in that it could have allowed the unfit to ski for longer when everything else, besides the quads, were heavily fatigued. They seem to have changed tack and stopped that approach. I spent some time looking at it recently, with the owner of the company. It may, potentially, have a role in reducing pain from osteoarthritis of the knee in skiers. I offered to do a proper scientific trial but i haven't heard, so they may not be interested, which is a shame as otherwise we all just have anecdotal tales to go on. Im sure we could recruit plenty of snowHeads to participate if they agreed to go ahead. It's quite a big financial outlay if it doesn't work, I don't know if it can be rented. I would still have reservation if the knee were getting very swollen. Sorry not to be more helpful
Jonathan Bell
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Jonathan Bell, I would certainly be very keen to volunteer for a proper trial. Edge & Wax used to hire them, we got in touch to ask if they still do, but they have stopped as apparently the insurance was too high.
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Johnathan , No that's very useful and makes complete sense . I believe its very important to try to do the strengthening exercises and allow the body to solve the issue without mechanical aid if possible ( and only use something like the Mojo as a last resort.) Clearly anecdotaly it seems to have helped many people with severe knee or hip problems to carry on skiing which is great so I would definitely try it if my situation gets worse.
As you very clearly pointed out the key is to understand and observe ones skiing threshold and stop there. A proper scientific trial of the Mojo would be excellent and I would be happy to volunteer but can see the downside from Mojo's perspective of doing one.
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Johnathan Bell : Sorry forgot to ask this .As I have no cartilage and osteoarthritis on the other side of the same knee will the osteoarthritis just get worse with time or will exercise ,staying fit and healthy etc help stabilize this too?
The knee consultant I saw said at best I may not need a partial knee op for up to 10 years and that it was a "lifestyle choice" i.e. how much pain I was prepared to live with. I guess only time will tell and skiing within
the threshold will ,I guess, make a big difference.

Thanks again and have a good ski season!
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brnttptr wrote:
Johnathan Bell : Sorry forgot to ask this .As I have no cartilage and osteoarthritis on the other side of the same knee will the osteoarthritis just get worse with time or will exercise ,staying fit and healthy etc help stabilize this too?
The knee consultant I saw said at best I may not need a partial knee op for up to 10 years and that it was a "lifestyle choice" i.e. how much pain I was prepared to live with. I guess only time will tell and skiing within
the threshold will ,I guess, make a big difference.

Thanks again and have a good ski season!


One of the fascinating facts about the osteoarthritic knee is that some knees are extremely worn yet dont hurt, whilst others with mild wear are very painful.
If you can get your strength up and participate in moderate, regular exercise you will probably be letter off. Remember that swelling is your enemy so deal with it aggressively. ( ice, elevation, anti inflamms, compression and modification of activity)

One word of caution. Worn knees do not like "new experiences" eg a minor injury, suddenly stepping up the exercise program or taking up squash after a ten year break. Make all changes gradual.

Jonathan Bell
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Jonathan , Have only just noticed your reply .Thanks again ! That all makes sense . I have been skiing for 5 mornings in a row this week (for aprox 2 hours) and have been very pleased with how the knee has held out
on the hard packed and icy snow . There has been slight swelling at the end of the day and I have managed it with ice and elevation for 30 mins . On my last day I did tighten my boots for a few runs (had not realized quite how loose they were ) and this made my knees feel a lot worse with much more more pain so I stopped early .After skiing I had a larger swelling than earlier in the week so will nor ski again with boots so tight. . As you said in an earlier post its all about finding the limit and stopping before the swelling gets too bad. Will have a 3 week break from the slopes now and continue with the daily training and gradually try to do more skiing in January armed with all the useful tips from this forum.

Have been using an anti inflammatory patch taped on the knee called TransAct (Flurbiprofene) which the Physios actively use here . It seems to have worked well.

Thanks again to everyone for your very useful tips. Have a great Christmas and enjoy your skiing !
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brnttptr, Jonathan Bell, fascinating. I realised that I'd left my contact lenses in last night, got up to remove them, made myself a cup of tea and sat down to check the weather forecast - and bingo!

Very interesting about skiing with tight boots. I wonder if the knees got sore because you were then able to be more aggressive with your skiing, leaning on the equipment? If you do that exercise where you ski with boots completely undone you have to use very subtle balance because any aggression means you fall over. So it's not the boots that affect the knees directly, but the effect that having tight boots has on your skiing?

Jonathan Bell, can you explain the way that swelling damages the joint, please?
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pam w wrote:
brnttptr, Jonathan Bell, fascinating.

Jonathan Bell, can you explain the way that swelling damages the joint, please?


Swelling is the result of the damaged joint, it is a sign that the lining of the joint ( the synovium) is inflamed.

This is why it is better to ice as early as possible to limit the synovium from becoming too inflamed.

Having a swollen knee will inhibit the muscles around it, which concerns me, and will lead to increased risk of injury.

That risk is also increased because the feedback mechanism carrying info. from the knee to the brain (proprioception) is less effective if the knee is swollen.

Finally having a knee that is repeatedly swollen leads to muscles wasting.

Jonathan Bell
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I skied for three days with boots open on the Glacier in November (part of the course I was doing) and do not have a problem skiing like that so have reasonably good balance . When I skied yesterday with tighter boots I did not change my skiing style at all .It was the same but just more painful . I was also thinking that yesterday,for the first time this week, I climbed lots of steps with the ski boots on which was not good and something I had until then avoided following tips on this forum. It could also just be the cumulative effect of skiing for 5 (albeit short )days only four weeks from my knee was very inflamed.

To be honest I still am not sure how much swelling,if any, is acceptable ?

All I can say is that in November I skied for 11 days on the course and at the end of each day I was limping and by day 11 it was very swollen.
This week for the first four days it was just a slight swelling and no limping and almost normal movement after . Yesterday there was more pain and more swelling but still no limping and I would expect the swelling to go down quite alot in the next few days. Today I was able to do all of my normal exercises too .With the benefit of hindsight maybe I should have stopped after 4 days this week but I guess its just trial and error to find the limit at which to stop ( or ideally before the limit)

Any clarification on how much swelling is acceptable ,if any , would be much appreciated.
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brnttptr wrote:


Any clarification on how much swelling is acceptable ,if any , would be much appreciated.


If I injected 20ml (4 teaspoons) of fluid into your knee your VMO will switch off.

The VMO is the part of the quad muscle that sits just above the kneecap and to the inner side. The function of the VMO is to help guide the tracking of the kneecap.

So, it takes just 20ml of fluid to aggravate mal-tracking of the kneecap( patella).

Jonathan Bell
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Thanks Jonathan . I am sure that my "reduced swelling " is more than 20ml . I was skiing last week for an average of 2 hours per day and was using pain as the guide when to stop skiing not the swelling .
In the first 4 days there was no pain just occasional twinging .On day 5 ,when I started to feel pain in some of the turns I stopped. The swelling on day 5 was larger than on days 1-4 and was on all 3 sides of the knee cap
except the inner side.

I am now back in the UK and will not have the chance to ski for another 3 weeks .

Given that all of this seems to be a bit of a trade off e.g. Giving up skiing altogether is much better for the knees than skiing etc!

Is there a massive benefit gained from not skiing any more until the swelling is down to Zero ? (and, if so, how long should swelling take to go down to zero ?)

Would it also be an acceptable strategy, as long as the swelling is much lower in Jan , just to continue to find my limits by continued trial and error and stopping when these limits are reached and accept that some swelling will cause muscle damage.
(All of this in conjunction with daily muscle strengthening exercises)
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brnttptr wrote:
Thanks Jonathan . I am sure that my "reduced swelling " is more than 20ml .

Would it also be an acceptable strategy, as long as the swelling is much lower in Jan , just to continue to find my limits by continued trial and error and stopping when these limits are reached and accept that some swelling will cause muscle damage.
(All of this in conjunction with daily muscle strengthening exercises)


Yes. Find a happy medium. The muscle loss caused by swelling isn't permanent damage , its just like to loss you get if you don't or can't exercise
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Jonathan .PHEW !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! You had me worried for a while about the muscle loss !

Thank you and everyone else who has posted replies , very much ,for all your good advice which I have found extremely helpful in understanding my knee problem and how to fix it !

MERRY CHRISTMAS ! .................and I hope you all enjoy great skiing this season.
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Quote:

PHEW !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! You had me worried for a while about the muscle loss

yes, me too! It's extremely useful to have that expert information to help us deal with the swelling and manage it in the longer term - getting the right balance. Fortunately I have industrial quantities of Ibuprofen.
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Bump

My left knee is quite swollen and stiff, limited range of movement, after quite a hard week's skiing - I only did the lessons, not a lot of extra stuff, but the off piste skiing was particularly hard on the knees (especially the way i do it... Embarassed ).

It's chronic - no specific incident caused it. Am doing ice, ibuprofen, etc but looking at some articles on this online it suggests that fluid can be drawn off the knee.

Is this something which could be done at the local medical centre? If I thought I could go and have someone stick a needle in and remove some fluid I'd go like a shot but I imagine that medical opinions as to the advisability of this might vary quite a bit.

Thing is, I am doing the Birthday bash next week and whilst I don't intend to go mad, inevitably I shall want to ski a fair bit and I don't want to risk worse damage.

The bad knee is not massive but markedly fatter than the bad one - 380mm as opposed to 368 - very puffy all round.
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pam w, presumably you are following RICE?
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NickyJ, yes but the fluid is pretty persistent and I know from past experience that it takes ages to settle down. Also found refs online to steroid injections. (I know that trying to identify treatments by surfing the internet is not very clever.....).

There is underlying arthritis in the joint, I guess, but I am looking for a "quick fix" here, because of the skiing next week.

Maybe I should just go into the medical centre tomorrow and ask the local doctor - he'll have seen plenty of swollen knees, I'm sure.
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pam w, def worth a visit to the medical centre. You wouldn't be able to do any more than you are already doing without an intervention.
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pam w, try and get a prescription for naproxen . Ibuprofen is OK, but naproxen is brilliant.
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and compression during the day with a strong knee support will help the swelling.
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pam w wrote:
NickyJ, yes but the fluid is pretty persistent and I know from past experience that it takes ages to settle down. Also found refs online to steroid injections. (I know that trying to identify treatments by surfing the internet is not very clever.....).

There is underlying arthritis in the joint, I guess, but I am looking for a "quick fix" here, because of the skiing next week.

Maybe I should just go into the medical centre tomorrow and ask the local doctor - he'll have seen plenty of swollen knees, I'm sure.


I suspected you were, but always worth checking.

Best of luck, definitely worth seeing the local doctor.
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 Ski the Net with snowHeads
Ski the Net with snowHeads
I'm sad to say I'm watching all this with great interest. This year my knee has been aching after a big day. Not too bad but warm enough to feel through my trousers with a dull pain above the knee cap. I will take the advice above seriously. Thanks.
ski holidays



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