Nice link on my knee problem: http://www.sportsinjurybulletin.com/archive/patello-femoral-syndrome.html.

On Friday I went to another massage session. We had a go at my left shoulder and my back. The shoulder was still too sore, as were my glutes. The hip flexors were tight - which I'd been told already - so it was good to get into them. Still, I move like a 90 year old when I try to get up or roll over on the massage table, so feel pretty depressed.

After this, I go and see the physio with the slightly bad breath. He is helpful if rather cold, and sets my mind clear on a number of things.

He encourages me to keep strengthening my left rotator cuff with the Theraband exercises to fix my left shoulder. These are going well. Since I am on holiday, I have been able to do these religiously twice a day. I am even doing them with my weaker (!) right arm to try to prevent any injury to that.

Finally, I get a reasonable sounding diagnosis for my hip clicking. The physio puts his finger on it and ask me to do the same. He says it's the ITB tendon flicking over some bone, which it does when it's inflamed or too tight. Hooray - always good to have a believable diagnosis.

He explains my long-standing knee pain with a pretty detailed plastic knee model. There is no current surgical solution which actually works. The patella is being pulled to the outside of my knee when I use my knees causing the pain, so I need to encourgae it to stay centred. To do this, basically I need to strengthen my VMOs - the muscles in the inside of my leg just above the knees - and stretch the ITB - the strong and long band of connective tissue that runs from my hip down the outside of my thigh. He gives me 2 stretches for my ITB - the usual glute stretches I have been given before, and one where I lean sideways on my forearm against a wall, with my free leg crossed over the leg I am stretching for stability. He also ask me to strengthen the VMO by standing on one leg and slowly dipping down on the leg until the point before it starts to hurt. He said it was pointless doing the exercise fast and that I had to feel the tightness in the VMO on the way down and the way up. I had to keep my upper body upright and not lean forward, and keep my hands on my hips. This was also supposed to be good for my gluteus muscles.

I feel refocussed after this and therefore see the way forward as follows:

(1) Keep doing the Theraband shoulder exercises 2-3 times a day to strengthen the shoulder. Ongoing massage should help the other muscles to relax as the rotator cuff strengthens, but I have been told that shoulders generally take a long time to reset themselves.

(2) Stretch the ITB by (a) rolling over the blue foam rollers you get in the gym, (b) doing the glute stretch, (c) doing the stretch where you lean against the wall. I had stopped doing (b) because it just seemed to aggravate my right SIJ, so I may have to see how it goes and rely on the other two for a while.

(3) Continue to strengthen my glutes and VMOs at the gym and at home.

Here is the chicken and egg as I see it:

(1) Fusion successful. (BTW, Dr. G said he thought the fusion looked successful too.)

(2) Sharp pain in right SIJ because of misalignment, or just general historical poor muscle strength in lower back.

(3) The pain causes bunching up of lower back muscles, although to a lesser degree than before the operation.

(4) The pain and the muscle tension causes me to walk differently, causing greater tension in the VMOs and hip flexors.

(5) This interferes with the correct operation of my knees, aggravating my knee pain.

(6) The knee pain means that I tend to place undue stress on my lower back when bending and crouching so the cycle perpetuates, viciously. It's touch to break it, but with this exercise regime and - more effectively - the PNS implant, I think I stand a good chance of getting my body back.

I went to have another massage on Wednesday. My hamstrings have always been tight and I felt that they were a contributing factor to my poor back. I asked the masseur to concentrate on them but it turned out they weren't too bad. Some tightness in my gluteus minimus on the left and gluteus medius on the right, plus some tightness in my calves. Hmm.

I then went back to see Dr. G, the osteopath. He cracked me at L4 which allowed me to be more flexible. So far so good, but the underlying sharp right SIJ pain was still there. Then I mentioned my problem shoulder and he pressed it down sharply as I lay on my tummy. This enabled me a greater range of motion turning my head to the left. He then cracked my neck and the limited range of motion seemed to return. A bit nervewracking if you're not used to it, but it felt a bit looser. Trouble is, he's now away on holiday and won't be around for the rest of my stay in Melbourne. My wife's cousin's wife said he'd really helped her back and she was pretty much back to 100%.

On Thursday, I went for another massage concentrating on my lower back. This also wasn't too tight, surprisingly, but it helped a little. In the afternoon, I went to see the doctor at Metrospinal again - a year since my last visit. He explained the peripheral nerve stimulator to me.

It costs around AU$ 3k for a one-week trial and around AU$ 50k for the permanent implant with the best current technology - a rechargable battery with a remote control and various cables. The main cost is the AU$ 40k for the device itself. The wires lie about 1cm under the skin, running parallel to it. Once the trial device (larger than the permanent one) is in, I won't be able to shower. The technician will program the device with different programmes which I can then swap between myself according to how I feel. The doctor said he'd be hoping for ~ 70%+ improvement in the pain, but it could be as low as 20%. The device comes with a remote control so I can change the programme - think of it like a radio which has been tuned to preset channels out of a million possible combinations. During the trial period I will have to go in every two days for the doctor to fine-tune the programs. The trial implant is under sedation and I walk out the same day. The permanent implant involves an overnight stay at the Masada hospital in St Kilda East.

Quite apart from the expense, the main thing I need to figure out is how to make the time to have all these things done. Only two doctors in Australia do this operation - both at this clinic - and they both have an international conference to attend in USA next week. They also have plenty of other work so the number of slots is limited. It looks as though I may be able to do the trail by Sep. I will need 10 days in Melbourne for the trial and then 2 weeks for the real thing if I go ahead.

The doctor - let's call him Dr. H as I am losing track of all my doctors - said that he didn't believe in my "3% degree theory" and basically said that the peripheral nerve stimulator ("PNS") would just turn the pain off. This should allow me to exercise and strengthen my lower back (SIJ, presumably) so I might eventually get to the point where I don't need the device. He wasn't promising anything, but told me all the usual risks - infection and movement of the wires. Apparently until around 6 months ago, they found that the wires kept becoming uncoupled from the device (!) so I'm glad that's sorted out.

The PNS sits around 2cm under the skin. They'd stick it high up in my left buttock. It wouldn't be visible but if you pressed the area, you'd be able to feel it. It's about the size and shape of an egg but flat like an iPod. It's made of titanium and resin so "won't break" even if I fall over. Some airport security systems may turn it off, but I'd be given a letter to explain myself. I asked, "Is it like a pacemaker?" and they said, "Exactly". My sister's boyfriend who has a pacemaker warned me to watch out for supermarkets as well, which sometimes have detection devices at their doors now. In any event, I will be able to turn it on and off.

Recharging it involves plugging a recharger into a wall socket for a few hours. This can then be disconnected and held against my buttock parallel to the PNS for 4 hours to completely recharge the PNS. I forget how long the PNS lasts on one charge - a few days? Apparently it's not like a notebook battery which tends to shorten its life the more you use it.

I also met the device saleswoman - Ms P - who was very clear and said she'd be helping me tune the PNS if I went ahead. She'd also check whether anyone from her company could support me in Hong Kong. To her knowledge, no one in Hong Kong has such a device.

So the plan is:

(1) Check my insurance
(2) Schedule the trial
(3) See what support I can get in Hong Kong

My first day back in Melbourne I get to see three people about my lousy back:

(1) Dr. G, osteopath. Twists me and turns me until I pop at L3-L4. This centralizes my pain, "which is a good thing". The pain is now lower down and more centralized in my tailbone than high in the right SIJ. I can also almost touch my toes again. He asks me to come back on Wed to move L5-S1! "But this is fused!" I say. "Yes, the vetebrae are fused but the right facet joint isn't. It's your call, but I want to try and move that." Hmm. Anyway, some progress.

(2) Massage man - gets to work on my stiff left shoulder. Immediately finds the sore spot and concentrates on freeing up the muscle around it.

(3) Physio - works higher on the neck and gives me some more exercises to do with a stronger Thera-band (blue) than I was given in HK. I have to do 2 x 4 x 15 repetitions religiously to strengthen my rotator cuff which will take the load off my stiff shoulder muscle and allow it to return to its normal state. There is no permanent injury, so if I do the right things I should be back to normal in that department.

I promised to discuss what Dr. F had recommended and see I haven't done that yet, so here goes.

Dr. F advised me that the titanium cage I had been given had subsided, ie. it had sunk into the bone of L5 and S1 and was not straight. He told me that titanium was 16 times harder than bone so that could be expected. He said that the current thinking - remember this is 2 years after my operation and I'm hearing this from a younger surgeon - involves using a plastic "ring" instead of titanium. He showed me one and it looked great. You could see just by looking at it how it would rest on the vertebra rather than cutting into it, and I liked the way it tapered slightly to account for the natural curve of the spine at that point.

Anyway, the titanium was in there and there was nothing to be done to change that. Dr. F recommended going in through the rear with screws and instrumentation to prop up L5 and to prevent the cage from further subsiding. The instrumentation he showed me looked nicely designed, but bulky and uncomfortable. He put me in touch with another of his patients to put me at ease. His other patients, though, didn't have a chunk of titanium in them already, which wouldn't budge. Having said that, many of the scans he showed me looked very scary - jockeys who'd been thrown from their horses, etc. It's enough to make you want to think three times about any more operations, and made me realize how "lucky" I am.

I'd rather have a go with a peripheral nerve stimulator for a while which is minimally invasive. Let's see how that goes.

This post-op CT scan (first image) and Photoshop-ed version showing a 3 degree rotation of S1 show the alarming alignment of the SIJs which would result from such a rotation. Note that the CT scan was taken in a lying down position and the SIJ alignment looks fine. So what does this mean about my mis-aligned fusuion theory? Does it mean that the 3-degree rotation is immaterial, or that when the MRI and CT scan were taken, I was lying down so the SIJs were in alignment but L5 and L4 were off? I'd need to go back and look more closely at L3-L5, presumably.

This last image shows S1, which is just below L5. In my body, S1 and L5 are fused with a titanium cage and bone fragments. The red lines drawn by me clearly show the alignment of S1. Equally clear, is the fact that S1 is not well aligned with L5 (or with L4 above it). S1 is rotated 3 degrees to the left of where it should be.

In this image - one vertebra lower down - note that the blue lines still line up neatly with the centre of L5. This shows that L4 and L5 line up correctly, as you'd expect from the healthy disc between them.

This is the post-op MRI through L4. I have drawn the blue and red lines. Note in this image, that the blue lines show the symmetry / centre of L4.

Melbourne's Metrospinal clinic: http://www.metrospinal.com.au/

Should check out this shop while in Melbourne: http://www.badbacks.com.au/contact.asp.

I now find that I can't sleep through the night. The last few nights I must have turned over more than 10 times due to pain. When I am lying down, I seem to be able to find about 3 different places in the right lumbar region to "crunch" my bones. While I am still waiting for a model skeleton to arrive to figure out what's rubbing against what, I suspect at least (1) my right SI joint, and (2) my lowest right facet joint. Occasionally the right hip lets out a big "pop" but I think that's just a correction to my overcompensating bum muscles, which I probably end up using instead of using my lower back.