Mystery knee pain

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01/05/2009 at 13:57

I have been running for about 2 years - generally about 3 times a week although I ran the Paris marathon this year and FLM last year and was running 4 times  a week when training for those.

Throughout this I have had a chronic (and annoying) pain in my right knee. I can pinpoint exactly when it started, which was about 3 weeks after I started running after a fast run down a relatively steep downhill stretch near my house.

Didn't feel any pain whilst running, but that day at work my right knee started to ache. Eased off the running for a week or two and it subsided slightly down to a level which it has been at pretty much ever since - although it varies from better to worse.

It doesn't hurt when I run (although it sometimes feels a little tight at the end of a long run (15 miles or more) and it doesn't hurt when I walk or stand.

It mainly hurts when I am driving or to a lesser extent sitting at my desk etc. with my leg bent. Feels like a dull burning / aching behind the kneecap but more on the inside of the knee rather than the outside (by which I mean the left side of my right knee).

It feels very slightly "clicky" behind the kneecap if I flex my quads in this position, but not audible clicking- just as if there is a tiny bit of slack somewhere.

It doesnt (or hasn't yet - touch wood) lock up, grind or feel stiff although sometimes feels a bit creaky if I touch the knee cap. There isn't any visible swelling and there wasn't even when I first did it.

Bizarelly it never seems to be that bad after running (even after marathons) but always seems to get worse if I haven't run for a few days or I ease back on my mileage - which is why it is annoying me at the moment. I think it is probably worse after sprinting / speedwork than after slower, longer distances as well.

I have seen a couple of physio's - first one said that it was patellar tendonopathy. I have got one of the straps which goes under your knee which I wear when running - but it doesn't seem to have made much difference.

The second one suggested that it wasn't that, but was probably due to bad tracking of the knee - possibly due to an old injury / weak spot in my right quad. Probably have more faith in that diagnosis as I never mentioned the injury (as it was from years ago) so she must have spotted that from the examination. Have tried various leg exercises (squats, straight leg lifts etc.) to try and help this, but if anything they make it worse.

My friend who is an orthopaedic surgeon reckons that it is some kind of meniscal tear - although I'm not convinced by this either as the symptoms don't seem to be that severe.

It isn't bad enough to stop me from running (and stopping running doesn't seem to help anyway) but it is starting to really annoy me.

Not necessarily expecting a diagnosis via this forum, but what I want to figure out is who I need to consult. I am reluctant to add a "fourth opinion" to all of the above and I really want to get a definitive answer as to what it is and how I need to resolve it now.

If anyone has any thoughts they would be most appreciated - or any recommendations for a good sports injury specialist in the Wirral / Merseyside area who I could consult.

 cheers - and aplogies for the lenght of this tedious post

01/05/2009 at 14:05

I'd go with the second physio.  Patello-femoral pain.

 "Move-Goer's Knee" is another term for that because it hurts after being wedged in a cinema seat for a while with your knees bent.

 If it's patellar tendinopathy, it'll hurt sharply if you do a standing squat.  But it's actually a very bad idea to try this!

01/05/2009 at 15:10
Cheers! I am inclined to agree - definitely no pain from standing squats. Also the fact that the PT treatment doesn't seem to do anything suggests it isn't patellar tendonopathy I suppose.
01/05/2009 at 15:18

"PT treatment doesn't seem to do anything" - to make it better, you mean?  Patellar tendinopathy is really slow to heal so you wouldn't expect to see much in the way of improvement over a short period irrespective of physio.

Worth taking your orthopod friend seriously - not sure I'm confident about ruling that one out.  The slight clicky thing sounds interesting, but not inconsistent with patello-femoral whatsit.

01/05/2009 at 15:58
fair enough - but it is probably about 18 months since the PT diagnosis so I would have thought some improvement would be seen by now if it was going to happen?

I think it probably comes back to the fact that I need to get it properly checked out - otherwise I am just going to drive myself mad googling symptoms and convincing myself about what is causing them!
07/05/2009 at 22:32

''It mainly hurts when I am driving or to a lesser extent sitting at my desk etc. with my leg bent. Feels like a dull burning / aching behind the kneecap but more on the inside of the knee rather than the outside (by which I mean the left side of my right knee).

It feels very slightly "clicky" behind the kneecap if I flex my quads in this position, but not audible clicking- just as if there is a tiny bit of slack somewhere.''

That is an exact description of my knee pain, sitting at a desk with leg bent etc.

Went to physio would said the ckicky noise and pain on the inside of my left knee indicated a wearing of the cartilage? Just told me to ice it...May get 2nd opinion? Don't know if he took me seriously to be honest.

08/05/2009 at 00:33
This is exactly my symptons, although the ache can be either the outside or inside of the knee.  Definitely worst if I can't fully stretch my leg out so the movie goers description is perfect.  Had it for years (literally - ie >20).  it put my off sports eg skiing and running for a long time and saw all manner of health care practitioners who couldn't diagnose anything.  I finally gave up and now just do what I want to do.  It never gets better (whatever I do - rest or run) but the same time it never gets worse, so I figure it's just part of me. 
08/05/2009 at 07:32
thanks both.

Reassuring to hear from others with the same kind of thing. Am looking at a few options so I will post back here if I have any luck with anything.
08/05/2009 at 09:48
I have the exact same symtoms & I have been recommended Glucosamine supplements. Told it takes 6 weeks to see an improvement - have been taking for 3 & no improvement yet - will update if it helps me.
08/05/2009 at 09:50

Jon,

Your right patellofemoral pain does not sound like a meniscal tear. It does sound like either Hoffa's superior posterior fat pad impingment or medial plica syndrome or torn ligamentum mucosum.

Here are the clues:

  1. steep downhill stretch
  2. driving or to a lesser extent sitting at my desk
  3. aching behind the kneecap
  4. left side of my right knee
  5. "clicky" behind the kneecap
  6. never seems to be that bad after running

What should you do next?  As your GP or Orthopaedic Surgeon to take a proper history and examine you knee by which time you should have a diagnosis.  Then ask for an MRI to confirm the diagnosis. If your Orthopaedic Surgeon has experience in this area he/she will know how to cure it.

 Hope this helps.

John Hardy

08/05/2009 at 19:32

I went to my physio today with something very similar, with a tight feeling across the back of the knee and discomfort at the sides of the knee

When he looked at the rage of movement in both legs the left (bad) one was definitely worse than the right with a real tightness in the muscles round my left knee which you could see in my left quad when I did a slow squat, and also lying on the table pushing my leg down (right one was under the table, left one nowhere near it)

He's given me some extra stretches to do, 4 times a day, and told me not to sit in the same position for long (I have a habit of curling my left leg under me on the sofa and he thinks this might have triggered/exacerbated it). As these muscles were tighter in one leg than the other, it was affecting my gait which was making the problem worse

So, RICE, stretches and then back to short runs next week he reckons will solve the problem

08/05/2009 at 21:29
thanks John - time to make an appointment with the GP I think. I'm sure my mate is a perfectly good surgeon, but somehow I'm not sure I would trust him to come near me with a scalpal - I have known him too long!
08/05/2009 at 22:07

JOn,

If  you have tracking problmes and this sounds very probable ( spent a year doing a thesis on kneecaps!)- at this stage the ligamententous part of the quads that inserts into the kneecap will have got tightened on the outside as the outer part of the quad near the ITB is much stronger and tighter due to mechanical advantage. When you tighten your quads- the outer portion is almost a straight line between both ends. The inner side becomes weakened and often is overstretched.  YOu may have a plica or fold but they are not usually very symptomatic unless they are very big.

Running downhill will have put huge pressure on the kneecap and this mechanism.

Doind straight leg raises and squats is a complete waste of time in my humble opinion because when using all the quads the outer lateralis part of the muscle will take over every single time and the medialis will struggle to have any impact at all.

What I do with my victims is to do lots of strengthening of the adductors on the inside of the leg while at the same time straightening....

08/05/2009 at 22:13

... so if you were sitting on the table with your legs dangling over the side. squeeze very tightly between your knees a heavy ball that keeps your kneees roughly the same distance apart as your hips WHILE at the same time slowly straightening out your leg. This works the inner portion much more. Similar kind of weight bearing exercises need the same approach.

You will also need to address the tight lateral retinaculum - ligament thingy at the outer side. Get a foam rolller and work the bejaysus out of your lateral quad and ITB. to try and make it as flexible as poss. It probaably woudnt need surgical release as if it was that tight you would probably be dislocating it fully or partially.

At this long chronic stage you might also benefit from a muscle stimulator. Again it neeeds to be set up so that the medial portion contracts at a different time to the main quads bulk so that the outer side isn't again getting all the benefit to the detriment of the inner weaker part.

Hope this might help a bit

Meant to say also that a band under the knee wont have any effect on this. YOu could try a Mulligan taping technique as it often helps certain ones that arent too severe.Im sure you could find it on youtube. I dont have broadband so would take me all day to track one down for you.Might be worth checking it out.

Edited: 08/05/2009 at 22:22
09/05/2009 at 19:43

Jon, your injury sounds very familiar to the one I picked up last September. I was training with my club doing some fast downhills with some tight turns, I didn't feel any pain at the time, just the usual discomfort I always get from fast downhill running. The next day however my knee was very stiff and quite painful when bending and straightening the leg. Attempting to do a squat on the injured leg was very painful.

I stopped running for a couple of weeks, when I started running again there was slight pain and the knee just felt like it didn't have the same smooth movement as my 'good' knee. After running the knee would very quickly stiffen up and swell slightly with what appeared to be a build-up of fluid. The next day the joint would still be very stiff and painful during movement. Also sitting with a bent leg for any amount of time caused pain.

I went to see a physio who thought it could be a tight ITB. I had four sessions with the phys doing stretching exercises, he also gave me some stability exercises to do at home.

After about 2 month's of doing these exercises I saw very little improvement so I visited my GP, his advice was to stop running as the injury was down to wear and tear due to my age (40). I insisted he refer me to a knee specialist.

I soon got an appointment with an NHS physio. Her diagnosis was that the injury was down to quad and hamstring imbalance, again I got exercises to do at home. After 6 weeks of exercises there was no improvement so I returned to see the physio and asked if a scan would show up the problem, she disagreed.

About 3 month's ago the pain in my knee was beginning to cause me to limp while walking so I decided to get private medical treatment. After an examination the consultant thought I had some articular cartlidge damage. Three weeks later i had keyhole surgery on the knee and damaged cartlidge behind the kneecap was removed.

I was advised that it would probably take two month's before I would be running comfortably again.

I recently started running again and I'm happy to say that the knee joint feels good though it is a little week and shaky due to the muscle wastage in that leg. It's just a case of building the mileage very slowly and doing leg strengthening exercises.

Sorry this post is a bit long-winded Jon but I know what it's like when you know you've got an injury but it seems like no one can help. Very frustrating.

Visit your GP and insist on seeing a specialist. Hope this helps.

10/05/2009 at 09:51

Hhmm - this all sounds depressingly similar to how my right knee has been for the last 4-5 weeks.

 Mine started playing up after a weekend of playing squash and going for a 5-6 mile off road in very slippy mud, and despite having now had three weeks without running (and applying ice / wearing a tubigrip), I still get a noticeable pain down the inside of my knee when driving or sitting with my leg bent, and my knee clicks (audibly) on eight out ten steps whilst I'm walking.

 I've also noticed that if my leg is straight and there's any sideways pressure on the inside of my knee that this can be painful, as is kicking a football with the inside of my foot. Finally, if I lock my knee and tense my thigh muscles, then any rotation of my leg gives a sharp pain on the inside of the knee, just below the knee joint.

The really annoying thing is that if I do go for a run there is very little pain whilst I'm running, so It's very tempting to keep running, and just apply ice and compression afterwards to keep the subsequent  swelling and discomfort manageable!

 However, sounds like I need to go see a physio..........

11/05/2009 at 13:03
Fizz - thanks very much, that is really helpful! Really appreciate you taking the time especially as I imagine you have clients to look after who actually pay!

I have a couple of daft questions:- firstly is the correct position sitting on a table so that thighs are supported and just lower legs are dangling (kind of like sitting on a very high chair?). Second is there some kind of physio ball you use between your knees? I am racking my brains a bit for what to use! Thirdly - is it just the one leg I straighten? Guess it would make sense to alternate and do the exercise on both? Sorry if these are numpty questions!

Will google the taping technique and give it a go.

I am going for a two pronged attack I think - am going to try some exercises as suggested and also try and get it checked out and get an MRI if appropriate to see if anything shows up on that. Obviously would much prefer a non invasive / surgical solution if possible.

Did a fairly fast 10k race yesterday and as usual my knee feels better than before! Usually seems to get worse a few days after a run.

The other thing that does strike me as strange is the lack of any swelling (or at least visible swelling!) as this seems to be a symptom of most knee problems I have looked up.

Hope everyone else who posted has some luck getting this sorted - obviously a fairly common problem?
14/05/2009 at 14:06

Sorry I was out of range of computers for a few days.

Yes sit with legs dangling. I got a cheap pilates ball in Tmexx cos it was cheap. It is a bit heavy so it is good to work the muscles but You could use a towel or even two fists side by side. Work one legs and when it gets tired do the other . Repeat about 3 sets. Ideally weight bearing ones would be better but you need to re=educate the muscle memory so non weight bearing is fine for the start.

If you have a disturbance of any tissues within a joint it is like having grit in your eye and it causes it to water.  In the joint the fluid will collect to form noticeable swelling. If there is none- the likely explanation is that it ( problem source) is outside of the joint itself and is more likely to do with the supporting structures. 

14/05/2009 at 14:10
Thanks Fizz! How dumb am I - went to buy a foam roller thinking they were like some kind of paint roller which you massaged yourself with! Bit surprised to find that they are about 4 feet long which you lie on top of. Hopefully will help though
14/05/2009 at 16:54

Jon,

If you have a plica syndrome, just to reassure regarding the surgery for this condition:  If you have a normal MRI a good physiotherapist will make a significant difference with the sort of instructions you have been given by Fizzio.  In my experience 505 of patients recover with physiotherapy.

However, I would recommend face to face with a physio for at least six weeks rather than just using internet based information.  The taping techniques are varied and you should only use the technique with trial and error that suits. Occasionally the taping works but gives a rash.  Depending on the direction of taping knee supports can frequently substitute for the tape.

Hope this helps

John Hardy

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