Medial, Lateral, & Posterior Knee Pain
Lateral Knee Pain
Pain about the lateral knee is a frequent problem, especially among distance runners. The most common conditions tend to be; iliotibial band friction syndrome; lateral meniscus abnormality, degenerative changes or a cyst formation.
Iliotibial Band Friction Syndrome
This condition occurs as a result of friction between the iliotibial band and the underlying lateral epicondyle of the femur. It is a common condition among distance runners, where the friction or impingement occurs near foot strike, or foot contact phase with the ground. Studies have shown that runners with this condition have significant weakness of their hip abductors in the affected limb.
The patient complains of an ache over the lateral aspect of the knee, aggravated by running. Longer runs or those downhill or on cambered courses are particularly aggravating.
On examination, tenderness is elicited over the lateral epicondyle of the femur, just above the joint line. Crepitus may also be felt and repeated flexion/extension of the knee may reproduce the patients symptoms.
Ober’s Test may reveal ITB tightness which may be a secondary condition. There can also be palpable trigger points along the body of the ITB which can also contribute to the symptoms.
* Activity modification. Avoid all pain-provoking exercises.
* Ice, anti-inflammatory medication, interferential therapy, ultrasound
* Corticosteroid injection into the bursa between the ITB and the lateral epicondyle reduces pain in acute cases
* Soft tissue therapy to correct tightness of the ITB. Trigger point treatment. Self-massage with foam roller.
* Frequent stretching of the ITB
* Strengthening of the gluteals / hip abductors
* Biomechanical abnormalities such as excessive sub-talar pronation should be corrected
* Surgery to release the ITB and excise the bursa may be indicated if conservative management fails.
* Resume running when there is no local tenderness and the strengthening exercises can be performed without pain. Initially run on alternate days and avoid downhill running.
Lateral Meniscus Abnormality
Osteoarthritis of the Lateral Compartment of the Knee
Initial treatment of osteoarthritis includes symptomatic relief with painkilling and anti-inflammatory medication, exercise prescription and weight loss if indicated. Intra-articular hyaluronic acid (Synvisc) injections have a similar effect to anti-inflammatories, but the patient does not have to take tablets daily.
Superior Tibiofibular Joint Injury
Manual mobilisation is an effective treatment for a stiff joint. Local electrotherapy may also help relieve pain. Biomechanical factors may also need to be addressed. Occasionally in patients who fail to respond to conservative measures, a corticosteroid injection may be used.
Medial Knee Pain
Osteoarthritis of the Medial Compartment of the Knee
Pes Anserinus Tendinopathy / Bursitis
These conditions are characterised by localised tenderness and swelling. Active contraction or stretching of the medial hamstring muscles reproduces pain. Treatment follows the general principles of tendinopathy / bursitis management. Corticosteroid injection into the bursa can be extremely effective.
Examination reveals marked restriction in knee joint range of motion with a tender lump in the proximal portion of the medial collateral ligament. Treatment consists of active mobilisation of the knee joint and infiltration of a corticosteroid to the tender medial collateral attachment if pain persists.
Posterior Knee Pain
Posterior knee pain precipitated by acceleration or deceleration when running and when kicking, is likely to be biceps tendinopathy or popliteus tendinopathy. Pain described as a poorly localised dull ache not directly related to activity suggests referred pain from the lumbar spine.
Treatment includes strengthening of the tibial rotators and hamstring muscles. Massage therapy and mobilsation may help to correct any restriction of tibial rotation or knee flexion.
Posterior knee structures, especially the hamstring muscles, should be stretched. Anti-inflammatory medication, ultrasound and interferential therapy may prove useful adjuncts to rehabilitation.
Patients who fail to respond to the above regimen may be helped by a corticosteroid injection posteriorly into the point of maximal tenderness.
Occasionally the cyst may rupture, leading to lower leg swelling simulating venous thrombosis. A ruptured cyst usually displays a ‘crescent sign’ – a bruised area around the ankle. Treatment of the Baker’s cyst involves treatment of the associated abnormality.
Other causes of medial knee pain
This condition is commonly referred as ‘breaststrokers knee’, and is actually a first degree sprain of the medial collateral ligament, or inflammation of the medial collateral ligament bursa due to excessive stress. Finally, a synovial plica may also present as medial knee pain.