Case History: Medial Knee Pain in a Runner

• Runners Knee

• 

  Richard Blake KRM team

  2/11/24, 10:26 PM

  Case History: Medial Knee Pain in a  Runner

  
  
  

  History and Chief Complaint

  • A long distance runner began to get right medial knee pain 
  • It came on running over 5 miles, but now bothers him at a mile, so the patient has stopped the last 2 weeks to get it checked out
  • It does not hurt at all walking, and only slightly (0-2) bicycling to and from work
  • There was never any swelling that was noted, or the stiffness that comes with the swelling which may be deep
  • However the patient did notice that the knee started making a non-painful clicking sound about 2 weeks prior to any pain
  • The pain developed while training for some 10K races with longer and faster workouts. 
  • The patient typically ran from his house up alot of hills and finished by running down hills back to his house
  • He tried getting more supportive shoes during the first week of pain, but it did not seem to make a difference.
  • He has never had this pain before, but never ran this much before
  • He has never had orthotic devices of any type
  • He has run once or twice per week for at least 10 years

   

  Question #1: People begin to get pain at weak spots of their bodies. What is the role of running downhill at the end of a hard workout in this problem?

   

  Gait Evaluation

  • Excessive Knee Internal Rotation at Impact walking, and more extreme internal knee rotation running  (he had no pain just jogging in my hallway)
  • Excessive Pronation pattern noted walking barefoot, and running in stability running shoes
  • Pronation worse right side over left (patient is right handed)

   

  Question #2: When people are right handed, what side of their body is their movement side and what side is their support side?

   

  Physical Examination

  • None of the medial knee structures were sore (as the patient had not run for two weeks)
  • The patient pointed to the medial side of the patellae as the area of pain
  • Quadriceps strength was good, but very soft vastus medialis on contraction
  • Hamstrings were both very tight and very weak
  • External Hip Rotators which help prevent excessive internal hip rotation were also weak on testing

   

  Question #3: How do tight hamstrings de-stabilize the knee and make it more prone to injury?

   

  Cursory Biomechanical Examination  and Asymmetry Noted

  • High forefoot varus right more than left
  • Weakness’ noted bilateral posterior tibial tendon, foot intrinsics with poor metatarsal doming, overall weakness gastroc/soleus, vastus medialis, and external hip rotators on both sides
  • Functional Hallux Limitus right greater than left
  • Pes Cavus foot type with arch collapse during weight bearing

   

  Question #4: What is the difference between forefoot varus and forefoot supinatus? 

   

  Tentative Working Diagnosis 

  • Runner’s Knee (aka patello femoral syndrome) related to overpronation 

   

  Question #5: What are 5 other names for this same syndrome in the literature besides runner’s knee and patello-femoral syndrome?

   

  Common Differential Diagnosis (2ndary Working Diagnosis)

  • Quadriceps Strain related to Hill Running

   

  Question #6: Which muscle is technically too strong and pulls the patella laterally?

   

  Occam’s Razor and Rule of 3

  • Quadriceps strengthening (particularly the vastus medialis) and gluteus medius strengthening (simplest solution)
  • The Rule of 3 here includes the simplest solutions, but adds pronation support right greater than left (varus wedges and stable shoes to start), training change when returns with less mileage and no downhill at the end of the workout when the muscle fatigued, and knee brace for instant stability until the muscles can get strong

   

  Question #7: Of the two tight hamstrings, which one is the most important to stretch out in this patient?

   

  What Phase of Rehabilitation?

  • Re-Strengthening  since can walk comfortably

   

  Question #8: How do you stretch the quadriceps to stretch the tighter vastus lateralis?

   

  Should We Image?

  • No swelling, locking, or giving way of the knee so no initial MD referral or images

   

  Question #9: What would locking be indicative of?

   

  First Decision: How to Reduce Pain 0-2

  • Already there with walking and putting together components to help him start a Walk Run Program when consistently better

   

  Question #10: In this case, the knee brace can give you instant pain relief to run, which you technically could. I would prefer 2 weeks of anti-inflammatory, strengthening, new more stable shoes, etc first. Is the chondromalacia aspect reversible or is it typically permanent damage to the patella?

   

  Second Decision: Inflammation Concerns

  • Patients always improve with ice packs 30 minutes twice daily with this diagnosis

   

  Question #11: The general rule with icing is less time when superficial and more time when the ice penetration needs to be deep. This injury of chondromalacia patella is deep under the kneecap so 30 minutes makes sense. What knee problems would 20 minutes be appropriate for?

   

  Third Decision: Any Nerve Component?

  • Does not appear

   

  Question #12: If there was an irritable nerve anterior medial knee, what nerve is probably involved and explain the basic mechanics of how neural flossing (gliding) would help?

  Fourth Decision: Initial Mechanical Changes

  • Strengthening of the external hip rotators with a PT Rx for strengthening of all the muscles listed above (included in Rx instruction for McConnell taping)
  • Advice to avoid hills for now
  • ¼ inch sulcus length Varus Wedges applied to his running shoe insert 
  • Bauerfiend Genutrain Knee Brace as begins to run

   

  Question #13: What direction is the main pull of the patella towards?

   

  Of course, you can not run before you can walk 30 minutes pain free for several weeks. Gradually the patient got stronger and stronger. The varus wedges were replaced over the first 4 visits with custom orthotic devices with intrinsic varus correction. To review all the mechanical changes at our disposal from Chapter 7 (and I will star the ones we have started to use):

   

  Common Mechanical Changes for Patellofemoral Pain Syndrome 

  1.  McConnell Taping*
  2. Patellar Bracing*
  3. Quadriceps strength especially short arc quads and single leg press (kneecap slightly turned out to emphasize vastus medialis)*
  4. Hamstring strength*
  5. Vastus lateralis stretching
  6. Medial hamstring stretching*
  7. External Hip Rotator strengthening*
  8. Varus Wedges or Custom Orthotic Devices to help control excessive internal patellar rotation*
  9. Shoe Selection*
  10. Gait Training
  11. Avoid Deep Knee Bend Positions

  Answers to Above Questions:

  1. Running downhill produces alot of knee instability as the ground falls away. At the end of a run, the athlete is the most fatigued. When you combine an event of instability with fatigue, the athlete will have more chance of injury during this time. 

  2. Right movement side, left support side

  3. The more a knee joint is flexed or bent in activity, the more the knee is unstable. Tight hamstrings cause knee instability due to increase time in a flexed or bent position. 

  4. Forefoot varus is a fixed deformity. Forefoot supinatus is a deformity that can change. Of Course you can have both together, with the supinatus subject to change. 

  5. Dancer's Knee, Biker's Knee, Quadriceps Insufficiency, Patello-femoral insufficiency, Patellofemoral Pain Syndrome, Chondromalacia Patellae

  6. Vastus Lateralis

  7. Medial Hamstrings

  8. You stretch the vastus lateralis better by using the opposite hand to the one you are stretching to pull your leg back.

  9. Flap in torn meniscus is stuck in wrong position

  10. Chondromalacia or "softening of the articular" is considered totally reversible.

  11. Quadriceps strain or patellar tendon pain or pre-patellar bursitis or pes anserinus tendonitis/bursitis

  12. Femoral nerve. Neural flossing is continuous motion of knee flexion and extension very rhythmical.

  13. You try to prevent the patella from abducting or laterally subluxing

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