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Sports Medicine

Severe pain behind knee

02/27/2007

Question:

Dear Sir / Madam, I am a regular visitor to the mountains & had a minor accident in 2005. While climbing down with legs stiff & straight, my right foot fell on a rock due to which I felt that my leg turned the wrong way (i.e. opposite of its normal movement). I felt a sudden pain in my knee near patella but within 5-10 minutes it was gone and after that I did not have much pain either. There was no swelling to cause any alarm. I even walked for several miles on uneven terrain without any problem. However now I feel some clicking sound in the left lower side of the patella (in my right knee). Infact after sitting crosslegged for sometime & then returning to normal position gives me pinching knee pain at the exact position where I hurt myself though the pain is not unbearable.

Even after this incident I have been actively climbing & I did not have any problem. Recently after a big Himalayan expedition in 2006, after my return, I have been experiencing pain in my knee. There is slight pain in the right knee below the patella & towards the left side. On touching the knee it seems as if something is sliding beneath. The pain is more so after getting up from bed or going downstairs. Further doing leg sliding exercises for knee while sitting also gives me knee pain for the right leg at the above mentioned position. It also pains if I do partial squatting with back against wall.

However there is severe pain in the back of the knee to the right side. This pain is present both for left leg & right leg but it is more for right leg. The pain manifests itself when squatting, during squatting position & I cannot straighten my legs for sometime after I get up from the squatting position as there is much pain.

I consulted 3 orthopaedic doctors & even had an X-ray. No abnormality in X-ray was found. These are what the three doctors have to say : 1) Probable meniscus injury - Suggested rest & Glucosamine, MSM, Chondroitin sulphate. 2) Overuse injury - Only suggested strengthening exercises & NSAID. 3) Lateral popliteal nerve injury - Gave methylcobalamin injections, NSAID, Vitamin supplement. Despite going through all this for the last 45 days, nothing has changed for me. Even after all these medications / exercises the pain has not reduced. Please suggest what may be wrong. I hope it is not ACL / MCL / meniscus tear. With thanks & regards

Answer:

In addition to broken bones, X-rays may reveal bone spurs, joint surface irregularities, and narrowing of the space between bones due to cartilage thinning (if severe enough). A joint may have significant cartilage damage, yet X-rays may still be normal; such changes, particularly meniscal (cartilage) tears, are usually revealed by an MRI scan. An MRI scan, however, is often reserved as a preoperative test, and unless surgery is the next step, an MRI may not change management at this time. If you were to undergo a steroid (cortisone) injection into the knee joint, benefit from this - which would indicate the presence of inflammation within your knee joint - could then allow you to make some progress. If the exercises you performed were painful, it's difficult to gain strength unless pain can be better controlled, whether by a steroid injection, 2 week trials of different NSAID's (nonsteroidal anti-inflammatory drug) - since one may work better than another for a particular person, and/or a knee sleeve or brace. Depending on your diagnosis, there may be exercises other than (or in addition to) those you've tried - specific stretching as well as strengthening exercises not only for muscles crossing the knee, but also for those crossing the hip and ankle - which could help.

Tears of the ACL (anterior cruciate ligament), MCL (medial collateral ligament), and meniscus (knee cartilage) are usually diagnosable by physical exam, but an MRI scan may be necessary to clarify whether just one - or more than one - structure has been injured, which would then determine the best treatment.

As long as you're not engaging in your preferred activity at the level you desire, you are advised to identify and regularly engage in a substitute exercise activity (which does not aggravate your symptoms) for purposes of cross-training, which will maintain your level of conditioning while a diagnosis and the best course of treatment continues to be pursued.

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Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University