Calf strain or Hamstring Tendonitis

[Brian_C]

Hi,
I'm at my wits end. I strained the back of my knee in Feb 2006 (almost 18mths) while out for a run, approx. 15 stone at the time, now 17stone. Stopped, stretched it and kept going. The next morning while swimming (preparing for the triathlon season) the back of the knee became very sore. Rested for 2-3weeks but the pain presisted.

It was at about this point I seen a physio, and am still seeing, who said it was a strain of the two hamstring tendons as they join the shin bone, 4 weeks you'll be fine. I've since had an knee MRI, spine MRI (with some disc compression, but nothing to be concerned about), X-Ray, Ultrasound scan, steriod injection and a Nerve conduction test of the left leg. I've seen a Ortapedhic and a sports injruy specialist. It's not a Bakers Cyst, ligaments and tendons are fine in the MRI. Nerve test was clear. But nothing has changed. I still have this constant dull pain with a little swelling at the back of the knee, just at the point where the skin folds, and below, in the centre not to the sides. When phsyio presses on the hamstring tendons at top of the calf, below the knee line it's very very sore in one little area, no bigger than a 10p peice.

If I do any cycling, running or swimming it gets very sore, but only after, not too bad during. Worst is a spinning class, very very sore for 2-3 days. Probably caused by all the out of saddle cycling. I can do hamstring curls and calf raises without pain, maybe a little but nothing major. We (physio and sports injury specialist) thought maybe a popliteal strain of the muscle or tendon or tight neural tissue. When I do a neural stretch, (sitting on bench, chin in chest, back straight, toes pointing up, and I straighten the knee the left leg does not have as much movement as the right.

Physio has noted I have hyper-extending knees. Not a big amount, he thinks this is not letting the injury heal.

We've tried RICE, strapped it up for about 5 days, slight improvement, but then back to normal constant dull pain. Next step is to stick in a camera and look at the popliteal, hamstring tendons and that general area.

Can anyone HELP!! Any idea's or suggestions??

The only thing apart from sticking in a camera I can think of is to put it in a brace for 2-4 weeks to let things settle down, or purposely make it very very sore for the camera going in.

Cheers

Brian

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[Brian_C]

BTW, I forgot to mention, that I can do calf stretches and hamstring stretches without any pain. Can someone tell me is there are popliteus test I can do??

[Yarok]

HI
have you done ultrsonography when the swelling was present, is it liquid or firm tenderness?

what about the functional and palpatory assessment, any findings?

Yaro

[Brian_C]

Hi,
The swelling is fluid to the touch and not tender, I can press on it pretty hard, as it's away from where the Physio found the very sore bit, which he said is hamstring tendons.

Hope this helps.

[karen.hankey]

What sort of physio treatment are you receiving?

I would doubt is was the popliteal tendon. Most muscle injuries occur to those muscles that oass over two joints as it cannot stretch fully over both joints at the same time. Popliteus is a single joint muscle, so you would have to get it into such a position to overstretch it, you would at least know about it.

[Brian_C]

What sort of physio treatment are you receiving?

Hi karen, I was getting friction on the hamstring tendon, but I've not had this for a while. More recently I been getting laser and ultrasound.

Thanks.

[ginger]

the very short answer to your pain problem is that you very likely have a referred ( neuralgic ) problem, stemming from hypomobility and irritation at the joint/nerve in your lower lumbar spine . In particular at L5S1. It is from this level that so called hamstring tenderness and calf, heel, achilles pain etc problems usually arise. No amount of rubbing ,lasering , frictions , massage , needles or other treatments applied local to your pain will fix a referred event . It is in fact very easy and quick to fix permanently. Physiotherapists routinely mobilise facet joints till protective tonicity at the L5S1 level is normalised ( about ten to twenty minutes ) . this will immediately reduce and ultimately eliminate pain ( and abnormal muscle behaviour , sensation etc )referred from this common source.

[Brian_C]

Hi Ginger,
The plot thickens. fun you should mention this. I did have some low back pain around Jan/Feb time this year, but that was after 10 months of the sore knee. Physio did treat the back, mobilising a number of discs, mostly L2/3, but it did take sometime to get on top of the pain. Hence the MRI of my spine, which came bakc pretty much clear. There was a couple of discs compressed but the report said it was nothing to be concerned about.

Can you explain how a physio mobilise the discs.

Thank you for your feedback.

[ginger]

Physios don't mobilise discs. re read my post.

[ginger]

I should add,
Low back pain is not , by it's presence , an indicator of the presence of inflammatory events sufficient to give rise to referred pain and altered behavior/sensation distally. The two are not mutally inclusive. In plain speak, you do not need to feel back pain to have evidence of back involvement in a referred event.
Secondly , the levels mobilised do not correspond with your symptoms, so whatever benefit was derived from this attention , presuming you are accurate in your understanding of exactly what levels were mobilised, this would not alter or benefit your sense of posterior knee pain.
Thirdly , x-ray and other highly valued information in the diagnosis of pathology , rarely if ever gives usefull direction in the presence of a hypomobile, irritated, but non "injured "spine. The best evidence is provided by sight and touch, history and experience. Not artifacts and photographs of details not involved in the protective responses active in a sore back.

[Brian_C]

Hi again Ginger,
Sorry mix up in disc/joint.

Can I press you on your response. I've looked at the report from my Spine MRI which says "some degeneration of T11/12, T12/L1 and L1/L2, their is minor degeneration at L4/5. Minor Schorl's node formation at the lower thoracic spine. L5/S1 there is no sign of disc pathology ..... L4/5 there is mild bulging of annulus." If you say mobising L5/S1 would clear up my problem would the above findings fit into this picture?

Also, if the nerve is compromised at L5/S1 would this not have been picked up in the nerve conduction tests?

I assure you I'm not trying to catch you out, I'm just trying to understand the problem.

I am greatful for any feedback.

Thanks.

[ginger]

Brian , the MRI information is irrelevant.
Nerve conduction tests and their results , are , for the most part, sometimes an indicator of nerve "entrapments " or focal irritations and compressions related to injury. Their results , by themselves , bear very little relationship to the kind of commonly observed spinal facet joint somatic referred events of which I speak.
Compromise , to L5S1, will most often occur , without injury , without nerve compression , and without pathological breakdown of any kind. The most common occasions giving rise to distal pain and other symptoms are those related to protective behaviour and a cascade of normal but irritating responses associated with an automatic response to threat.
These can be and are routinely turned off by continuous mobilisation to facet joints. By doing so the normal unprotected behaviour of the spine is restored, giving immediate and lasting ( in most cases ) relief from referred pain such as to your calf.

[Brian_C]

Hi again,
I've seen a second physio (to get someone with a new ideas and a clean slate). We had a chat about my history, how the injury happened etc etc...
She did a couple of range of movement tests of the left leg/knee and movements to bring on the pain. She thinks it's irritation to the nerve. I've had three session of her mobilizing the T10-12 disc/joints. She has noted my L4 is a little tight but in no way as tight as T10-12 which very sore when she works on them. She's only worked T10-12 not L4.
My question(s) are: can T10-12 becausing knee pain, I thought they were back and chest root nerves? Also why would there be a little swelling behind the knee?

The treatment on T10-12 I don't think is really working, should I give it another couple of sessions?

Any feedback would be most helpful.

[karen.hankey]

If you don't think the treatment is working you need to discuss this with the physio and then they can decide wether to continue or to change tact.

[ginger]

T10 to 12 has no relationship to the knee, where did he/she learn spinal neurology?, from a box top? honestly. You are in the wrong place to get treatment if they can claim to be dealing with your knee problem by attention to a series of joints nerves that relate to your groin and lower pelvic floor. You may as well be treating yourself for all the good that will do. Wonders never cease.

[Yarok]

hi Ginger

re:

T10 to 12 has no relationship to the knee, where did he/she learn spinal neurology

?,

this is not so simple and cant negate any direct or indirect involvement, and is good to clear spinal up,

e.g., you can find in literature that jammed OC/C1 can couse a pelvic twist-pelvic imbalance which after time gives strain on a hip joint but initially pain is felt in a knee joint. means origin of a knee pain is in OC/C1, is it any "direct neurological connection"?

thanks Yaro

[ginger]

L5 referrs to the "back of the knee " as this person complains of pain there , this would be a spinal segment/joint of interest. L4 will refer to the lateral knee and thigh , L3 to medial knee and thigh , possibly beyond , in to the tib. post area and be confused with that structure ( "shin splints" )
Interest in the thoraco lumbar junction ( is this what you refer to as Oc/C1 ?? , or are you referring to the upper cervical area , usually written and abbrevaited as C1 ? , bit confused by your use of these letters ), would be appropriate if this fellow had groin or anterior lower abdominal pain, not for what he complains of. Plenty of good reason to fully explore the lumbar spine , as you point out. Being thorough certainly will pay off , however to zero in on an uninvolved spinal joint area seems not in keeping with any known fundamental of spinal neurology or common sense.

[Yarok]

hi
sorry for abbraviations, OC/C1 means occipitoatlantal joint.
my example was not reffered to this case, only giving example of complexity of our body ( means OC/C1 means occipitoatlantal joint can couse knee pain).

from another hand, in theory if certain area is hypomobile another as a compensation will be hypermobile, if thoracic 11/12 is locked below/above segments can be hypermobile which after time can couse a problem. and our primar goal will be improving mobility in thoracic 11/12. i do not defend the physio, i want to explain, it isnt so obvious and our job is very often an art than engineering.

thanks
Yaro

[ginger]

Yaro, presuming your patients are human , and not from the planet Zorg, then C1 will refer to the occipital/frontal zones of the head including the auricular area/ sinus etc but not into any area of the leg or thigh.
Try Gray"s Anatomy.

[Yarok]

hi Ginger

you still do not understand, i mean biomechanical chain where one link very remote can cause problem.if are specialised in manual therapy you should know about it. read Levitt, Maigne, Bischoff, Mannel, etc

thanks

[alophysio]

Hi all - interesting discussion!

With all due respect, there is research that suggests that there is innervation of spinal segments up to 4 levels IN EACH DIRECTION via the long sinuvertebral nerve. Therefore, it is not inconceivable that referral of pain from L1 can be picked up at the L5 level and then moved on...

Secondly, fascial tension is a funny thing - it is not directly related to dermatonal distribution nor easily and obkectively measured. I would support Yarok's assertion that CO/C1 can cause dysfunctions that lead to the said knee pain but usually this idea is scoffed at amongst physiotherapists. Having said that, i have seen people who come to me with neck and apparently unrelated back pain and have their back pain improve with only C/S treatment...go figure! I am not brave enough to rule it out, not these days - i have seen too many wierd things to do that!!

In this current case, it seems to me that the problem is not a knee problem. My initial impressions were:
1. What is the lumbopelvic hip complex doing
2. Referral from L/S
3. Thorax dysfunction
4. Foot dysfunction

T10-T12 may be tight but it is an area where long erector spinae muscles attach - why are they overactive (if they are in fact overactive causing stiffness)??

THere hasn't been any mention of pelvic assessment, load transfer tests, assessment of vascular status (although it doesn't sound like this is a problem...), etc.

Brian_C - how are you going?

[ginger]

thanks yarok and alophysio, I think I see your point now yarok, excuse my small rant there. A small disturbance along the spine , distant from immediate referral sources may incurr elements of protective behaviour further along the spine. Agreed. If treatments at the thoraco lumbar area had failed to provide immediate verification of it's involvement , then looking further afield would be logical. Including other spinal segments seemingly not related. I'm with you. Dural connections , as you point out alophysio, are manifestly more complex than simply a string of fibrous tissue.
The logic of most likely first, least likely last , however , still applies.

[Brian_C]

Hi guys, no change at all. I've stopped attending physio now as I thought working on T10-12 is way off.
It's got to the point where I've pretty much given up, I have £2000.00Stg bike hanging in the garage collecting dust.

Can I just add a few things. I've pulled or strained my back a couple of times, always around T10-12, over the years. When it's sore the upper body will slump to the left. Normally 3-7 days it's fine. I've pulled/strained it while running, having a shower, picking up a newspaper, putting on a shirt.... normal everyday tasks. When I get a bad strain it can be sore taking a deep breath. On one occassion, before hurting the knee I had to go to A&E it was that sore. X-rayed for fear of punctured lung but was clear.

I can't say the knee gets sore when I sit for long periods.

No tenderness or stiffness in the groin, or pelvic region.

I can bound up a stairs from time to time no pain at all but it could get sore just standing up. No logic to it.


Re:alophysio.

1. What is the lumbopelvic hip complex doing
Sports injury doc looked at general body alignment, visually, no measurements. It seemed fine.

2. Referral from L/S
L/S ???? Lumbar Spine. I've noted in the past 4-6months my lumber region does get tender and sore from time to time. No direct link in soreness between knee and lumbar. I can't say the knee gets sore when I sit for long periods.

3. Thorax dysfunction. mmm this is a strange one. I think my general breathing is ok, no problems or discomfort. Also see above

4. Foot dysfunction
Looking back through my diary I seen that I did have some shin soreness in the left shin (same as sore knee) on a couple of runs prior to the the knee getting sore. I mostly stopped the run, stretched it out and continued.

HELP!!!

[alophysio]

Hi Brian,

Ok, i have reread this thread and i have a few questions (if you don't mind!)

1. How long are your physio sessions. I run at 15mins for a short standard consultation and i can get through all the spinal joints on both sides in that time. Is your physio only doing T10-T12??

2. Has anyone really tried to treat your L/S (lumbar spine)?? By that i mean mobilisations or manipulation - it will feel like rhythmic "bouncing" or "pushing" on your back just off centre? I don't think massage will be relevant here but let us know what all your therapists have done with their hands (manual therapy)

3. Checking alignment is one thing but has anyone done a "stork test" or "active straight leg raise test (ASLR)"?? Stork is standing on one leg and feeling from behind what happens in the pelvis/low back. ASLR is where you lift up one striaght leg when lying on your back - we look at what your pelvis/L/S and T/S does (rolling, lifting, tilting, etc)

4. Shin soreness could be an indicator that your lower limb biomechanics (a fancy way of saying how your body moves down there!) is not efficient.

5. You are a big lad - 95kg before but now 108kg. How tall are you? Is it muscle or fat?

6. Thoracic dysfunction is not just breathing. It can be seen in how you do activities, one arm might feel "heavier" to lift compared to another, etc. Twisting may be limited. The Thorax is a VERY poorly taught and understood area of the body. The pelvis is difficult enough for physios to comprehend but a typical thoracic "ring" or two ribs, two vertebrae to a sternum has 13 joints! Also, there are 12 ribs so it is like having 12 little pelves sitting on top of each other - i would not be suprised if you don't find someone who can treat this area well. Most people (like me) are taught just to poke and prod and "crack" the back...pretty unsophisticated stuff. Had to learn after uni what to do properly. One of my mentors is researching the thorax - pity for you she is Canadian (in Canada) - she does teach in the UK periodically!

7. You mention that activity in itself is not painful but rather it is afterwards that is the problem. Have you tried to vary the length of time during activity and whether the time has an effect on your symptoms?

8. Some simple questions from a standard history - can you please list all:
a. aggravating activities
b. easing activities
c. What happens when you wake up, during the day, how you feel before bed and what happens at night.
d. ALL the treatment you have had from various people looking at various bits of your body.
e. What you think is wrong with yourself - what does your gut tell you? From what you have read and listened to and felt, what seems to be the most effective way to treat this problem? I have found that while a lot of people get the theory wrong, they tell me enough information from their limited uderstanding to help me get them over the line.

9. Lastly, if you are able, can you post a short video of 2 or 3 mins (if you are able to) of you riding (your bike on rollers should be perfect) and the view from behind?? A big ask i know but we physios prefer to see and feel rather than use words!

Thanks. I hope i haven't been too imposing on you!

[alophysio]

PS - don't give up hope!!