back of knee pain

[clarett]

Hi

I'm treating a 40 year old man with back of knee pain and medial joint line pain.

He is physically very active and does a large variety of sports including yoga. In January he was playing tennis, didn't notice anything but a couple of days later he felt the tension in the hamstrings increasing. He gradually became aware that he was getting medial joint pain on full flexion of the knee (used in lots of yoga positions). It's a sharp pain that gradually decreases if he maintains full flexion. This pain can be a little elusive - it does not always come on with the same degrees of flexion and sometimes it is palpable with the leg extended, sometimes not. And it sometimes higher or lower along the joint line. When the pain is palpable with the leg extended it can be relieved with a Positional Release Technique.
All ligament tests were negative. McMurray's was positive, apley's negative. He has slight decreased quads strength in comparison to left, but only slight and no functional implications as he is stronger than average.
He also suffers from pain in the popliteal fossa on full flexion - this I believe is secondary to tension in the hamstrings - he had spasms++ when I first saw him and this has decreased with release of spasms & tension. A small level of increased tension remains, even following complete relaxation and relief of this pain during a session - this low level returns. Tightness in quads also increases this pain.
His patella was originally v. fixed secondary to quads tension but this has been relieved.

He is unable to see an orthopod for another 2 months. Is the medial joint line pain likely to be meniscal? If it is - what can he do to improve it?
Or could that pain be due to something else?

Any suggestions for further management would be appreciated.

He is currently doing a regime of stretches to maintain length in quads and hamstrings. And he is doing exercises for strength in quads, hamstrings, VMO

Thanks

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[marj]

Have you assessed his lumbar spine, pelvis and hips? A more proximal problem may be causing neural irritability. Have you tested this pain to see if it can be reproduced with tensioning the saphenous nerve with hip extension and abduction combined with knee flexion? Marj

[karen.hankey]

What strength exercises is he doing?

[clarett]

Hi
He's doing
-v.m.o in sitting
- SLR with hip lat rotation
- knee F against resistance in sitting
- gastroc against resistance

His muscles are really strong bilaterally. It's just that the right is slightly weaker than the left.

[karen.hankey]

When I suspect meniscal damage I usually find that squats with correct alignment help.

You might find WB strength exercises help as thats when you will have increased pressure on the meniscus.

Hope that helps

[okphysio]

Hi Clarett,
Have you had a look at his calf length. The medial head of the gastroc does have a small attachment to the MM. I have found in the past that a calf release technique and relavant stretches are often quite helpful. I also agree with Karen with alignment exercises. Has he had any xrays done? If there is degenerative changes then it may be a matter of modified rest until his swelling reduces. Hope this helps

[clarett]

Thanks very much - we'll have a go.
okphysio - what do you mean by a calf release technique? He did get v. occasional pain but more in the lateral head of gastroc not the medial.
He hasn't had any x-rays done and won't have any done for the meantime (at least 1-2 months) and there's no history of swelling.
No active trigger points in the calf or foot.