MCL Strain or Pes Anserine Bursitis?

[Need2Run]

Hi,

I am a 40 mpw runner who competes in 5+10k races occasionally. Up until October, I hadn’t been injured for around a year. Up until this point I had never sustained a left leg injury.

In October, having had a lay off from running for a couple of weeks, I ran in some new shoes, doing mile intervals (flat concrete). The next day I awoke with a stiff knee, which was painful in the area I’ve marked in the attached photo. This was after trying new ‘stability’ shoes… It was suggested I try them after gait analysis… These shoes felt unnaturally ‘straight’, stopping my usual pronation. My theory is that the knee took the strain – instead of the shoe everting / pronating.

When I resumed running I found that, after around 20-30 mins of running, the pain came back. I decided it was due to running on uneven surfaces (particularly camber) and started using the treadmill. The treadmill doesn’t seem to cause pain…(I binned the ‘stability’ shoes). Around 4 weeks ago I started running outside again, gently ramping up mileage to previous level. There was NO pain on the knee and I thought I was rid of the injury.

Yesterday, about 8 miles into a 10-mile run, when running downhill fast (very steep) on uneven grass, I felt a sharp twinge in the highlighted spot… It didn’t stop me running and hasn’t been as bad as before. It was more painful this morning than last night. Note that I tend to run downhill with a lot of knee flexion, attempting to minimise braking forces. I suspect the foot hit an uneven lump of ground, whilst knee was flexed, at speed, under considerable load.

If I palpate the marked area I feel a sharp pain, as if the tissue underneath is inflamed.

If I plant my left foot on the floor, flat, and rotate my thigh CW with bent knee, I trigger the pain.

I have seen a physio (an expensive one who specialises in sports injury). She couldn’t decide between MCL or Pes Anserine Bursitis and told me to book another appointment... Can anyone here describe a fool-proof way to discern between the two conditions?

Thanks in advance.

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[Ironmike]

Did the physio rule out medial meniscus trouble? The mechanism of injury coupled with what you are describing as aggravating factors would certainly lead me to be concerned about that. When you bend and straighten your knee, do you get any clicking or locking at all? Any feeling of the knee giving way? Where you have drawn the cross looks to me to be on the joint line between your tibia and your femur. If so, it is definitely something to think about!

A serious MCL injury would be easy to spot as your knee would be very lax whilst applying a valgus force to it as shown here

MCL rupture - YouTube

If you have a grade 1 or 2 sprain, this would be harder to properly diagnose, but some laxity and pain along with inflammation will be picked up depending on how acute the injury is.

If I were to test for pes anserine bursitis, I would want to know if you have localised tenderness or swelling, which you do. To isolate, I would get you to perform a resisted flexion of the knee with a bias to the medial hamstring side by internally rotating your hip (semitendinosus and semimembranosus). Also, I'd perform resisted adduction for Gracilis and for Sartorius it would be a mix of a few movements - harder to test. If this recreates your pain, I would suspect hamstring over ligament.

The difficulty is that tests don't tend to rule out everything else and point to the one diagnosis.

[Need2Run]

>When you bend and straighten your knee, do you get any clicking or locking at all? Any feeling of the knee giving way?

No and no. If it is an MCL issue, it's certainly not a rupture as portrayed in the Youtube link.

The Gracilis is definitely tender - there seems to be a 'tender' line, going from in-between the Ham and Quad (i.e. top of Gracilis), leading over the medial side of the knee (where the 'x' is) and down behind the calf. It should be noted that, due to the lay-off, when I first strained the knee a few weeks back, my calf was very tight.

It seems easy to think it's a tight Gracilis, irritating the bursa because of the slight tenderness behind the calf and into where the Gracilis inserts between Ham and Quad. However, I am wondering if this tenderness is simply due to the fact that if you put tension into the Gracilis, it's going to create a feeling of tension in the general area if there's a ligament / bursa issue.

The physio I saw didn't seem to think an MRI was necessary as I could use the treadmill ok... If it were a meniscus issue, would this flare up 20-30 mins into a run?

Thanks, Mike.

BTW - I've been doing 'windmill toe touches', lunges and leg presses with the leg, with no issues. It's not as stable as the other leg on the wobble board, but I am right-legged. I can still stand for a couple of minutes on a wobble board without pain.

[Ironmike]

The meniscus can tear or degenerate in a number of different ways, and as such, can present differently in different cases. If you can use the treadmill ok then it would probably suggest it wasn't an issue, but then if using a treadmill to run doesn't bring on any of your pain, then it would also cast doubt on it being a bursitis or hamstring issue in my view. Can you run on the treadmill ad infinitum with no pain at all? If so, what is it that you do differently there that you do/don't do whilst running outside?

The fact that your pain came on very markedly and suddenly to me suggests it's not a bursitis. For an inflammation to occur, you would probably have noticed a gradual worsening of the area over time as opposed to a very clear cut, ouch that hurts! What you describe about sitting down and getting pain if you turn your knee in is very similar to a positive test for McMurrays:

Knee Exam (18 of 27): McMurray's test - YouTube

Could you perform the Thesaly test and let us know if that recreates any of your pain, or problems?

Thessaly Test - YouTube

Ignore the squatting man at the start - don't know what is going on there. Have your knee flexed to about 15 degrees and then bend a little more if you can and repeat.