Mystery Knee Pain

[sdotbailey]

Hi All,

I apologize in advance because this is probably going to be a pretty long post.I’m here because i feel like I’m running out of options and this is kind of my last resort and I’m hoping maybe some of the brightest minds in Physio from around the world can help me out.

First of all, my background/medical history is as follows: I am a 30 year old male who is very athletic and have been my whole life. I playAmerican football and train(ed)/workout/play on average about 5-6 days a week.My job is not necessarily a desk job that I have to sit at a desk for 8 hours a day but I do ultimately sit a lot when I'm not working out. I’ve never had any major injuries of any kind. My worst would probably be a pretty bad ankle sprain about 4-5 years ago which I ultimately played through (braced) and hasn’t given me any direct issues since. Other than that my only other issues in chronological order of their occurrence are right distal biceps demoted tendinitis/oasis, and then grade 2 hamstring strain in my left leg, and then a grade 2 hamstring strain in my right leg. I missed little to no time through most of these “injuries”. Maybe 2 weeks off from the second hammy because I learned from my first. I utilized the lateral movement and proprioceptive protocol to come back from that.

Now to my current issue... About a year and a half ago I was camping and was in what I would describe as a deep squat position (ass to grass) position building a fire for what I guess for my body was an unusually long period of time. When I went to stand up I felt whatI can only describe as a twinge in the anteriomedial aspect of my left knee. The best way to describe the location would would be the“void”/“soft spot” immediately adjacent to the medial aspect of the patellar tendon. There was no audible sound of any kind. And the twinge while quite uncomfortable wasn’t excruciatingly painful or anything but definitely enough to take notice of. Since I was camping I was unable to ice right away not thatI think that would have made that big of a difference but it did feel sore for the balance of the weekend. Ultimately when I returned back from camping I resumed my activities as if nothing happened, only I made sure to ice after every run, football practice, or game as the left knee was always “puffier” than my right knee since the camping trip. This went on for 9 months to a year all the whileI was trying to figure it out on my own. Then I finally decided to go see my family doc who did all the basic stability tests which as far as I know didn’t yield any positive signs for injury to any of the major ligaments etc. He prescribed me some pensaid (topical nsaid) and sent me on my way. I fulfilled the prescription went along with the program and it felt ok while I was on it but came back right after I stopped which leads me to believe that he was treating my symptoms not the cause. Feeling frustrated because my on field performance began to degrade I went back which resulted in my getting x rays(allegedly unremarkable), and an mri which was also allegedly unremarkable(although I actually have the written report for this and. I would be happy to share if it will help). So there I was having taken advantage of Canada’s wonderful healthcare system but still with no answers. I kinda get the impression that none of the doctors really care that much because I’m obvious not dying from my knee pain but football means the world to me and I’m not ready yet to just succumb to this knee pain. So the I set out to research on my own feeling helpless as ever and figured that perhaps it’s PFPS or Patellar Tendinosis/itis. I managed to do enough research to assemble what I think was a pretty good program using heavy slow resistance closed chain exercises with an extra focus on my posterior chain (ie glute Medius etc). I should also mention that very early in my rehab i experienced a very similar (although to a lesser degree) sensation in my right knee but I just dropped the weights as soon as I felt it because I knew “that” feeling. So there was a brief period where I was dealing with this issue in both knees. My right knee now is close to 100% and I rarely have any pain in it since I’ve been doing my strengthening program.However just a couple of days ago while doing some cardio (i worked up slowly)I felt the pain in that “soft spot” of my left knee again. It’s not anywhere near as bad as it was at first 18 months ago but it’s annoying and frustrating to feel anything like that after feeling like I was progressing so well. I need to get as close to 100% as possible before the end of May when the season starts again. And I just want to make sure that I’m on the right track and not treating the wrong thing.

When I look at the anatomy of the knee I can honestly say that the pain is in the exact area of the MPTL or MPML. When it’s aggravated I can almost feel a small cord-like body in that exact area running in the almost exact same pathway as it appears the MPTL and MPML do. I’ve never suggested these two ligaments to my doc because I never want to be that guy who thinks he knows more than the doctor and I figured if there was something to it they would pick up on it since they physically inspected my knee. They did not however.

In any case here I am. Running out of options. I would be eternally grateful to all of you if you think you can help and will provide whatever additional information necessary in order to figure this out.

Thank you all so much in advance for your time. I look forward to your responses.

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[mmwr715]

Are you sure it is not a medial Knee plica? - they tend to be sore all along the inner kneecap and snap at times.
https://www.physio-pedia.com/images/e/e6/Plica.jpg
If you press on the sore spot and flex and extend knee, it should hurt and snap.
Hughston Plica Test
You can inject it with steroid or have it excised:

Gerrard, Adam Daniel, and Charalambos P. Charalambous. "Arthroscopic Excision of Medial Knee Plica: A Meta-Analysis of Outcomes." Knee surgery & related research 30.4 (2018): 356.
Arthroscopic Excision of Medial Knee Plica: A Meta-Analysis of Outcomes

There is a dumbed down version of it described here:
Nottage, Wesley M., et al. "The medial patellar plica syndrome." The American journal of sports medicine 11.4 (1983): 211-214.
SAGE Journals: Your gateway to world-class journal research
which is the infrapatellar plica:
"infrapatellar plica, or ligamentum mucosum, which runs parallel to the anterior cruciate ligament, and is only of significance in that it can act as an obstruction to the passage of the arthroscope from the medial to the lateral compartments of the knee"

It could give medial joint line tenderness.

Possible differential diagnosis would be a medial fat pad syndrome

Dragoo, Jason L., Christina Johnson, and Jenny McConnell. "Evaluation and treatment of disorders of the infrapatellar fat pad." Sports medicine 42.1 (2012): 51-67.
https://www.researchgate.net/profile...c6f5000000.pdf

Hoffa test - Press on sore joint line spot with knee flexed and when straight - should be more sore when straight (pic in article)-

Article (free online) goes over various approaches in detail.
Hope you are enjoying our cold snap
From Canada...

[sdotbailey]

Mmwr715,

First off, thank you so much for taking the time to try an help me with this...

You response has prompted a couple of follow up questions on my end. I hope you don't mind answering them.

Medial Knee Plica:

1) Would this not show up on an MRI?

2) With respect to the hughston plica test: I am noticing that this is somewhat difficult to do on myself. I tried it a couple of times without much response. Only when I pressed really quite hard on the area and flexed and extended my knee, did I feel any pain at all. That being said, when that movement did elicit pain was when going from extended to flexed (But not the opposite really). However I am not sure than this pain is much worse than if I just pressed that hard on the area without the flexion/extension movement. Also of note, is that I did not really feel a "snapping/popping" sensation per se but maybe more of something kind of "rolling" under my thumb as I flexed the knee. Maybe snapping/popping is synonymous with this rolling sensation in the world of physio. I would appreciate your feedback on this.

Medial Fat Pad Syndrome:

1) Same as above...would this not have been identified by the MRI? I know that in the write up of the MRI results provided to me said that my "Suprapatellar fat pad is slightly thickened and mildly oedematous" ( I have no pain at all above my knee cap) and that my "Pre femoral fat pad and Hoffa's fat pad are normal". Would these two statements rule out a Medial Fat Pad Syndrome?

From one cold Canadian to another, I appreciate your help more than you know and I hope you're staying warm!

-S. Bailey

[mmwr715]

I have a medial plica and it snaps quite nicely under my fingers on flexion/extension even though it is not tender.
Annoyingly, the fat pad scenario is fraught with comorbidities with patellar tendonitis, cruciate tears, meniscus lesion and so forth so just an isolated fat pad might be uncommon:
Duri, Zaid AA, et al. "The fat pad and its relationship to anterior knee pain." The Knee 4.4 (1997): 227-236. The fat pad and its relationship to anterior knee pain - ScienceDirect
Having said that, both those issues can be treated with steroid injection though a fat pad will return which is not surprising given their comorbidities. MRI imaging? beyond my expertise and not readily searchable - maybe someone can comment?