Posterior and Medial knee pain

Hi there i am 1st year out of university and struggling with a diagnosis of a pt.

A 17yr old soccer player was referred to me(physiotherapist) and complains of posterior and medial knee pain with swelling of the medial aspect of the knee. He has difficulty with full extention(causing post. kn. pain) and active knee flexion (causing hamstring pain) after active knee flexion was complete the ptexperiences ant. kn. pain distal to the patella whilst attemping active knee extension . He also compains of ankle pain (dorsum) and drease balance on that limb. On palpation : tender posterior to the knee with a small "lump"; tender medial aspect of the knee distal to the condyle and tight ITB. All stress tests and McMurrays' are negative. he has trigger points of his gluts below the ITB that refers to his ankle.

the pt's symptoms started 2 months ago and has not been plying soccer since last year. He is not doing anyother exercise programmes.

please help me with the diagnosis of this patient. thank you :)

Hi,

Have you examined all lower limb neurological signs and stress tests?
Dermatomes, Myotomes?

Regards

i've checked the med,lat, ant and post drawer plus the mc murrary. myotomes and dermatomes are intake.

After doing trigger point release, his ankle pain subsided and was wondering if the two problems were perhaps not related? i've read just because mc murrary test does not indicate as positive it can not always be rules out? but i am still having difficulty with this case?

thank you Canuck

I would check his SLR and assess how he runs. Has he had a sudden growth spurt recently or does he sit slumped at a computer all day? From my experience patients blame thier sport but its usually what they do for the majority of the time that gives them the problem.ie sitting, standing


This does not sound like a primary knee problem and the referred pain is probably referred somatic pain from his spine (and hence no change in dermatomes.myotomes).
I am not a big fan of trigger points and think these are an indication of a problem elsewhere.

Steve
Hallamshire Physiotherapy

hello,
if you could find a palpable lump, it may correlate with osteochondritis dissecans, considering his age. google this condition, look if it fits with your patient. if thats the case physio may not be a huge help. other possible chance could be an intraarticular loose body, from the fact other lig/menisci are normal. i agree with steve, for slim chances of referred pain. Other thing u could do, is a slr and add components such as hip add and ankle DF/PF and Inv/Eve sometimes if your sural nerve is involved or stretched u may get anke pain. does his knee give way, has he got an x-ray done, just to rule out. check his pirformis length. look for resisted knee extension in mid and outer ranges, to rule out osgood schlatters. there isn't a box standard answers, treat as u go. do update pls.

Although a little old check the hip and clear it as a potential referral site e.g. slipped epiphysis. If there are local knee signs (e.g. tenderness over fenoraml condyle and pain with loaded knee ROM) then an OCD lesion should be suspected and ruled out given his age and activity it doesn't sound like a loose body yet but it may be the early stages. Beyond that I would throroughly check the hamstrings and associated neural provocation tests as a potential source.

Thanks for all the replys and wow its overwelming all the opions that i could do, and most of it i would have to research as i have a basic knowledge considering that this is my first year.

The feedback might take some time as i am working in a rural area where money is scares and the patients are not able to attend physio regularly. That is also why the subjective assessment is so poor because of the language barrier :((pt speaks zulu).

Thanks again
meagan

I would be inclined to try to relate back to how the pain started in the first place. McMurray's test along with any other manual test, is not sensitive nor specific to diagnose meniscal injury. Also consider patellofemoral joint.

Good luck,
M.

hi friend
As everybody has describe our opinion, let me put it in this way have u thought of his bursa it must b inflammed after doing over use of joint well and i would also like to know from how he is playing this sport,we can also think about his hamstring tendon sheath inflammation, and regarding his ankle(dorsum) pain see to it how he's kicking the ball