Please help solve this problem - sharp pain in back of knee

Hey everyone, I have an ongoing knee problem and I want to get everyone's input on what it might be and how I can fix it. I've been to a few physios and a sports physician, and had an MRI done, none of which have been able to identify/solve the problem. So I'm hoping someone here can do a bit better . . .


Here's the summary:

- I get a sharp pain in the back of my left knee when it's bent under load such as when squatting, lunging, walking stairs etc.

- The pain is right in the back center of the knee, not far from the surface.

- I can bend it through a full range of motion with no pain at all if there's no weight on it.

- It gets aggravated much more by fast bending movements under bodyweight than by slow movements (even under much heavier weight). For example, I can do multiple heavy barbell squat sets and be fine, but if I lunge quickly onto it (such as doing a fast dip when dancing, or even dipping quickly in a push press), that's what seems to aggravate it.

- When the problem comes up, if I take it easy for a few days, it goes away and I can go back to doing everything pain free.

- However, even when the pain is gone, the knee still doesn't feel very strong and usually I instinctively don't want to push it too hard.

- The MRI showed everything normal - no signs of meniscal tear, ligament damage or other cartilage problems, no cysts, no tendon problems etc.

- I've read about the popliteus muscle causing problems in this area, but I don't get any pain when I press into the back of the knee, so that doesn't sound like the root of the problem.


As far as I can see, the main things that could cause pain in this area are either a meniscus tear or a hamstring injury. It's been basically a year since I first felt the injury, so I would have thought it's not a hamstring problem?

I did jar the knee when I accidentally stepped into a pothole while running 3 weeks before the problem came up. Is it possible that I tore the meniscus then but the problem didn't manifest until afterward? I heard that MRIs are not always accurate in detecting meniscus tears, so I'm still wondering if that could be the problem.

Has anyone got any ideas on what it might be and what I can do to solve the problem?

Thanks in advance

Jay

- - - Updated - - -

Here's some more background:

In mid-December 2012, I was running along the beach in shallow water when my foot stepped into a pothole while the knee was fully extended. This jarred the knee and I had some pain (not in the same place as now) for a couple of days, but then it went away completely after that. This may or may not be relevant. I did lots of leg work in the weeks following this with no problems at all.

The first day I felt the problem I'm having now was in January 2013. In the morning, I did a jump rope warm-up (this is a strong point of mine and my style is very low jump height / low impact) and then a Tabata workout with kipping pull-ups, sit-ups, dumbell shoulder press and kettlebell swings. I didn't feel any problem whatsoever at that point, so I'm not sure if anything in that training session was the original cause.

A few hours later I felt the sharp pain in the back of the left knee when I was walking up stairs. By the evening, it was so bad that I couldn't even push the clutch in my car without getting massive pain.

For the next few days, the knee and calf/foot/toes swelled right up and the knee felt like jelly. I didn't even walk on it for about a week. After a few days, the swelling went down, but it still felt very weak. I went back to walking normally after a couple of weeks, but basically rested it (ie didn't put any weight on it when it was bent) for 2 whole months.

It slowly got better over the next few months and I got back into bodyweight squats and step-ups to strengthen the muscles again, but there was lots of clicking in the knee joint at different times - mostly on the lateral side.

Then, in the middle of the year, I'd been doing a lot of physical farming work overseas and the pain in the back of the knee came back again. Ever since then, it's come and gone - sometimes as a result of fast weight-bearing movements, but sometimes after I've done nothing demanding at all.

None of the specialists I've seen have had any ideas on what the problem might be or what I can do to solve it. The only thing the sports physician came up with was that the PCL looked a bit thin in the MRI. But since it was totally intact, there was nothing that could be done about it.

The only advice I got from the physios was "strengthen the quad", but I've done a lot of that and reached a point where I was back squatting more than I ever have before, yet this hasn't solved the problem by itself.

Quote:

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Originally Posted by JRoberts

Hey everyone, I have an ongoing knee problem and I want to get everyone's input on what it might be and how I can fix it. I've been to a few physios and a sports physician, and had an MRI done, none of which have been able to identify/solve the problem. So I'm hoping someone here can do a bit better . . .


Here's the summary:

- I get a sharp pain in the back of my left knee when it's bent under load such as when squatting, lunging, walking stairs etc.

- The pain is right in the back center of the knee, not far from the surface.

- I can bend it through a full range of motion with no pain at all if there's no weight on it.

- It gets aggravated much more by fast bending movements under bodyweight than by slow movements (even under much heavier weight). For example, I can do multiple heavy barbell squat sets and be fine, but if I lunge quickly onto it (such as doing a fast dip when dancing, or even dipping quickly in a push press), that's what seems to aggravate it.

- When the problem comes up, if I take it easy for a few days, it goes away and I can go back to doing everything pain free.

- However, even when the pain is gone, the knee still doesn't feel very strong and usually I instinctively don't want to push it too hard.

- The MRI showed everything normal - no signs of meniscal tear, ligament damage or other cartilage problems, no cysts, no tendon problems etc.

- I've read about the popliteus muscle causing problems in this area, but I don't get any pain when I press into the back of the knee, so that doesn't sound like the root of the problem.


As far as I can see, the main things that could cause pain in this area are either a meniscus tear or a hamstring injury. It's been basically a year since I first felt the injury, so I would have thought it's not a hamstring problem?

I did jar the knee when I accidentally stepped into a pothole while running 3 weeks before the problem came up. Is it possible that I tore the meniscus then but the problem didn't manifest until afterward? I heard that MRIs are not always accurate in detecting meniscus tears, so I'm still wondering if that could be the problem.

Has anyone got any ideas on what it might be and what I can do to solve the problem?

Thanks in advance

Jay

- - - Updated - - -

Here's some more background:

In mid-December 2012, I was running along the beach in shallow water when my foot stepped into a pothole while the knee was fully extended. This jarred the knee and I had some pain (not in the same place as now) for a couple of days, but then it went away completely after that. This may or may not be relevant. I did lots of leg work in the weeks following this with no problems at all.

The first day I felt the problem I'm having now was in January 2013. In the morning, I did a jump rope warm-up (this is a strong point of mine and my style is very low jump height / low impact) and then a Tabata workout with kipping pull-ups, sit-ups, dumbell shoulder press and kettlebell swings. I didn't feel any problem whatsoever at that point, so I'm not sure if anything in that training session was the original cause.

A few hours later I felt the sharp pain in the back of the left knee when I was walking up stairs. By the evening, it was so bad that I couldn't even push the clutch in my car without getting massive pain.

For the next few days, the knee and calf/foot/toes swelled right up and the knee felt like jelly. I didn't even walk on it for about a week. After a few days, the swelling went down, but it still felt very weak. I went back to walking normally after a couple of weeks, but basically rested it (ie didn't put any weight on it when it was bent) for 2 whole months.

It slowly got better over the next few months and I got back into bodyweight squats and step-ups to strengthen the muscles again, but there was lots of clicking in the knee joint at different times - mostly on the lateral side.

Then, in the middle of the year, I'd been doing a lot of physical farming work overseas and the pain in the back of the knee came back again. Ever since then, it's come and gone - sometimes as a result of fast weight-bearing movements, but sometimes after I've done nothing demanding at all.

None of the specialists I've seen have had any ideas on what the problem might be or what I can do to solve it. The only thing the sports physician came up with was that the PCL looked a bit thin in the MRI. But since it was totally intact, there was nothing that could be done about it.

The only advice I got from the physios was "strengthen the quad", but I've done a lot of that and reached a point where I was back squatting more than I ever have before, yet this hasn't solved the problem by itself.

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Hi

MRI is gold standard imaging for the knee so you know there is no significant damage to the knee joint or surrounding tendons/ligaments/cartilage. Has anyone checked your neural structures (straight leg raise, slump test) and circulation? A decent physio should check both as part of a neuro-musculoskeletal examination. It may be that you have tibial/peroneal nerve entrapment or even popliteal artery compression. Neither of these would show on MRI.

Quote:

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Originally Posted by ajp2477

Hi

MRI is gold standard imaging for the knee so you know there is no significant damage to the knee joint or surrounding tendons/ligaments/cartilage. Has anyone checked your neural structures (straight leg raise, slump test) and circulation? A decent physio should check both as part of a neuro-musculoskeletal examination. It may be that you have tibial/peroneal nerve entrapment or even popliteal artery compression. Neither of these would show on MRI.

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Thanks, ajp.

I heard that MRIs don't always show up meniscal tears - is there any chance that that's what happened but it hasn't appeared in the imaging? It was a 3T MRI, so I'm hoping that it's accurate, but I don't want to rule anything out.

I haven't had anyone do any of the tests you described. The specialists I've seen have each done what I would consider a cursory examination - no in-depth testing.

If it was a nerve entrapment or artery compression, would I be able to feel the pain by pressing into the back of the knee? I don't get any pain through manual touch. But bending the knee quickly under load (such as lunging quickly to the left) seems to be the prime aggravator. Does that sound characteristic of either of these problems?

If you had a meniscal tear you would have problems loading and turning on the knee. They can also produce locking symptoms and clicking. They normally occur with a trauma rather than gradual onset. Im not sure of the exact statistics of missed meniscal tears on MRI but its got to be pretty slim. If you are convinced you have some internal derangement of the knee you should get an arthroscopy where they place a camera in the knee joint and have a good look round. This would be the only way to be sure if there are any tears. The nerve and artery entrapment can not always be palpated but can produce distal symptoms to the knee such as pins and needles and pain during exercise in the calf/foot which is relieved shortly after stopping exercise.

Andy

Thanks again, Andy. I really appreciate your input.

I'm not convinced that there's any internal derangement (and I'm hoping there's not), but just want to be able to rule it out. If I can stand on the affected leg (with a straight leg and varying degrees of knee bend) and twist from side to side with my foot planted and not feel any pain at all, is it safe to say it's probably not a meniscal tear? I haven't had any locking at all, but I did have some clicking for a few months after the problem first came up.

On the nerve/artery entrapment possibility, is this something that would always come up each time I did the same movement? My problem settles down after a few days of rest and I get pain-free full range of motion again . . . until I do anything where I bend it quickly with my weight on it (eg lunging to the side). The lungeing aggravates it, and then I can't bend it very far with weight on it for a little while. How do those characteristics fit with nerve/artery entrapment?

Thanks in advance for helping me with this!

Jay

The Thesely test you describe (twisting on the knee with knee flexion) is one if the tests I use regularly to asses for meniscal tears as it is much more functional than a McMurrays test for example. If this is negative and there is no locking then I reckon a meniscal tear is probably out. If it Is sore after lunging and then settles with rest it could be more of an inflammatory problem such as a synovitis.
Does your knee swell after lunging?

Andy

Thanks, Andy.

The first time the problem came up, I had massive swelling for a few days. All around the knee, right down my calf and into my foot. But once that went away and everything settled, it's never swollen up again since, even though the pain has returned many times (and recently the pain felt nearly as bad as the first time when it did swell).

In the last couple of weeks (based on the advice of an occupational therapist I saw recently), I started stretching all muscles in my legs thoroughly. The knee has started feeling a lot more normal and strong since then - whether that's the result of the stretching or whether it's just recovering because I haven't been pushing it, I'm not sure.

I also read some materials saying that tight calves can cause knee pain. That was interesting to me, since I had been doing jump rope on the morning the problem set in, which obviously uses the calves heavily. I'm now hoping that if I stretch the calves (and everything else) properly, it might solve the problem.

I'll report back in a little while about the results. In the mean time, if you (or anyone else) has any further thoughts on this, they're always welcome.

Thanks again

Jay

Hey Andy

It's been a while since I posted. Since you were very generous with your time and input, and because it seems to be a baffling problem, I wanted to get back with an update so we can all take something away here.

I've been to see a few more physios, and here's the summary of what I can piece together:

- I have a lot of movement in the knee joint, possibly due to a minor PCL injury/stretch (which my sports physician picked up on the MRI, even though this wasn't in the report).
- This extra play makes the knee joint a bit unstable, and when I put weight on it while flexing it quickly, it can get slightly out of alignment and cause aggravation/inflammation in the joint.
- If this happens enough without any recovery time, the inflammation builds and leads to pain when bending the knee with weight on it.
- If I let it recover for long enough, the inflammation settles down and the pain goes away . . . until the next time I put weight on it when flexing quickly.

To treat this, I am using a combination of:

- Strengthening exercises for the hamstrings, calves and quads so they can compensate better for the instability in the joint.
- Activating my hamstring immediately before and during knee flexion - this massively reduces the amount of play/movement within the knee joint.
- Stretching, mobility and soft tissue work in my leg muscles so they don't pull things further out of alignment.

I'm not through the woods with this yet, but I can feel some improvement already (it was only in the last few weeks that all these pieces have finally come together). Now I'm going to continue with these strategies so I can get back to being pain-free and functional again.

Thanks again for your help!

Roberts it's good to hear that you are recovering from the pain. All the best for future!