popliteus/biceps femoris tendinosis

[fishtaco]

I wondered if anyone here might be able to help with treatment (and diagnosis) recommendations. I've had a dull aching pain from the posterior, lateral area of my right knee for 16+ months. It feels like a dull ache that's most focally located in the lateral, posterior region of the knee, but it does radiate up the hamstrings on the lateral side of the thigh. The pain occurs mostly with cycling and running. The pain isn't so bad as to keep me off the bike, and for nearly a year, I was stubborn and rode in spite of the pain. Stupid in retrospect. I've been to 3 doctors and 2 physical therapists who seem to think it's popliteus vs biceps femoris tendinopathy.

For the past 6 months, I've nearly stopped running and biking. The pain goes away with rest. But returns immediately with any light re-introduction of biking or running. I've had 2 steroid injections: one into the muscle bodies (biceps femoris and popliteus) and one into the joint capsule, with no relief. I've tried deep tissue massage, which didn't seem to help. I've been seeing a PT weekly for the past 6 weeks. She does some massage and is trying to having me strengthen the muscles without aggravating the pain. So I've been doing a gym routine of low weight, eccentric strength exercises for hamstrings, quads, and hip abductors. I've also been swimming for some aerobic exercise. This combination of low weight strength and swimming seems to do well in terms of being pain free. But I worry that I'm not making any progress toward fixing the actual problem. I tried an easy treadmill run for 30 minutes earlier this week, and the dull ache was back exactly as before. I should also mention that I've had an MRI of the knee that shows no tears to ligaments or meniscus. I've also had my bike re-fit professionally since the pain began.

Does this sound familiar to anyone? And can anyone provide some insight as to treatment? I'm ready to give this the time and attention it needs to get better. But I miss the bike.

Thanks for the help!

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[ATTIreland]

Hi fishtaco,

Obviously without examining you I cant get into much detail but just to say that if you were continueing through the pain for a year and it is indeed a tendonopathy then it is likely to be fairly well developed with significant structural changes that will take a lot of time and energy to reverse.

Its not clear how long you have been doing the eccentric strengthening (6 months? or just since seeing the PT 6 weeks ago?) but often times it will take 12 weeks or more. In your case it may be even longer than that due to the continued exercising.

You mention steroid injections but in my experience these are not greatly effective with tendinopathies. Depending on your resources and determination to get back cycling you could investigate other treatments such as PRP, prolotherapy or sclerosing injections.

The other posibility is that its referred pain from your back although I imagine this has already been investigated fully.

Anyway hope this helps and just keep plugging away at it.

[fishtaco]

ATTIreland - thanks for your reply. I've only been doing the eccentric strength exercises for ~6 weeks. So I don't think it's been long enough to judge if that's working. My plan for now is to continue with the strength exercises, since they don't seem to aggravate the pain. And to continue to avoid biking and running, since they do aggravate the pain. It's helpful to hear that the eccentric strength work often takes 12 wks or more - I think I just needed some sort of general time frame to reference. It's frustrating to be off the bike for so long without any sense of when or if things may get better.

I have thought of PRP - an orthopaedic surgeon suggested it at a recent visit. It sounds interesting and promising. But as I understand it, it's also not very well studied. Since it's a new therapy, my insurance will likely not pay for PRP, and I would have to pay $1000+ out of pocket. At this point, I would be happy to pay $1000 for a complete fix. But it's a lot of money for something that's experimental and not sure to work.

Do you have any experience with PRP or sclerosing therapy?

Again, thanks for the reply!

[ATTIreland]

Hi fishtaco,

Its not really my area as I'm not an orthopaedic surgeon or sports physician but I've heard some good things about PRP. Your right though about the lack of evidence for it at the moment so best thing would be to see does your insurance cover it. Worst thing they can say is no!

However (and this is only my viewpoint) I think that PRP may not be as effective for tendinopathies as it is for treating acute or some other chronic inuries due to the fact that most tendinopathies are actually tendonosis (degeneration of the tendon - replacment of 'good/normal' collagen with 'poor/abnormal' collagen) and you don't need more collagen (tendon tissue) but rather the right type of collagen. Also there is a theory that tendinopathy pain is largely due to ingrowth of blood vessels and nerves into the tendon in responce to prolonged overuse, in this case sclerosing or high volume injections may be more effective.

As is said injections arn't really my area so you'd need to talk to a specialist. Personally I'd give it the 12 weeks and see how it is then.

[lucas_]

i suggest only eccentric exercises with progression; i mean that you must feel pain doing that exercise...

tens for analgesia...

also recommends stretching and laser (8J) for redirect and gain more fibroblast (dont know how to say, sorry)

[roycar]

sorry i may have missed some info, just did a quick scan.

has your knee been properly assessed? did you have any trauma to the knee at any stage?

the symptoms you describe could be coming from a lateral meniscal lesion.

[fishtaco]

Sorry I missed your post. Life got busy over the holidays.

My knee has been assessed by two orthopaedic surgeons by physical exam and MRI. Neither thinks I have a surgical problem, and the MRI didn't show any tears to the meniscus.

I'm continuing with eccentric strengthening and stretching. Not much progress so far (after 8 weeks of strength exercises), but I haven't given up yet. Some local folks have suggested a local chiropracter who does some work with a laser - but "laser therapy" sounds suspiciously gimmicky to me. Anyone have experience with it or know if there's any evidence for it? Thanks!

[Lachlan]

As far as im aware laser is the snake oil of the 21st century. Doesnt penetrate past the skin.

[gcoe]

Generally the evidence for any electrophysical agent in these sorts of problems is disappointing. However There is some evidence for a beneficial effect of laser at the right dosage for a number of tendon problems around the body. Here is a look on PEDro for evidence for laser:

PEDro - Search Results

However I would interpret the benefit from laser as most likely some form of pain modulation and therefore is very much a symptomatic treatment - rather than doing a lot for the tendon. What really is going to count is the appropriate sort of exercise which it sounds like you are already doing. To get the beneficial effects of eccentric muscle training, it can take quite some time. So you could throw laser in the mix so to speak (to get some pain relief so you can do more) but keep persisting and progressing with the eccentric training. Tendons take time to remodel. If you don't get any improvements in your symptoms at 3 months then it is time to get it reviewed.

Here are some questions
What exercise are you actually doing and how do you progress the exercise as the muscle gets stronger?
Is your exercise being supervised by a PT?
Did the PT really check your back and hip? You want to be sure there isn't a referred pain component to your problem - this may be unlikely but it is worth getting it ruled out.

[fishtaco]

Here are some questions
What exercise are you actually doing and how do you progress the exercise as the muscle gets stronger?
Is your exercise being supervised by a PT?
Did the PT really check your back and hip? You want to be sure there isn't a referred pain component to your problem - this may be unlikely but it is worth getting it ruled out.

I'm doing hamstring curls, using both legs to curl the weight back, and then using the affected leg alone to slowly lower the weight. I'm also doing a mix of other exercises suggested by my PT - balance exercises standing on one leg and bending forward while holding a ball (this triggers the pain much more than I expected), squats (without weights), quads, and lunges. When I use a weight machine, I'm using the lowest weight setting and doing high reps.

My original strength routine was set up by a PT who I was seeing weekly. She wasn't sure what to do next - since we weren't getting much improvement. My insurance will only cover 15 PT sessions/year for a given injury. So she suggested we put our sessions on hold until I have another appt with the referring physician. So my strength routine is currently unsupervised - but I'm open to suggestions and changes. I'm seeing a new physician in 2 weeks, and I imagine he'll suggest more PT.

My PT did check my hip and back to see if this could be due to referred pain, but she didn't think that was the cause.

Thanks for the help!

[gcoe]

Hi fishtaco

Thanks for the info on your exercise programme - Sounds all good to me. No real suggestions there.

So standing on one leg and bending forward brings the symptom on - could possibly be adverse neural tension of the sciatic nerve. Adverse neural tension can masquerade as hamstrings injury quite easily. Neural pain can be dramatic too which might explain the severity of the pain The diagnostic test for this is called the slump test - you could check if your PT did this. The cause of adverse neural tension is usually some sort of impingement along the course of the nerve: the back, piriformis or could be something going on at the back of the knee. If it is this then the treatment is mobilisation of the nerve.

Other then that I can't think of what else it might be.

[fishtaco]

Gcoe - thanks for the helpful responses! After googling 'slump test,' I don't think anyone has tried that. I've tried to crudely reproduce the test myself based on pictures I found, but I'll ask the doc I see in 2 weeks to perform the test. I can reproduce the pain to some degree when I stretch my hamstrings and adduct my leg across the midline - not sure if this is at all similar to the medial hip rotation mentioned in the description of the slump test. I'll leave that to my physician and PT. Again, thanks for the response!

[gcoe]

Yes if with hip flexion and knee extension you get a stronger response when you adduct the leg that sounds quite likely to be a positive response. An orthopaedic Pt should know the test. Here is a site explaining it:

The Slump Test

You can sort of do the test yourself but a clinician can do it better. The treatment can be conducted by an orthopaedic PT who uses manual therapy. It is quite an art to treating it as too much mobilisation of the nerve will stir it up while not enough and you won't make progress.

The specific exercise that makes it worse is probably not doing you much good. Just go easy on it and get some help

[f1progeny]

Hi fishtaco,
bit late to the discussion but it's an interesting problem, any luck so far with the docs?
definitely sounds like you've got some good neural signs goin on, not surprising given the length of time you've had that trouble. Probably already been looked at but was your superior tib/fib joint checked for hypermobility or laxity versus the other side? any history of ankle sprains that side? Laxity here could place the biceps femoris under additional strain and further stress the joint contributing to your pain. bit of a long shot but it can happen.
I'd go with gcoe's suggestion and see an ortho PT anyway because you'll need some help reducing the neural sensitivity(s),if you get the pain in slump/SLR with inversion of the ankle you'll need a thorough exam from back to ankle.

Good luck with it!!!

[aprillove20]

Hi,


What exercise can you recommend to me?

[Yarok]

Hi

guys probably are right your back and pelvis werent assessed properly.

exercises back stretches
sacro-iliac joint self mobs
sciatic nerve mobs
gluts stretches
trigger points work on ilitibial bend

take care get well

[vam44]

I concur with Yarok s ideas for exercises and treatment especially ITB releases
I would add in review of foot posture for orthotics because poor foot posture will have a mechanical effect on the rotation of the knee joint and can perpetuate popliteus and biceps femoris muscle symptoms.

You should also review foot position on the pedals and or the cleat positions,

[kateaustralia]

fishtaco,

Any luck with the treatment? I am suffering similar symptoms. After 12 months (and many extended breaks from exercise), whenever I return to running I have the same pain below my knee on the lateral sign. MRI has ruled out any meniscus tears etc.

Have you had any luck? Would be great to hear how you have gone...