patients knee pain- confusing symptoms

[cleehaddock]

Hi all,

I was wondering if someone could help me with this patient I have at the moment.

He presented with referred pain down the common peroneal distribution, It has been an insidious onset, gradually geting worse over 1/12.

The symptoms only come on when he touches the superior aspect of the tibia. Nothing else brings on the symptoms.

I have been through a knee, hip, Lx and SIJ examination and have nothing that brings on the symptoms. Apart from palpation over the tibia.

Another confusing sign that he told me was that if he stroked the spot in a clockwise fashion, then the pain will appear down the distribution site in a clock wise fashion, and vice-versa.

Has anyone seen anything similar or could give me some advice on where to go from here.

Kind Regards

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[Physio Dace]

Hi,

Can you be more specific about the positive palpation results? Exactly where on the fibula - ant-post-lat/neck/head/shaft etc.

Also what does the person do that aggs the condition other than clockwise palpation? Does the condition appear to have pattern e.g. inflammatory/degenerative/non mechanical? How old is this person?

Have you checked in depth for neurodynamic or muscular provocation with particular biasing for popliteus pain (end range knee ext + ER).

To assist more info particularly subjective reports will be very helpful.

Cheers

[shasadah]

In this case we need more subjective and objective findings.Pt. age , any history of injury or fever.
In objective findings is there any swelling around this area ?? what is the exect site of pelpation ?how deep pelpation aggs the symptoms?any X-rays of knee done?
Any thing which helps like joint position, warm tub, nsaids.
Lets see if we could help.
Thanks

[linbin]

hi friends
the patient complaints of pain when he tries to touch the tibia....??????
tries to touch tibia in which position and movement transition
what i mean is
is it in standing and while forward bending
is it long sitting and forward bending
is it high sitting and forward bending??????????
or any other way?????????

[cleehaddock]

Thankyou for your replies. here is a bit more info

The patient is 40-50's. Long history of low back pain. which has cleared up over the last six months, and does regular activity and is otherwise fit and healthy. Only other relevant hx was 20 years ago had motorbike accident and 'smashed' both knees. not sure of any more deatils of that.

Pt. Has been ill recently so hasn't trained or done anything to AGG it, except long distance plane travel. First noticed it whilst knealing down about 1/12 ago. and has started to get worse. No specific AGGS or EAS and 24 hr pattern has no change

No swelling, inflamation or abnormalities of posture. Only scaring from motorbike accident (bilateral)

AROM and PROM was pain free. including extension and ER.
Only test that I could do that brought on the symptoms was palpation of the superior, central tibia. This caused the sharp pain down the lateral fibula (5/10)

Palpation was very light, (a stroke) and this caused symtoms, although more pressure=increase in pain. Palpation in knee flexion was worse than knee extension.

I tested accessory movements of the tibio-femoral joint, and tried longitudinal caudad- had no affect.

I then tested low back, esp. L5- no symptoms were brought on during back examination. I also cleared the hip.

I then progressed onto functional testing, with the Pt. able to squat (10 reps), lunge(10 reps), single leg squat, jog and run without symptoms being brought on. However when i palpated at the end to re test, the symptoms were the same.


Anymore more info then please ask. I appreciate your time and effort.

Regards

[Physio Dace]

Hi,

Thanks for more info. My initial concern would be a non-musculoskeletal cause (e.g. osteoid sarcoma, malignancy) or a bone marrow oedema problem such as spontaneous osteonecrosis, bone bruise etc - though these tend to have mechanical patterns i.e. worse under loading. If he passed a full passive,active and functional assessment and he reports no specific aggs/eases or pattern or MOI then I would be very careful not to miss any nasties. To me your report so far suggests a non-mechanical disorder.

Good luck.