Frustrating Mystery Knee Injury

Triathlon Forum
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Maybe you guys can help diagnosis what’s going on with my left knee. 2-weeks before Boston I strained my left hamstring on a meaningless training run (running with an out-of-control cough is a bad idea). During the first few miles of the race I knew it was going to nag me the entire way but I’ve run 2+ hours before with various hamstring strains so I decided to gut it out. Around the half way point I started getting some medial L knee pain hoping it would just go away (some aches do). But each mile the pain would return (especially on the downhills) and when descending Heartbreak I decided to stop and stretch due to the pain. The last 5 miles was a pathetic walk/stretch/hobble but I made it. I knew finishing was stupid (the Boston College and Fenway fanatics won’t let you quit) and my knee was a wreck the next day. I had the knee examined by my orthopod the following Thursday (it was already feeling much better at rest) and based on his exam, he thought it was a “strained MCL” at worst and did not recommend a MRI.

Its been three weeks and my knee feels normal at rest. In fact, I can bike and do the rowing ergometer without any pain whatsoever. I’ve been doing agility ladder drills pain free. I’ve even performed the Thessaly & Ege’s tests for meninscus without any trouble. However, when I run - just running at normal training pace - after about 4-5 mins I start getting a dull medial pain and builds rather quickly. By 1-mile I’m ready to toss in the towel. What’s going on? Could it be a meniscus tear or am I just jumping the gun?

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The differential diagnosis for medial joint pain in a runner would include: medial tibial stress reaction (or fracture), pes anserine bursitis, medial meniscus tear, medial femoral condyle osteochondral defect, medial plica syndrome. An MCL strain without a history of trama would not be on my list. Thats about all I got. Good Luck!

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To OP: I agree with RCope that MCL strain is unlikely. My 1st impression is pes anserine tendinoburstis.

The differential diagnosis for medial joint pain in a runner would include: medial tibial stress reaction (or fracture), pes anserine bursitis, medial meniscus tear, medial femoral condyle osteochondral defect, medial plica syndrome. An MCL strain without a history of trama would not be on my list. Thats about all I got. Good Luck!

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Thanks guys, would any of these conditions be detectable from a X-ray? I did get one.

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In addition to the previous differential diagnosis I have also personally seen and experienced the kind of pain you are having from tight lateral structures (ITB and hips) and weak hip musculature.

Bursitis will not show on an x-ray and a stress fracture ‘likely’ would not (it often takes 6 weeks for them to be seen on x-ray)

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I think I can help…

I’ve had several issues in my left knee over the years – ITB, Hamstring pulls, Patellar tendinitis. Few months ago, I felt a tweak in my left knee on a simple run. Maybe a very small pop, more of a feeling. Stopped running and stayed off it for a week with zero pain or discomfort. After a run or two, I felt it again on mile 3-4 - a dull medial discomfort. Kept doing everything else I do without any pain (skiing, Ice Hockey, biking, etc). Very normal at rest…odd.

After 4 months, finally got a MRI. Initial Diagnosis – Grade IV articular Cartilage Lesion, recommendation was OATS graft, 6 months of rehab. Very hard to hear. Naturally sought a second and a third opinion with different treatment recommendations. Being confused, I went for a fourth opinion which was different from the start. Listened far more to my overall story and thought outside the box. Asked me about my back. I have had minor lower back discomfort in the past, nothing requiring treatment. He wanted me to get a second knee MRI, a back MRI (Lumbar) and blood work to exhaust all possibilities.

The back MRI sure enough showed a herniated disc in the L4-5 region, which is the nerve area that sends signals to many areas including the left knee. Pressure on the nerve can cause direct pain/discomfort but also muscle weakness (quads/Hams) that can put further pressure on the joint. Reflecting back, my back would flare up more when I trained on my tri bike a lot and my run was always sapped when riding a lot. I never put the two together. I have never been able to run well in an Ironman or during training for one and it frustrated the heck out of me. After my second Ironman, I did a marathon 4 months later, taking a full month off before training again. When I started running again, my training speed was immediately a full minute faster at the same effort than at any point of my Ironman training - it was likely my back all along.

Here is where it gets interesting. 2nd MRI showed NORMAL articular cartilage. Apparently, MRIs can show false images (stunning to me) resulting in false positives. It did show strong plica and I could have medial plica syndrome. Recommended treatment: 4-6 weeks of anti-inflammatories and rehab to treat plica syndrome and L4-L5 protrusion and build core strength. In addition, he gave me arch supports for my shoes. 1 week into anti-inflammatories and results are positive. It’s working.

To think, I was facing 6-9 months of rehab after an OATS procedure. Bottomline, the first 3 docs treated the MRI and NOT all of my symptoms. To their defense, the MRI was likely wrong.

In your case, I would think about a) your back and b) plica syndrome. Either way, resolve it before you continue. Cartilage tears can be symptom free and you want to know if it’s that sooner than later as the options for that suck.

Good luck…

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Pes anserine?

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I was about to post a new thread about my ITBS issues and some recent discoveries to see if the ST medical community had any ideas when I came across this recent post (after one last search so I wouldn’t get slammed for not using the search feature).

I have been having severe left ITBS issues since the end of March - have not run more than a few steps since 3/31. I completed the 100run/100 day challenge on ST and did a half marathon the final weekend on March 24th. Felt fine the week after and took it easy running until later in the week but probably didn’t take enough time off. The 30th I did an easy 5 mile run and stopped about a half mile from the house we were staying at (we were away) to look at a garage sale - when I started back up the IT pain was immediate and pretty bad. I limped my way home and tried to stretch it out but being away had no foam roller. The next day I tried to gut out a short run and couldn’t do it.

I have tried various treatment options since then - Chiro who does ART (who I had seen in the past). We did not see any improvement and the pain was pretty bad so we decided to see if I needed an MRI - so off to an Ortho Sports Doc who had x-ray and MRI done (based on exam he thought I tore my lateral meniscus). X-ray showed lateral bone spur, MRI later showed medial tear of the meniscus (that doesn’t hurt at all) and “thick” IT Band. Treatment options were rehab via all the various exercises you see here on ST in posts about ITBS to address hips, glutes, etc. He said I could ride the bike and do elliptical but no running and continue with the ART.

After a few more weeks I was unable to ride or use the elliptical for more than 20 mins without extreme pain and consulted with my Chiro who said maybe we should try something else - I asked the Ortho about a cortisone shot. He said it might help - but he can’t provide one (he is not a surgeon, not sure if that is why) and referred me to a knee specialist locally. Long story short - saw him, he agreed with the original diagnosis after exam and review of the MRI/X-Ray, no cortisone shot yet and started PT. Been in PT for 2.5 weeks and they noted that my low back and hamstrings are very, very tight and said I should try a sports massage (in addition to the PT) - and now I get to the point of my post.

I had a sports massage Sat and found out that I have knots in the muscles of my lower back on both sides. Actually, I knew they were there, just thought they were supposed to be. I thought they were kind of weird but just figured they were natural. They don’t stick out or look like lumps but you can feel the knots in there. I also had two very large knots on either side below my shoulder blades that she was able to work out. The knots in my lower back wouldn’t release. Left hamstring is also extremely tight. The massage therapist and PT both confirmed for me that the knots/lumps aren’t normal. PT checked out today - she’s not ruling out back issues as the source of my pain but can’t work on it without a referral from the Doc due to insurance issues. We’re going to see how this week goes and then see if that is needed.

So my question to the ST community - have others either seen this if you are a medical professional or dealt with it as your own medical issue? My back isn’t really in pain now - and I don’t think it has been but there is something going on there. I’d say my IT Band is no better in about 6 weeks of treatment. The only exercise I’ve had since I saw the surgeon is walking (our dog) and hot yoga (which the second Doc OK’d) + the rehab exercises at PT and the gym on my off days. After 6 weeks of hip, core, glute strengthing exercises I guess I was expecting at least a slight improvement which makes me think we’re not really addressing the problem - which may be my low back??

For what it’s worth - the IT pain does seem like text book ITBS pain. Outside of the left knee and also up higher where the ITB passes over the hip bone. The hamstring issues are on the outside hamstring muscle closest to the ITB.

So, ST internet medical community. What do you think?