RehabEdge Physical Therapy Forum

Forums  Register  Login  Forgot Login?
  My Profile 
My Subscription
  My Forums 
Search
  FAQ  Log Out
Follow @RehabEdge

Posterior Knee pain

 
Logged in as: Guest
Users viewing this topic: none
  Printable Version
All Forums >> [RehabEdge Forum] >> Orthopedics >> Posterior Knee pain Page: [1] 2   next >   >>
Login
Message << Older Topic   Newer Topic >>
Posterior Knee pain - October 5, 2008 3:43:13 AM   
Keith06

 

Posts: 13
Joined: November 9, 2006
Status: offline
Pt. referred from PCP with posterior knee pain. The pt. is a recreational athlete in his late 20's. The pt. just woke up one morning with knee pain that is only present with full knee flexion. This has been present for just over 2 months. Pain gets very intense if he kneels down on the knee with it flexed fully. Recently, the knee has started hurting with close chain knee hyperextension and open chain resistant leg curls. The pain is located deep into the popliteal fossa area. He has been able to continue with playing basketball, running, and working out including squats without symptoms. Standing quadriceps stretch is also very painful.

Knee AROM is 12-0-145, strength is normal, no tenderness with palpation, ligament/meniscal tests negative, cleared lumbar spine and SI joint. Hamstring are tight B.

The pt. also has a left great toe hyperextension injury that occured about 3 weeks prior to the onset of knee pain. The pt. feels like when he was taking ibuprofen 800 mg twice a day for 2 days secondary to toe flareup that his knee pain was better.

Any thoughts would be helpful, thanks.
Post #: 1
RE: Posterior Knee pain - October 5, 2008 1:11:22 PM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Tell him to quit fully flexing the knee... to quit kneeling on it fully flexed.

(in reply to Keith06)
Post #: 2
RE: Posterior Knee pain - October 5, 2008 1:47:45 PM   
TexasOrtho


Posts: 1090
Joined: December 22, 2007
Status: offline
There is the possibility of a small popliteal or Baker's cyst with posterior knee pain.  I have had maybe 3 symptomatic cases in six years, so it isn't too common.  When it is however, I've found presentations similar to the one you've described.  It doesn't sound emergent so I'd treat conservatively for about 3-5 visits and see what direction it takes.  Here's an emedicine link to this condition:

http://www.emedicine.com/radio/TOPIC72.HTM

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to SJBird55)
Post #: 3
RE: Posterior Knee pain - October 5, 2008 3:34:26 PM   
mmr-pt-atc

 

Posts: 131
Joined: August 16, 2008
Status: offline
Keith, Highly suspicious for meniscus tear.  You say meniscal testing is negative, but many meniscal tests are poor at best.  In my experience, the most indicative signs and symptoms for meniscal tears are simple pain with end range knee flexion (which is exacerbated by deep knee flexion while weightbearing, similar to what you say with squating), joint line pain, decrease in quad strength, and effusion. 

A couple of other things: 

* When he is kneeling and deep flexing the knee the condyles roll posteriorly and impinge on the menisci
* When he contracts his hamstrings, such as in OKC as you mention, the hamstring's attachment to the capsular tissue can irriate the meniscal attachment to the capsular tissue.
* In addition to the meniscus itself, the posterior pain can also be from effusion, even if mild and you can barely notice.  I would bet there is a mild difference in girth around his joint line and a decrease in quad girth as well (from inhibition).  The knee is very congruent and there is not a lot of space for effusion to move to.  When you flx his knee the effusion is pushed out posterior and pinches on the capsular tissue, or from a Baker's cyst as mentioned above.  Try this:  Place him prone and passive flex his knee until pain is experienced.  Note the degree.  Now extend the knee and put your hand posteriorly in the popliteal space, hold tightly compressing the area.  Now flex again and see if pain is better at the same degree.
* I find it hard to differentiate between mild weakness of large muscles, like the quad, with MMT.  Try using a hand-held dynamometer as well as the girth measurement of the quad, maybe about 20-25 cm proximal to joint line. 

Try: Bauerfiend knee sleeve (they work the best for me), quad strengthening, NMES with quad sets and SLRs as warm-up prior to exercise, icing at end of day and PT session, Gameready works great for the knee if you have access.

_____________________________

******
Mike Reinold
Visit my physical therapy blog

(in reply to TexasOrtho)
Post #: 4
RE: Posterior Knee pain - October 5, 2008 3:36:20 PM   
jma

 

Posts: 2638
Joined: August 25, 2000
From: NY
Status: offline
I also agree that this could be a cyst, although maybe not as palpable at this, since it was not mentioned.  I've heard of wedges that some construction workers use to put behind the knee when kneeling on the floor to prevent full knee flexion.

(in reply to TexasOrtho)
Post #: 5
RE: Posterior Knee pain - October 5, 2008 3:37:59 PM   
PTupdate.com


Posts: 1562
Joined: October 9, 2001
From: Pittsburgh, PA USA
Status: offline
I'm thinking meniscal irritation or even tear.  Have had many people "wake up" with a tear over the years, and the menisci can move as far as 11mm posteriorly when going from extension to full flexion....thus putting quite a bit of shear force on an irritated and/or symptomatic derangement.  And, this type of derangement can certainly lead to a cyst as Rod notes, due to the synovial stalk that forms and excess synovial production due to the irritation.

You could try and confirm via Thessaly test, McMurray type IR/ER torquing as you take them to end range flexion, and aggressively muscle test hamstrings with foot in IR and then ER to stress (especially medially) the hamstring connective tissue attachments to the menisci.

And, as SJ says, tell the guy to quit doing what hurts!  It's surprising how people heal when they quit irritatng their injury!!!!  (or, in so many cases, when their PT quits irritating their injury!!!!)

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to TexasOrtho)
Post #: 6
RE: Posterior Knee pain - October 5, 2008 3:45:28 PM   
rwillcott

 

Posts: 1123
Joined: March 21, 2006
From: Canada
Status: offline
I also would re-check for a meniscal tear.  I had a patient once with the same symptoms and I thought meniscal tests were clear.  I then rechecked Apley's but with compression with in a bit more flexion than 90 degrees.  It was positive.

I would check Apley's as well as the tests listed by PTupdate.


(in reply to PTupdate.com)
Post #: 7
RE: Posterior Knee pain - October 5, 2008 3:55:34 PM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
The guy is young with full function... he's playing sports with no problems.  He's not a candidate for any invasive procedure - telling him he might have a meniscal problem is going to probably have the same impact of telling someone they have a herniated disc.  (He's going to overly focus on it and potentially have a fear response and want something done about it.)  He shouldn't be hyperextending his knee and he shouldn't be fully flexing his knee.  Even if he has a Baker's cyst... his function isn't being limited, so even that doesn't matter.  I'd advise him to worry when he has locking and buckling and feeling of giving away.  Until then, avoid whatever irritates it (his issues are at the extremes of his motion)... focus on neuromuscular re-education type activities (balance and proprioception).  Assess his performance with hamstring curls and reduce the motion into a painfree range.  If there is no painfree range, then instead have the patient focus on strengthening via a leg press.  No deep knee squats.  Each time the patient strengthens, attempt the hamstring curl to see if the condition is changing.

(in reply to PTupdate.com)
Post #: 8
RE: Posterior Knee pain - October 5, 2008 5:29:06 PM   
TexasOrtho


Posts: 1090
Joined: December 22, 2007
Status: offline
quote:

ORIGINAL: SJBird55

The guy is young with full function... he's playing sports with no problems.  He's not a candidate for any invasive procedure - telling him he might have a meniscal problem is going to probably have the same impact of telling someone they have a herniated disc.  (He's going to overly focus on it and potentially have a fear response and want something done about it.)  He shouldn't be hyperextending his knee and he shouldn't be fully flexing his knee.  Even if he has a Baker's cyst... his function isn't being limited, so even that doesn't matter.  I'd advise him to worry when he has locking and buckling and feeling of giving away.  Until then, avoid whatever irritates it (his issues are at the extremes of his motion)... focus on neuromuscular re-education type activities (balance and proprioception).  Assess his performance with hamstring curls and reduce the motion into a painfree range.  If there is no painfree range, then instead have the patient focus on strengthening via a leg press.  No deep knee squats.  Each time the patient strengthens, attempt the hamstring curl to see if the condition is changing.


If you hear hoofbeats think horses not zebras...it is most likely a meniscus tear.  However, I agree completely with SJ that, even if it is a tear or cyst (and it is likely a mild case of one or the other), I can't imagine any surgeon worth his/her salt would suggest doing anything about it.  I would follow SJ's recommendations regarding management in either case.

< Message edited by TexasOrtho -- October 5, 2008 5:34:12 PM >


_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to SJBird55)
Post #: 9
RE: Posterior Knee pain - October 5, 2008 10:25:44 PM   
Tom Reeves DPT ATC

 

Posts: 1121
Joined: March 15, 2006
Status: offline
I wonder if he is not hyperextending his knee during gait to avoid dorsiflexing the toe.  that would cause nebulous posterior knee pain, swelling that you can't see, and pain with deep squats.  I would treat the toe and work on his gait and see what happens before the MRI or ortho appointment to r/o the meniscus.

(in reply to TexasOrtho)
Post #: 10
RE: Posterior Knee pain - October 6, 2008 12:18:49 AM   
TexasOrtho


Posts: 1090
Joined: December 22, 2007
Status: offline
Good catch Tom.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to Tom Reeves DPT ATC)
Post #: 11
RE: Posterior Knee pain - October 6, 2008 1:37:43 AM   
Keith06

 

Posts: 13
Joined: November 9, 2006
Status: offline
Thanks for all the advice. I was initially thinking meniscus, but there was no mechanism of injury and even Thessaly test negative. Tom, I added that bit about his turf toe injury because I was also thinking along the lines of him avoiding pushoff. Because the knee pain started about 3 weeks after toe injury. He tapes his toe for sports, he has had a turf toe injury a few years back so he learned how to take care of it. He did take a month off all activities to let the toe rest, but it never got completely better. He reported it taking about 6-8 months to completely be pain free from his previous toe injury. He is able to perform a full squat without pain, he just can't kneel down on his fully flexed knee. In other words he can't sit back on his heels with his knee flexed fully without intense pain. I know this seem like a postion that could be avoided but he reports doing it a few times a day for job duties. I was also thinking that the popliteus could be inflamed. I will re-check some things mentioned above and give an update later in the week.

(in reply to TexasOrtho)
Post #: 12
RE: Posterior Knee pain - October 6, 2008 2:28:49 AM   
PTupdate.com


Posts: 1562
Joined: October 9, 2001
From: Pittsburgh, PA USA
Status: offline
Keith, remember there does not have to be a mechanism of injury for a meniscus tear or injury.

You could consider the Cluffy Wedge for the toe, and KneeSaver's for work....you'll see some MLB catchers use these, along with minor leagues, college, etc.

SJ:  I am not sure I agree with you regarding NOT telling him what you may suspect.  If one suspects a meniscus injury, tear or otherwise, tell the patient that it's in your thought process, and you may just convince him/her of the reasons why you are treating in a certain way, why you are telling them not to do certain tasks, etc.  It's part of the buy in, as long as you also educate regarding the huge numbers of people strolling around just fine with meniscal tears, etc.  And, you'll have more credibility if/when they go to the ortho and perhaps get told the same thing.  Otherwise, they come back, tell you the MD said they had a meniscus injury, and they think you're a doofus....and the MD may as well

I like when patients return from the MD, and the doc quizzed them as to what I thought the problem was......a friendly test, but one that creates respect.

< Message edited by PTupdate.com -- October 6, 2008 2:33:48 AM >


_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to Keith06)
Post #: 13
RE: Posterior Knee pain - October 6, 2008 6:15:44 AM   
bonez

 

Posts: 701
Joined: August 29, 2007
Status: offline
How about a problem with his popliteus muscle due to altered gait from the big toe. Feel for decreased tibial external rotation joint play with the leg dangling at 90 degrees and or resisting hamstring activity from prone extension while holding the tibia in internal rotation causing symptom reproduction. Been fooled by this beast a time or too.

(in reply to PTupdate.com)
Post #: 14
RE: Posterior Knee pain - October 6, 2008 10:56:25 AM   
ginger

 

Posts: 1196
Joined: February 27, 2005
From: Melbourne Victoria
Status: offline
L5S1,     d'oh

(in reply to bonez)
Post #: 15
RE: Posterior Knee pain - October 6, 2008 9:53:00 PM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Duffy... I'm all for educating as long as the spin put on what is told is as you are suggesting.  To leave it as "probable" meniscal tear would probably create issues.

(in reply to ginger)
Post #: 16
RE: Posterior Knee pain - October 7, 2008 9:46:40 PM   
Shill

 

Posts: 1377
Joined: February 14, 2003
From: Madison WI USA
Status: offline
Ive actually had this myself, chalked it up to a menscal "tweak" for lack of a better definition.  Had no MRI, but knew if I waited it would improve.  It did take a while (about 8 months), but is now just fine, and I still have full squatting range.  It took about a year to get that back, but I would rather wait, and keep my meniscus than cut it out and have a TKA later.

_____________________________

Steve Hill PT

(in reply to SJBird55)
Post #: 17
RE: Posterior Knee pain - October 8, 2008 1:54:29 AM   
jma

 

Posts: 2638
Joined: August 25, 2000
From: NY
Status: offline
If you did not have squatting range or continued pain by that time, what would have been your options at that point? Curious

(in reply to Shill)
Post #: 18
RE: Posterior Knee pain - October 8, 2008 1:21:24 PM   
Shill

 

Posts: 1377
Joined: February 14, 2003
From: Madison WI USA
Status: offline
I think the longer you go without improvement, your options for conservative care obviously decrease, which I am sure you are well aware.  I am not a pro athlete, but am an avid cyclist, and do a fair amount of running around coaching kids in baseball.  Early on, I could not run above 25% speed, or have any forceful hamstring contraction on the affected side without fairly significant posterior corner knee pain, but I could cycle and do everything else BUT run and squat.  The way I see it, if one can wait, when weighing whether to hack into a joint, then he or she should do so.  If this indeed was meniscal, and did not improve, a scope would have been the answer, though I would have asked for an MRI prior to letting anyone dive in.  There is rarely any harm in waiting on something like this. Impatience is a big problem, but the more data that comes in on scopes and meniscectomies, the more it seems to set up later troubles.   Failure of time and appropriate conservative mechanisms, with relative rest from aggravating stresses, always makes someone a better candidate for surgery.

(in reply to jma)
Post #: 19
RE: Posterior Knee pain - October 9, 2008 12:30:30 AM   
PTupdate.com


Posts: 1562
Joined: October 9, 2001
From: Pittsburgh, PA USA
Status: offline
Shill: I usually think and treat just like you in this case.  However, I always have in the back of my mind:  Does the constant state of inflammation of the meniscus accelerate any type of damage to the articular cartilage?  We read how low grade inflammation is now tied to heart disease, and I wonder if the chemical mediators from constant synovial/meniscal inflammation destroy the knee.

The surgeon asked me if I want an MRI, and I said no.....it's not worth the time and the money to POSSIBLY verify what I am pretty sure I have.  Plus, we've all had those cases where the MRI was negative, and the physician finds all kinds of damage upon arthroscopic examination

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to Shill)
Post #: 20
Page:   [1] 2   next >   >>
All Forums >> [RehabEdge Forum] >> Orthopedics >> Posterior Knee pain Page: [1] 2   next >   >>
Jump to:





New Messages No New Messages
Hot Topic w/ New Messages Hot Topic w/o New Messages
Locked w/ New Messages Locked w/o New Messages
 Post New Thread
 Reply to Message
 Post New Poll
 Submit Vote
 Delete My Own Post
 Delete My Own Thread
 Rate Posts



Google Custom Search
Forum Software © ASPPlayground.NET Advanced Edition 2.5.5 Unicode

0.266