Lateral Knee Pain

Groin

 

Biceps femoris

 

I have moved this section around so many times because I really don't know what to say about it. However it is the upper-most area of the body so I need it in support of the Kinetic Chain.

 

In order to link the groin area with the knee, I have looked at my biceps femoris muscle in relation to the description given by:

http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/biceps-femoris-tendinopathy

 

The biceps femoris tendon is one of the hamstring muscle tendons. Injury to this tendon causes pain at the outside, back of the knee...

Symptoms [of biceps femoris tendinopathy] include tenderness and swelling where the tendon inserts into the bone. With biceps femoris tendinopathy the tender area is to the outside back of the knee. If the other two tendons are involved there may be tenderness medially. There may be pain when trying to bend the knee against resistance as well as stiffness after exercise and the next day. The athlete will often have tight hamstring muscles.

 

Although I am not able to tell if I am touching the long or short head of my biceps femoris tendon, it seems to me that it is uneven, undulating as perhaps the thickness changes. It doesn't appear to be tender whilst investigating with touch, but afterwards and the next day or 2, it was so very painful. Even a nerve, maybe the common peroneal nerve found in that area, or maybe the tibial nerve which adjoins a little higher up, appeared very implicit! I am going to assume that the nerve involvement was purely as a result of the investigation of the biceps femoris tendon as it hadn't happened before.

 

I am pondering though on whether the biceps femoris tendinopathy is instrumental in causing incapacity to my leg. I do think that it may be partially responsible for my knee. And as the long head tendon of the biceps femoris originates from the groin / hip area, and as the long and short head tendon primarily insert on the head of the fibular, this may be implicit in groin pain.

 

 

Gluteus medius

 

However, it has been said that I have a weak gluteus medius muscle in my right leg. It seems to me that this may indicate a Trendelenburg sign as the gluteus medius is very important during the stance phase of the gait cycle to maintain both hips at the same level, as discussed in http://en.wikipedia.org/wiki/Trendelenburg's_sign:

 

A Trendelenburg sign can occur when there is presence of a muscular dysfunction (weakness of the gluteus medius or minimus) or when someone is experiencing pain. The body is not able to maintain the center of gravity on the side of the stance leg. Normally, the body shifts the weight to the stance leg, allowing the shift of the center of gravity and consequently stabilizing or balancing the body. However, in this scenario, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability.

 

Therefore it seems that this may be a pain avoidance strategy, along with exhibiting instability, and an inability of the foot to clear the ground as discussed in http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1529872377:

 

During the step, instead of the pelvis being raised on the side of the lifted foot, it drops. Thus it is seen as the patient's pelvis tilting towards the lifted foot, with much flexion needed at the knee on the affected side in order for the foot to clear the ground.

 

Well, that's a few of my issues dealt with mainly thanks to Wikipedia (blush!). And I can also add in dorsiflexion and footdrop too under this guise of Trendelenburg Gait by 

http://www.physio-pedia.com/Trendelenburg_Gait:

 

A trendelenburg gait, in which there is weakness of the hip abductors (gluteus medius muscle), is characterized by trunk shift over the affected hip and is best visualized from behind of in front of the patient...

Observation from the side also enables detection of ankle dorsiflexor weakness and footdrop leading to inability of the foot to clear the ground, which is compensated for by excessive lower extremity flexion to facilitate foor clearande of the ground (steppage gait).[17]

 

Perhaps a more reliably acceptable reference source:

 

http://www.sportsinjurybulletin.com/archive/gluteus-medius.htm#

(On website)

 

During closed kinetic chain actions, such as the stance phase of running, the normal role of gluteus medius as a mover muscle is reversed, causing it to act as a pelvic stabiliser. So, for instance, during right stance phase, the muscle contracts to slow the downward motion of the left side of the pelvis so that the pelvis doesn’t tilt more than seven to eight degrees from parallel to the ground. If the gluteus medius is not functioning well enough to achieve this control, the athlete is said to have a ‘Trendelenburg gait’. Often, but not always, you may see the same weakness in walking (producing a waddling motion or, in extremis, a limp), and the dysfunction will then be more marked when they run...

 

Weakness in gluteus medius will have implications all the way down the kinetic chain. Take adaptation 2. From heel contact to mid stance phase, gluteus medius weakness allows:

• the femur to adduct and internally rotate excessively

• the knee to fall into a valgus position

• the tibia to rotate internally relative to the foot

• an increase in weight transfer to the medial aspect of the foot.

As a result the athlete is at increased risk of any condition relating to excessive and/or prolonged pronation of the foot, such as medial tibial stress syndrome or Achilles tendinitis.

Adaptation 3 is particularly interesting. As it is not often seen in the clinic or documented in the literature, many sports injury practitioners may not be aware of it. It occurs when the athlete is running in excessive anterior tilt and forward trunk position. At ground contact the knee is thrown laterally so that the gluteus medius is offloaded and the foot is forced into a more supinated position. Shock absorption through the lower limb is affected.

 

I have told a physiotherapist that I feel like I am 'tipping forward'. He told me to stand up straight!

 

But I'm not too sure what this means. Has the weakness in my gluteus medius developed because of my lateral knee pain? Or has this weakness caused the slapping motion in my foot when I was jogging? Or is it possible for the kinetic chain to work in reverse... and maybe damage to my Achilles tendon has resulted in dorsiflexion and footdrop which has eventually caused weakness to my gluteus medius...I certainly don't walk very energetically...!!!

 

 

Trendelenburg Pathologies

 

• Limp

• Foot slap

• Foot /ankle weakness

• 5 point turn to counteract instability

 

Although I do seem to have these characteristics, there are others that I have that may be included here too:

Also

• Weight-bearing through heel

• I feel that I am spending more time in stance phase of gait

• Weak gluteus medius

• Ankle weakness... dorsiflex / plantar flex...???

• Cannot support my weight when standing on one leg, the bad, right leg.

 

http://www.spine-health.com/conditions/leg-pain/foot-drop-symptoms-steppage-gait-other-warning-signs

 

Foot drop typically affects the muscles responsible for moving the ankle and foot upward, specifically the anterior tibialis, extensor hallucis longus and extensor digitorum longus.

With foot drop, these muscles are inhibited from performing several functions during a normal walking stride, including swinging the toes up from the ground at the start of a stride and controlling the foot after the heel is planted near the end of a stride. Consequently, the most recognized foot drop symptom occurs: high steppage gait.

 

I definately wear down the sole of my right shoe at the toes suggesting that I am not clearing the ground as I walk. And my big toe toenail on that foot has been damaged by knocking it on things instead of clearing them.

 

There is also significant wear on the lateral side of the right sole, however I can't say when this started. It may be the result of recent muscle weakness or pain avoidance strategies, so this cannot be relied upon.

 

 

Neurology

 

Although my local neurologist said that he couldn't find anything that might cause lateral knee pain in my leg, I am wondering whether this notion should still be kept in mind... after all he did deny that I had a problem with walking.

 

See the Neurology page.