Lateral Knee Pain

Knee

 

Swelling

 

I have had what seems to me to be a substantial swelling on the lateral side of my knee (A). I can't remember when it appeared but has been there for many years now. It is soft and squashy, and has remained the same size since I noticed it. Another swelling has more laterly developed on the medial side (B). Unlike the lateral side, this one is slowly getting larger.

 

I am bemused as to why the arthroscopy insertion points are into these swellings...? They cannot be filled with fluid or it may possibly have drained away...? I wonder if they are areas of oedema, but I was under the impression that oedema faded over time, and this has had over 8 years now..? And why is the medial swelling only developing fairly recently, whereas the lateral one has been there for some years...?

 

The photograph of both knees highlights the lateral and medial swelling in comparision to the good, left leg, and a more generalised area of swelling above the knee... and is the good leg showing signs of hyperextension that is not the case with the bad leg...?

 

And I am sure that the area of swelling on the medial side of my knee (B in Fig X) is getting bigger, and is definately much more painful in recent times.

 

 

Pain

 

It seems to me that pains in my knee change depending on what physiotherapy exercises I have been doing and what activities I have attempted at home. Pain in the posteriolateral corner (PLC) of the knee are discussed under 'Symptoms of PLC' damage by http://www.kneeguru.co.uk/KNEEnotes/courses/posterolateral-corner-injuries-knee-course-frank-noyes-md/what-posterolateral-corner-and-why

 

Patients who have chronic deficiency of the one or more structures of the PLC may complain of:

 

• Pain in this area of the knee joint, or in the medial (inside) area of the knee joint

• Hyperextension of the knee during walking, where the knee feels like it is going backwards

• Varus, or bowed leg, which is very noticeable during walking and jogging – especially compared to the opposite leg which is normal

• Feelings of instability, or actual giving-way, during sports or daily activities (sometimes with activities as simple as walking)

• A failed ACL or PCL reconstruction

• Severe atrophy (wasting) of the quadriceps muscle and other muscles in the leg and hip

 

... Patients with severe untreated deficiency to the PLC have tremendous disability with normal daily activities, are not able to walk normally, and have constant pain. The reasons for this are all of the abnormal motions that occur in the knee which technically are:

 

• Abnormally increased lateral joint opening...

• Posterior subluxation of the lateral tibial plateau with tibial rotation (the flattened top of the tibia bone on the outer side has excessive backwards movement)

• Knee hyperextension

• Varus recurvatum

 

http://www.kneeguru.co.uk/KNEEnotes/blogs/admin/pain-back-knee

 

If we consider just the bit at the back of the knee - the posterior horn - of the lateral meniscus, there may be a tear of the meniscus itself, or there may be a disruption in the fibres that frequently attach the rim of the posterior horn to the popliteus tendon as it sweeps along the back of the meniscus. Either of these possibilities may result in pain at the back of the knee. The pain may be accompanied by feelings of knee instability and giving way.

 

It seems to me that if either: 

• a tear in the lateral meniscus,

• a disruption in the fibres that frequently attach the rim of the posterior horn to the popliteus tendon,

So then if one is corrected and the pain still persists, then it might be expected that the uncorrected issue was causing the pain. In my case, the tear in the lateral meniscus was corrected, so the problem must stem from a disruption in the fibres that frequently attach the rim of the posterior horn to the popliteus tendon.

 

 

http://www.drallenfanderson.com/knee/meniscal-injuries

 

Chronic Meniscal Tear

A patient who has had a meniscal tear for several months or longer typically presents with intermittent pain, catching or locking symptoms. Physical examination also reveals tenderness over the joint line, pain with forced hyperflexion, and occasionally muscle atrophy and an effusion...

 

Meniscal tears can be either traumatic or degenerative in nature. Meniscal tears are uncommon in persons under 10 years of age, but become increasingly common during and after adolescence. Degenerative tears can be found in as much as 60 percent of the population over age 65. The majority of these tears, however, are asymptomatic and occur in association with degenerative joint disease. The changing patterns of meniscal injury with chronological age most likely correlate with alteration in collagen fiber orientation with aging, as well as increasing intrasubstance degeneration.

 

This shows the importance of understanding the background of the injury. Clearly if there is no trauma recorded and the patient is elderly, then think 'degenerative'. But whatever the age of the patient, if trauma was involved, then this must be considered. Damage to structures within the area of the knee may cause damage that may be deemed 'degenerative', and there may also be damage that results from misalignment issues.

 

Also see Proximal Tibiofibular Joint

 

 

Radial Lateral meniscus tear

 

http://www.orthop.washington.edu/?q=patient-care/articles/sports/torn-meniscus.html

 

Traumatic meniscal tears are usually radial or vertical in the meniscus and are more likely to produce a moveable fragment that can catch in the knee and therefore require surgical treatment...

 

Most traumatic meniscal tears occur as a result of a twisting injury when the knee rotates but the foot stays fixed in position...

 

A torn meniscus often causes the knee to make extra joint fluid. There is more room in the knee for fluid when the knee is slightly bent. Therefore, people with chronic swelling tend to hold the involved knee in a bent position and develop hamstring tightness and joint contracture. Also, a piece of torn meniscus that is moving in and out of place can damage the nearby articular (gliding) surfaces and lead to arthritis...

 

 

http://www.ajronline.org/doi/full/10.2214/AJR.07.2051

 

The popliteus muscle is a major dynamic stabilizer of the lateral knee and arises from the posterior medial proximal tibia, extending superiorly and laterally to form a tendon that continues into the joint through the popliteal hiatus, deep in relation to the fabellofibular and arcuate ligaments [33, 35–37]. The popliteus tendon has a major insertion at the anterior aspect of the popliteal sulcus of the lateral femoral condyle, anterior and inferior to the femoral origin of the fibular collateral ligament [29]. The popliteus tendon also sends fibers to insert on the posterior horn of the lateral meniscus (anteroinferior, posterosuperior, and posteroinferior popliteomeniscal fascicles) that form a strong attachment to the posterior horn lateral meniscus around the popliteal hiatus [28, 37] and prevent the lateral meniscus from excessive forward displacement during knee extension [31].

 

 

Snapping

 

http://www.healio.com/orthopedics/journals/ortho/2012-7-35-7/%7B9337a9c6-d5da-4601-a494-550892ddf5a4%7D/snapping-knee-caused-by-a-popliteomeniscal-fascicle-tear-of-the-lateral-meniscus-in-a-professional-taekwondo-athlete

 

The popliteomeniscal fascicles consisted of 3 fasciculi (anteroinferior, posterosuperior, and posteroinferior), resulting in static and dynamic connections between the lateral meniscus and the popliteus tendon. The popliteomeniscal fascicles are also important in controlling the motion of the lateral meniscus during knee flexion and extension.2,9,10

Popliteomeniscal fascicle tears are difficult to diagnose because their clinical manifestations and MRI findings resemble those of other conditions.2 Although injury to an isolated popliteomeniscal fascicle may result in instability of the lateral meniscus and mechanical symptoms, the clinical manifestations of popliteomeniscal fascicle tears are nonspecific...

Discussion

This article describes the diagnosis and treatment of a snapping knee caused by a posterosuperior popliteomeniscal fascicle tear of the lateral meniscus. The snapping symptom could be induced voluntarily, but evidence of structural disorder around the knee joint was not detected by physical examination or radiologic evaluation. A posterosuperior popliteomeniscal fascicle tear was confirmed by arthroscopic examination via a popliteal hiatus view and by the finding of meniscal subluxation into the joint during arthroscopic probing. Direct repair of the popliteomeniscal junction resulted in a clinically successful outcome...

Conclusion

Snapping of the lateral aspect of the knee can be caused by a popliteomeniscal fascicle tear with no trauma in a professional athlete. On arthroscopy, the popliteal hiatus view can be valuable for the diagnosis of popliteomeniscal fascicle tear, a condition difficult to diagnose due to nonspecific results on physical examination and low accuracy of MRI.

 

However it is thought that the popliteomeniscal fascicles are best seen on sagittal MR arthographic images as discussed by: http://www.ortopediavirtual.com.br/docs/ar20080200_Popliteomeniscal_Fascicles_Anatomic_Considerations_.pdf

 

 

Static stability

 

http://bjsm.bmj.com/content/37/4/358.full

(Br J Sports Med 2003;37:358-360 doi:10.1136/bjsm.37.4.358)

 

Various static and dynamic functions have been attributed to the popliteus, including “unlocking” of the knee joint,10 initiation and maintenance of internal rotation of the tibia on the femur,1,2,6,9 and preventing forward dislocation of the femur on the tibia during initial flexion.2It is the only muscle that has sufficient mechanical advantage to produce internal rotation of the tibia on the femur during gait.11 It is said to be an important static stabiliser of the posterolateral corner, acts as a secondary restraint to posterior displacement of the tibia in posterior cruciate ligament deficient knees, 12 and produces an active pivot shift if electrically stimulated.9 In our case, however, when the joint was stressed, the other posterolateral structures compensated for the lack of the popliteus and maintained the stability of the joint.

 

Various static and dynamic functions have been attributed to the popliteus:

1. unlocking the knee joint,

2. initiating and maintenance of internal rotation of the tibia on the femur,

3. preventing forward dislocation of the femur on the tibia during initial flexion.

 

It seems to me that, if the popliteus is contracted when the knee is extended, then the 'grip' of the popliteofibular ligament will be tighter as there is more bulk to hold. Therefore when the knee is flexed, the popliteus will be thinner, so the popliteofibular ligament will not have so much to 'grip' or hold on to. See Fig xxxxxxxxxx.

 

http://www.boneandjoint.org.uk/highwire/filestream/16763/field_highwire_article_pdf/0/636.full-text.pdf

(J Bone Joint Surg [Br] 1999;81-B:636-42)

 

We believe that dynamic stability of the posterolateral corner of the knee is provided by the iliotibial band, the lateral head of the gastrocnemius, biceps femoris and popliteus. Static stability is provided by the PFL [popliteofibular ligament], LCL, patello-fibular ligament and the arcuate ligament...

Conclusion...

1. The PFL is an integral structure in the posterolateral corner of the knee.

2. The popliteus muscle has static and dynamic functions. The latter is attributable to the muscle belly originating from the posterolateral corner of the tibia. The static function is served by the popliteofibular ligament

3. The PFL plays an important part in stabilising the posterolateral corner of the knee

by preventing posterior translation, varus angulation and coupled and primary external rotation...

 

 

http://www.drsarahsimison.com/biomechanics-blog/fibular-head-and-associated-lateral-knee-pain

(15/04/2013)

 

Actions of the fibula relate to upper leg and down to the foot

... one thing stands out - the lateral hamstring (biceps femoris) is the only upper leg muscle that attaches to the fibula.  However it is a large muscle and a prime mover for knee flexion.  Interestingly, since the long head of the biceps femoris also attaches to the pelvis it is also a hip extensor.  This muscle acts best as a hip extensor when the knee is flexed, and as a knee flexor when the hip is flexed.  It is inefficient at producing both movements simultaneously.

Interestingly the fibula is also the origin for many of the muslces that insert into the toes. This makes it an integral portion of both the lateral kinetic chain as well as the chains that run through the deeper sections of the front of the body.  It plays an important role in transmitting forces from the knee to the ankle.

 

 

Note: This article deals with all the areas affected after my injury:

groin,

knee,

ankle,

toes,

AND all under the heading of 'Fibular'...

 

   I wonder if my fibular is loose...??? 

 

Popliteomeniscal_Fascicles

 

http://www.ortopediavirtual.com.br/docs/ar20080200_Popliteomeniscal_Fascicles_Anatomic_Considerations_.pdf

(AJR 2008; 190:442–448)

(See page 447 for indepth discussion about the popliteus muscle - tendon complex)

 

... the popliteus muscle-tendon complex has attachments that form a robust-appearing cruciate arrangement: a superior attachment to the femur at the popliteal sulcus, an inferior trianglular attachment of the main muscle bulk to the posterior aspect of the tibia, a robust inferolateral attachment to the fibular styloid process via the popliteofibular ligament, and several complex superomedial attachments to the joint capsule, lateral meniscus, oblique popliteal ligament, and the ligament of Wrisberg. The importance of the popliteus muscle-tendon unit is highlighted by these robust-appearing attachments and by ... dynamic and static functions that include balancing and controlling neutral tibial rotation, acting as a principle dorsolateral knee stabilizer, and preventing lateral meniscus entrapment during knee flexion by retraction of the meniscus via popliteomeniscal fascicle attachments...

... the popliteomeniscal fascicles were best seen on sagittal MR arthographic images.

 

It might seem that it is not the popliteofibular ligament, rather popliteomeniscal fascicles that retract the lateral meniscus to prevent its damage, and so they do.

 

The popliteomeniscal fascicles are considered functionally important stabilizers of the lateral meniscus, working in conjunction with the popliteus musculotendinous unit to prevent excessive lateral meniscal movement and possible entrapment.

 

There has been increasing interest in the meniscocapsular attachments of the popliteus muscle-tendon complex. These attachments not only are important in allowing the tendon to pass through the joint capsule to assume an extraarticular location but also act in concert with the popliteus complex to retract the lateral meniscus from the joint during knee flexion to prevent excessive meniscal shearing forces and entrapment...

 

... the lateral portion of the anteroinferior popliteomeniscal fascicle passed downward and in a lateral direction to form a conjoined attachment with the popliteofibular ligament at the fibular styloid process, resulting in a connection between the lateral aspect of the body of the lateral meniscus and the styloid process of the fibular...

 

The anteroinferior popliteomeniscal fascicle joins up with the popliteofibular ligament at the fibular styloid process / apex of the fibular head, and consequently with the lateral aspect of the body of the lateral meniscus.

 

This does give a link between the retraction of the lateral meniscus and the popliteofibular ligament. So it may be the popliteofibular ligament that initiates the retraction of the lateral meniscus via the anteroinferior popliteomeniscal fascicle.

 

eot