Lateral Knee Pain

Mimicks of Lateral Meniscus tear

 

I have had a debridement of a radial tear in the lateral meniscus... but I still have the same symptoms. I was told that there didn't appear to be a second lateral meniscus tear... so I suggest then that there are extra-articular pathologies at play mimicking an intra-articular lateral meniscus tear.

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445190/

(2011)

Extra-articular Mimickers of Lateral Meniscal Tears

 

Although lateral-side knee pain is often the result of a meniscus injury, several extra-articular pathologies share signs and symptoms with a meniscus tear...

 

Common extra-articular pathologies that can mimic lateral meniscal tears include iliotibial band syndrome, proximal tibiofibular joint instability, snapping biceps femoris or popliteus tendons, and peroneal nerve compression syndrome or neuritis. The patient history, physical examination features, and radiographic findings can be used to separate these entities from the more common intra-articular knee pathologies...

 

Tears of the lateral meniscus are commonly seen in association with acute anterior cruciate ligament ruptures; however, isolated injuries often occur in a twisting injury or a hyperflexion event.22 Patients with lateral meniscal pathology typically present with swelling, lateral joint line pain, and mechanical symptoms localizing to the lateral aspect of the knee... However, a number of other pathologic entities may present with a similar clinical history and physical examination.

 

 

Common extra-articular pathologies that can mimic lateral meniscal tears include:

1. iliotibial band syndrome,

2. proximal tibiofibular joint instability,

3. snapping biceps femoris,

4. snapping popliteus tendons,

5. peroneal nerve compression syndrome or neuritis.

 

As I glance down this list, I notice that:

• these are all extra-articular pathologies, and would not have been visible during the arthroscopy,

• most of them apply to my leg.

 

Note that these same pathologies are referred to as symptoms of 'snapping':

http://www.scielo.br/scielo.php?pid=S0102-36162012000600021&script=sci_arttext&tlng=en

(2012)

Lateral pain in an athlete's knee: a rare case of dislocation of the femoral biceps tendon

The symptoms of knee "clicks", also called knee snapping, may be due to numerous causes both intra- and extra-articular. The intra-articular causes that are most commonly described are: discoid meniscus, meniscal injury, loose bodies, and synovial plica(2). Extra-articular causes include iliotibial tract syndrome, popliteus tendon syndrome, semitendinosus syndrome and, more rarely, subluxation of the biceps femoris(1-8).

 

In the case described, it was noted during surgery that the tendon of the long portion of the biceps femoris glided over the fibular head and the reflex portion was apparently ruptured, allowing slippage of the tendon that caused the click. Note that it is often difficult to characterize the etiology of dislocation because the use of a pneumatic tourniquet or even the muscle relaxation from anesthesia cause subluxation to not occur. In this case, during the approach, synovial fluid output was noted after opening the bursa described on MRI, suggesting a local inflammatory process, and possibly confirming the presence of the local irritation process. We chose lateral osteoplasty in the fibular head. After this procedure, tendon stabilization was observed without requiring tenodesis.

 

 

Iliotibial Band Syndrome (ITBS) symptoms do not apply to my leg:

• a stiff-legged gait on the affected side as the patient attempts to avoid flexion,

• most patients will walk normally,

• on palpation, there may be tenderness over the lateral femoral epicondyle,

• persistent night pain, pain at rest, or suspicion of additional joint pathology require investigation.

 

Iliotibial band syndrome symptoms do not apply to my leg. However, those of proximal tibiofibular joint stability do, and also include conditions related to other mimicks of lateral meniscal tear pathology.

 

 

Proximal tibiofibular joint stability (PTJS)

 

• chronic dislocation closely mimics lateral meniscus injury,

• complaints of lateral knee popping, clicking, and catching,

• history of symptoms worsening with twisting motions,

• usually lateral pain that increases with direct pressure over the fibular head,

• usually stable with the knee in full extension unless a posterolateral corner injury is present,

• acute traumatic tibiofibular joint dislocation usually presents with a lateral mass and severe proximal pain, especially with dorsiflexion and eversion of the foot.

 

I have just realised the implication of proximal tibiofibular joint stability here. I have been saying for years that my knee is unstable, but nobody agrees with me. However, I don't know exactly what it is that they believe is 'stable', so must assume that they are looking at all the usual ligaments in the knee. So I don't know whether my proximal tibiofibular joint is clinically stable or not...

 

Discussed further at Proximal Tibiofibular Joint

 

 

Biceps femoris tendon

• knee 'clicks' when going down stairs, usually between a third and half way down a standard domestic staircase,

• knee often clicks when I am in the process of sitting down on a chair or the side of my bed and my knee is bent at about 90 degrees,

• extremely tender to touch near the fibular head,

• may appear to have a corregated, wavy feel to it,

• may be extremely painful the day after investigation.

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3014471/

(2010)

Symptomatic snapping knee from biceps femoris tendon subluxation: an unusual case of lateral pain in a marathon runner

Biceps femoris snapping over the fibular head is a rare condition. Reported causes include an anomalous insertion of the tendon into the tibia, trauma, and fibular-head abnormality. However, none of those conditions accounted for his symptoms. Failing conservative treatment, the patient underwent surgery for partial resection of the fibular head, with subsequent sudden resolution of symptoms and return to sport. Accurate knowledge and management of this rare condition is mandatory to avoid inappropriate therapy and unnecessary surgical procedures.

 

He was diagnosed with snapping biceps femoris syndrome and was scheduled for operative exploration. The surgical procedure was performed under combined spinal anesthesia (CSA) without motor block, permitting active knee movement upon request. As noted, at clinical examination, when the tourniquet was placed around the thigh and inflated, tendon subluxation could not be reproduced. A 4-in. longitudinal incision was performed over the fibular head, and the tendon and the common peroneal nerve were isolated (Fig. 3). The diagnosis was confirmed, as the biceps femoris tendon subluxated over the fibular head during knee extension from 120° to 100° with internal rotation.

 

The tendon was inserted normally, with no anatomic anomaly on the anterior portion of the fibular head; however, the tendon subluxated on the superior and posterior portions. We partially resected the posterior portion of the fibular head (Fig. 4) without supplementary procedure on the tendon. Snapping resolved when the knee was passively moved in flexion–extension. Sufficient bone resection was confirmed when the patient moved his knee, with no evidence of tendon subluxation.

 

The patient was discharged the following day and was permitted early motion and progression to full weight bearing, as tolerated, within a few days. After 10 days, a rehabilitation program was started, including range of motion, strengthening, and stretching exercises. The patient was immediately asymptomatic and returned to all sport activities after 2 months.

 

 

www.researchgate.net/...proximal_tibiofibular_joint.../0fcfd51013b896a...

(2010)

Anatomic reconstruction of chronic symptomatic anterolateral proximal tibiofibular joint instability

The most important finding of the present study was that an anatomic reconstruction of the proximal tibiofibular joint restored stability for patients with chronic, symptomatic proximal tibiofibular joint anterolateral subluxation. The proximal tibiofibular joint is stabilized by both its anterior and posterior ligamentous attachments [7, 10]. The anterior aspect of the proximal tibiofibular joint consists of two to three flat ligamentous bands and is reinforced by the biceps femoris tendon, which makes it stronger and less likely to tear than the posterior ligament, which exists as only a single band [1, 16]. 

 

 

http://www.scielo.br/scielo.php?pid=S0102-36162012000600021&script=sci_arttext&tlng=en

(2012)

Lateral pain in an athlete's knee: a rare case of dislocation of the femoral biceps tendon

It was initially reported as an anomalous insertion of the long head of the femoral biceps. Subsequently, it was found to be caused by abnormal mobility of the tendon over the prominence of the fibu lar head at certain angles of knee flexion.

 

This might explain the pain that I had in my right groin area... but it is the tendon of the short head that inserts into the fibular head...???

 

 

Popliteus tendon

 

• knee 'clicks' when going down stairs, usually between a third and half way down a standard domestic staircase,

• knee often clicks when I am in the process of sitting down on a chair or the side of my bed and my knee is bent at about 90 degrees,

• very painful at the back of my knee where the popliteus muscle passes.

 

http://www.wheelessonline.com/ortho/proximal_tibiofibular_joint_injuries

(On website)

PTFJ anatomy:
- synovial joint
- in 10% of the population, the proximal tibiofibular joint is contiguous with the knee joint
- product of embryogenesis

- anterior joint capsule significantly thicker than posterior

• - anterior joint capsule composed of three ligamentous bands

• - bands pass obliquely upward and attach to the lateral tibial condyle

- posterior tibiofibular ligament is composed of two broad, thick ligamentous bands

• - bands pass obliquely from the fibular head to the posterior aspect of the tibial condyle

• - reinforced by the popliteus tendon

 

So the popliteus tendon reinforces the posterior tibiofibular ligament... BUT is my posterior tibiofibular ligament, the weaker of the two ligaments, intact...???

 

And, although I have recently discussed the popliteus system with reference to my MRI scans, it has only just occurred to me that this was of the intra-articular parts of the popliteus, yet most popliteal injuries occur extra-articularly, as discussed by several people. And it is under the guise of extra-articular pathologies, mimicking the lateral meniscus, that now requires examination, especially due to its close proximity to the fibular head.

 

 

Peroneal nerve compression syndrome or neuritis

 

• peripheral nerve sensitivity when brushing my hand along the lateral side of my knee before arthroscopy,

• pulling, pulsing, throbbing, twitching pains down the lateral side of my knee, and also towards the back of my knee...

 

https://depts.washington.edu/neurolog/images/emg-resources/Fibular_Peroneal_Neuropathy.pdf

(2013)

Fibular neuropathy is the most common lower limb mononeuropathy encountered in

athletes.33,34 Common or proximal deep fibular nerve injuries at or near the level of the fibular head are most often found, particularly in football or soccer players, and may be seen in isolation or in association with severe ligamentous knee injuries or fractures.33,34

Some athletes reporting pain and weakness in a fibular nerve distribution have been found to have constriction of the nerve by the fibularis longus muscle.35

Acute or chronic exertional compartment syndrome may also result in foot drop and

should be considered, particularly in athletes with intermittent complaints.36 Superficial fibular nerve injuries at the ankle have been described in soccer players.34 Due to excursion of superficial nerve with inversion, injury may be seen in association

with ankle inversion sprains.37,38

Nerve abnormalities may also occur at the fibular head in the setting of ankle sprains due to traction of the nerve at the posterolateral knee because the patient’s foot is forced into plantar flexion and inversion.39...

 

CLINICAL FEATURES

Patients with fibular neuropathy often present with complaints of “foot drop” or

catching their toe with ambulation, which may develop acutely or subacutely depending

on the precipitating cause. There may also be complaints of sensory loss over the

foot dorsum.

 

Clinical motor examination demonstrates weakness in ankle dorsiflexion and great toe extension with deep fibular and eversion weakness with superficial fibular involvement. Superficial peroneal nerve abnormalities are rarely present in isolation.16,41 Toe flexion and ankle plantar flexion strength should be normal. In the setting of a deep fibular neuropathy in conjunction with an accessory deep fibular nerve supplying complete innervation of the extensor digitorum brevis muscle, foot drop with preserved toe extension can be seen.42

 

I've got little understanding of this last paragraph, and the gist that I do get is that my symptoms are not all the same, but there are 'terms of interest' that might be relevant to my leg:

 

• weakness in ankle dorsiflexion,

• toe extension,

• eversion,

• toe flexion,

• ankle plantar flexion

• extensor digitorum brevis muscle

• foot drop...

 

 

But I know for sure that I present with:

 

... complaints of a “foot drop” AND catching toe with ambulation...

 

 

Symptoms differ

 

This article includes 3 case studies from 1983, showing similarities and differences to meniscal injury.

 

http://www.boneandjoint.org.uk/highwire/filestream/12989/field_highwire_article_pdf/0/310.full-text.pdf

(1983)

In Case 2 the patient had had symptoms from the very begining, but these were so mild that he did not get refered until six years after the injury. The clinical

findings were evident, and resection of the fibular head relieved his symptoms.

Case 3 ilustrates the consequences of misnterpreting the symptoms. Several surgeons had, independently of each other, interpreted the conditon as meniscal, and

unecesary arthrotomies had consequently ben performed.

 

The symptoms in the last two cases were identical: uncharacteristic episodes of locking with an audible “pop” lateraly in the kne ; difuse pain ; a sensation of the kne giving way; and prominence or laxity of the fibular head and distinct tendernes at the site (Sijbrandij 1978). Radiography may confirm the diagnosi.

 

As sen in Case 3, anterior dislocations in the proximal tibiofibular joint may simulate meniscal injury, but the symptoms difer, there being neither intraarticular efusion nor atrophy of the quadriceps, and the episodes of locking are uncharacteristic, brief and

spontaneously reducible.

 

This article is difficult to read but I think it means that anterior dislocation of the proximal tibiofibular joint may show:

• intra-articular effusion,

• atrophy of the quadriceps,

• but episodes of locking are uncharacteristic.

 

In my case:

As I reread, yet again, I've noticed that it is intra-articular effusion that is thought to be connected to meniscal tears and not xxxxxxxxxxxxxxxxxxxxxxxxxxxx

I have weak gluteus medius muscles which may be linked to the cause of the injury, and other muscle weakness including quadriceps, but after so long it is impossible to say when this might have occurred.

I have had symptoms of clicking, but no locking.

 

It seems that there cannot be a right or wrong list of symptoms... but it might be important to consider the consequences, not just of additional surgery and its cost, but also the possibility for pending arthritis in the future. However it seems to me that, with so many possibilities of tendon and ligament laxity surrounding this joint, the potential for a mistake must be high...