Lateral Knee Pain

Retrospectively

 

As life progresses, seemingly negligible incidents need to be pulled together to add to the history of the injury, despite being unable to place them precisely in chronological order.

 

Dorsiflexion of the ankle

 

​It was Winter, and it had snowed quite heavily (for the UK anyway). In preparation for going outside to take some photographs, I wore a pair of old boots. These were rigid plastic with very little 'give' in them. Yes... they were as bad as they sound... I'll say no more than that I overplayed the 'I would really, really love a pair of those boots' card, whilst trying to persuade my daughter, who was about 6 at the time, that they would be so warm and cosy and dry for her... Never mind, nice of her to remember me when the opportunity arose for her to buy them for me... LOL.

 

​After having walked around for a couple of hours, I returned home only to find that I couldn't remove my right boot. The left one pulled off easily, but I couldn't pull off the right one. I couldn't lever it off using my left foot, nor with the doorstep. And, to make matters worse, although I did manage to inch my foot out slowly, this meant that I couldn't stand up on that foot during this process. It must have taken at least an hour to slowly inch off that boot.

 

It was some years later, when my ankle was described as being in dorsiflexion, that I recalled this incident. So it was because my ankle was dorsiflexed that prevented me from removing my boot? Or was it because it couldn't plantarflex? And is there even a difference? As I think back now, I couldn't straighten my ankle joint which I had to do in order to manoeuvre around the rigid 90 degree angle that shaped the boot in order to wriggle out. However https://aclandanatomy.com/abstract/4010439 states that:

 

There’s one muscle on the front of the leg for dorsiflexion, tibialis anterior. There are three on the back of the leg for plantar flexion, gastrocnemius, soleus, and plantaris.

 

The function of the tibialis posterior muscle is described as implicit in both dorsiflexion and plantar flexion by: 

http://www.sportsinjurybulletin.com/archive/tibialis-tendinitis.html:

 

... the tibialis-posterior muscle and its tendon help to plantar-flex your ankle and ‘invert’ your foot (rotate it inward, with the pivot axis at the ankle joint). These basic, concentric actions are not, however, the ones which cause injury in the tibialis posterior and its tendon as you engage in your athletic activity. The problem occurs when the reverse actions take place, ie, when you evert your foot (rotate it outward, with the pivot axis at the ankle joint) and when you dorsi-flex your ankle. 

 

Clearly this was a medical issue that related to the physical performance of my bad, right foot, and may have added light to the dorsiflex vs plantar flex dilemma.

 

 

Uncomfortable chairs

 

It was only just recently that I gave more thought to a problem that I had had probably since the injury. I can vividly remember the neurologist asking me where did I have pain. And basically I hadn't had any pain since the violent, violent, violent pain, but I remembered sitting in agony in the waiting room at the hospital. I told him that the chairs were so uncomfortable for me causing great pain around my thigh. The neurologist said nothing.

 

As I recall events now, I had this great pain in my thigh at every hospital appointment that I went to:

Local orthopedic clinic

Local physiotherapy department

Another local orthopedic clinic

London orthopedic clinic

London physiotherapy department

London Sports Injury clinic.

 

And each time I mentioned this pain, staff at the hospitals would say something like... 'Well, it is unfortunate but the chairs have to fit everyone and I can't possibly expect to have different styles to suit me...' which quickly put me in my place.

 

However, as I reflect now, nobody actually asked me if it was in both legs... and 'No', it wasn't. It was only in my right (bad) leg. It seems to me that this, which still continues to this day, must be implicit as I had no such pain in my left (good) leg. And it may add infomation as to why my right bum cheek is numb, and my '... quadriceps muscles and gluteus medius...' appear weaker on the right hand side.

 

 

Walking at an angle

 

When walking back from the town some years ago, I met a friend, or rather an acquaintance. He detoured from his route cycling into town and approached me on the pavement. I apologuised to him saying that I didn't immediately recognise him to which he replied... 'I always recognise you by the way you walk'... Well, I was gobsmacked! I had no idea that my walking was not normal.

 

Then, perhaps some months later, I caught sight of my shadow on the front door curtain in the hall... I was continually lurching towards the right as I walked. This may have coincided with a description that I gave the GP... 'I feel like I am walking around at an angle'... and would hold my left hand up illustrating this leaning motion, like a forward slash, '/' on the keybroad.

 

It seems now that this lurching may have related to an extended amount of time I spent in the stance phase of gait with my right foot.

 

 

Start at the beginning

 

When you are in pain and feeling vulnerable, it is very difficult to object to anything that a doctor tells you. Outpatient doctors always seem to be short of time, and probably consultations are kept brief in misguided attempts to save money. But it is sooooo very important to start right at the beginning!

 

At my first London appointment, I was asked, 'What's the main problem?' I wasn't prepared for this starting point and hastily went on to discuss pains in the lateral side of my right knee, omitting the issues with my ankle and even the fact that I was jogging. Oh... it was supposed to be a sports injury appointment. I did mention that I thought that it was a popliteus problem, thinking that that knowledge would bring with it all the relevant baggage associated with the popliteus, but my comment was not welcomed.

 

Although I had been told that we could discuss the popliteus in more detail at my next appointment, that second doctor / fellow / student / whatever, said that he hadn't studied the popliteus and therefore couldn't answer any questions about it, nor show me it on the MRI on his PC screen. Neither would he discuss the gait of my right foot, saying that they only do '... knees and hips...' I remember saying, 'I'm not asking you to fix it, just to consider it in relation to the problem with my knee...'

 

It was at this point that he asked me if I wanted to have the arthroscopy to repair a small tear in the lateral meniscus or not, and I replied 'Yes'; however, I do believe, retrospectively, that perhaps I should have declined...

 

 

Think outside the box

 

If as a physiotherapist, you find that a patient does not appear to be consistant with their recollections of pain, you need to consider 'why' such ambiguities may occur:

 

• Did you give them a new exercise to include in their therapy?

• Do the patient's comments reflect more than that given in your brief?

• Have you seriously considered the posterolateral corner of the knee when working on the lateral side?

 

It seems to me that if, for example, a patient is given gait-training exercises that they have never done before, then this might alter their whole pattern of pain. Their comments may stretch beyond the remit and perhaps be covered by the notion of proprioception, but may equally be explaining a yet undiscovered pathology.

 

And everyone who encounters pain in the lateral side of the knee must include an awareness of the posterolateral corner, and the popliteus system, which can swap its functionality depending on whether it may be deemed the origin or insertion point for the activity. And the easily forgotten proximal tibiofibular joint near the head of the fibular.

 

 

Additional memories

 

As I work through this website and additional information unfolds, I remember more 'little bits' that virtually passed unnoticed.

 

Loose fibular

 

Some years ago now, and not getting anywhere with my local NHS, I paid for private physiotherapy. Nothing noteworthy happened until the next morning when I got out of bed... I did not notice, but I had no pain! As usual, I walked from my bed to the window and looked out for a few seconds. Then I walked around the side of my bed and along the end... Then pain hit the lateral side of my knee!... I realised that I had had no pain in my leg and could walk properly after getting out of bed up to this point... From getting out of bed to walking around my bed, the morning after having physiotherapy, I had had no pain for a short time. A while later, I asked the physiotherapist what she had done that might result in this painfree moment, but she could not remember...

 

I told the GP that I had been seeing, but he made no comment!

 

Some time later, I was concerned about my fibular, probably because of pain, I can't precisely remember. I saw another GP and asked him about a couple of issues:

• clicking in my right knee,

• is my fibular was 'loose'. 

 

He made some comment to the effect that as we get older we are bound to get some clicking in the joints, and that he, himself, gets clicking in his knees.

 

When I asked about my fibular, he quickly pulled my leg up across his lap and attempted to move the head of my fibular. He made no comment but to say that he would write to the consultant... but nothing materialised...

 

 

'Stone' behind knee

 

I can remember telling a physiotherapist that it felt to me as if there was a stone-like object behind the lateral area of my knee, about the size of a hen's egg, but flattened. She couldn't feel anything... But it was at this point that my local NHS stopped the physiotherapy sessions!