A 22-year-old male runner complains of lateral right knee pain that radiated from the lateral aspect of the knee, up the lateral thigh, and down to the proximal aspect of the lateral tibia. The pain is aggravated with running, especially on hills, and began about 6 weeks ago while he was training for a triathlon. The patient reported no pain with walking. The patient saw his physician, who prescribed a course of nonsteroidal anti-inflammatory drugs (NSAIDs) and recommended physical therapy. The patient reported being in generally good health and had no significant medical or surgical history.
What structure(s) could be at fault with complaints of lateral knee pain aggravated with running?
A number of structures could cause lateral knee pain with running including the lateral meniscus, lateral collateral muscle, iliotibial band, or lateral band of the gastrocnemius, involvement of the popliteus, or biceps femoris tendonitis.
What might the history of a gradual onset of pain related to a change in training tell the clinician?
This type of history is indicative of an overuse injury.
Why do you think the patient’s symptoms are worsened with running on hills, but not affected with walking?
During walking there is little change in knee flexion and extension during weight bearing whereas with running there is more repetitive knee flexion and extension.
What additional questions would you ask to help rule out referred pain from the lumbar spine?
Questions to ask to help rule out lumbar spine involvement include whether the symptoms are affected with lumbar motions or positions, whether other symptoms such as paresthesia are involved, and whether there have ever been any feelings of weakness.
What is your best working hypothesis at this stage?
The best working hypothesis would be iliotibial band syndrome.
Does this presentation/history warrant a lower quarter screening examination? Why or why not?
This case presents with a clear cause and effect between mechanism and symptoms, so a screening examination should not be necessary.
- An area of mild swelling over the left lateral femoral condyle.
- A slight dimpling of the skin was noted along the midline of the lateral length of the left thigh.
- Patient ambulates with evidence of a heel whip. The feet are held in slight external rotation throughout gait, with the right side more noticeable than the left.
- Excessive pronation noted with gait and weight bearing, right side greater than left.
- There is decreased static and dynamic balance on the right leg as evidenced by unilateral balance activities.
- Pain is elicited with resisted hip abduction.
- Hamstring ...