Lateral Knee
LATERAL KNEE
Dull Ache / Sharp Pain
Biceps femoris tendinopathy
- May present as a constant dull ache at rest
- Can be sharp on certain active movements
- May be sore when walking up or down stairs
- Tender on palpation of proximal fibula
- Diagnosed through palpation and active resisted muscle testing with patient prone
- Treatment through manual therapy and rehab exercises (heavy slow resistance training)
Popliteus tendinopathy
- May present as a constant dull ache at rest
- Can be sharp on lateral active movements
- Tender on palpation of lateral femoral condyle
- May occur after injuries to knee involving hyperextension or suddenly stopping
- Diagnosed through palpation and active resisted muscle testing with patient prone
- Treatment through manual therapy and rehab exercises (heavy slow resistance training)
Lateral collateral ligament sprain (M=F 15–35)
- Local pain on outside lateral knee
- Painful to try and flex or straighten leg
- May be accompanied with a limp depending on sprain level (1,2,3)
- Can be painful when actively flexing knee (walking upstairs)
- May be caused by direct trauma (tackled in sport)
- Increased severity of symptoms may indicate a tear
- Diagnosed through palpation, ultrasound, or MRI
- Treatment through rest from activity and manual therapy to surrounding tissues and joints
Fibula head / tibia joint capsular sprain
- Local pain on outside lateral knee
- Painful to try and flex or straighten leg
- Can be painful when actively flexing knee (walking upstairs)
- May be caused by sudden movements in knee
- Diagnosed through case history and palpation
- Treatment through rest from activity and manual therapy to surrounding tissues and joints
Delayed onset muscle soreness (DOMS)
- Pain on lateral knee felt after gym sessions, exercise, or repetitive activities
- Exercise routine may have included squats, jumps, or high intensity group classes
- Self resolves within a week
Foraminal / Central canal stenosis with nerve root compression at Lumbar vertebra L5
Symptoms:
- May present as local dull ache
- Unrelenting lower limb pain with neurological symptoms in related areas of the leg
- Radiculopathy down leg – burning, pins and needles, numbness, tingling
- Painful to extend back
- Weakness in leg(s)
- Muscle atrophy in lower limb
A) Lumbar Disc herniation (M>F 40-60)
Caused by:
- trauma
- poor posture,
- repetitive activity
- overweight
Diagnosed via:
- Muscle testing (myotomes)
- Sensory testing (dermatomes)
- Patella tendon reflexes
- Lying / Sitting straight leg test
- Valsalva manoeuvre
- Observing for atrophy in muscles
- Case history of trauma, or poor lifting techniques involving twisting
- MRI
Treatment:
- Surgery
- Cortisone injection
- Conservative – medication, rest, manual therapy to surrounding musculature
- Disc herniations can heal on their own in 6-9 months
B) Vertebral spurs
Caused by:
- Osteoarthritis
- Trauma / Injury / fractures
Diagnosed by:
- X-ray
Treatment:
- Medication to reduce inflammation and pain
- Cortisone injection
- Surgery
- Manual therapy to surrounding musculature
C) Anterior longitudinal ligament ossification (Thickening)
Caused by:
- Unknown
- Hereditary
- Diffuse idiopathic skeletal hyperostosis (DISH)
- Trauma
Diagnosed by:
- X-ray / MRI
Treatment:
- Medication to reduce inflammation and pain
- Manual therapy to surrounding musculature
- Cortisone injection
- Surgery indicated when airways are potentially being blocked
D) Space occupying lesion (Cyst)
Caused by:
- Genetics
- Chronic inflammatory conditions
- Trauma / Injury to arteries, veins, lymphatics
- Blockages to ducts
Diagnosed by:
- MRI
Treatment:
- Surgery
Drainage
- Injecting cyst to reduce swelling and pain
- Laser removal
E) Space occupying lesion (Tumour)
Symptoms:
- May include systemic signs such as night pain, night sweats, fever, or enlarged lymph nodes
Caused by:
- Genetics
- Trauma / Injury
- Infectious disease
- Obesity
- Cigarette smoking / Excessive alcohol
Diagnosed by:
- MRI
Treatment:
- Surgery
- Radiation / Chemotherapy
LATERAL KNEE
Numbness, Tingling, Weakness, Burning or Muscle atrophy
Foraminal / Central canal stenosis with nerve root compression at Lumbar vertebra L5
Symptoms:
- Numbness, tingling, or burning sensation with radiculopathy down leg
- May also present only locally on outside of knee with similar neurological symptoms
- Severe pain in low back region
- Painful to lean backwards (may produce sharp pain or neurological symptoms outside of knee)
- Weakness in leg(s)
- Muscle atrophy in lower limb
- Patient may find relief laying on their back with knees bent and legs raised onto a chair
A) Lumbar Disc herniation (M>F 40-60)
Caused by:
- trauma
- poor posture,
- repetitive activity
- overweight
Diagnosed via:
- Muscle testing (myotomes)
- Sensory testing (dermatomes)
- Patella tendon reflexes
- Lying / Sitting straight leg test
- Valsalva manoeuvre
- Observing for atrophy in muscles
- Case history of trauma, or poor lifting techniques involving twisting
- MRI
Treatment:
- Surgery
- Cortisone injection
- Conservative – medication, rest, manual therapy to surrounding musculature
- Disc herniations can heal on their own in 6-9 months
B) Vertebral spurs
Caused by:
- Osteoarthritis
- Trauma / Injury / fractures
Diagnosed by:
- X-ray
Treatment:
- Medication to reduce inflammation and pain
- Cortisone injection
- Surgery
- Manual therapy to surrounding musculature
C) Anterior longitudinal ligament ossification (Thickening)
Caused by:
- Unknown
- Hereditary
- Diffuse idiopathic skeletal hyperostosis (DISH)
- Trauma
Diagnosed by:
- X-ray / MRI
Treatment:
- Medication to reduce inflammation and pain
- Manual therapy to surrounding musculature
- Cortisone injection
- Surgery indicated when airways are potentially being blocked
D) Space occupying lesion (Cyst)
Caused by:
- Genetics
- Chronic inflammatory conditions
- Trauma / Injury to arteries, veins, lymphatics
- Blockages to ducts
Diagnosed by:
- MRI
Treatment:
- Surgery
Drainage
- Injecting cyst to reduce swelling and pain
- Laser removal
E) Space occupying lesion (Tumour)
Symptoms:
- May include systemic signs such as night pain, night sweats, fever, or enlarged lymph nodes
Caused by:
- Genetics
- Trauma / Injury
- Infectious disease
- Obesity
- Cigarette smoking / Excessive alcohol
Diagnosed by:
- MRI
Treatment:
- Surgery
- Radiation / Chemotherapy
Multiple sclerosis (F>M 20-40)
- Peripheral neuropathies
- Commonly unilateral
- Blurred or loss of vision in one eye
- May cause atrophy of muscles or loss of motor control
- May cause tremors
- Weakness in one or both legs
- Clumsiness of limb
- Feeling of walking on cotton wool
- Diagnosed through MRI (looking for lesions on brain or spinal cord), Lumbar puncture looking for abnormalities in antibodies in cerebrospinal fluid associated with MS)
- Often a diagnosis of exclusion as other conditions produce similar symptoms
- Treatment: medications
Local peripheral nerve damage (Lateral femoral cutaneous)
- Numbness and tingling
- Sharp, jabbing, or throbbing pain
- Sensitive to touch
- Gradual onset of symptoms
- Caused by local trauma, repetitive movements, crushed, or cut nerves (surgery),
- Medical causes: Diabetes, Multiple sclerosis, Guillain-Barre syndrome
- Electromyography (EMG test), Ultrasound, Nerve conduction test
- Treatment: self-resolving in 12 months, Surgery, or may not fully resolve
Reflex sympathetic dystrophy (Complex regional pain syndrome)
- Chronic limb pain
- Pain is greater than expected than injury that may have caused it
- Continuous throbbing, burning, numbness and tingling
- Sensitive to touch (painful)
- Skin colour and temperature changes
- Not well understood
- May be post-surgery, injury, stroke, or heart attack
- May involve abnormal inflammation or nerve dysfunction
LATERAL KNEE
Medical Considerations
Lateral collateral ligament sprain / tear (Grade 1,2,3)
- Local pain on outside lateral knee
- Painful to try and flex or straighten leg
- May be accompanied with a limp
- Can be painful when actively flexing knee (walking upstairs)
- May be caused by direct trauma (tackled in sport)
- Unable to walk may indicate a tear (grades 2,3)
- Diagnosed through palpation, ultrasound, or MRI
- Grades 2 or 3 tears may require surgery if pain and limping persist for more than 6-8 weeks
Fibula head fracture
- History of trauma
- Immediate swelling
- Tender to touch
- Bruising
- Limping
- May have visible signs of deformity
- Unable to weight bear
- Diagnosed via X-ray
Lateral femoral condyle fracture
- History of trauma
- Immediate swelling
- Tender to touch
- Bruising
- Limping
- May have visible signs of deformity
- Unable to weight bear
- Diagnosed via X-ray
Osteoarthritis (F>M 50+)
Degeneration of joint cartilage and underlying bone
- Stiff, tender, and swollen joints
- Morning stiffness lasting up to 30 minutes
- Aches and pains in muscles
- Decreased joint range of motion
- Fatigue feeling or tiredness
- Can cause physical deformity
Caused by:
- Increased weight (obesity)
- Females > Males
- Increased age
- Joint injuries
- History of fractures
- Repeated stress on joints (repetitive activities)
- Genetics
- Bone deformities
- Metabolic disorders
Diagnosed via: X – rays, observation for physical deformity
Treatment:
Condition can not be reversed. Treatment is aimed at reducing symptoms and increasing range of motion
- Manual therapy to help with surrounding soft tissue structures
- Exercise to help strengthen muscles and joints
- Medications to help reduce inflammation
- Cortisone injections into joint
- Surgery for joint replacements
Rheumatoid arthritis
Definition: an autoimmune disease, where the body mistakes its own cells as foreign invaders.
This causes an attack of the body’s joint synovium by inflammatory chemicals. Flare ups may
last from months to a lifetime with symptoms being episodic in nature.
Symptoms: (mimics many other arthritic conditions in early stages)
- Insidious onset of pain and stiffness, swelling and warmth that begins with thesmall joints of the hands and/or feet.
- Commonly affects people aged 25-45 years old.
- More than 1 joint is affected, usually bilateral involvement
- Symmetrical involvement of the metacarpophalangeal or metatarsophalangeal joints
- Symptoms may come and go
- Morning stiffness which can last hours
- Fatigue, low-grade fever, weakness
- Soft tissue swelling
- Joint effusion and synovial swelling
- Tenderness on palpation or movement of joint
- Joint Deformities (Boutonniere, Swan Neck, Z deformity of wrist, Ulnar deviation)
Caused by:
- Genetics: gene HLA-DR1
- May be associated with poor diet (high in red meats, processed meats, refined grains, fried foods, high fat dairy and sugar can increase chances of developing RA
Examination:
- Physical examination of joints observing for swelling, warmth, redness, tenderness, decreased range of motion, palpation of joint line irregularities, and joint deformity.
- Morning stiffness lasting more than 30 minutes
- Blood tests will be looking to diagnose:
- Rheumatoid factor
- Erythrocyte sedimentation rate (ESR)
- Full blood count (CBC)
- CCP antibodies
- Antinuclear antibody (ANA)
- C – reactive protein (CRP)
Treatment:
- Disease Modifying Anti -Rheumatic Drugs (DMARDs)
- Analgesics and NSAIDs
- Education on exercises
- Hydrotherapy
- Diet – introducing omega3 and fish oils
- Acute flare ups require rest
- Rheumatologist management
Prognosis:
- Fair to poor. Depending on number of symptoms. Can last for months to a lifetime depending on flare ups and management.
Psoriatic arthritis (M=F 30-55)
Definition: chronic, autoimmune form of arthritis that causes joint inflammation and occurs with the skin condition psoriasis. Immune system attacks healthy cells in the body by mistake causing symptoms
Symptoms:
- Red patches of skin topped with silvery scales
- Multiple joint pain, stiffness, and swelling
- Swollen fingers and toes
- Nails may form pits, crumble, or separate from the nail beds.
- May present similarly as Ankylosing spondylitis
Caused by:
- Genetic predisposition (HLA-B27 gene)
- May be triggered by a viral or bacterial infection when genetically predisposed
- Physical trauma to joints may predispose to Psoriatic arthritis
- Psoriasis skin condition often predisposes Psoriatic arthritis
Examination:
- Observe for signs of swelling and tenderness around joint
- Pitted fingernails
- May present unilaterally or bilaterally
- PsA should be suspected in any patient who has psoriasis and arthritis, however it may be present in both
- Blood tests provide negative Rheumatoid factor
- Joint fluid test. Small fluid is aspirated from affected joint and examined for uric crystals which will indicate gout rather than PsA )
- X- ray to examine for joint destruction
Treatment
- DMARDS
- NSAIDS
- Management through Rheumatologist
- UV Light therapy for skin issues
- Steroid injections
- Joint replacement surgery
- Manual therapy to help increase joint ROM and reduce muscle HT
Prognosis:
Fair to poor. Although a chronic condition with no cure, condition can be managed conservatively with Rheumatologist, medications, and manual therapy
Reactive arthritis (Reiter’s syndrome M>F 20-50)
- Auto immune condition that develops in response to an infection
- Common infections found are Sexually transmitted (Chlamydia Trachomatis)
- Currently no cure
- Sausage-like swelling in fingers and toes
- Morning joint stiffness
- Pain, tenderness, swelling in your joints and tendons
- Low back pain
- Eye irritation
- Burning sensation on urination
- Symptoms may only last up to 6 months
- HLA-B27 genotype is predisposing factor in 65% of patients
- Blood and infection tests
- Antibiotics, Non steroid anti inflammatory medications, Steroids, Immunosuppressive medications, rest, and light exercise to help strengthen muscles and improve joint function
Reflex sympathetic disorder / Complex regional pain syndrome (CRPS)
- Chronic limb pain
- Pain is greater than expected than injury that may have caused it
- Continuous throbbing, burning, numbness and tingling
- Sensitive to touch (painful)
- Skin colour and temperature changes
- Not well understood
- May be post-surgery, injury, stroke, or heart attack
- May involve abnormal inflammation or nerve dysfunction
Treatment: Challenging to manage as results vary between patients. Some options may include:
- Acupuncture
- Pain relief medication, anti inflammatory medication
- Nerve block injection, morphine
- Intravenous Ketamine
- Manual / Physical / Exercise therapy
- Meditation, relaxation therapies