T Nation

Frustrating Posterior Right Knee Problem


#1

In mid-May of this year while performing sitting hamstring curls, probably too recklessly, I injured the rear of my right knee. I didn’t notice anything during the exercise, but when I stood up from the machine, I noticed severe tightness in the back of the knee that just wouldn’t go away. No pain, just tightness. Only feel anything while standing, not sitting or lying down.

Ever since then, it comes and goes but always comes back. Vast majority of the time I only feel tightness and no pain. Sometimes though I only feel pain and no tightness. Sometimes even both. I feel pain and/or tightness in different parts behind the knee. 97% of the time I feel the pain or tightness below the knee, the remaining time I feel a substantial pain above the knee. When the pain is below the knee, it isn’t that bad. When it is above the knee, it is usually significant. On one brief occasion, it was extreme. So I feel the pain and/or tightness in several different places, the only constants are that they are always the medial and posterior parts of the knee.

Even though I feel it in multiple different locations behind the knee, they are always mutually exclusive.

When stretching, I always have a harder time stretching the right hamstring.

Over the months warming up, stretching, and foam rolling the area always provides temporary relief, but invariably it always returns like nothing ever happened. It hasn’t gotten any better or worse.

For a while I thought it was a cyst moving around the knee, but my doctor told me cysts don’t move around. MRI did find a cyst, but on the OPPOSITE side of the knee.

X-rays found nothing.

MRI found:
“No definite tear of the lateral meniscus. There is a focal fluid collection/paramensical cyst anterior to the anterior horn of the lateral meniscus measuring .9 x 1.2 x 1.5 cm. Parameniscal cyst can be associated with meniscal tears, but no discrete meniscal tear can be visualized. There is some T2 hyperintensity/edema and mild irregularity of the articular cartilage, midline and lateral facet, consistent some chondromalacia patella/prior trauma.”

I’ve seen two doctors about it but they almost laugh at me. The only things they suggest is a cortisone injection. I want to solve the underlying issue. I believe this tightness is affecting my right hip because I now have right hip problems. Need to get it solved, but I don’t know what else to do. The only thing I can think of doing is having the cyst removed, but since it’s on the opposite side of the knee, it doesn’t seem like that would help much. I’ve never felt anything on the lateral side of the knee where the cyst supposedly resides.

Another thing is my right kneecap painlessly pops all the time, but not sure if this has anything to do with the problem. This is also kind of a recent thing.

Anyone know what could possibly be the issue? I’ve pretty much reached the end of the line with doctors.


#2

Sorry to hear about your past experiences. Must be truly frustrating. You aren’t paying doctors enough to go full diagnostician on your injury ala House M.D. which takes plenty of time and money with a case like your’s that isn’t so cut and dry. Often an exact diagnosis and identification of the structure that is the source of symptoms and mechanism of symptoms is simply jargon that offers little more than peace of mind. Treating symptoms with corticosteroids is often enough and can give important information as to the inflammatory component or otherwise of the injury

It sounds like you’ll need to see a physical therapist or physiotherapist who you’ve paid good money to take the time and put together a comprehensive history and examination to identify the source of your systems.

Many potential symptom sources/ structures are located in the area posteromedial to your knee joint and immediately above and below. Muscles, tendons, scar, ligaments, nerves, joint capsule and other structures you’ve never even heard of could be possible sources.

Here’s some thoughts:

  • Time since injury >3months implies that the issue remains or you’ve not allowed it to heal properly e.g. rest from and gradual return to activity. Mismanagement can lead to chronic issues.

  • The asymptomatic cyst is probably not relevant. Imaging findings have to be taken in context and any abnormalities not consistent with presentation and clinical findings are likely irrelevant to the case at hand.

  • Standing lengthens many structures and puts them on stretch, aggravating your symptoms

Tbh could be many things from nerve entrapment to tendinopathy so would recommend seeing someone who will take the time to properly take a look.


#3

I’ve honestly noticed no change in the condition since the injury. I’ve gone through periods of rest and intense physical activity, you could argue it felt better during the latter. Based on personal experience I’m beginning to think that I need an operation, rest or activity has no effect. I’m being far more careful doing sitting hamstring curls, have continued doing them, the problem has not worsened despite that. I noticed that my form was poor at the time.

Is there any possible benefit of a steroid shot? I mean, the pain/tightness I can live with. I’m a man lol, I’ve dealt with far worse pain such as crippling back pain for years and was like whatever. But would there be a path to recovering from this by getting it? For many ailments in the past it has been recommended for “pain management” but I never cared about managing pain, I only want to do things that make the underlying problem go away.

I’ve seen a few PTs since the injury, not specifically for this injury, but they did give me their opinions. One said he thinks its my hamstring tightness that led to this and I need to stretch it out. It is true that I have really tight hamstrings. The other PTs didn’t have much to say. The city where I live is small and so access to world class physical therapy is really hard to find if it even exists here. I’ve had many many PTs in my time and I can honestly say I’ve received very little return on investment. Out of a dozen PTs that I’ve seen in my time, the only time a PT seemed to help me was my current PT who suggested I was tight in a lot of places and really needed to stretch like a madman, and that seems to be helping my hip problem. But the only opinion he offered me on my problem is that it might be some sort of “referred tightness from the cyst”, like somehow the cyst is causing this even though it’s on the opposite side of the knee. No other doctor or PT seems to share this opinion and I can’t find anything about it online so I’m thinking he probably just pulled it out of his ass.

Resting actually seems to aggravate it. It is worst in the morning. When I am most active during the day is when I feel the least amount of pain/tightness. In particular, when the leg is warmed up such as when doing cardio or lifting. Also foam rolling and stretching seems to keep the tightness at bay. I took 2 weeks off at one point and it was just tight the whole time.

I plan to move to a major city in a few months so maybe I should wait and see some world class doctor’s and PTs there, which I’m sure exist.


#4

Textbook inflammatory behavior. Do you respond well to nonsteroidal anti inflammatories (NSAIDs) or heat therapy such as a heat pack or hot shower?

Given the inflammatory behaviour it’s likely a cortisone/corticosteroid injection will be effective if the source of your symptoms is in the area. If inflammation or an inflammatory condition of something or another is the cause of your symptoms then a cortisone injection may treat it. If the inflammation is secondary to the actual cause the injection will be managing the symptoms.

May not sound too encouraging but it’s information/clues that take you a step closer to an answer. If you don’t mind could you answer a few questions:

For past PTs and Doctor/Medical what has and hasn’t worked for you specifically? e.g. treatment techniques or other things that have improved your symptoms or examination techniques that have been positive/provoked your symptoms?

Where: Exactly are the symptoms localised to. Can they be localised? You describe symptoms both above and below the knee. How far below and above? An inch or two?

Pain or other symptoms in your lower limb or back? Any issues elsewhere that may refer to the area?

Other Symptoms: e.g. numbness, weakness, swelling, tenderness to touching or pins and needles. Increased tone (medical definition) where the muscle feels taut and tighter when not being actively contracted similar to tightness except you’re not stretching it to find out.

Aggravating Factors: Are their specific movement/postures/activities that will aggravate your symptoms? What brings on the pain, if anything? Is it different for above and below the knee?

Easing Factors: as for aggravating except makes you feel better.

Superficial/Deep?: Sounds a bit weird but do you feel the symptoms are coming from structures near the surface or deep towards the inside of the joint?

Nature: When you experience pain how would you describe it?. Is it dull/sharp, severe (9/10), shooting, burning, aching etc.?

  • Meniscus Injury has been ruled out by imaging

  • Ligamentous Injury or Issues: Medial/Lateral Collateral Ligaments, PCL, ACL

  • Possibly Pes Anserinus Bursitis or Tendinitis but inconsistent with pain behaviours

  • Popliteal Cysts and others would have been seen on MRI

  • Nerve Entrapment Syndrome or adverse neurodynamics/tension is possible e.g. Saphenous Nerve, Tibial nerve the popliteal fossa, Hamstring etc. but atypical given there’s little pain or neurological symptoms

  • Maybe unresolved musculotendinous injury e.g.Hamstring Tendinopathy, Adductors, Sartorius, Popliteus or Gastrocnemius Tendinopathy

  • Referred Pain from Hip, Sacroiliac Joint, Back etc. History of back pain relevant?

Feel free to look any of these up and see if they fit you.


#5

There’s occasionally pain to the touch when it is below the knee but the pain is very mild when it’s located there. What I experience doesn’t seem to be provoked by anything other than inactivity. There are no aggravating movements that I know of, in fact activity makes it feel better. Almost always when I wear my knee strap the tightness is gone, no matter how tight it was before I wrapped the strap around it.

It comes and goes (and moves) on its own, I go through periods where I don’t feel anything then periods where I feel it. I have felt pain or tightness in different locations as far apart as 6 or 7 inches, on all the medial/posterior side. A couple times I have even felt pain just a couple inches from the kneecap on the medial side, maybe technically not on the posterior side. Rarely above the knee. Next time I feel tightness I’ll try to remember to take an NSAID but since the tightness comes and goes on its own that even if it went away it would be hard to say the NSAID did it.

There’s no numbness, weakness, tenderness, pins and needles, swelling, etc that I know of. I know what swelling feels like, this is definitely not that. I would only describe the pain as intense on one occasion when I got up out of bed one time to take a pee I could barely walk on it, this was another one of the very rare times that the pain was above the knee. It was like 7 or 8 out of 10. But 99% of the time when I feel pain, usually below the knee, it’s like a 2/10.

What I can describe to you is there is a “pressure” that moves around the back of the knee, and it affects different parts of the knee one area at a time. Sometimes I don’t feel anything even when inactive, but it seems like it’s influenced by gravity. One time I had my knee elevated when I was sleeping for a long time by my bedsheets and I woke up with an intense pain above the knee. When I stood up on the leg, the pain slowly subsided and moved further south down the knee. This is the only time my knee ever bothered me while I was lying down or sitting.

I have no doubt there is something moving around the knee, and wherever it goes, it causes surrounding tissue to feel stretched/tight. I already have tight hamstrings, and this tightens them further. I think this led to hip issues by my hamstrings tugging excessively on my hip. My hip started bothering me quite some time after this injury, so if anything my hip issues are referred from my knee. I’ve had back problems int he past but after strengthening the hell out of my core I haven’t felt any back pain in at least 6 months (I actually went against doctor’s advice to rest from the gym and did back extensions and rows for months until my pain was completely eliminated).

From the MRI doctor ruled out most of the things you listed. I did specifically ask him about tendons, ligaments, tears, etc and he essentially ruled them out. For a time I wondered if maybe I had an MCL injury since I often feel pain/tightness in that exact area, but he said no. I got a second opinion and that doctor had nothing to add, he had even less to say.

As for nerves, I really doubt this. What I mainly feel is pressure, and sometimes this pressure causes pain but usually it causes things to feel “stretched”. There’s no real pattern to things other than I only feel it during inactivity and almost always when I’m standing. 99% of the time it’s a slight pain and/or tightness. About 75% of the time it’s strictly tightness. The pain doesn’t pulse or fluctuate, if I stand up there it is if I sit down there it goes. It’s why I thought there was a cyst moving around in there for a long time, but of course the MRI found no cyst in that region and cysts don’t move around.

If I feel pain/tightness in one area then the other areas where I have felt it in the past feel absolutely fine. For instance, if I feel it below the knee, above the knee feels fine. If I feel it above the knee, below feels totally fine. They are totally mutually exclusive.


#6

Tbh am frustrated myself, tho probably not as much as you are, while also being driven by the challenge of finding out what’s up.

Adding Arthrofibrosis or Stiff Knee Syndrome to the List

Could be anything we’ve mentioned previously if missed on the Knee MRI or not looked for. Also am assuming you didn’t get a full body or full LL MRI?

Should’ve asked this before but is your tightness restricting the straightening, bending or all movements of the knee?

Maybe reevaluate swelling/edema = stiffness + pressure and greater physical feedback/sensation of these

Medical History & Family History
Is personal stuff so shouldnt share if you don’t want to:

  • Joint Diseases e.g. Rheumatioid Arthritis, Ankylosing Spondylitis, Gout, Osteoarthritis or other

  • Back Pain: Wut was Diagnosis? Treatment/Management and Timeline

  • Other musculoskeletal injuries & Treatment/Management and Timeline

  • Systemic: Fatigue, lethargy, generalised weakness, unexplained weight loss, recent infection, cancer history

When referring to nerve we aren’t talking about what you’d usually think when it comes to nerve injury such as peripheral neuropathies (nerve injury outside the spinal cord cord and nerve roots) or radiculopathy (irritation to the nerve roots e.g. slipped disc) but to altered neurodynamics.

Neurodynamics
Sounds fancy and complicated but is actually much more straightforward than other nerve related injuries. Nerves are physical structure like muscles, bones or ligaments and some are quite large. When you move your nerves slide, glide, stretch and tension like other physical structures. Hence neuro (relating to nerves) and dynamics (movement). This is part of normal movement.

Normally this occurs smoothly and the stretch of your nerves is almost imperceptible due to the extra slack in the nerves or the sensation of your other structures e.g. muscles being stretched out mask this.

Adverse or abnormal Neurodynamics can occur. As a nerve courses through the body, innervating and branching off, it passes by and around structures as well as thru natural tunnels, spaces, muscles, etc.

These are multiple opportunities or locations where a nerve’s movement can be limited or trapped. For example following a hamstring injury layering of new tissue and scar can lead to proximal tendinopathy-related sciatic nerve entrapment.

Now since the nerve has been caught at one or more points along its length an attempt to stretch or tension the nerve will generate a much greater sensation of stretch because you don’t have the slack of the full nerve to work with. You can feel the abnormal stretch/tension of your nerve.

Importantly the stretch felt and other neurological symptoms (neurological pain behaviour, paresthesia or numbness) do not necessarily occur together in these cases. Adverse neurodynamics can occur with or without irritation or injury to the nerve itself which is what causes the neurological symptoms.

Nerve Tension Testing
Kind of bad practice but if you can be fucked try some nerve tension tests out yourself or with a partner. The videos may to about pain or numbness or tingling but we are concerned about your symptoms namely tightness and pain, their location and how/if they respond to testing and sensitizing movements. Symptoms & change in symptoms should be recorded after every change in position.

Take the straight leg raise test for example. You should be able to SLR quite high before feeling a stretch in your hamstrings, any lower and this should be recorded.

Once you are at this position you can do sensitizing/tensioning (tensioning the nerve further) or differentiating movements (to differentiate between hamstring/musculoskeletal tightness and nerve tightness)

e.g. In the max SLR position if you nod your head forward or flex your neck as far as you can it should not have any effect on the stretch felt in your hamstrings. However this movement lengthens and tensions the nerve.

Does the sensitizing movement change (increase, decrease, bring on etc.) your symptoms?


#7

Have you ruled out a gastrocnemius or plantaris issue?
I’ve torn both of my gastrocs and one plantaris. I tore my right gastroc and plantaris at the same time and I have a lot of weird issues behind/below/above the knee, especially when doing GHR type movements.


#8

There’s been a new development. Last week or so, pain/tightness around the knee has mostly gone away. I’ve noticed some new pain/tightness much further south into the calf. So it’s officially a calf problem now. But it’s not nearly as problematic down there. And this is the first time since the injury back in May that this has happened.

I think it might have coincided with me buying a new chair with my feet flat on the floor. My old chair was a recliner where my feet were usually kicked back.

There has got to be something moving around in the leg. What are the possibilities?


#9

IMO “something moving” is probably just in your head. There are only a few things that can “move” around:

  • Thromboembolism e.g. Popliteal Vein Thrombosis or Deep Vein Thrombosis of the Leg (Risk increased with history of DVT or peripheral vascular disease, recent surgery, certain medications, periods of immobility e.g. airplane flights)

  • Ruptured Muscle/Tendon e.g. gastocnemius, plantaris, popliteus etc. Other injury or shortening e.g. trigger points to these muscles could be your culprit
    https://en.wikipedia.org/wiki/Posterolateral_corner_injuries#Anatomy_and_function

Where: Gastrocs (superficial in the top half of the calf), Soleus (deeper anywhere along the length of the calf), neither?

Localised (can easy point out the exact area of symptoms) or poorly localised (can only determine a general area of symptoms)?

Nature of Pain: dull, achy, sharp, shooting, burning, cramping etc.

Other Symptoms: e.g. temperature/warmth, colour of skin, neurological symptoms

Aggravating/Easing Factors: same as before or different. Over 24 hrs e.g. morning/night pain, with activity/rest, etc.? New chair use?

Particularly noticeable during/after certain activities, movements or postures?

Other Areas: e.g. still no symptoms in your back, hips etc. ? What was your diagnosis for your previous back pain?

Unlikely, but if there’s back involvement peripheralisation of symptoms (symptoms "travelling away from central structures/the spine) suggests condition is worsening.

Narrowing it down will let us generate some hypotheses and try some simple tests.


#10

Thanks for your help. There’s not much pain/tightness to speak of now. So I’ll probably just put it on the back burner if/until it becomes a real issue again. Buying the new chair seems to have made it almost a non-issue.

I have a bad shoulder and really bad hip so they could use the extra attention.

Still don’t know what it is but because of our discussion I know a few more of the things it isn’t.


#11

Hey, sounds like your issue is rooted in a combination of uneven hip strength as well as poor biomechanics, I would suggest stretching your hamstrings,groin, calves, and hip flexor then performing these glute activation drills 1. hip thrusts 2. Clamshell 3. Banded side walk to get those glutes active and take the strain off your lateral hamstrings. Its is likely your ql on that side is tight and glute is less active putting excess strain on the hamstring.


#12

solvesallyourproblems I’ve been stretching the hell out of my hams/hip/calves, the lower body as a whole for months and haven’t noticed any improvement, only temporary improvements that quickly vanish.

I’ve been doing hip thrusts with a barbell as well as lunges and the glute machine and hip abductors/adductors for months. This also didn’t seem to make much difference.

I took 4 weeks off from the gym and returned about 2 weeks ago. It’s been 6 weeks since I worked out my quads. During those 4 weeks the tightness didn’t change. I’ve been thinking maybe my quads are too strong and my hamstrings are too weak. My hamstring strength has mostly caught up with my quads though not entirely yet, and a lot of the tightness seems to be gone, especially at and above the knee is almost gone. I still feel some tightness in the upper calf area so I’m thinking maybe if I neglect the calves and continue strengthening the hamstrings that this tightness will be gone too.