Chronic Medial Knee Pain in a Collegiate Basketball Player and Marching Band Member

Abstract

HISTORY: Patient 1: A 17 year-old female collegiate basketball player presented with insidious onset right medial knee pain for the last 8 months. Pain waxed and waned with activity. No history of swelling, instability or locking. No numbness or weakness. Pain located diffusely over the medial knee and proximal medial tibia. Symptoms refractory to PT, patellofemoral kinesiotaping, medial arch support orthotics and NSAIDs. No relief following Medrol dose pack, intraarticular corticosteroid injection, or pes anserine bursa corticosteroid injection. Patient 2: A 19 year-old female collegiate marching band member presented with insidious onset right medial knee pain present for 4 years. Patient reported intermittent swelling but denied instability or locking. Symptoms were worse with walking and marching. Previous Rheumatologic consult unrevealing. Symptoms refractory to PT, knee sleeve, and patellar straps. No relief following right pes anserine bursa corticosteroid injection. PHYSICAL EXAMINATION: Patient 1 - Knee without effusion. Diffuse tenderness to palpation over the medial knee at and below mid medial joint line. ROM and strength normal. No laxity. Neurovascular intact. Patient 2 - Knee without effusion. Tenderness to palpation over the medial joint line and distally over pes anserine. Tinel’s sign positive over the medial femoral condyle. ROM and strength normal. No laxity. Neurovascular intact. DIFFERENTIAL DIAGNOSIS: 1. Pes anserine bursitis 2. MCL bursitis 3. Patellofemoral syndrome 4. Medial meniscal tear 5. Medial patellar plica 6. Saphenous neuralgia TEST AND RESULTS: 7. Patient 1: XR Knee - No fracture or joint effusion. MRI knee - No meniscus tear. No internal derangement. Mild increased T2 signal within the superior lateral aspect of Hoffa’s fat. Diagnostic saphenous nerve block - 0.5% bupivacaine injected 2 inches cephalad to the medial joint line - 24 hours of relief. Patient 2: XR Knee - No fracture or malalignment. MRI knee - Unremarkable MRI of the knee. Labs - ESR 8, TSH 1.7 FINAL/WORKING DIAGNOSIS: Saphenous Neuralgia TREATMENT AND OUTCOMES:Patient 1: Saphenous nerve injection - 40 mg triamcinolone/0.5% bupivacaine - 5 months of relief. US guided hydrodissection saphenous nerve - Full resolution for 1.5 years. Patient 2: US guided hydrodissection saphenous nerve - 6 months of relief.