Disruptive Knee Pain in a Cross Country Runner

Abstract

HISTORY: An 18 year old male cross country runner presented to the office for non-radiating sharp lateral right knee pain. He was running approximately 20 miles per week. His pain progressively worsened over the past 10 months and he could no longer run. He had no pain at rest or while walking, and no locking, clicking, snapping, or buckling. His knee did swell mildly the last time he ran. There was no trauma and he never experienced any back or hip pain. He was initially seen by his PMD who diagnosed him with a knee sprain and prescribed physical therapy (PT), rest, ice, naproxen, and ordered an MRI. The MRI showed a trace knee effusion, but was otherwise negative. After completing PT with no relief, he was referred to a sports medicine orthopedist who diagnosed him with IT band friction syndrome and continued PT with rest. He did not improve and had a landmark based cortisone injection into the distal IT band with no relief. PHYSICAL EXAMINATION: Right knee exam: normal alignment and gait, no effusion, and tender lateral joint line. Quadriceps and hamstring strength was 4/5 with 100 loss of flexion. Positive Noble’s and McMurray test. All other provocative tests were negative, including Ober. Hip exam normal DIFFERENTIAL DIAGNOSIS: IT band syndrome Occult lateral meniscus tear Patellofemoral pain syndrome Loose body TEST AND RESULTS: MRI T2 STIR images showed a subtle signal abnormality between the IT band and the lateral femoral condyle consistent with IT band friction syndrome and a minimal linear signal abnormality posterior of the lateral meniscus junction within the distal strut in the popliteus hiatus of indeterminate significance. The posterolateral corner structures were normal. A dynamic study of an ultrasound guided cortisone injection into the distal IT band insertion and then running directly afterward and at one week produced no relief. An intra-articular lidocaine injection and running directly afterward produced complete resolution of symptoms. FINAL WORKING DIAGNOSIS: Meniscal capsular disruption TREATMENT AND OUTCOMES: He had a knee arthroscopy that repaired the meniscal capsular junction tear and a hypermobile lateral meniscus. After repair, bone marrow aspirate concentrate was injected into the posterior lateral capsule. He completed post-operative PT and is now long distance running pain-free.