Member Case Study: Below the Kneecap Pain

author : AMSSM

comments : 0

Since my last marathon (October, 2007), the area below my right kneecap towards the outside of my leg (but not the ITB) aches every time I run, especially afterwards.

Question from Shiggy
Since my last marathon (October, 2007), the area below my right kneecap towards the outside of my leg (but not the ITB) aches every time I run, especially afterwards. If I run long or fast enough, the achy feeling will turn more into that of a sharper pain. In 2004 I had a stress fracture in this area (top of the lower leg bone), so to be careful, I got an MRI in December 2007 to get it checked out. This revealed that I had some "fluid in my knee" but otherwise all was okay. I was told I could run in moderation.

Although I am following the 10% (or less) increase rule, and I am running only 15-20 miles per week currently, I still have a constant achy/sometimes more painful feeling in this knee unless I take several days off (but the problem returns as soon as I begin to run again). I do stretch and ice it after every single run which helps quite a bit. Is there anything else I can do, and am I making it worse by continuing to run through all the achy feelings?

Answer from Benjamin A. Hasan, MD

Member AMSSM

Thank you for your question concerning pain near your knee during and after your runs. I think you bring up several interesting medical issues that might contribute to a solution or solutions. Various components of your question suggest different possibilities. Any specific recommendations for you depend on the correctness of the diagnosis. It is certainly true in sports medicine that an athlete may have more than one diagnosis contributing to his symptoms.

Character of pain

For athletes involved in longer distances, aching turning into sharper pain near the outside of the knee can actually be iliotibial band (ITB) syndrome. I know you had stated that your pain was not at the site of the ITB, but different cases of ITB syndrome can occur a little bit differently. This diagnosis needs to be considered, and a physical examination during an evaluation by a sports physician experienced in seeing running athletes can be helpful in making a specific diagnosis. Available rehabilitation therapies are quite good, but they require persistence to see good results in chronic cases.

Stress fracture

Any athlete, male or female, that has had one stress fracture can have another. Women have been considered at higher risk for osteoporosis- related stress fractures due to issues related to a lack of estrogen for young and older athletes. We are now seeing an increase in men with osteoporosis as well, suggesting that we should consider osteoporosis in both genders. Eating disorders can play a significant role in osteoporosis for both younger men and younger women. Many athletes suffer traumatic fractures (sudden fractures of a bone due to sudden impact) or stress fractures (gradual occurrence of an initially mild defect in the surface of a bone from repetitive and cumulative impact).

The diagnosis of a stress fracture can be made with a plain x-ray, an MRI, or a bone scan. Each study has advantages and disadvantages, and specific imaging choices, if needed, can be guided by your physician.

Fluid, or effusion

The knee joint is covered by a leather-like covering called the capsule. If structures inside the capsule are irritated or injured they can produce fluid inside the capsule. This is called a knee effusion. This is a sign that often points to specific diagnoses. The presence of an effusion needs to be explained in order to make a correct diagnosis. The structures inside the knee capsule that complain enough to cause an effusion often include the medial and lateral meniscus (cartilage), the anterior and posterior cruciate ligaments, the under-surface of the patella (kneecap), the smooth tissue lining the knee joint (synovium), and the inside of the capsule itself. Traumatic fractures near the knee can cause an effusion as well. Also, degenerative arthritis (known also as “osteoarthritis”) is a common cause of recurrent knee effusions in adult athletes.

Physicians can help you sort through the various problems contributing to your knee effusion by going over your medical history and current symptoms, and by examining you now and as you continue to address potential treatments. Follow-up visits and repeat examinations are critical tools to allow physicians to focus on a specific diagnosis in a case such as yours where the most serious (fracture, osteoporosis), most common (patellofemoral syndrome, osteoarthritis), and most likely (symptoms sound like ITB syndrome) need to be sorted out correctly.

Patellofemoral syndrome (PFS)

The most common condition presenting to a sports medicine office is patellofemoral syndrome. This is a condition that results from irritation underneath the kneecap during running sports. We usually see this early in a training season or in athletes competing in a new team sport that involves running, but it can occur in any running athlete at any time.

Good treatments for PFS are clearer to most of us than the specific reasons for developing this problem. Physical therapy techniques aiming at coordinating the function of the nerve to the quad muscles are effective. This may indicate that the problem stems from irritation under the patella due to improper sliding of the patella over the thigh bone with each step. Research has not yet proved the cause, but this is a very common condition and can be treated once diagnosed. Other, more serious, conditions need to be ruled out prior to focusing on this diagnosis in many athletes seeing us for knee pain, and in your case.

The 10% rule

You are doing a good job by sticking to the 10% rule (increasing mileage by no more than 10% of the miles run in the previous week). Congratulations on maintaining this difficult rule. Runners want to run. Stretching can help according to traditional teaching from coaches and therapists. I believe that your stretching is helpful, although this has been difficult to prove in statistical medical research. We also generally approve of following a course of training that allows you to avoid deconditioning while also allowing you to recover. You seem to be doing that now by continuing to tolerate 15 to 20 miles per week. You mentioned that your stretching as well as your icing helps “quite a bit,” which tells me things are not worsening. However, your entire case tells me that this problem has been chronic and that a specific diagnosis (or diagnoses) is needed in order for you to return to your peak running form.

Return to play

As team physicians we are often called upon to help alleviate pain and make medical diagnoses. As athletes, we all want to protect our bodies and remain healthy. However, many of our cases (including yours) come down to the simple question of “How much can I run?” Runners, and all athletes, can train through some types of injuries, but in your question you mention several issues that really do need to be addressed (type of pain, previous stress fracture, location of pain, current mileage, knee effusion, home treatments helping). My best recommendation is for you to focus on moving through a process of getting the issues mentioned above taken care of by seeing a sports medicine physician for an initial visit and for follow-up visits, by getting additional imaging done if needed, and by emphasizing the need to make a specific diagnosis as well as the need to find a specific training program that will work now. This will allow you to continue your running comfortably both this season and many years into the future.

Benjamin A. Hasan, MD
Family Medicine and Sports Medicine
Director of Sports Medicine
UIC/Illinois Masonic Medical Center Family Medicine Residency
Chicago, IL

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date: April 14, 2008