Member Case Study: Knee Pain

author : AMSSM

comments : 0

After about 45-60 minutes of generally light jogging I am getting shooting pain in the left side of the knee under the patella.

Member question from ssheahan
In 2001 I had my patella broken in half and slightly severed the lower knee ligaments (rugby injury). I had a pin put into the patella and the lower ligaments were repaired. I am currently training for and Ironman and have completed two marathons in 2006 and 2007. Of late I am getting strange pain in my left knee. After about 45-60 minutes of generally light jogging I am getting shooting pain in the left side of the knee under the patella.

I have done strength tests on the knee and it appears that the ligaments are not a problem. The pain can only be identified when on the run or going up the stairs or standing up on the bike. I have also noticed that in my long swims (2 km and longer) my left shoulder (another old rugby injury) starts to go dead. I have noticed that my shoulder is slightly raised (my neck muscles tense from protecting).

Are these injuries related, and what can I do for prevention and cure?

Answer by Kevin D. Walter, MD, FAAP and Travis Vande Berg, MPT

Member AMSSM

Knee pain is very common in endurance athletes. Your symptoms sound like patellofemoral pain syndrome (PFS), which is more common in people who have had a fracture around their knees. This is usually an overuse injury, but also may be a sign of arthritis. The cartilage on the undersurface of the kneecap rubs on the femur (thigh bone) with motion causing pain, which in turn may lessen the shock absorbing function of that cartilage. There are many other factors that can influence PFS, including poor flexibility, strength imbalances and deficits in the lower body, and biomechanical or alignment issues (like flat feet).

Most people will typically complain of pain during and after activity. It is usually worsened by stairs, running or biking hills, and even squatting or remaining in a sitting position for extended periods of time (like going to a movie theater). PFS should not cause knee swelling, locking, or instability.

Often cross training to decrease weight bearing activities and decrease hills can be helpful. Icing your knee after activity is also beneficial. However, some athletes need more restrictions and rest, and potentially physical therapy. Athletes with knee pain outside of activity and knee pain that impairs performance often need more aggressive treatment. It is important to be sure that you do a good warm up and do not suddenly increase your workout intensity. It is also necessary to make sure that your shoes fit properly and to ensure that they are not old or worn out. Athletes with flat feet may benefit from shoe inserts/orthotics.

Due to your old fracture, you are at increased risk for degenerative arthritis and chondromalacia (thinning of the hard cartilage on the undersurface of the kneecap). I would recommend seeing a physician to obtain x-rays of your knee and discuss further treatment. Since PFS can potentially be related to biomechanical abnormalities and muscular imbalances, I feel it is very difficult to treat without the assistance of medical professionals.

Regarding your shoulder, without knowing more about your initial injury and your current symptoms, it is difficult to make any recommendations. It is unlikely that it is directly related to your knee pain, although it most likely is due to overuse as well. However, it could be do to a pinched or compressed nerve which gives you the dead arm sensation slowly over time as you repetitively compress it with the overhead motion of swimming. I would ask your sports medicine physician to evaluate your shoulder as well.

Kevin D. Walter, MD, FAAP
Travis Vande Berg, MPT
Medical College of Wisconsin
Children's Hospital of Wisconsin

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date: August 12, 2008