Member Case Study: Meniscus Tear?

author : AMSSM

comments : 2

Woke up at 7am and physically could not walk. Pain was shooting in my knee (almost dropped me to my knees). Later I went to my sports doc. He could not simulate the pain whatsoever.

Member Question from Jeepguy2358

I am both confused and concerned about my status.  I begin IM training in two weeks and have a bad feeling I might not be able to get started.  Here is what I have experienced over the past week:

Monday:  Rode 35 miles on bike, Swam 2000 - all good.

Tuesday:  Woke up at 7am and physically could not walk.  Pain was shooting in my knee (almost dropped me to my knees).  After hopping around, the pain subsided.  At work, the pain dulled significantly and eventually went away. 

Tuesday evening: I did a nice and easy five mile run with zero pain.  Body felt great.

Wednesday:  Woke up at 6:30am.  Again, could not walk.  Pain lasted throughout the day.  Going up stairs was a killer. 

Wednesday evening:

I went to my sports doc.  He could not simulate pain even by poking, pushing, twisting, or turning.  It took a physical therapist coming in and trying another motion to open up the knee joint and even feel any pain at all, but that was only very mild.  Took x-rays and they saw nothing.  They agreed the joints looked good.  No arthritis or foreign objects.  Not ITBS.  Plan was to rest and take NSAID's for a week, then reevaluate.

Thursday:  Slight dull pain, but very tolerable.  Hurt mostly on inclines, but very little elsewhere.  Still had trouble with stairs, but could get up and down them.  Felt great during the day, but feel like I may be compensating, by not bending my knee as much when I walk.  (Even though it doesn't hurt to.)

Friday, Saturday, Sunday:  Same as Thursday.

To describe the area where the pain is:
Left leg, 1/2 way down patella tendon and take a left (lateral side) about 1.5".

No MRI was done due to cost ($2000), but that, along with Cortizone shot, is next if rest is not enough.  Doc told me worst case scenario was surgery.  Miss about one month of training.  Now he has me considering alternate IM plans.  (Signed up for IMLOO, but am now looking at B2B).  Thanks for any help you can give.

Answer from Marjie Delo, MD
Member AMSSM

Lateral knee pain can have multiple etiologies, the most common being iliotibial band syndrome and lateral meniscal abnormalities.  Other less common etiologies include osteoarthritis of the lateral compartment of the knee, patellofemoral pain syndrome or “runner’s knee”, lateral hamstring tendonosis, inflammation of the synovial lining of the joint, or referred pain from the spine. 

Meniscal pain can be from an acute tear or a degenerative tear.  These will not be seen on x-ray, only on MRI or under arthroscopy.  If you are suffering from an acute tear, I would expect swelling in your joint.  Flare of a degenerative tear, however, isn’t necessarily associated with swelling.  Exam findings would include tenderness along the lateral joint line (2-3 cm below the site of tenderness in iliotibial band syndrome) and reproduction of pain with flexion/rotation of the knee.  With an unstable meniscal tear, you could have “mechanical symptoms” such as painful clicking, locking of the knee, or gross instability. 

Most meniscal tears are in the posterior aspect of the cartilage, where you describe your pain could very well be iliotibial band syndrome.  The nature of your pain is more consistent with a repetitive overuse injury, such as pain first thing in the morning the day after training.  Also, incline running can predispose to ITBS.  The meniscus is a cartilage structure, so I would not expect pain following rest.  However, a muscle or connective tissue structure will tighten up overnight after aggravating activity. 

Two recommendations that I would make to determine the etiology of your pain would be (1) an exam when the pain is flared, and (2) diagnostic lidocaine injection.  If the lidocaine was injected into the ITB bursa, outside the joint, and your pain went away, then that is the source, and ditto with a joint injection.  In either case, without instability, cortisone could be tried as treatment.  If the pain is from the iliotibial band, I would recommend myofascial work and a biomechanical evaluation. 

If your doctor believes that it is coming from the meniscus, and cortisone does not relieve your discomfort, you should consider arthroscopic evaluation and debridement.  The downtime from such a procedure should be minimal!  Osteoarthritis was already ruled out with xrays (preferably done weight-bearing), and I would expect physical exam findings with synovial inflammation, hamstring tendonosis, or patellofemoral pain.  Referred pain from the spine can be tricky, but the characteristics of your pain sound more localized.  I recommend seeing your doctor or therapist when your pain is present, and hopefully a clear diagnosis will result!

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date: May 21, 2010