Mike Montgomery: A 26-Year-Old Male Long-Distance Runner With Right Lateral Knee Pain

Learning Objectives

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Learn the common causes of knee pain.
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Develop an understanding of the unique anatomy of the knee joint.
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Develop an understanding of the bursae of the knee.
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Develop an understanding of the ligaments of the knee.
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Develop an understanding of the tendons of the knee.
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Develop an understanding of the differential diagnosis of knee pain.
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Learn the clinical presentation of runner’s knee.
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Learn how to examine the knee and associated ligaments.
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Learn how to use physical examination to identify runner’s knee.
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Develop an understanding of the treatment options for runner’s knee.

Mike Montgomery

Mike Montgomery is a 26-year-old male long-distance runner with the chief complaint of, “My right knee is killing me.” Mike stated that he just got back from running an Iron Man triathlon in Hawaii. “Doc, it was a rough one this time. Between the rain and the humidity, it was really a challenge—even for me. A lot of the course was wet and there was a fair amount of mud, so I was really slipping around. The unsteady footing was really hard on my knees. Since I got back, I can barely walk because the outside of my knee hurts so much. I keep looking at it expecting a big bruise, but there’s nothing to look at. I can barely touch it, though, because it hurts so bad.” Mike said that he tried resting the knee, using the hot tub at the gym, Icy Hot, an Ace wrap, and Advil, but in spite of all of this, his knee just hadn’t improved. If anything, it was a little worse.

“Doc, I’ve really got to get my knee better. I deliver for UPS and if I can’t get in and out of the truck and carry packages up to the door, I am screwed.” I asked Mike about any previous injuries to the right knee and he said that both of his knees could be sore after a long run, but he had never had anything like this.

I asked Mike what made his symptoms worse and he said, “Anytime I put weight on my right knee, I’m in trouble. Like I said, I can barely walk, and stairs are a real pistol. My sleep is completely jacked up because of the knee pain and worry.”

I asked Mike to point with one finger to show me where the pain was and he pointed to a point over the lateral epicondyle of the femur. “X marks the spot. It’s right here!” I asked if the pain radiated anywhere else and Mike just shook his head.

On physical examination, Mike was afebrile. His respirations were 16 and his pulse was 62 and regular. His blood pressure was 118/68. Mike’s head, eyes, ears, nose, and throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal, as was his abdominal examination. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the right knee revealed no evidence of ecchymosis or swelling. The area over the right lateral knee was warm but did not appear to be infected. There was significant point tenderness over the lateral epicondyle of the femur. Examination of the bursae of the knee revealed no obvious bursitis, but a subtle iliotibial bursitis could be hard to identify given the amount of pain elicited when palpating the area.

Range of motion of the knee joint and resisted abduction of the joint reproduced Mike’s pain. A modified Noble compression test was positive on the right ( Fig. 6.1 ). The left knee examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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Onset of right lateral knee pain following completing an Iron Man triathalon
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Significant pain on ambulation
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Pain localized to the lateral knee
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Difficulty walking stairs
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No other specific traumatic event to the area identified
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No fever or chills
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Sleep disturbance

The Physical Examination

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The patient is afebrile
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There is no ecchymosis over the lateral knee
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There is significant swelling of the knee
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Point tenderness over the lateral epicondyle of the right femur
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No evidence of infection
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Pain on resisted abduction of the affected lower extremity
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The modified Noble compression test was positive on the right (see Fig. 6.1 )

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
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No evidence of bursitis
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Examinations of other joints other than the right knee were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the right knee
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Ultrasound of the right knee
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Magnetic resonance imaging (MRI) of the right knee

Test Results

The plain radiographs of the right knee were reported as normal. Ultrasound examination of the right knee revealed edematous swelling of the soft tissues deep to the iliotibial band ( Fig. 6.2 ). MRI examination of the right knee demonstrates high intensity signal deep to the iliotibial tract consistent with runner’s knee ( Fig. 6.3 ).