Tony Garcia: A 24-Year-Old Male Football Player With Severe Posterior Knee Pain

Learning Objectives

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Learn the common causes of knee pain.
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Learn the common causes of semimembranosus insertion syndrome.
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Develop an understanding of the anatomy of the semimembranosus muscle.
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Develop an understanding of the differential diagnosis of semimembranosus insertion syndrome.
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Learn the clinical presentation of semimembranosus insertion syndrome.
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Learn how to examine the knee.
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Learn how to examine the semimembranosus muscle.
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Learn how to use physical examination to identify semimembranosus insertion syndrome.
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Develop an understanding of the treatment options for semimembranosus insertion syndrome.

Tony Garcia

Tony Garcia is a 24-year-old football player with the chief complaint of, “I can’t play because my knee is killing me.” Tony stated that his problems begin during last Sunday’s game when “that hoople head cut blocked me. The bad part was that jackass didn’t even get a penalty! I limp off the field while he stands there laughing. Doc, it’s been almost a week and my knee just isn’t getting any better, even though I’ve been living in the whirlpool. The Advil, topical analgesic balm, and ice packs aren’t touching it, either.” He stated that usually when he gets injured, he just tries to “burn through it” because he doesn’t want to “mess with my routine.” Tony noted that the pain was made worse with weight bearing and walking. “Doc, I can barely get in and out of my SUV because of the pain.” I asked Tony how he was sleeping and he shook his head and said, “Not worth a crap. I’m really getting worn out.” I asked Tony if he ever had anything like this happen in the past and he said, “Not really, just the usual postgame aches and pains. It goes with the territory. We spend all the time between games just trying to heal for the next game. It’s just part of the deal—muscle strains that go along with staying fit.” I asked if he was experiencing any numbness or weakness and he shook his head no. “But you know, Doc, there is this one spot that hurts about as bad as a spot can hurt. It’s really weirding me out.” I said, “Show me the spot,” and Tony pointed to a spot in the posterior medial knee and said, “Right here, Doc. If I hadn’t had an X-ray, I would be sure that I fractured it.” I reassured him that we would get things figured out, and then I asked Tony about any fever, chills, or other constitutional symptoms such as weight loss, night sweats, etc., and he just shook his head no.

On physical examination, Tony was afebrile. His respirations were 16, his pulse was 66 and regular, and his blood pressure was 112/68. Tony’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. He was well muscled. His abdominal examination revealed no abnormal mass or organomegaly. 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 resolving ecchymosis. There was no rubor, obvious infection, or bursitis. Palpation of the medial aspect posterior knee revealed point tenderness over the distal insertion of the semimembranosus muscle on the medial surface of the medial condyle of the tibia. Tony exhibited a positive semimembranosus twist test ( Fig. 3.1 ).

The left knee examination was normal. A careful neurologic examination of the upper extremities was completely normal. Deep tendon reflexes were normal.

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

The History

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A history of onset of right posterior knee pain following being tackled while playing football
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No numbness
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No weakness
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No history of previous significant knee pain
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No fever or chills
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Sleep disturbance
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Pain on getting in and out of car
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Pain on weightbearing and walking

The Physical Examination

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The patient is afebrile
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Point tenderness over the insertion of the semimembranosus muscle on the medial tibial condyle
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Positive semimembranosus twist test
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Resolving ecchymosis over the posterior knee
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No obvious bursitis
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No obvious infection

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 extremity neurologic examination, motor and sensory examination

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 revealed no evidence of bony abnormality or fracture. Ultrasound examination of the right knee revealed partial tearing of the semimembranosus tendon ( Fig. 3.2 ). MRI scan of the right knee reveals edema of the tibial insertions of the semimembranosus muscle ( Fig. 3.3 ).