Chris arrived at my office complaining of L lateral knee pain. Based on the initial assessment I performed, I thought it might be ITB Friction Syndrome, but the first thing I did was test his knee for hyper-mobility/instability.
Chris is a half-marathon runner for Stotan Racing, a Nike sponsored running team in Central New York.
Anterior/Posterior Drawer Tests were negative, as was the Lachman’s. The Valgus Stress (MCL Sprain Test) was also negative. I then proceeded with the Varus stress test (LCL Sprain Test) to determine if there was any damage to the fibular collateral ligament (also known as the lateral collateral ligament, or LCL). The LCL Sprain Test was negative.
Next, I tested Apley’s Compression for any meniscus problem. L Lateral and medial meniscii were both negative… Apley’s Decompression with lateral medial/tibial rotation was also negative.
I proceeded to the ITB friction test, and this was a positive (4/10) on the pain scale.
AROM testing revealed both knee flexion and extension to be WNL, 135˚ and 0˚, respectively. Slightly abnormal external tibial rotation was observed at 10-15˚.
Since I wasn’t picking up much in terms of ‘causality’, I decided to run through the hip ROM tests.
AROM (active range of motion) PROM (passive range of motion) RROM (resisted range of motion)
- AROM L hip flexion was somewhat restricted at approx. 75˚, with PROM exhibiting a soft end-feel, and RROM performed with no pain.
- AROM L hip extension was WNL at 35-40˚, with a soft PROM end-feel. RROM did however, create some lateral knee pain.
- AROM, PROM, and RROM for L internal hip rotation were all WNL.
- AROM L hip external rotation was restricted to 45˚. PROM was soft, and no pain was observed with RROM.
- Hip abduction and adduction were WNL for all tests.
The limited external rotation started me thinking ‘short/tight, TFL/Gmax’, leading toward the possibility of ITB Friction Syndrome. The restricted hip flexion and abnormal external tibial rotation left me thinking ‘short/tight biceps femoris (lateral hamstring)’, not so much ITB Friction Syndrome, but maybe some lateral patellar tracking leading to Chondromalacia. (I immediately performed the patella femoral compression test, but discovered neither grating nor pain).
To begin treatment, I first performed the ITB Friction Syndrome protocol for Knee and Thigh Conditions. This included Gmax compression broadening and TFL myofascial release, the Gmax lateral fiber stretch and TFL stretch. I then performed ITB mobilization.
I ended the session by instructing Chris in the ‘home’ stretching techniques for the TFL/Vastus Lateralis, Gmax, and Biceps Femoris. I also instructed him in strengthening exercises for the lateral hip rotators, VMO, and medial hamstrings.
I asked him to text me about his progress, or lack thereof, over the next few days. Chris did so, but he was not experiencing any improvement of his L lateral knee pain. I rescheduled him immediately, but clearly I was missing something. ITB Friction Syndrome and Chondromalacia (due to lateral patellar tracking) didn’t seem to be the problem. I was starting to think that Chris’ problem might not actually be lateral knee, but something else (close by) that could be mistakenly interpreted as lateral knee pain. I decided to look at syndromes that are considered to be less common in runners.
From my previous work with Chris, I knew that there was some L hamstring tightness as well as L external tibial rotation. The external tibial rotation was leading me toward thinking ‘a possible fixated fibular head’, but I also wanted to test for ‘Proximal Tibiofibular Glide Syndrome’ (PTGS) and ‘Insufficient Talocrural Dorsiflexion Syndrome’.
The principal movement impairment (pain) associated with PTGS is excessive posterior and or superior motion of the fibula on the tibia during active hamstring contraction (especially during running). The principal positional impairment is the fibula located anteriorly, posteriorly, superiorly, or inferiorly to the normal position on the tibia after trauma, particularly an ankle sprain. Pain in the posterolateral or lateral aspect of the tibiofibular joint is often associated with running, or general tibiofibular pain is associated with a history of lateral ankle sprains. Hamstring length impairment and loss of ankle dorsiflexion range of motion are common with this diagnosis. PTGS is either a positional fault generally occurring after ankle and foot trauma (ankle sprain) or movement impairment (pain) as a result of hamstring contraction pulling the fibula posteriorly.
At the beginning of this session, I asked Chris about any previous ankle sprains, particularly left ankle sprains, and he reported that he had had several over the years.
Next, I assessed the four single-plane movements of the L ankle joint:
- AROM for plantar flexion was WNL (30-50˚). PROM was soft/ligamentous. RROM was negative.
- AROM for dorsiflexion was restricted (<20˚). PROM was bone-on-bone. RROM was negative.
- AROM for inversion was WNL, but all the way out to 50˚, maybe 50˚+. PROM was soft/ligamentous. RROM was negative.
- AROM for eversion was restricted (<15˚). PROM was bone-on-bone (normal). RROM was negative.
I put Chris in the prone position and began treatment by releasing the ankle plantar flexors—gastrocnemius, soleus, tibialis posterior, flexor digitorum longus, flexor hallicus longus, peroneus brevis, peroneus longus and plantaris—trying to restore normal muscle resting lengths. I then retested dorsiflexion ROMs. There was no change in AROM and PROM was still bone-on-bone. I concluded possible Insufficient Talocrural Dorsiflexion Syndrome (fixated talus).
I then moved Chris into the supine position with his left hip and knee both flexed at 45˚. I grasped Chris’ fibular head between my thumb and first two fingers (being careful not to irritate the common fibular (peroneal) nerve. I then tested the mobility of the fibular head by trying to create both anterior and posterior motion. I was looking for either a fixation (hypomobility), or hypermobility in the form of excessive posterior glide. There was no fixation, but significant posterior hypermobility. As I pushed the fibular head posteriorly, Chris reported lateral knee discomfort similar to what he was experiencing when running.
I tested Chris’ R fibular head in an identical manner, to compare sides. There was neither a fixation, nor hypermobility, as compared to the left leg.
My conclusion was that Chris had a combination of a fixated L talus and short/tight L lateral hamstring. Every time his hammy contracted, the fibular head was getting pulled posteriorly, irritating the common fibular nerve and causing lateral knee pain (at the proximal tibiofibular joint). The fixated talus may have contributed to a fixated (hypo-mobile) distal fibular head, which in turn contributed to the hyper-mobile proximal fibular head.
Hamstring length and talocrural dorsiflexion impairments are common with this diagnosis. Positions when the lateral hamstring is stretched or when the talocrural joint is at the end-range of motion can reproduce the symptoms. Correction of a suspected positional impairment or stabilization of the proximal fibular head during the stretch (contracting biceps femoris) decreases symptoms.
The positional or movement impairments are difficult to see and palpate, but when correction of a suspected positional impairment or stabilization against a suspected motion decreases the symptoms, the diagnosis is supported.
I proceeded to:
- First, structurally re-align the L biceps femoris, and then teach Chris how to stretch the L biceps femoris and strengthen the L medial hamstrings, on his own.
- Structurally re-align the L ankle inverters (extensor hallicus longus, flexor digitorum longus, flexor hallicus longus, tibialis anterior, and tibialis posterior) to restore normal muscle resting lengths, which allows the L ankle everters (extensor digitorum longus, peroneus brevis, peroneus longus, and peroneus tertius) to return to their normal muscle resting lengths… so they could be strengthened. Again, teaching Chris how to stretch/strengthen the respective muscle groups, on his own.
- Mobilize the L talus with ankle arthrokinetic technique.
- K-tape the head of the L proximal fibula to resist posterior glide.
Chris ran with no pain immediately following the session (on a treadmill), and continues to train and race pain-free.