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Posterior knee pain at heel strike

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Pod on sea, Mar 6, 2013.

  1. Pod on sea

    Pod on sea Active Member

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    Dear Colleagues,
    Any thoughts regarding this patient with posterior knee pain..?
    She describes the pain as a sharp jarring sensation. It happens with every step she takes.
    34 y/o female generally fit. Referred to me by knee surgeon whose diagnosis was hamstring spasm. Unresponsive to physio. Gradual onset 18 months ago when training for a marathon. Cycling out of saddle gives no pain. Only pain is on heel strike when walking (and running, but she's had to give up), and on dismounting from her bike when putting her foot on the ground. Better in cushioned shoes, worse in higher heel and barefoot. If she mid foot strikes, pain is easier. Any help appreciated.
    She had hx of anterior knee pain, lateral patella facet pain, arthroscopy for this, and no other knee joint pathology evident.She has ongoing discomfort in the region of vastus lateralis , which she reports is worse as she tries to offload the posterior knee pain, but this is manageable. The posterior knee pain is preventing activity.
    Many thanks, Helen
  2. Craig Payne

    Craig Payne Moderator

    Slump test? Referred from low back?
  3. Ian Linane

    Ian Linane Well-Known Member

    Hi Helen

    In terms of practical intervention:

    1 Following on from Craig's post it is worth asking the patient if the physio did any neuromobilisation treatments (neuro-dynamic techniques developed by Australian physio David Butler). Within the low limb I have found these to be helpful for pain that persists when possible causes or contributors have been eliminated but pain still occurs and is associated with certain movements only i.e. there is a history of pain associated with those movements

    2 A further thought, considering the history of knee problems and scope intervention. Mulligans mobilisations with movement(MWM's) have brought relief for some of my patients with knee problems. As a treatment it is simple to apply and will either work, quite quickly, or not.

    3 One quick intervention, a trouble shooting approach given it appears to be a weight bearing issue), is to check the motion at the inferior and superior fibular heads. Posterior to anterior, anterior to posterior and cephalad and caudad. Post previous injury or knee interventions may contribute to an increased stiffening in these motions. They are simple to remedy and may help.

    Just my take on it mind.
  4. David Smith

    David Smith Well-Known Member


    There are a lot of tissues and structures in the posterior knee, can you be more precise about the location of pain?

    Dave Smith
  5. Pod on sea

    Pod on sea Active Member

    Thank you all. I'll have more dialogue with my physio colleague who is still working with this patient and raise these points.
  6. DActon

    DActon Member

    Hello Helen,

    I am new to the podiatry arena and have been reading this thread.
    The pain for the patient at heel strike has made me think of the Gastrocnemius and it's insertions of the two heads associated with previous knee treatment. Could this be food for thought?
  7. Helen:

    You could try a 1/4" cushioned heel lift inside her shoes since this may lessen the force from impact with the ground. Sounds like the knee pain is a problem when the knee is fully extended so this may be any number of structures including popliteus muscle strain, gastrocnemius muscle origin strain, hamstring insertion insertional tendinitis, a Baker's cyst or degnerative joint disease. I recommend an MRI due to her many knee injuries and surgeries.

    I have attached a good article on posterior knee pain differential diagnosis for you.:drinks
  8. drdebrule

    drdebrule Active Member

    Thanks Kevin for the article. There are just too many things that could be causing her knee pain. I do like the idea of a heel lift. Would gait retraining help as well? Increase cadence, decrease stride length? Teach patient to forefoot strike (barefoot/minimal shoes) to decrease/eliminate high forces from heel strike transient?

    Good luck and keep us posted.
  9. Michael:

    Gait retraining would be the next step if the heel lifts weren't successful and the MRI was negative.
  10. NMT

    NMT Welcome New Poster

    Hi. I timidly ask ... has this person had deep neuro muscular therapy - deep massage to the full leg. I would pin point certain muscles - ie vastus lateralis etc-however with not seeing the patient I would do a full Leg release on that side. The findings - areas of tightness in named muscles could then be communicated to the Podiatrist and may help with asessment or treatment plan. NMT is cheap, noninvasive and quick.

    All the best and I'll follow your post with interest. I have a good relationship with our local Podiatrist and am happy to work with his instruction or comminucate my findings.
  11. Pod on sea

    Pod on sea Active Member

    As Kevin suggested, I had already tried a cushioned heel raise and this was indeed helpful. As long as she wears it plus big cushioned trainers she is less symptomatic but alas it's not solved the problem. Since starting the thread, I have been given the report from her knee arthroscopy, performed 12 months ago.
    ''Medial compartment, medial meniscus and cruciate ligaments intact, 30-40% lateral tibial plateau posterior thickness fibrillation with an intact lateral femoral condyle. The lateral meniscus was intact.''
    ''Using a synovator shaver an arthroscopic chondroplasty to the lateral tibial plateau and patella was performed.''
    The orthopaedic consultant who did the op thinks it's a hamstring issue, but the symptoms of jarring on heel strike sound more 'jointy' than soft tissue. I think a new MRI would be a good idea.
    Thanks all for your ideas.
  12. As mentioned earlier, you may also try some gait retraining in low heel height differential running shoes on softer surfaces, trying to get her to run more on her forefoot. This may decrease the knee joint loading forces, but may cause more risk of injury to the forefoot and Achilles tendon/gastrocnemius/soleus complex.

    However, my guess that it may be time for her to retire her running shoes for awhile until the MRI scan gives her a better idea of what is causing the posterior knee pain (I agree that is likely a joint/meniscal issue rather than a hamstring tendon issue). Given her extensive knee surgery history, you may consider suggesting she get an elliptical trainer which will likely cause no pain in the knee. Here is the one I purchased which I use frequently when my knees are bothering me.


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