Suprapatella Pain following half marathon

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Hi

I have an interesting patient who presents with the following:

35 year old, 85kg, runner.
Complains of pain suprapatella bilaterally and on the medial aspect, at the post tib medial insertion on the navicular, of the right foot only.

He has recently run three back-to-back (weekends) half marathons, but felt the pain after the first.

He runs in Asics Cumulus (neutral stability) and has done +- 150km in them. His previous pair was replaced after +- 800km.

I initially treated him successfully for tired/ aching feet with an appropriate orthotic following these (summarised) findings: medial deviation STJ axis, sagittal plane block, LLD (right > left), metatarsalgia.
He has run in them with no previous problems and is a regular half marathon runner.
No changes in his training and has always mixed trail and road running.

Clinical examination showed pain at the suprapatella (thinking the Quadriceps muscles tendon and not suprapatella bursitis) during active resisted knee extension with sudden release (causing more pain).
No swelling, effusion and the rest of both knees where fine.
Pain on lunging (and stairs - mainly down) and on standing.
No pain during ambulation at the suprapatella region, however, the right foot illicited pain on hard palpation at the medial navicular with no posterior tibial tendon pain on clinical evaluation.
He reprots pain at this region mainly at midstance from heel lift to propulsion. Left foot was unremarkeable.

Differential diagnosis:
Knees - Quadriceps tendonitis, suprapatella bursitis, patellafemoral syndrome.
Right foot - posterior tibial insertion tendonitis, navicular stress #

Treatment - REST, conservative measures, NSAID, physio. BUT what concerns me, is what happened to the biomechanics within the knee (driven by the feet) to have caused this (i.e. more/ less rear foot control?, greater 1st ray cut-out? etc) and what and why the right foot only?

Any thoughts greatly appreciated.

Regards

Brandon

 

Brandon:

Sounds like quadriceps insertional tendinitis (you may also want to rule out plica syndrome) in an individual that is running too many races. I had this injury once when I was doing marathon training back in my 20s. The knee pain would best respond to alternative training (bike, elliptical trainer, swimming) with no running for about two weeks and some physical therapy (ice and ultrasound). You may want to have him try to train on all softer surfaces if possible since the quadriceps will generally be less active when running on grass, soft dirt or trails than on asphalt or cement. It looks like you have the posterior tibial insertional tendinitis under control.

By the way, running back to back weekend half-marathons is just asking for an injury, unless he is just using them as training and not racing these events. Try to emphasize to your patient the benefit of racing less and training more sensibly.....in other words, he should have cancelled the last two half-marathon runs with his quadriceps and foot bothering him!

Good luck.

 

Hi Kevin

Thanks for the reply.
On his follow up I am going to specifically rule out Plica syndrome.
In the mean time I have advised him on training alterations and rehab.

Oh, and I have been sure to mention how unnecessary it is to do the amount of competing - and not training for a specific event.

Thanks again

Brandon