Understanding Common Knee Injuries And Lower Extremity Implications In Runners

By John F. Connors, DPM, and Ana J. Sanz, DPM

Keys To Recognizing Stress Fractures In Runners
With distance runners, stress reactions and fractures within the tibia are common. They occur less frequently in the medial tibial plateau than in the diaphysis. Medial tibial plateau stress injuries are often misdiagnosed as pes anserinus tendinitis or bursitis. While distal femoral stress fractures are not common, they do exist. Femoral stress fractures are more common proximally. The “fulcrum test” is very useful to assess femoral stress fractures.

In regard to patients with stress fractures in the tibia, I do allow them to cross-train (i.e. with deep water running). The use of electrical bone stimulators such as the Exogen Bone Healing System (Smith and Nephew) has proven to be beneficial with these injuries as well.

What About Symptomatic Synovial Plica?
Symptomatic synovial plica is another cause of knee pain in runners. A plicae is an embryonic synovial fold or septum which normally separates the suprapatellar pouch from the major part of the knee.

This usually disappears but may become a fibrous band due to trauma. During knee flexion and extension, the fibrous plicae rubs across the medial femoral condyle, causing pain that mimics a medial meniscus tear as well as degenerative changes in the medial femoral condyle.

There are three types of plicae: medial plicae (which is the most common), and suprapatellar and intrapatellar plicae (which are less common). The key finding in a knee with plicae syndrome is tenderness along the midmedial retinaculum. The medial joint line is not tender. If fibrous hypertrophy has occurred, one may be able to palpate a reproducible tender band. No effusion, ligament laxity or loss of motion is present. Foot type is not a factor with these injuries.

One often makes the diagnosis clinically. Magnetic resonance imaging studies are also useful. Conservative treatment consisting of physical therapy, NSAIDs and injection therapy has proven to be helpful. If conservative treatment fails and symptoms persist, one should consider referral for arthroscopic resection of the symptomatic plicae.

Understanding The Signs And Symptoms Of Iliotibial
Band Syndrome
The iliotibial band (ITB) is a fascia strip that passes down the lateral aspect of the thigh from the crest of the ilium and inserts into Gerdy’s tubercle of the lateral tibial condyle. As the knee flexes and extends during running, this band repeatedly rubs over the lateral femoral condyle. This causes inflammation and pain. The resulting knee pain is just above the joint line. Runners with these injuries usually have increased their mileage too soon, have biomechanical imbalances, run on hills and/or run on a banked surface.

The ITB moves anteriorly onto the lateral femoral condyle as the knee extends and slides posteriorly as the knee flexes. However, it remains under tension in both positions. This makes the ITB susceptible to inflammation. The symptoms usually consist of sharp pain or burning on the lateral aspect of the knee.

One would make this diagnosis clinically. Magnetic resonance imaging studies can show a focus of soft tissue edema adjacent to the ITB, usually on the deep aspect near the lateral femoral epicondyle.
The key to successful treatment of ITBS is an aggressive stretching program, which reduces the compression force between the band and the lateral epicondyle, according to Gary Guerriero, PT, the Head Physical Therapist and Director of the U.S. Athletic Training Center in New York City. Other treatment options include physical therapy modalities, injection therapy and orthotics. In my experience, only two patients with this injury required surgical management in 17 years of practice.

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