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Sports Medicine

Knee Pain

07/27/2000

Question:

Three weeks ago, I went on a 25 mile walk through Luxembourg. I was either walking up or down a large steep incline. Immediately after the walk, the muscles in my leg were severely fatigued, but there was no real pain.

The next day, pain started appearing in my left heel and behind my left knee (in the soft tissue at the back of the leg--not directly underneath or around the patella). I took ibuprofen for two days and limped around for two weeks.

Before the 25 mile walk, I did yoga positions that stretched and strenghthened the bottom of the feet and the back of the legs as well as my thigh muscles (6 times a week for 3 months before the walk). I also went rock climbing about 2-3 times a week (for the past five years) and was used to walking about 3 miles a day.

Currently, there is stiffness/pain in my left ankle that goes away after 25 minutes of walking at a fast rate. As the ankle stiffness and pain recedes, my knee pain gets worse. It is the worst when my leg is fully extended behind me. I am trying not to change my stride and cause other problems, but it is still uncomfortable to walk because of the pain in the soft tissue behind my knee. Sitting and standing is quite comfortable, but keeping my legs straight and touching my toes or bending over and placing my hands three feet in front of my knees (while keeping my legs straight) causes pain.

Do you have any recommendations for treatment for my knee? Or comments on what could be causing the pain? I do not currently have access to medical care, but will have access in about 3 weeks once my paperwork becomes official and I am a resident of Europe, instead of just a tourist.

Answer:

Three weeks ago, you went on a 25-mile walk which involved going up and down steep inclines. Your legs were fatigued immediately after the walk, but the next day, you noticed pain in your left heel and behind your left knee. Ankle pain and stiffness improve after about 25 minutes of fast walking, but that makes the pain behind your knee worse. You have no pain sitting nor standing, but have increased pain when bent forward from the waist with your arms stretched down toward the ground or when trying to touch your toes.

One possible cause for your symptoms is a strain of your left calf muscles, due to overload/overuse. Despite the exercises you performed in preparation for this 25 mile walk, these activities were not of the same type and intensity to sufficiently prepare you to do that much hill walking over that great a distance, so the result was that your body was "overloaded" and developed pain as a result. Your calf muscles attach behind the knee, and also form the Achilles tendon which attaches to your heel bone. You may have not only strained the calf muscle attachment at the knee, but also, developed an Achilles tendinitis.

Another possible cause for your symptoms is a pinched nerve in your lower back. You didn`t mention how old you are, but beyond around 35 years of age, discs begin to degenerate... more so, the older you are. The more degenerated your discs become, the more they tend to protrude, and possibly result in nerve irritation. If a nerve becomes irritated, there is typically pain in the leg, and also, numbness. Usually either sitting or standing makes this pain worse, but given that you are comfortable in both positions, a pinched nerve would seem less likely.

A third possibility is that your knee became inflamed as a result of the unaccustomed degree and type of activity, with resultant fluid accumulation within the joint ("water on the knee"). If that occurred, this fluid can sometimes form a cyst behind the knee, which can then extend down your calf, causing pain. If this occurred, there would be obvious swelling behind the knee, which you didn`t specifically mention.

Placing ice behind the knee for 10-15 minutes every hour or so may reduce pain and improve function. An anti-inflammatory medication - over-the-counter such as Ibuprofen or Naproxen, or prescription - at an adequate dose and for at least a week or two, may help reduce inflammation and pain. If this is a strained calf muscle and Achilles tendon, placing a small lift under the heel on both sides - to keep leg lengths equal - may help, as may wrapping your calf with an Ace bandage.

If your pain symptoms don`t progressively improve, it would be advisable for you to be examined by a sports-oriented physician to obtain a correct diagnosis, from which, then, the most appropriate rehabilitation plan can be developed.

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Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University