In a continuing series, Paul and Howard talk about parts of the body that sometimes hurt. This time we’re on about Why Knees Sometimes Hurt.
- What pain in the knee means
- Where the most common injuries mean
- Why surgery isn’t generally required
- Arthritis and the knee
About The Show
Paul Kedrosky is a frequently injured athlete and a venture capitalist. Howard Luks is a top sports orthopedic surgeon. Smart, candid, and experienced analysis, ideas and tips about health, fitness, and longevity from two athletes and sports orthopedic surgeon—and guests.
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Paul: [00:00:00] Hey Howard.
Howard: [00:00:01] Hi, Paul.
Paul: [00:00:02] So we were we were talking the other day we saw, I, I think it was a Google trends thing or something. But one of the things that I thought was really interesting was there’s been there’s record highs in three. Closely related searches. And those are a fill in the blank search of why does my blank hurt? And the top three were back knee and shoulder. And these are at all three adjusted for, you know, population and whatever are at all time highs, which just.
Floored me. I had no idea that everyone around me was in, I mean, I like to say everyone always remember everyone around you is suffering, but I didn’t realize I was actually truthful statement.
Howard: [00:00:42] I wonder if they’re actually suffering more or they’re bored. They’re home. They’re sitting at their computers, right?
Paul: [00:00:50] I, all of the above is a, my, my guests. I, and, and it’s wonderful. We’ve talked about this before, but there’s wonderful, naive confidence that the th th Dr. Google can solve my problem.
Howard: [00:01:02] funniest. Some, some patients are coming in now and apologizing. It’s like, I have to apologize. I looked on Google.
Paul: [00:01:10] Isn’t that funny?
Howard: [00:01:11] was dying.
Paul: [00:01:12] Oh, man. It’s really interesting. It’s as if they’ve violated some doctor patient warranty thing where it’s like, dude, I’m fact checking you before I came in and I’m really sorry about it.
Howard: [00:01:23] I love when they do the second opinion thing. So I don’t mind. Right. When I give them their diagnosis, I have a pad in the office. It’s simple. It says what we discussed and I’ll write down a bunch of keywords and send them out, come on back in a week or two.
Paul: [00:01:39] Yeah. And see if there’s some, somebody else you’d like to talk to you
Howard: [00:01:42] all for it.
Paul: [00:01:43] to share my Sarah my notes. Right. So anyway, so I thought, and we thought, I think it would be fun to just, let’s just take these on and it’s for whatever, there’s a bunch of different reasons that this is going on, but maybe just walk through let’s start.
And what about knee? You want to start there?
Howard: [00:01:59] sure. Let’s start with the knee.
Paul: [00:02:04] I’m a big knee guy. So why does my knee hurt? And so let’s maybe start with. What is ni I mean, and this is a weird one, most philosophical question, but what’s the spectrum of what let’s leave aside. I’m tiger woods. And I just blew up my leg in a car accident, but let’s say of all the other kinds of knee pain people tend to show up with, give us a basket of what people come in and say, like it aches, it feels like something’s tearing.
I mean, what are some of the things, the symptom type talk you hear when people walk in and they’re saying, why does my knee hurt?
Howard: [00:02:38] Yeah, that’s a great question. So I’d say the vast majority of people that I see in a typical ambulatory practice have pain in the front of the knee. it tends to associate a lot with being in poor condition. It tends to associate lot with people with some early arthritic change. Poor strength et cetera.
Paul: [00:03:00] So front of the front of the knee is is a, is a common location and it feels like what if it’s there in general? I mean, obviously I can get a thousand different sensations, but if it’s a con, if a typical presentation with front of the knee pain is someone who says it, it aches, it’s
Howard: [00:03:17] Is burning, burning, aching, annoying. A lot of people will note that they have crepitus and crepitus as that crunching sound. I mean, there there’s some people that you hear as they’re entering the room, they’re their knees are so noisy and interesting. Only interesting tidbit crepitus tends to associate more with inflammation and not necessarily.
With a mechanical event. So it’s not too rough surfaces rubbing together. It certainly can be, but it’s usually not.
Paul: [00:03:53] Yeah, mine have, might’ve been noisy forever. So I just,
Howard: [00:03:57] well, you got to rid people of that because otherwise they’ll try and avoid activities that
Paul: [00:04:02] Yeah, yeah, yeah, yeah, yeah. So, okay. So burning sensation, there’s obviously one of the more common, maybe not so common, maybe it just think it is a, is a feeling of something catching that’s. That’s a typical presentation. You hear a lot or is that not particularly common?
Howard: [00:04:17] No you do catching can associate with Penn the front of the ear or what we call anterior knee pain. Especially in people with some arthritic or degenerative changes. You know, it. It takes a lot of energy to decelerate the body. So going downstairs or downhill requires a lot more energy than going up.
And if there’s any pain sensation, a lot of times that knee can catch or give way very rarely there’s a mechanical issue where something’s getting caught or stuck that will make the knee give out. Of course giving way can be associated with ligament issues. But those are far more rare.
Paul: [00:04:58] So when someone says. As an example, then let’s go away from catching. You brought up the idea of the here’s. Another presentation to someone says this feeling like my knee is going to give way. I find that one’s a really interesting presentation because years ago, I think I told you this story at one of my many ridiculous injuries.
I I was, this is a great sentence coming by the way. So stay tuned. Here we go. I was, I was mountain biking across a teeter-totter.
Howard: [00:05:25] Yeah,
Paul: [00:05:27] Which is a sentence that, you know, is always followed by everything went well or the opposite, actually. So I was mountain biking across a teeter-totter got to the middle and the guy I was with, it was a guided thing up in Whistler, British Columbia.
And the guide said, Oh, you’re doing great, dude. And of course immediately at that moment, I just fell off sideways. In the middle of the teeter-totter and it was over a Creek, so it wasn’t just over flat ground. So I went down into a Creek and there was rocks and stuff, and I landed and hyperextended my left knee backwards.
I’m like 10 degrees, maybe like really backwards. Yeah. And so I knew I had done something really bad to it. I just didn’t know what, and so I just smiled and got all manly and said, yeah, that didn’t go very well and got on my bike and went to the bottom. Cause I had to actually catch a plane to fly back down to San Diego for, for something.
And by the time I got out of my rental car at the, at the airport in Vancouver, I. Basically couldn’t walk by the time I got home in San Diego for three hours later, the knee is swollen app and it was, you know, it was just a mess long story short. I was like a partial ACL tear, which is obviously a a useless euphemism, but it was, it was just, I was lucky in a sense.
It was just a bad sprain, I suppose, if you will. And But, but for like four weeks afterwards, it felt like I was like balancing on roller skates and the roller skates were all inside my left knee. Right. So there’s this constant feeling of like, Whoa, Whoa, can I go this way? Well, you know what I mean? And and eventually that subsided, so that’s always been what I thought people meant when they said, Oh, it feels like it’s going to give way, but maybe that’s just my version of it.
Howard: [00:07:05] Yeah, well, you know, hyperextension injury is a rough cause you can tear the PCL. You could tear the
Paul: [00:07:13] Yup. Yup.
Howard: [00:07:14] Can dislocate their, their knee that way. So I hate seeing those injuries. Partial ACL tears can actually cause instability. You got to subdivide these, these, these, these, these partial injuries into those that create a stable knee.
Are those that end in an unstable knee. So some, some, some partial tears will create a functionally unstable knee and actually need a full reconstruction. But many times, you know, the pain sensation that you have will give you a sense of giving way. So if you look hyperextend uni, you go for an MRI because she needed swollen and it hurts.
And you have a feeling of giving way. There’s a really good chance that once that swelling and inflammation go down and you rehab the knee, that feeling of instability is going away.
Paul: [00:08:10] Yeah. And that was a hundred percent the case with me. I mean, it was four, three, four weeks later, but I mean, I can’t, I honestly, I would just, when I was telling you the story, I had to try and remember which knee it was, cause they both feel the same. I don’t know. I don’t notice any difference anymore. And the, and I’ll be, there was a.
I forget. I think it was the second a guy. I got a second opinion from said he was actually fairly gung-ho to do something. He said, you’re going to have to do something here. This is, this is probably going to be an instability for the rest of your life and he was wrong. So. Yeah. Yeah, no, I’m, I’m, I’m S small mercies. I was, I was glad to have that happen,
so let’s let’s continue with the basket of symptoms and the way people present. So that’s we talk front of the knee and a little bit about back of the knee, but we can do some more back stuff. If you hear it’s, you know, medial lateral, either side of the knee.
What, how common is that? And what typical sorts of things immediately pop to mind?
Howard: [00:09:06] medial. A lot of this will depend on your age and what you do. So right. If I have a middle-age runner, it’s frequently a typical degenerative meniscus tear. Or it can be some stress reaction or even a stress fracture. You can get stress fractures at the end of your femur on the inner side of the knee.
You can get them on the top of the tibia
Paul: [00:09:30] You know, just to, just to stop you for a second there, I heard an amazing story the other day about someone with a sh I didn’t even realize this was a thing. And you just said it. So a femur stress fracture as a result, this was a woman I was reading about in a book. Book, who was just, who was an ultra runner huge distances.
And she had just was in the process of completing like an 11 day run through the Pyrenees and part of the Alps or something. And every day, her, it would take her a progressively longer to quote up because her knee was really hurting. And then sometimes through the run, the knee would get worse.
Eventually she stopped and got some imaging done and found out she had a femoral stress fracture. Okay.
Howard: [00:10:08] Along the distal part of the end of the femur, just above the knee. It’s not actually an uncommon area. And in long distance runners, unfortunately in women,
Paul: [00:10:17] I would think the femur is so damn beefy that it’s nothing should go wrong. But
Howard: [00:10:21] Yeah. You know, that area, that where the fractures tend to occur, it’s not critical. It’s the bone is spongier and softer. It’s what we call the metathesis. So it’s pretty common area. For these, the stress-related injuries again is especially in women. They tend to be a little osteopenic, light bones are osteoporotic.
Especially if they’re, if they’re distant runners and caloric intake is off, et cetera.
Paul: [00:10:47] So let’s continue on the medial lateral side. You talked a little bit about if it’s on the medial side and it’s like a middle-age runner prob might be some degenerative meniscal problem. What a lateral side, anything in particular that shows up a lot that immediately
Howard: [00:11:02] Yes. So let’s stay on runners, right? The lateral side, you get it ITB syndrome. If you dive into ITB syndrome, we really don’t know why it occurs. You know, I mean, the ITB is a super tight tissue and the research is really clear. You can’t stretch the ITB, you can roll it all you want, but you’re not changing its length or size.
And. There are people who say it’s a friction issue between a little, a little bony prominence and the backside of the ITB
Paul: [00:11:32] Epicon died or
Howard: [00:11:33] epi condo. Yes. Which is where the lateral collateral ligament. Attaches up on the femur, but you know, it’s a very real entity and somebody, people are really crippled by it.
But it’s a common source of pain. Now, the lateral meniscus can be a source of pain, much like the medial meniscus, but much less common. However the Papa T is tendon. This is an interesting little tendon. It’s a small tendon that has, it’s an, it’s an inter articular tenant. So it’s inside the joint.
There’s actually a little, a little hiatus or a hole on the back of the lateral meniscus that this, this tendon comes up as it wraps around the femur and attaches to it. And what it does is it on locks, the knee. So when you fully straighten. Your knee is screws home. The two bones rotate and lock on one another.
So uni is actually super stable when it’s fully straight. if you can’t lock out your knee, you know, it, it feels weird. So the Papa T is what unlocks it when gate initiate, but the Papa T is. Can become tendonitis or degenerate much like we’ve talked about with patella tendons, Achilles and the rotator cuff. And so it’s not an uncommon source of pain along the lateral side of the knee.
Paul: [00:12:59] That’s more typically seen in, in runners.
Howard: [00:13:02] I I’ve seen it more commonly in very active people runners and cyclists alike,
Paul: [00:13:09] Interesting.
Howard: [00:13:09] it’s a common, second opinion. Diagnosis, you know, typically see someone I’ve had pain, they thought it was a meniscus tear. The meniscus is fine. They’re thinking of an arthroscopy or this. And we’ll look more closely specifically at the Poplar Ts and, and there’s the problem.
Paul: [00:13:30] And what do you do about it? Just out
Howard: [00:13:32] It’s a good question. The Papa T is, is actually in a little sheath. Yeah. So you can inject it separate from other structures, the knee. So oftentimes we’ll do an ultrasound guided injection inside the sheet. So it’s not inside the tendon itself and that will ameliorate the symptoms.
Sometimes people have instability of the Papa Tia’s tendon, where it’s snapping around and moving around. Inside that hiatus where it transits through the meniscus and those cases, we can stabilize it and fix it back into its position. But the Papa T is, is an unrecognized troublemaker.
Paul: [00:14:10] Yeah, you don’t hear about it very often. At least not among my running crowds.
So back of the knee, anything in particular that you symptoms you hear about that you presentations, you hear about a lot and what they mean,
Howard: [00:14:25] so the back of the knee, it’s a common place for people with severe osteoarthritis to complain of pain yet. It’s interesting because they’ll say it’s not my knee. It’s behind,
Paul: [00:14:40] I see.
Howard: [00:14:40] don’t realize it’s the back of the knee. Right. So now. Arthritic pain can really arthritic knee pain can radiate anywhere it can.
On the inner side, it can radiate down the shin all the way to the ankle sometimes on the, on the lateral side or really up the back of the thigh. And the back of the knee is always a source of fullness many times because of a Baker’s cyst, which is just a fluid filled collection in the back of your knee.
It’s a potential space. And when you get fluid in the knee it can accumulate there.
Paul: [00:15:18] is that a genetic thing by the way,
Howard: [00:15:20] Not really? No. So you, you, you have this collapsed potential space and for some reason you develop a lot of fluid in your knee, usually in association with an injury or arthritis, then it just evacuated and goes through into the cyst.
Paul: [00:15:39] Interesting. Okay. Let’s two other quick ones while we’re on presentations. How does someone with jumper’s knee typically show up?
Howard: [00:15:46] jumper’s knee is a term we use for patella tendonitis and they always have pain at the lower pole, the lower end of their patella dead center, right where the patella tendon. Attaches to the patella, always in the same area,
Paul: [00:16:06] Okay. So not, not at the upper, it’s usually at the lower, the lower pole,
Howard: [00:16:10] lower pole of the patella, right? Where the patella tendon attaches quadriceps quad tendonitis from jumping not unheard of, but far more rare.
Paul: [00:16:21] Yeah. I’ve never even heard of that before. I
Howard: [00:16:23] have the.
Paul: [00:16:25] patella, tendonitis all the time, but the quads are jumping, not so much.
Howard: [00:16:29] Jumper’s knee is brutal for some people
Paul: [00:16:32] Oh, I I’ve. I know people who were high school, basketball players and volleyball players. These are, you know, really guys, you know, really common, really common places to have this happen, especially when they’re over-training and practicing a lot and trying to work on their jump and whatever Boyle boy, and then getting past it is just awful.
Howard: [00:16:51] absolutely,
Paul: [00:16:52] Let’s go back to another w you talked to for a second about it ban and it’s interesting. Cause it can present sometimes and I’ve had it once this way, where they initially thought it was a knee problem, right?
Howard: [00:17:03] it is so low that it really is, you know, they’ll say the side of my knee hurts. They don’t think it’s their ITB initially, unless they’ve done some reading. They’ll all assume that they have a meniscus tear or a stress fracture, especially if they’re a runner. And you know why it’s only about a centimeter centimeter and a half away from the joint line where the meniscus is, everything is, is so closed, but on a good exam, you could clearly tell the difference
Paul: [00:17:36] Yeah. I
Howard: [00:17:37] you can feel the I B condo there.
Paul: [00:17:40] yeah. Which is where it attaches. Right. Let’s do a couple of weirdo ones. What’s what’s some of the weirder unicorn. You hardly ever see it, but boil boy, you better notice if you do kinds of things you might, that might be causing knee pain,
Howard: [00:17:52] so that’s a good question. There are three. Three tendons that attach to the top inner side of a tibia about two inches below the joint. We call them the Pez tendons because they have the shape of a Goose’s foot. And as a matter of fact, one of these tendons is the one we usually will. We’ll harvest for a ligament reconstruction.
But inauthentic knees, these Pez tendons, and a bursa fluid-filled SAC that surrounds them can be a real troublemaker. So you can see people typically older. They come in with they complain of pain on the inner side of the knee. They don’t necessarily localize it. Well, They are on the runway for a knee replacement in another office and their x-ray show, show terrible arthritis, but they’ve known that they’ve had it for 10 years and this pain just came on and it was pretty severe.
You touch down there and you can feel these tendons and these people jump off the table.
Paul: [00:18:59] Okay.
Howard: [00:19:00] and these people are super happy because a simple injection under ultrasound and the pain is gone most of the time. And they don’t need a joint replacement. So it’s an interesting little problem.
Paul: [00:19:15] Huh? I’ve never even heard of that one. That’s interesting. And is that that’s not an overuse injury. Isn’t a campy, not
Howard: [00:19:21] No, it is associates with arthritic changes. So we, we’re not exactly sure it, because you would think, okay, maybe it’s close to the joint, so it’s rubbing, but it’s not because it’s really poster or behind the joint. And doesn’t rub up against it. But it highly associates with arthritic change. And if you, if you can find these people, they do great.
Paul: [00:19:47] as you can tell, like a miracle worker.
Howard: [00:19:49] yeah, they come in expecting to hear, yes, you need to dry replacement or maybe they want to sign up and have me do it. And then they here, they need a little injection and we get the ultrasound machine out and boom,
Paul: [00:20:03] There it is.
Howard: [00:20:04] really happy people
Paul: [00:20:09] Any other weirdo stuff that comes to mind? Anything else that’s strange and unusual that you’ve, you’ve seen and just struck you,
Howard: [00:20:16] was stranger than you usual, strange and unusual to patients like patella instability. A lot of people are born with a predisposition. So their patella, which floats in a groove on the femur that we call the trochlea, sometimes that trochlea, isn’t really a groove and it’s too flat. Sometimes the patella itself on its underside. Isn’t V-shaped and it’s more like a, a long L and so it doesn’t sit well in the trochlea, so it can dislocate and slide out each time you straighten the knee. Okay. Reach time, you can try and go up and down the stairs. And some people for some, it had a traumatic cause and for others, they were simply born with the predisposition.
Paul: [00:21:02] That’s a, you know, I’ll tell you, I had a guy years ago, tell me, I forget what the expression was. I think it’s like they said, mal tracking or something like this. There was an, it turned out that, I mean, a long story short had nothing to do with it, but I became very suspicious of diagnosis of patella because it just felt to me like one of those, yeah.
I have one of these. And and if they were going to do anything about it, it was one of these, what do you call it? Just , you know, green smoke operations. We just go, I’ll just go, I’ll just have a wander around and change some things. And I was like, yeah, I’m not, I’m not into this whatsoever.
Howard: [00:21:35] It is one of those diagnoses that drives me nuts because I’ll send someone to therapy for one reason. And sometimes the patient will come back and say, well, my therapist says I have patella mouth tracking,
And you know, it’s a problem because, you know, Now they have that doubt in their mind, and they have that doubt in implanted in their brain, by someone who they’re seeing two or three days a week.
And they’re seeing me every four, six weeks. So it has some validity to them. And now they’re not sure. And I assure them, I’m like, look, you wouldn’t have made it to 50 or 60 years old if your patella was dislocating
Paul: [00:22:23] you would note you’d notice.
Howard: [00:22:26] absolutely. And I can find subtle mouse tracking issues in everyone.
Paul: [00:22:31] No, no. That’s and that’s, what’s interesting though. And that’s why I find a lot. And we’ve talked about this a lot before, but the idea that any phone numbers settling out the imaging or even physical exam, I’m going to find something that’s, you know, one standard deviation from the norm, but who cares?
We’re all on a distribution. It’s really not a big deal. Don’t don’t, don’t sweat that you’re not exactly normal. None of us, none of us are, and it doesn’t matter. Right.
Howard: [00:22:56] You know, every time I order an MRI and someone over 40, I have a talk and it’s a good solid five minute talk. We’re going to find five things in your knee. And if I MRI your other knee, I’d find the same five things. That’s not the reason why we’re getting those right. We’re looking for X, but we may find Y and Z, Y and Z just don’t matter.
Paul: [00:23:19] Yeah. Unless you lost.
Howard: [00:23:20] for you to forget.
Paul: [00:23:22] Unless you lost a credit card in there. Just ignore everything. Just leave it alone. Yeah. No, I’m, I’m, I’ve, I’m a convert to that camp. We haven’t talked too much. Let’s let’s maybe talk about one other thing before we move on. Swelling, all these other things that none of these things, it’s a fairly mean that something’s that serious.
Right? I mean, lots of the knee is prone to swelling at relatively mild provocation. It doesn’t necessarily mean there’s something super serious on. I, you know, I twisted my knee playing basketball on the weekend, my knees swollen on Monday. It’s just, these things can happen. Right? I mean, things swell up.
Howard: [00:23:57] yeah, true. But the context matters and the story
Paul: [00:24:01] sure. If there’s a pop or something else.
Howard: [00:24:04] exactly. So if you’re playing basketball, you twist your knee and that knee is swollen by the time that you get home. Then that’s that’s blood and you’ve torn something. And oftentimes it will be the ACL, but it could also be a meniscus, et cetera.
If you twist your knee or tweak it, you could still play, but it’s bothering you a little, you wake up the next morning and it’s swollen. Yeah. Yeah. It’s probably not something serious. If you have some arthritic change, some degenerative changes. The knees been achy then every now and then your knee will swell.
And interestingly, it’s not going to swell because you did something right. You may spend the whole day in the garden or the whole day running or hiking and you need doesn’t swell the next day. You spend it in a chair watching football games and you get up the next day and your knees swollen. So it can be infuriating like that.
Paul: [00:25:02] Yeah.
Howard: [00:25:02] You know, you know, one thing we should talk about things that masquerade as knee pain, and this is super important,
Paul: [00:25:10] Yeah. So I was thinking of it. Band is one example, but I’m sure you
Howard: [00:25:13] okay. Here’s the better one. You you’re a 60 something year old, 70 year old, the lower end of your thigh hurts down near the knee on the inner side. And just matter of fact, you come in saying your knee hurts and you’re limping.
Yet in the student, observer will note that your gait is because your hip is hurting you. And these, these are crazy visits because I have to send them back to x-ray and I said, look, I have to x-ray your hip. And they ask why and you get an x-ray of the hip and the hip is destroyed because certain forms of hip arthritis, if they have a bone spur.
Along the inner part will irritate a nerve that comes all the way down. The inner side of your sides. It’s called the opterator nerve. And so nerves will always bother you with that the end. So like a pinched nerve and your back will hurt in your calf or your ankle.
Paul: [00:26:11] Yeah.
Howard: [00:26:11] same thing with the opterator nerve.
So these people came into you with knee pain and you’re telling them they need it hip replacement and they think you’re absolutely insane. So you have to pull out your ultrasound machine or send them to the x-ray suite to get an injection into their head. And once you put the lighter cane in there, their pain goes away.
Now they think you’re a genius.
Paul: [00:26:35] Yeah, no, that’s a great example. And I actually I’ve even heard of exactly that happening. At least one, maybe two cases in, in, in runner, friends of mine, where it turned out, it was a, it was a hip problem in their case. I think it was like a, I don’t know if there’s like a neuropathy, there was an inflamed obturator nerve for whatever reason.
And it eventually settled down and it wasn’t didn’t turn out to be the hip specifically, but it was that region. It wasn’t the knee.
Howard: [00:26:56] yeah, this happens in kids too. There are well known causes of hip pain, hip issues in kids that manifest as knee pain. And if you don’t get a hip x-ray, you’re going to miss this. It’s called a Skiffy a slip. Capitol prefaces. And that’s a surgical case. You have to fix that hip. So kids of certain ages pain in certain areas around the knee, you’re imaging, the hip
Paul: [00:27:25] Yeah, no, no. That’s really any other cases like that, that come to mind, things that mask his knee pain that aren’t
I guess the low back hood, it’s not typical, but it absolutely could If you have a pinched nerve on the higher side of the lumbar spine not the typical L five S one that that can manifest as lower thigh and knee pain. Yeah, nothing really good.
no, no, no. That’s good though. At least that’s mostly because he paid supposedly about the knee, which is handy.
Right. So okay, good. Well, that’s been a great basket of have a good look at why, you know, the answer to that Google question of why does my knee hurt? So we’re not going to get into, you know, treatments or anything else, so let’s leave it there.
Howard: [00:28:10] Sure Paul take
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