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Runner, cyclist
ACL reconstruction with LET (lateral extra-articular tenodesis) 1 year ago
Good progress with rehabilitation – however at final stages, intrusive lateral clicking & aching on repetitive 30 degrees flexion into full extension with jogging and more intense bike work
OE -
Similar picture to ITB friction syndrome; palpation pain close to lateral femoral epicondyle, positive Nobles compression test
Negative fat pad compression
No meniscal or PFJ signs
MRI (axials T2) –
Oedema / high signal around the LET (in this case, technically a portion of the ITB folded back under the LCL and sutured down)
POCUS video QR code (second half is dynamic flexion / terminal extension assessment) –
Anechoic fluid noted around the LET interface just inferior to the suture (bright) – is this suggestive of inflammation and LET ‘impingement’?
US guided diagnostic injection with LA at this fluid interface 100% abolished pain on incremental treadmill test
It’s possible that impingement is under-reported or recognised; that aside, new lateral knee pain after ACL reconstruction can often be patellofemoral or fat pad in origin due to the change in joint biomechanics and loading patterns, as well as popliteus tendinopathy pain – have these on your radar before thinking about more esoteric causes
Research link –
SANTI group – three times reduced ACL graft failure with LET
https://t.co/cZZtKJUijA
@DrJN_SportsMed I learnt from Dr Bruce Reid (Essendon Football Club in Melbourne) to always check the syndesmosis and the base of 5th metatarsal in ankle sprains
Radiculopathy, surgical infection & managing it - a clinician's real world experience & observation:
1. Radicular pain - for some - is different level pain; like a rat gnawing your thigh & shin from the inside whilst a poorly gauged UV sun bed is applied externally
2. With these levels of pain, I couldn't care less about the foot drop; it doesn't even come in to the equation; however operating early makes sense esp with objective motor loss
3. Disciitis is hugely rare as a complication. Think re immunosupression, previous high doses of local region CS
4. As I've said a million times before, discogenic somatic pain behaviour is myriad - belt like, corset, groin thigh - my personal pain is worst in groin & thigh
5. If you've had a unilateral discectomy & you develop symmetrical pelvic pain, you've got an infection until proven otherwise - get blood markers at least
6. Disciitis pain is agonising - and equal to having a long bone fracture that can't be immobilised effectively - things start to fuse overnight then you move early am and you want to kill yourself
7. Early physio input is pointless - sleep, eat well, get your head in the right place. Give yourself the time it needs. I didn't.
8. Pain will lag well behind blood & imaging markers improving. Don't give up.
9. It's almost impossible to gauge / titrate load levels vs carry over effect the next few days.
10. Prioritise your mental - not physical health. You don't really have a choice.
11. If the disc infection is aggressive enough, the VBs will auto fuse (see image); but need to monitor which may it uses rg kyphotic - which in itself may require correction at a later date ) esp if causes foraminal stenosis
12. It takes time - I'm not patient!
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