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Chronic Knee Pain But Normal Mri

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My husband is 25 and has had chronic knee pain for a little over four years. He was active duty military and injured his left knee during basic training. It seemed to heal well though and didn't give him problems for a while. He started to have some knee pain when he was in korea and ran eight miles daily and climbed inumerable stairs. After he returned to the states, it gradually worsened until he could no longer pass his pt tests. It was especially difficult since he was a cook and spent as many as fourteen hours on his feet. He was passed from doctor to doctor in the military and since he rarely saw the same doctor, they never saw him fequently enough to make a diagnosis. His doctor recommended a medical discharge but it was denied and he was sent to iraq. When his active duty contract expired he stilled owed the military four more years, either in the individual ready reserve or the national guard. He joined the guard because the recruiter told him he would probably be sent to iraq again if he joined the irr. For a while his pain was better since he wasn't on his feet as much. Recently it has been getting worse even though he has a desk job. He is unable to run or perform other duties in the guard so they required him to go to civilian doctor and get recommendations on what kind of limitations he should have. He recently got a government job and finally has health insurance so we had been talking about taking him to the doctor anyway. He went to a orthopedic surgeon, Dr. Beller, and he ordered an mri. Since Dr. Beller was out of town after the mri, he picked up the results himself. Another doctor had written the mri report and said there was some abnormal fluid on both of his joints and that his left knee showed "increased signal intensity within the mid portion of the medial meiscus....It cannot be called a clear cut meniscal tear but it is statistically more likely to be torn there because of the segmental changes." we anxiously waited for his doctor to get back from vacation to help us understand what might be going on. In talking to his mom I discovered that she was diagnosed with osteoarthritis in junior high and his nine year old brother has also been diagnosed with osteoarthritis. He tried to pop his knee one evening and felt excruciating pain. He's not a complainer but he said it felt like he'd broken it and it was hanging by a thread. We planned to talk to the doctor about both of these issues and had many questions. We waited an hour and a half before he ever showed up for the appointment and the nurse told us he had forgotten the appointment until he called and reminded him. When he finally arrived, he did not greet either of us or apologize for being late for the appointment. He just said,"your mri shows nothing." we asked about the abnormal levels of fluid that the other doctor had written about. Dr beller said,"there are no abnormal levels." I asked about the possibility of meniscus tearing in the future and Dr. Beller apparently misunderstood me because he said, "there is no meniscus tear." he then said,"you should return to the guard with no physical limitations whatsoever." I left the room crying because we had put so much hope towards this appointment.
After I left my husband told me he said,"okay," and waited for Dr. Beller to offer any other options or even to at least offer him pain medication.
Dr beller just said,"okay, that's it," and got up and left. The entire time lasted between three and five minutes.
My husband is still in terrible pain. It is especially bad in the evenings and sometimes he takes a wrong step and cries out. He says he hates being a "coward" in front of me. He can't even stand up to shower or brush his teeth and shave anymore. His walk is a painful limp. I feel at my wits end. We've talked about going to another doctor but I don't know if I can go through it again if the doctor doesn't believe he's in pain, as apparently Dr. Beller didn't. I'm not sure what questions I have. I really just appreciate if anyone took the time to read all this. I don't know whether we should go to another doctor and if so, what kind. It hurts so much to see my husband in so much pain and not be able to do anything.
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replied August 11th, 2011
Chronic knee or ankle pain with normal MRI may be due to
Biomechanic Pain Syndrome
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replied August 11th, 2011
Especially eHealthy
Jadeswan,

You do not say what he has tried or is currently doing for the discomfort. Also, where is the pain located exactly? Does he have any other symptoms, other than the pain, such as locking in extension, giving way with cutting activities, swelling within the joint, swelling below the patella, etc?

As for the MRI, it is not uncommon to see some fluid within the joint, as the knee has to have synovial fluid to move smoothly. It is then up to the surgeon to determine if it is enough to be considered abnormal, as correlated with what was found on the physical exam.

The finding within the body of the meniscus is called a Grade II signal. This is considered to be a myxoid degeneration of the meniscus, without a discrete tear. This was not known about until the MRI was developed, as when you look at the meniscus directly (either after it was removed as in the old days, or with the arthroscope now days), you cannot tell there is anything different about it, just by looking at it. So, there is nothing to fix or take out with surgery.

The good thing about the MRI and knee exam is that there are no significant meniscal cartilage tears, the articular cartilage is intact (a very good thing), and the ligaments are intact.


As to this being a type of arthritis, that is always a possibility, but it is not osteoarthritis. Osteoarthritis is degenerative joint disease (DJD), which is seen in the older population, as the joint wears out. In this population, cortisone or hylan injections may help to put off having to have the joint replaced.

But, there are a lot of different types of inflammatory arthropathies. These, however, usually present in multiple joints, with chronic swelling and redness, and specific patterns of involvement. The patient's lab studies would also show elevated inflammatory markers.

One monoarthritis, which affects the knee mostly, is Lyme disease. But, if he has not been exposed to ticks, or has had the classic bullseye rash, it is down on the list.


Unfortunately, knee pain is almost ubiquitous in the human population. Some patients have significant pain with about any activity, while others it only bothers occasionally, or with activities such as going down stairs.

One condition which is very frustrating to patients and surgeons alike is anterior knee pain (also called patellofemoral syndrome or retropatellar pain syndrome). This is pain around the patella, and below it, under the patellar tendon. There may be swelling of the infrapatellar fat pad, called Hoffa's sign. The pain may be increased with compression of the patella against the femur. The patient usually has pain with sitting for long periods (theater sign), pain with climbing ladders or going down stairs, squatting, and sometimes with just general activities.

Why it is so frustrating, is that there is still no known cause for the pain. The treatment is keeping the quadriceps strong (especially the VMO), hamstrings stretched, and avoiding activities which bother the patient. The quad station on the weight machine is also to be avoided. squats also should not be done. Some patients get relief with the use of a neoprene knee sleeve, with a patellar cut out (while others feel it just pushes the patella back into the femur causing more pain), but the only way to know is to try one. Antiinflammatory medicine may help in some patients.

Most people have the condition the worse when they are young, and it tends to subside as they reach maturity, though most patients will have it some what thoughout their whole life. There is no magic pill or surgery to make this go away. And that is why it is so frustrating.



If you feel that there is still something to be found, then you should, by all means, get a second opinion. Good luck.
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replied August 13th, 2011
Jadeswan,
As Gaelic mentioned, what treatments has he had so far? I also agree that there are many "abnormalities" which are read on MRIs that may not be of clinical significance. If he fell directly on the kneecap, sometimes you can damage the joint cartilage but significant damage here might show on the MRI. Did the orthopedic MD do a thorough exam? Has he tried physical therapy? I would think that he may have had Physical Therapy by now from the military. Not all PT is the same however. A comprehensive assessment that looks at hips, back, knee and feet can uncover some contributing factors.
Patella femoral pain syndrome is common and addressing all of the contributing factors can be helpful. Individuals who stand with their knees in a hyperextended position are more prone as this places excessive stress on the front (anterior) part of the knee and kneecap.
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replied February 7th, 2012
I feel for you and your husband. I am going through a very similar situation right now.. I have identicle symptoms as your husband does and my MRI has come back "normal" as well. the dr. I saw said to try physio. I had surgery on this knee 7yrs ago and have had cronic pain before and ever since. I just left the dr. office when I got the mri results and broke down as all these years later still no answers. I feel like I am letting my entire family down as I am unable to do all the activities I used to and worry that my daughter will be the one that suffers when I have to say "sorry I can't because of my knee". My knee even gives out causing me to fall and have taken 3 tumbles down the stairs because of it. If you and your husband figure anything out please let me know as I understand how you guys must feel.your not alone out there. all my best and good luck... "bigmac"
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replied December 4th, 2012
I Have been through the same thing only my pain startede when i was 13. i am now 18 and back to another doctor. i have been to 2 different orthopedic surgeons and 3 different MD and they have all said the same thing. there is nuthing wrong. but i have yet to take that for an answer I am now going to another surgeon in a few weeks. I have had two MRI done one when i was 14 and one a few weeks ago and they come back normal. i will continue to go to doctors untill someone takes enough kindness in there heart to care. if i figure something out i will post back just to help all the other people in the world with the same problem.
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replied December 4th, 2012
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There are many, many patients who have patellofemoral syndrome (PFS) in their knees. This is a condition which can cause discomfort around the sides or underneath of the patella (kneecap). Most of the time, the discomfort is increased when going down stairs or ladders, squatting, and using the knee extension station on the weight machine.

In many patients the discomfort can be brought on by sitting with the knee bent to 90 degrees for extended periods of time (as in a movie, lecture, long car ride).


There is not a whole lot seen in the knee upon examination. Some patients may have a little swelling under the patellar tendon (called Hoffa's sign). Most will have tenderness with compression of the patella against the femur. But, the patient has full range of motion and the joint is stable ligamentously.

The MRI is always negative for any pathology. If there is any pathology noted, then it is not PFS.


Many patients are bothered with PFS during adolescences and young adulthood. Some have to give up sports due to the discomfort, while others drive on despite the discomfort. In most, as their activity level goes down (as they get older), the condition seems to bother them less. But, many will still have some discomfort behind the patella when really stressing the patellofemoral joint by going down ladders or squatting.


This is probably to most common condition seen in patient’s knees, when the MRI is negative for any pathology. And, just because the MRI is negative does not mean that the patient is not having significant discomfort in the joint. It just means that there is no anatomical structure which has been damaged, no abnormalities within the joint.

An MRI does not diagnose pain. It is just a computer’s interpertation of radio signals, converted into black and white images. It is a static snapshot of the anatomy of the body part. It cannot look at the physiology of the body or dynamic conditions. It is just an ancillary study which may help the physician/surgeon make a determination of what is going on, along with the patient’s history, symptoms, and examination.


Just because an evaluation does not find any anatomical abnormality does not mean that the patient is not having significant problems with something like PFS. Unfortunately, there is no cure for PFS, no surgery to correct an abnormality. Some patients can be helped with change in activity and biomechanics, with stretching and strengthening of the muscles that cross the knee joint (especially the quads and hamstrings). But, this is not a “sexy” knee condition to have, something to tell friends about over a beer, to be able to show off surgical scars. It is just a pain, literally.

Unfortunately, many patients just cannot believe that their knee can hurt so much, and not have any pathology present. It is not that there is no pathology, it just cannot be picked up on MRI or surgically fixed. As a result, patients go from surgeon to surgeon to surgeon. The sad thing is that a lot of patients finally find some surgeon will to operate, even though there is nothing really to do, to “just take a look”. But, then the patient has a “surgical knee”, and may end up with just further problems from the surgery. With no resolution of their original problem.

This can be seen in the procedures which used to be done for PFS, because there had to be some treatment for it. That was at a time when medicine was beginning to believe its own hype, that it could do daily miracles and cure everything. Many patients had the articular cartilage shaved down on the back side of the patella. For PFS, this does nothing, but make the cartilage thinner so that it wears out quicker. So, a lot of unnecessary surgery was done. Again, PFS is not the same thing as chondromalacia (which is actually a pathological diagnosis) or discrete cartilage defects.


So, anyone who is told that there is “nothing wrong” with the knee, because the exam and MRI do not show anything, should understand that they can still have a significant condition, which may be PFS. They may want to see an orthopedic surgeon who has been fellowship trained in sportsmedicine or a physiatrist (a specialist in PM&R - physical medicine and rehabilitation) to discuss if they might have PFS and what they can to help with the discomfort. But, the patient does have to be realistic. Not all painful conditions can be cured or treated surgically.


Wishing everyone the best.
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