The second, an athlete with a long history of knee pain:
Hi Dr. Post-
I'll make this brief, and if you would please take a moment to help me, I would truly and dearly appreciate an objective criticism of the condition that I have gotten myself into.
40 y/o male.
Frequent Ultra runner.
Registered Nurse (humbly before you)
Because of a clogged sweat gland on the bottom of my foot (took 3 yrs for me to see the right person to get it fixed), I altered my walking and running form and also my cleat position on my cycling shoes.
Changing my active forms of movement caused me to develop hip pain that was unexplainable, undiagnosable, and was found negative after 2 standard MRIs and 1 MRI Arthrogram (a 1cm x 2cm cyst was found and that's why the arthrogram).
Lumbar MRI was unremarkable and interpreted as not causative of my hip pain, nor the knee pain that sometimes flares-up.
After the arthrogram and Lumbar MRIs were negative, I went back to my most natural feeling movement patterns and relocated my cleats---AND THEN after about 3 months the hip pain stopped.
I have one remaining residual issue that I need to ask about to better understand what I need to discuss with my orthopedist. I get a tight/pinching feeling (probably inflammation) at the distal head of one of my medial hamstring tendons.
I rarely take NSAIDS, but it does improve with 800mg Ibuprofen BID. However, without medication the medial hamstring tendon bothers me while sitting, squatting (to play with my children), and also if I sleep with my knee in flexion.
The orthopedist said it wouldn't hurt to check my knee with imaging and the knee MRI says that I have a popliteal cyst and some horizontal signal intensity on the posterior horn of my medial meniscus that, in the presence of the cyst, might be indicative of a meniscal tear.
I am at a loss about how to approach this. My sports medicine doctor says that orthopedist might want to take out the cyst, but that a meniscus repair is probably not warranted.
Should I just chill out and check back with the orthopedist in another 4-8 weeks, or should I press on and have the cyst removed? It seems like it will resolve itself, but the sports medicine doctor is wanting to use ultrasound to inject the cyst with cortisone, but then tells me about how that the cortisone is caustic and that it might damage me and then require surgery.
Financially I'm running on fumes, and I really need to concentrate on my family and my work, but I desperately want to return to the sports that I love for both my physical and mental health (which also help me to concentrate on my family and my work).
Thank you Sir.
You didn't give me your name so I'll call you Steve. After reading your note, I have a few observations that may help. In no particular order, any doc with an active knee practice likely gives a couple thousand knee injections each year. If there were a significant downside, that number would likely be lower. Popliteal cysts themselves are rarely primary and rarely the source of the patient's symptoms. I'm surprised between the radiologist and the ortho guy they can't be more certain of the presence/absence of torn meniscus. That said, the situation where a meniscus is repairable occurs much less frequently than that where the torn piece is simply removed, something done every day in the operating room by many docs. Is there a mild degree of early arthritis present in this medial side of the joint on would wonder as well.
Your doc, after your knee exam, must have some opinion as to which of these two is more likely the source of distress. My money would be on a torn meniscus. If the decision to scope the knee is made, doing something to the cyst would be unusual. The norm is arthroscopically address the problems inside the joint and leave the cyst alone. If indeed you have a medial meniscus tear, removing the torn portion is quite easy and you'll back on the roads quickly.
Steve - it sounds like you have a Sports doc and an ortho guy. If so, two opinions may benefit you more than one!
Good luck, John
John H. Post, III, MD Medical Director, Training Bible Coaching Contributor, Ironman.com firstname.lastname@example.org
Below is the full text of our followup e-mail traffic if you might be interested.
Thanks Dr. Post. I'm Mark.
I agree that the cyst is probably not primary.
An analogous situation occurred with my hip MRI and the presence of a cyst there, but then the arthrogram showed no tear. For whatever reason, I seem to be forming cysts due to minor injuries and overuse (or poor ergonomics) because I also had a ganglion cyst on my wrist this year.
I'm very apprehensive about general anesthesia especially because the cyst might spontaneously resolve.
I'm further distressed about the fact that neither radiology, ortho, nor sports Med has a conclusive opinion.
Isn't it possible that the popliteal cyst is from an injury to my distal hamstring tendon?
Dear Mark (maybe Steve in a former life? Ha!)
Re: I'm very apprehensive about general anesthesia especially because the cyst might spontaneously resolve.
Nobody is pushing you so take your time. And if you don't want general anes, don't have it. I've had a couple procedures on my legs had either local or spinal. No GA.
Re: I'm further distressed about the fact that neither radiology, ortho, nor sports Med has a conclusive opinion. That may be good. No one is forcing your hand...."well sir, your only way out is an operation.." You got over the hip pain without a trip to the OR. Here in VA there's a resource the athletes love. It's called the speed clinic. They examine you, look at your studies, put you on a treadmill and try to heal you with exercise. One of my group had butt pain for a year, two injections, but since going to the SC, is planing IM Chatannooga in the fall. I wrote it up for LAVA - yet to be published - but if you promise not to share it and send me an email add I'll send it to you. email@example.com
Maybe there's one near you wherever you live. Google UVA Speed Clinic.
Re: Isn't it possible that the popliteal cyst is from an injury to my distal hamstring tendon?
I doubt it
Mark has since read the Speed Clinic piece and offered:
Thx for allowing me to talk this through. I cannot tell you (succinctly) how much that this dialogue has helped me.
I appreciate your email. I will consider the concepts of speed clinic and whether it might help me.
Merry Christmas, and all the best in the new year.
Thanks Mark, Happy Holidays to you and your family.