Jonathan Aarons M.D.

Tired of Chronic Pain?

Tibiofibular pain

 

Tibiofibular pain
Tibiofibular pain

Tibiofibular pain is an uncommon cause of pain on the outside of the knee joint.  The tibia and fibula are two bones that support the lower leg.  There is a joint that forms between those two bones.  This joint may communicate with the knee joint and diseases that affect the knee may also affect this joint.  Tibiofibular pain occurs on the outside of the knee.  It is worse with motion, particularly pointing the ankle up and climbing up stairs.  There can be swelling, limited knee motion and locking or popping of the knee.  The pain is usually caused by injuries sustained through sports activities but may also occur with diseases such as arthritis , tumors, ganglion cysts, Lyme disease, collagen vascular disease and Pigmented Villonodular Synovitis.  X-rays and MRI scans of the area may be useful to look for tumors and fractures.  Bone scans can also be used to look for more subtle disease.  Laboratory test are used to screen for collagen vascular diseases.  Initial treatment includes conservative management such as non-steroidal anti-inflammatory medications, rest, heat, ice and physical therapy.  An injection into the joint of a local anesthetic and a steroid can be helpful.

Adductor Tendinitis

Adductor Tendinitis
Adductor Tendinitis

Adductor Tendinitis is a painful problem in the hip that usually occurs with sports injuries or injuries occurring using gym equipment.  The adductor group of muscles includes the adductor magnus, minimus, brevis, and longus as well as the gracilis and pectineus.  During exercise or sports, these muscles can become stretched and injured.  The junction between the muscle and its tendon is particularly susceptible to injury.  All of the adductor muscles are innervated by the obturator nerve (L2-L4) except the pectineus, which is innervated by the femoral nerve (L2-L4). The adductor magnus also is innervated by the tibial nerve (L4-S3).  The pain of adductor tendinis occurs mainly in the groin area.  The intensity can be moderate to severe.  There are numerous other causes of hip pain such as osteitis pubis, iliopsoas strain, conjoined tendon lesion and obturator neuropathy and these must be excluded.  The workup of adductor tendinitis includes X-rays of the hip, MRI scan, EMG and NCV to look both for the cause of pain and eliminate potential other diagnostic considerations.  Treatment begins with conservative modalities including rest, heat, ice, physical therapy and non-steroidal anti-inflammatory medications.  Injection of a solution of a local anesthetic with a steroid into the painful area may be useful.  Surgery is only indicated if there is a rupture of the tendons.

Saphenous Neuralgia

Saphenous Neuralgia
Saphenous Neuralgia

Saphenous Neuralgia is an uncommon nerve problem that causes pain on the inside of the knee.  It is a branch of the femoral nerve with contributions from the L3 and L4 nerve root.  The pain from saphenous neuralgia is described as burning, is located on the medial (inside) portion of the leg and is often worse at night. It may radiate down to the foot.  The pain is worsened by activities such as climbing stairs.  There may be numbness and tingling in the area but no loss of muscle function.  The nerve may be injured by surgery or trauma.  It may become entrapped in a small space called Hunter’s Canal where it travels in the leg.  Diagnosis of saphenous neuralgia is made by history and physical exam.  Electromyography (EMG) and Nerve Conduction Studies (NCV) are useful to determine the exact site of injury in the nerve and to exclude other causes of pain such as herniated disc or diabetic nerve injury.  MRI and CT scan of the leg, pelvis and lumbar spine are useful to exclude other causes of pain and look for tumors or hemorrhage.  Treatment begins with conservative modalities such as rest, heat, ice, physical therapy and analgesics such as non-steroidal anti-inflammatory medications.  Medications such as gabapentin, pregabalin, or the tricyclic antidepressants are useful to treat symptoms.  Injections of the saphenous nerve with a local anesthetic and a steroid may be helpful.  If the nerve is entrapped, surgical release may be necessary.

Obturator Neuralgia

Obturator Neuralgia
Obturator Neuralgia

Obturator Neuralgia is an uncommon painful condition of the inside of the thigh.  It is caused by injury or compression of the obturator nerve.  The obturator nerve originals from the L2, L3 and L4 nerve roots of the spine.  The obturator nerve descends through a hole called the obturator foramen in the pelvis and then divides into anterior (front) and posterior (back) branches.  This nerve ennervates the adductors of the thigh, the muscles that move the legs close together, as well as the skin of the inside of the thigh.  Patients with obturator neuralgia have pain in the groin and loss of sensation in the inner thigh.  Their gate is unsteady and wide due to muscle weakness.  The nerve is usually injured by trauma, tumor, hemorrhage or birth-related injuries.  It can also be injured during surgery to repair or replace a hip.  Diagnosis of Obturator Neuralgia is done with Electromyography (EMG) and Nerve Conduction Studies (NCV).  X-rays, MRI scans and CT scans are useful to exclude tumors or fractures.  Treatment of Obturator Neuralgia begins with physical therapy and non-steroidal anti-inflammatory agents.  Other medications can be tried such as anti-depressants ( notriptyline, duloxetine, and others) as well as gabapentin and pregabalin.  Injection of the nerve with a local anesthetic and a steroid can be helpful.  Where documented nerve entrapment is found, surgery to release the nerve may be useful as well.

Femoral Neuropathy

Femoral Neuropathy
Femoral Neuropathy

Femoral Neuropathy is a disease of the femoral nerve, a very large nerve in the leg.  This nerve controls the quadriceps muscle and causes difficulty in walking.  The nerve can be damaged by compression, trauma or metabolic causes.  The motor portion of the femoral nerve governs knee extension and hip flexion.  The sensory portion of the femoral nerve governs the inside portion of the thigh and calf.  The pain of femoral neuropathy may be described as “burning” and can be moderate to severe in intensity.  Femoral Neuropathy can be caused by compression inside the pelvis from tumors or hemorrhage.  Compression can occur outside the pelvis as well.  Diabetes Mellitus is a common cause of femoral neuropathy as well as to damage of other nerves in the body.  Patients with femoral neuropathy have difficulty walking up stairs and complain of pain on the inside of the leg.  On physical exam there may be weakness and muscle wasting of the quadriceps.  There may be sensory loss and tingling or pain in the distribution of the femoral nerve.  Diagnosis is made by history and physical exam.  CT scans or MRI scans can look for tumors in the pelvis.  Electromyography (EMG) and Nerve Conduction studies (NCV) can be used to determine the exact site of nerve injury.  It may be difficult to distinguish femoral neuropathy from injury to the L4 nerve root of the spine and these studies can help to determine the exact cause.  Treatment of Femoral Neuropathy depends on the site and cause of the problem.  Tumors of the pelvis may need to be surgically removed.  Damage from diabetes should be address with better control of blood glucose.  Physical therapy can be used to strengthen weak muscles.  Pain and tingling can be treated with anti-convulsants such as Gabapentin or Pregabalin.  Anti-depressants such as Amitriptyline and Nortriptyline and newer agents such as Cymbalta are effective in treating this type of neuropathic pain.

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