Case Study: Knee Pain Caused by Nerve Entrapment

Our Patient

Our patient was a 65 year-old male complaining of medial knee pain, with a history of low back pain. He had previously undergone a lumbar discectomy where a degenerative disc had been removed at L4-L5. He suffered from mild arthritis in both knees, and had an old medial meniscus tear. The patient had seen more than one orthopedist and several physical therapists who were unable to resolve his knee pain.

The Challenge

By the time he reached our clinic, the patient had been given two plasma injections into his knee, undergone four months of physical therapy, and was given an epidural steroid injection and a pain block injection in the left hip by a pain management specialist. The various treatments did not relieve his knee pain, and he developed left groin pain as well.

Our Diagnostic Approach

Our clinical exam included a lumbar compression test and a SLUMP test, both of which were negative, ruling out the lumbar region as the source of pain. Our exam revealed a leftward rotation of the pelvis, and the left hip had significantly restricted external rotation, with multiple densifications and trigger points in the fascia along the medial thigh.


We used diagnostic ultrasonography and found thickening and irregularity of the adductor longus tendon. Other than mild bursitis and effusion (fluid accumulation) in the upper patellar recess, the knee itself was unremarkable. However, palpation of the densified fascia reproduced the patient’s knee pain. We traced the entire pathway of the saphenous nerve with ultrasound, and while we detected no damage, the nerve did not appear to glide during movement.

Our Treatment Approach

We used the following treatment methods to resolve the patient’s medial knee pain:

  • Focused shockwave therapy of the adductor longus muscle and tendon
  • Extracorporeal magnetic transduction therapy (EMTT) of the medial knee
  • Manual fascia manipulation of the densified fascia of the medial thigh
  • Hydrodissection of the saphenous nerve and its branches to restore gliding


Our Results

After treatment, the patient’s symptoms were completely resolved.


Knee pain is common in the early stages of knee osteoarthritis, caused by a drying up of hyaluronic fluid in the joint capsule and surrounding ligaments. This can spread along the fascia, entrapping nerves surrounding the knee and preventing them from gliding. Such entrapment causes pain without the classic signs of neuropathy.


When patients with joint pain have seen multiple providers with no improvement, nerve dysfunction should be suspected. Ultrasonography of the knee and surrounding fascia and nerves should always be included in the examination of knee pain. Percutaneous hydrodissection can help free up nerves entrapped in thickened fascia.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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