What is the best course of action for managing worsening left knee pain in a daily runner with sciatic nerve impingement?

From the Guidelines

For a daily runner experiencing worsening left knee pain with sciatic nerve impingement, the best course of action is to temporarily reduce running volume while addressing both conditions through a comprehensive approach, as recommended by the most recent and highest quality study 1. The patient's complaint of worsening left knee pain with sciatic nerve impingement, without any reported injury, suggests a need for a multifaceted approach that addresses both the knee pain and the sciatic nerve impingement. Given the patient's daily running habit, it is essential to consider the potential impact of running on the knee joint and the sciatic nerve.

Key Considerations

• The patient denies redness or swelling but reports the knee feeling hot, which may indicate inflammation.
• The patient is already seeing a pain management specialist for sciatic nerve impingement, which is a positive step.
• The patient is seeking an appointment for imaging of the knee if indicated, which may be necessary to rule out any underlying structural issues.

Recommended Approach

• Begin with a 1-2 week relative rest period, replacing some running sessions with low-impact cross-training like swimming or cycling, as suggested by 1.
• Apply ice to the knee for 15-20 minutes after activity to reduce inflammation.
• Consider taking an NSAID like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily with food) for 7-10 days to reduce inflammation, as recommended by 1.
• Incorporate daily nerve gliding exercises for the sciatic nerve, performing 2-3 sets of 10 repetitions, to address the sciatic nerve impingement.
• Strengthen the hip and core muscles with exercises such as bridges, clamshells, and planks to improve biomechanics, as suggested by 1.
• Gradually return to running using a 10% weekly increase rule while maintaining the strengthening program.

Rationale

The recommended approach is based on the most recent and highest quality study 1, which emphasizes the importance of a comprehensive approach to managing knee pain and sciatic nerve impingement. The study suggests that a combination of relative rest, ice, NSAIDs, nerve gliding exercises, and strengthening exercises can be effective in reducing symptoms and improving function. Additionally, the study recommends a gradual return to running using a 10% weekly increase rule to minimize the risk of exacerbating the condition.

Next Steps

If symptoms persist beyond 2-3 weeks of this regimen, consultation with a sports medicine physician or physical therapist is recommended for more targeted treatment, as suggested by 1. Imaging of the knee may be necessary to rule out any underlying structural issues, but this should be determined on a case-by-case basis.

From the Research

Initial Evaluation

The patient reports worsening left knee pain over the past week with no history of injury, but does run daily and has a history of sciatic nerve impingement to the left leg. The initial evaluation of acute knee pain should include:

• Plain radiography, which is a quick and cost-effective way to identify a wide range of problems, including fracture, degenerative changes, osteochondral defects, and effusions 2
• The patient denies redness or swelling to the leg, but states "the knee does feel hot", which may indicate inflammation or other underlying conditions

Imaging Tests

For further evaluation, the following imaging tests may be considered:

• Computed Tomography (CT) to better delineate fractures in patients who have knee trauma 2
• Magnetic Resonance Imaging (MRI) to evaluate the cartilage, menisci, and cruciate and collateral ligaments, especially if arthroscopy is contemplated 2
• MRI of the whole sciatic nerve with a dedicated protocol covering the lumbar spine and the lower limb to diagnose localized hypertrophic neuropathy (LHN) of the sciatic nerve 3

Sciatic Nerve Impingement

The patient's history of sciatic nerve impingement to the left leg should be considered in the evaluation:

• Sciatica is a common symptom that can be caused by various pathologies affecting the sciatic nerve within its intraspinal or extraspinal course 4
• Extraspinal causes of sciatic pain, such as impingement between the greater trochanter and ischium, should be considered in the differential diagnosis of snapping hip and/or sciatica 5
• Early diagnosis of sciatica significantly improves the likelihood of relieving symptoms, as well as avoiding any additional neurologic injury and unnecessary surgery 4