What is the most common cause of lateral knee pain that is extremely tender when kneeling?

Lateral Knee Pain Tender with Kneeling

The most common cause of lateral knee pain that is extremely tender when kneeling is iliotibial band (ITB) syndrome, which results from inflammation and impingement of the distal ITB over the lateral femoral epicondyle during repetitive knee flexion activities. 1, 2

Clinical Presentation

ITB syndrome is the most common cause of lateral knee pain in runners and athletes, affecting 7-14% of runners. 2, 3 The condition presents with:

• Diffuse lateral knee pain that is exacerbated by direct pressure over the lateral femoral epicondyle, making kneeling particularly painful 1
• Pain occurring at approximately 30 degrees of knee flexion during repetitive activities 2
• Symptoms worsened by running (especially downhill or on tracks in the same direction), cycling, and activities requiring repetitive knee flexion 1, 2

The diagnosis is primarily clinical, based on characteristic lateral knee pain with point tenderness over the lateral femoral epicondyle that reproduces symptoms with direct pressure (as occurs during kneeling). 1, 4

Underlying Pathophysiology

The current understanding has evolved from the outdated "friction syndrome" model to ITB impingement syndrome, which recognizes that pain results from compression of fat and connective tissue deep to the ITB, chronic inflammation of the ITB bursa, and impingement rather than simple friction. 4, 5

Weakness or inhibition of the lateral gluteal muscles (particularly gluteus medius) is a key causative factor, leading to decreased pelvic stability and excessive compensatory soft tissue tightness. 2

Treatment Algorithm

Initial Conservative Management (First 6 Weeks)

Most patients (>90%) respond to conservative treatment within 6 weeks when properly implemented: 2

1. Activity modification: Reduce or temporarily cease aggravating activities 1, 2
2. Anti-inflammatory measures: NSAIDs and therapeutic modalities to decrease local inflammation 2
3. Corticosteroid injection: Consider if visible swelling or pain with ambulation persists for more than 3 days after initiating treatment 1

Progressive Rehabilitation (Once Acute Inflammation Controlled)

The rehabilitation sequence must follow this specific order: 2

1. Stretching exercises for the ITB once acute inflammation subsides 1, 2
2. Identify and eliminate myofascial restrictions before strengthening 2
3. Strengthening of gluteus medius with emphasis on eccentric contractions, triplanar motions, and integrated movement patterns 1, 2
4. Gradual return to activity: Start with faster-paced running (which paradoxically aggravates ITB syndrome less than slower jogging), then gradually increase distance and frequency 2

Surgical Intervention (Refractory Cases)

A small percentage of patients require surgical release if conservative treatment fails after 6 weeks. 1, 2 Options include:

• Traditional open release/lengthening of the posterior ITB at the lateral femoral condyle 2
• Ultrasound-guided minimally invasive release (Z-plasty or transverse section), which can be performed under local anesthesia in an outpatient setting with faster recovery 3

Critical Pitfalls to Avoid

Do not confuse ITB syndrome with patellofemoral pain syndrome (PFPS), which causes anterior or peripatellar pain rather than lateral knee pain, and is exacerbated by stairs and prolonged sitting rather than direct pressure during kneeling. 6, 7

Training errors must be addressed: excessive weekly mileage, running in the same direction on tracks, and downhill running all contribute to ITB syndrome and will cause treatment failure if not corrected. 2

Imaging is reserved for recalcitrant cases to rule out other pathology; the diagnosis is clinical. 4