Post-Accident Knee Pain: Insights from Rehabilitation

Post-traumatic sequelae from a lateral impact to the right knee in a car accident?

Hello Doctor: I was in a car accident in July 2017, primarily suffering from a fracture of the left femoral shaft, along with some abrasions and contusions on both legs.
The inner side of my right knee seemed to be the most severely bruised area, with a large bruise.
The bruise faded after about 1.5 to 2 months, but there are still some faint purple marks nearby, and there is a slight indentation in one spot that is extremely painful when pressed.
Upon careful examination, I can feel a lump.
Now, more than two years later, the lump has slightly decreased in size, but it still feels different from my normal leg; it has an uneven surface with highs and lows.
I am unsure if it is bone or a lump, and it remains very painful when pressed.
Although it does not affect my walking, it can be quite sensitive if I accidentally bump into it, and I am unsure what to do.

I consulted the orthopedic surgeon who performed my surgery, and after an X-ray, he found no significant issues, suggesting it might be soft tissue injury.
I then visited a rehabilitation department where they performed an ultrasound and indicated that the medial collateral ligament might be injured, so they arranged for rehabilitation, which included heat therapy, electrical stimulation, and laser treatment.
However, I did not feel much improvement, and the pain upon pressure persisted.
At a clinic, they also conducted an ultrasound and after a long examination, concluded that there was no apparent issue.
They suggested that there might have been a small fracture in the bone at the time of impact, which would not show up on an X-ray, and that the bone healing could have led to the uneven surface I feel now.
When I asked if treatment was possible, the doctor said that if it does not hurt while walking, it is not a concern.
I replied that it is very painful when touched, to which the doctor responded, "Then just avoid touching it."
This made me realize that during my visits to the rehabilitation department, the doctors focused more on treating my more severe left leg, and if it did not affect my daily life, they would say it was fine.
However, I still want to explore possible treatments.
Therefore, I would like to ask: 1.
Is it really possible to have such a small fracture that does not show up on tests, yet does not cause pain when bearing weight on that leg? (I remember that during the fracture, my weight was primarily on the right side; wouldn’t a fracture cause significant pain?) 2.
Is the pain upon pressure and the uneven surface more related to soft tissue injury? Why do the doctors say there is no issue after the ultrasound? Is it not possible to identify the cause of the pain for targeted treatment? 3.
If treatment is needed, should I continue to seek rehabilitation from the rehabilitation department?

Niming, 20~29 year old female. Ask Date: 2020/05/04

Dr. Wang Zhaomin reply Rehabilitation

1.
Impact from external forces may cause linear fractures that are undetectable by X-ray, and pain may only occur under certain specific circumstances.

2.
Soft tissue injuries may not fully recover, and factors such as scar tissue or fibrosis can lead to localized discomfort.
If a linear fracture has not completely healed, there may not be symptoms during normal activities, but tenderness can occur when stimulated.

3.
Please visit an orthopedic or rehabilitation specialist to arrange for further treatment and rehabilitation plans.

Reply Date: 2020/05/04

More Info

Understanding post-accident knee pain can be complex, especially when the injury involves multiple structures such as bones, ligaments, and soft tissues. Based on your description, it seems you are experiencing persistent pain and discomfort in your knee area following a significant injury from a car accident. Let's address your questions systematically.

1. Small Bone Fractures and Pain: Yes, it is indeed possible to have small fractures or stress reactions in the bone that may not be visible on standard X-rays. These are often referred to as "hairline fractures" or stress fractures. They can occur due to the trauma of the accident and may not cause significant pain unless weight is applied or pressure is exerted on the area. In some cases, these fractures can heal improperly or lead to complications such as malunion or nonunion, which could explain the ongoing discomfort. However, if you are able to bear weight without pain, it is less likely that a significant fracture is present.

2. Soft Tissue Injuries and Pain: The symptoms you describe—such as the presence of a lump, tenderness to touch, and the uneven surface of the area—are indeed consistent with soft tissue injuries. These could include hematomas (localized collections of blood outside of blood vessels), scar tissue formation, or even damage to the ligaments or tendons surrounding the knee. The fact that ultrasound did not reveal any significant issues does not rule out soft tissue injuries, as some injuries can be subtle and may require more advanced imaging techniques like MRI for a comprehensive evaluation. MRI is particularly useful for assessing soft tissue structures and can provide a clearer picture of any underlying issues that may not be visible on X-rays or ultrasound.

3. Rehabilitation and Treatment Options: Given your ongoing symptoms, it would be advisable to continue seeking rehabilitation. Physical therapy can be beneficial in managing pain, improving function, and addressing any biomechanical issues that may have arisen due to your injury. A physical therapist can design a tailored rehabilitation program that focuses on strengthening the muscles around the knee, improving flexibility, and correcting any gait abnormalities that may have developed as a result of your injury. Additionally, modalities such as ultrasound therapy, electrical stimulation, and manual therapy techniques can help alleviate pain and promote healing.

If your symptoms persist despite rehabilitation, it may be worth considering a referral to a specialist, such as an orthopedic surgeon or a sports medicine physician, who can provide a more in-depth evaluation and discuss potential interventions. This could include further imaging studies or even minimally invasive procedures if deemed necessary.

In summary, while it is possible to have small, undetected fractures, the symptoms you describe are more likely related to soft tissue injuries. Continuing with rehabilitation and possibly seeking further evaluation from specialists will be key in managing your pain and improving your overall function. Remember, it is important to communicate openly with your healthcare providers about your symptoms and concerns to ensure you receive the appropriate care.

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