Working Diagnosis:
Scar tissue of the semimembranosus likely as a result of prior endovenous thermal ablation of the great saphenous vein for treatment of varicose veins.

Treatment:
Given the patient already had arthroscopic surgery and two rounds of physical therapy, we opted to try injecting high dose corticosteroids into the scar tissue. This is a similar technique to how intralesional corticosteroids are used to treat keloids. The patient noted improvement in symptoms after the injection. At the patient's two week follow up, he noted complete resolution of his pain. Case Photo #4

Outcome:
The patient had self advanced his activity to walking and jogging and will continue to progress as tolerated.

Author's Comments:
Endovenous thermal ablation is a common technique used to ablate superficial veins for treatment of varicose veins. The great saphenous vein is one of the main superficial veins in the lower extremity. It originates from the foot and tracks up towards the medial aspect of leg. It then runs posteriorly over the medial epicondyle of the femur before tracking up the proximal thigh.

Common complications of endovenous thermal ablation include bruising, hematomas, skin burns, superficial thrombophlebitis, deep vein thrombosis, and injury to surrounding soft tissues. During the procedure, tumescent fluid is used to not only provide anesthesia, but also to act as a heat sink to protect surrounding tissues from thermal damage during treatment. If not enough fluid is used or if too much heat is applied, nearby tissues including nerves, skin, and muscle can be injured.

Editor's Comments:
Endovenous thermal ablation is a widely accepted non-invasive procedure to treat venous reflux. Complications may still occur and include bruising and pain along the site of ablation, the development of a blood clots in the veins in the treated leg, and irritation of the nerves that run along with the treated veins.

References:
Van Den Bos RR, Neumann M, De Roos KP, Nijsten T. Endovenous laser ablation-induced complications: review of the literature and new cases. Dermatologic Surgery. Aug 2009.

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