Background. There are multiple causes of posterior knee pain and radicular symptoms. A symptomatic fabella is a rare cause but should be considered in the differential diagnosis. Purpose. Physicians should consider a symptomatic fabella as a diagnosis when common treatments for posterior knee pain have not alleviated the symptoms. Study Design. Case report. Methods. Review of clinical documentations of an orthopedist, physiatrist, physical therapist, 2 primary care sports medicine physicians, and the surgical report of an orthopedist. Results. It took time and resources including several referrals and imaging modalities to make a final diagnosis. Conclusion. Symptomatic fabellae are an uncommon finding but should be considered in the differential diagnosis with an athlete with posterior knee pain. Clinical Relevance. Considerable time and resources were used to ultimately diagnose and treat a NCAA Division 1 athlete. Surgical excision was required of a sesamoid bone that is present in 30% of individuals.