TOC  |  Rheumatology  

Approach to Knee Pain       REF: Painful Knee Test 2008
Strategy I.  
Separate all knee pain patients into one of three categories:

  1. Routine office visit knee pain
  2. The hot swollen atraumatic knee - need knee tap
    Septic arthritis
    Gout, pseudogout
    Autoimmune-inflammatory
  3. Acute knee injury:  the blow out  --> See  the Examination &  the Referral Decisions for acutely injured knee below!

Strategy II.  
Analyze the location of the most painful part of knee in all routine office visit knee pain complaints
Anterior - Medial - Lateral - Posterior Knee Areas

 

 

Anteriorly

Medially
  • Meniscal tear or cyst
    Symptoms of meniscal pathology:  pain, swelling, locking with flexion, giving way
    Signs: medial joint line tenderness, effusion/synovitis, locked knee, atrophy, loss of full extension or flexion
  • Osteoarthritis
    History: older age, activity trauma, surgery, effusions, pain
    P/E:  joint line tenderness, varus, crepitation, effusion, Pain at extreme motion
    X-ray:  narrowing, osteophytes, sclerosis, cysts
    Rx:  bicycling, PT Rx, NSAID, chondroitin & glucosamine, activity modification, steroid injection, surgery, ? hyaluronate injection?
  • Osteochondritis dissecans (rare)
    Cause unknown, may be avascular necrosis of bone or femoral condyle
    Teenage boys ? girls 10:1
    Pain, swelling +/- locking, effusion, atrophy, tenderness, 1 year course
    Knee X-ray of Tunnel View
    Refer to Ortho for persistent pain, effusion, or locking
    Rx: activity modification _/- arthroscopy
  • Osteonecrosis of the femoral condyle (rare)
    Older age group > 60 yo  with sudden severe pain while walking ("spontaneous")
    Pain unrelenting, tumor like , unresponsive to usual Osteoarthritis Rx
    Initial X-ray negative, Tunnel View x-ray positive, later MRI shows avascular necrosis (AVN)
    Crutches, steroids, bike exercise, may need TKR (Total Knee Replacement)

Laterally
  • Meniscal tear, cyst, discoid
    Meniscal Cyst (Lateral > Medial) is the mucinous degeneration in a meniscus that produces a mass over or near lateral joint line.  Never a tumor.
    Ignore if possible.  Aspirate if requested x1.  Definitive Rx includes a menisectomy, so treat by benign neglect if possible.
    Symptoms of meniscal pathology:  pain, swelling, locking with flexion, giving way
    Signs: join line tenderness, effusion/synovitis, locked knee, atrophy, loss of full extension or flexion
  • Osteoarthritis
  • Ilio-Tibio-"Band" Fascia Friction syndrome
    Usually sports related, high arches, the only cause of pain & tenderness above lateral joint line!
    Rx:  stretch ITB, warm up, ice, NSAID, steroid injections last resort.
  • Biceps tendinitis
    Activity related, tender tendon at posterolateral side of knee above fibular head.

Posteriorly
  • Knee Effusion of any cause
    Large amount of synovial fluid commonly produces tightness, fullness, or discomfort in back of knee.
    Rx the cause of effusion.
  • Baker's cyst
    Usually due to the herniation of fibrosynovial knee tissue into the popliteal fossa due to intra-articular disease.  Always benign, best ignored.
    Aspirate x1 only if needed to prove diagnosis.
  • Sciatica
    May cause pain behind knee from radiculopathy or hamstring spasm.  A pseudo-flexion contracture may be present.

   

Strategy III. ** Consider Timely Orthopedic Referral for the following patients:

Patello-femoral Pain Syndrome      

Symptoms of Patello-femoral Pain Syndrome

Physical Findings in Patello-femoral Pain Syndrome

Conservative Rx of Patello-femoral Pain Syndrome  

Surgical Rx of Patello-femoral Pain Syndrome

 

Prepatellar Bursitis ("Housemaid's Knee") :  Sterile bursitis

Patellar Tendinitis ("Jumper's Knee")

Quadriceps Tendinitis

Pes Anserinus Bursitis/ Tendinitis

Plica Syndrome

Chondromalacia patella

Osgood-Schlatter Disease:

General Treatment of Painful Knees:        

Bicycling!

Others:

The Examination of The Acutely Injured Knee         
*  Must get knee x-ray for all acute injured knee to rule out fracture or loose bodies.

The Critical Questions (History)

  1. 1st time or recurrent problem, has it happened before?
  2. Loud "POP" at time of injury (Anterior Cruciate Ligament Tear?)
  3. Timing of swelling (SLOW - effusion; FAST - hemarthrosis)
  4. Can pt continue the activity/sport or not

Six Steps to Evaluating The Acutely Injured Knee:

  1. Support the painful knee with a support ("a can") to keep the flexion about 20o
  2. Check for knee effusion vs hemarthrosis
  3. Check for Range of Motion assisted:  Is the knee locked, cannot extend of flex over 90o
  4. Examine the Patella for stability & retinacular tenderness
    - Apprehension  Sign (Fairbank's Test) - move Patella laterally
    - Medial patellar Retinacular tenderness
    - Hemarthrosis
  5. Examine the Ligaments (R/O Tear) by palpation & stress maneuver
    - MCL (Medial Collateral Ligament): palpate & stress it
    - ACL (Anterior Cruciate Ligament):  Lachman's test & pivot shift
    - LCL (Lateral Collateral Ligament):  palpate & stress it
    - PCL (Posterior Cruciate Ligament): Sag sign
  6. Examine the Extensor mechanism: integrity versus disruption
    - active extension possible?
    - palpate patellar tendon for defect (rupture)
    - palpate quadriceps tendon for defect (rupture)
    - compare location of right & left patellae

Initial Treatment of Sprained Knee (Except displaced fractures)

Referral Decisions for The Acutely Injured Knee:    

Immediate Orthopedic Consultation for:

Early (within 1 week) Orthopedic Consultation for:

Elective Orthopedic Consultation for:

                                                                                                                       

       05072003 Most of the written material from the Knee Workshop  by Dr. Barry J. Miller 2003