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Knee History

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Groups of Knee Pain

Acute knee pain with history of trauma or overuse Atraumatic knee pain with effusion Atraumatic knee pain without effusion Referred pain Location based

History

  • Mechanism
    • Trauma vs atraumatic sudden vs insidious
  • Pain
    • Location and character
      • Any neuropathic qualities?
    • Pattern
      • Inflammatory arthropathy – morning stiffness, rest pain, relief on movement
      • Mechanical – pain on weightbearing, worse later in day
    • Severity – although limited clinical utility
  • Swelling – immediate vs delayed?
  • Locking, giving way, instability – internal derangement
  • Snapping - consider ITB, pes anserine tendons
  • Constitutional symptoms – fever, night sweats, weight loss, rash
  • Back pain?
  • Other joint involvement
  • Previous injuries and treatments
  • Medical history – any systemic or rheumatological disease?
  • Occupation and hobbies/sports
  • Training history
  • Possible differential based on history of trauma
    • Flexion, rotation, compression: meniscus
    • Valgus force: MCL
    • Sudden deceleration or change in direction with planted/fixed foot: ACL
    • Landing on flexed knee or MVA with posterior force to tibia: PCL
    • Force to anteromedial extended knee or external rotation and hyperextension: posterolateral corner injury
    • Swelling in knee with occasional locking and clicking: meniscus or loose body
    • Pain on prolonged knee flexion, during squats, up and down stairs: PFS
    • Anterior knee pain jumping and on full flexion: patellar tendinitis, PFS

Differential Diagnoses

Anterior, focal or vague

Medial

Lateral

Posterior

  • Baker's or popliteal cyst
  • Popliteus Tendinopathy
  • Popliteal artery aneurysm
  • Popliteal artery entrapment
  • Posterior capsule tear
  • Posterior cruciate ligament tear
  • Tibiofemoral dislocation

Effusion present without trauma

  • Osteochondral injury
  • Osteoarthritis exacerbation
  • Rheumatological disease (gout, RA, psoriatic arthritis)
  • Septic arthritis


Differential Based on Age

  • Children
    • Septic/osteomyelitis
    • Apophysitis
      • Osgood Schlatters
      • Sinding-Larssen- Johanssen
    • Neoplasm
      • Osteosarcoma
      • Ewings sarcoma
    • Referred
      • Perthes, DDH related AVN
      • SUFE
      • Transient synovitis
    • Non accidental injury
  • <50 year old adults
    • Trauma
    • Overuse syndromes
    • Arthritis – Degenerative vs inflammatory
  • >50 years
    • Trauma
    • Arthritis – more likely degenerative, consider gout, late onset RA and other autoimmune arthritides

History of Conditions

ACL

Immediate effusion, popping sensation, giving way Sensitivity 0.71; Specificity 0.71; PPV 42%; LR+ 2.5[1]

Meniscal Injury

  • Giving way and locking: PPV 98%, NPV 19%, LR+ 8.3[2]
  • Clicking: LR+ 2.4, LR– 7.0[3]

Osteosarcoma

In children, distal femur is 75% of cases. In adults, typically occur more in axial locations. However, lower limb long bones are still the most common site (27%)[4]

References

  1. ↑ Wagemakers HP, Luijsterburg PA, Boks SS, Heintjes EM, Berger MY, Verhaar JA, Koes BW, Bierma-Zeinstra SM. Diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament lesions of the knee in primary care. Archives of physical medicine and rehabilitation. 2010 Sep 1;91(9):1452-9.
  2. ↑ Yan, R., Wang, H., Yang, Z., Ji, Z. H., & Guo, Y. M.. Predicted probability of meniscus tears: Comparing history and physical examination with MRI. Swiss Medical Weekly, 141(DECEMBER 2010). https://doi.org/10.4414/smw.2011.13314
  3. ↑ Cleland J, Koppenhaver S, Su J. Netter’s Orthopaedic Clinical Examination: An evidence based approach. 2016
  4. ↑ Mirabello L, Troisi RJ, Savage SA. Osteosarcoma incidence and survival rates from 1973 to 2004: data from the Surveillance, Epidemiology, and End Results Program. Cancer 2009; 115:1531.
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