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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 โ morning stiffness, rest pain, relief on movement
- Mechanical โ pain on weightbearing, worse later in day
- Severity โ although limited clinical utility
- Location and character
- Swelling โ immediate vs delayed?
- Locking, giving way, instability โ internal derangement
- Snapping - consider ITB, pes anserine tendons
- Constitutional symptoms โ fever, night sweats, weight loss, rash
- Back pain?
- Other joint involvement
- Previous injuries and treatments
- Medical history โ 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
- Patellofemoral Pain Syndrome
- Knee Osteoarthritis
- Patellar Tendinopathy
- Plica Syndrome
- Quadriceps Tendinopathy
- Patellar Instability
- Hoffa's Fat Pad Inflammation
- Prepatellar Bursitis and Infrapatellar Bursitis
- Osgood-Schlatter Disease
- Sinding-Larsen-Johansson Disease
- Referred hip pain
- Avascular necrosis
- Patellar Stress Fractures
- Anterior cruciate ligament tear
- Osteochondral defect
- Posterior cruciate ligament tear
- Tibiofemoral dislocation
- Parameniscal cyst
Medial
- Knee Osteoarthritis
- Medial collateral ligament tear
- Medial meniscal tear
- Medial meniscal cyst
- Bakers cyst
- Medial Plica Syndrome
- Pes anserine bursitis/tendinopathy
- Inflammatory arthritis
- Osteochondral lesion medial femoral condyle (lateral aspect of medial epicondyle most common)
- Saphenous Nerve Entrapment
- Medial friction syndrome
- Medial collateral ligament bursitis
- Osteonecrosis
- Semimembranosus-Tibial Collateral Ligament Bursitis
- Pigmented Villonodular Synovitis
- Synovial Chondromatosis
- Referred Pain - Hip Joint, Lumbosacral spine pathology
- Neoplasm - soft tissue, intraosseous
Lateral
- Lateral meniscus tear
- Posterolateral corner injury
- Patellar dislocation or subluxation
- Lateral collateral ligament tear
- Iliotibial Band Syndrome
- Osteoarthritis exacerbation
- Osteochondral lesion lateral femoral condyle
- Popliteus Tendinopathy
- Biceps Femoris Tendinoapthy
- Semimembranosus Tendinopathy/bursitis
- Fibula head fracture
- Proximal Tibiofibular Joint Instability
- Snapping Biceps Femoris and Popliteus Tendons
- Peroneal Nerve Compression/Neuritis
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 โ Degenerative vs inflammatory
- >50 years
- Trauma
- Arthritis โ 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
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
- โ 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.
- โ 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
- โ Cleland J, Koppenhaver S, Su J. Netterโs Orthopaedic Clinical Examination: An evidence based approach. 2016
- โ 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.
