knee pain
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Etiology
- traumatic acute knee injury (see traumatic knee injury)
- non-traumatic acute knee pain
- common causes
- arthritis
- gout
- pseudogout
- referred pain
- adults
- children - hip pathology
- uncommon causes
- septic knee
- ruptured Baker's cyst
- rare cause - ruptured popliteal aneurysm
- common causes
- chronic knee pain
- common causes
- arthritis
- patellofemoral pain syndrome (PFPS) (< 45 years)
- less common causes
- patellar tendonitis "jumper's knee"
- iliotibial band syndrome "runner's knee" (lateral knee pain)
- meniscal tear
- prepatellar bursitis
- pes anserine bursitis
- Osgood-Schlatter disease (adolescents)
- quadriceps tendonitis
- medial retinaculitis
- uncommon causes
- Baker's cyst
- plica syndrome (focal synovitis)
- recurrent patellar subluxation
- loose bodies 'joint mice'
- chondral or osteochondral fracture
- rare causes
- osteochondritis dessicans (OCD)
- neoplasm
- vascular disease (venous or arterial)
- common causes
Clinical manifestations
- injury (see traumatic knee injury)
- swelling (see traumatic knee injury)
- pain
- sharp, stabbing - mechanical
- dull, aching - degenerative of overuse
- anterior knee pain worsened by climbing stairs, running, or prolonged sitting (patellofemoral pain syndrome)[3]
- sharp, sudden - loose body (joint mice)
- buckling
- anterior cruciate ligament (ACL)
- meniscal tear
- pseudobuckling (feeling of buckling without knee giving way)
- anterior cruciate ligament (ACL)
- patellofemoral pain syndrome
- arthritis
- locking (knee getting caught in specific positions)
- meniscal injury
- loose bodies
- osteochondritis dessicans
- patellar dislocation
- pseudolocking (feels like it catches, but does not lock)
- patellofemoral pain syndrome
- arthritis
- patellar subluxation
- general
- effusion
- quadriceps atrophy
- standing position
- gait
- alignment of joint
- malalignments frequently associated with overuse
- common malalignments
- palpation: effusion, patellar facets, tendons, joint line
- range of motion: passive, active, resisted, patellar tracking
- specific physical examination testing
- Lachman test, anterior drawer test & pivot shift test evaluate anterior cruciate ligament (ACL) stability
- posterior drawer test, shelf test & posterior sag test evaluate posterior cruciate ligament (PCL) stability
- varus & valgus stress testing evaluate lateral & medial collateral ligament integrity, respectively
- Grind test, crepitus test, compression test & shrug test evaluate patellofemoral pain syndrome
- patellar apprehension test evaluates patella subluxation & dislocation
- McMurray's test & Appley test (circumduction tests) evaluate medial & lateral menisci
- pain with resisted quadriceps contraction (knee should be partially flexed)
- functional tests
Laboratory
- ESR or CRP
- serologic tests for rheumatologic diseases
- complete blood count (CBC)
- serum uric acid
- joint aspiration for cell count, crystals, Gram stain & culture if indicated
Radiology
- plain radiographs (see Ottawa knee rule)
- magnetic resonance imaging (MRI)
- excellent for meniscal & articular cartilage
- poorly demonstrates ligamentous injury
- computed tomography (CT)
- bone scan
- arthrography
Management
- pharmacologic agents
- non-steroidal anti-inflammatory drugs (NSAIDs)
- tricyclic antidepressants
- acetaminophen
- topical capsaicin
- short-term narcotics for acute pain
- joint injection with anesthetic/corticosteroid
- symptom improvement may last 24 weeks[5]
- number needed to treat 4.4 for 1 to benefit at 16-24 weeks
- physical modalities
- heat, ice, ultrasound
- rest, compression, elevation
- physical therapy to maintain range of motion & strengthen target muscle groups when pain is adequately controlled
- quadriceps strength training[3]
- weight loss
- address mechanical abnormalities in the foot & ankle
- neoprene sleeve
- reduced weight-bearing using cane in opposite hand
- needle or laser acupuncture of no benefit for chronic knee pain[7]
- internet-based therapy of benefit[8]
- interactive online training in pain-coping skills (8 automated sessions)
- videoconferencing with a physiotherapist focused on lower-limb-strengthening exercises (7 sessions)
- surgery
Notes
Management of knee pain secondary to septic arthritis or osteomyelitis differs from that described above.
More general terms
More specific terms
Additional terms
- knee injury, traumatic
- medial retinaculitis
- osteoarthritis of the knee
- Ottawa knee rule
- physical examination of the knee
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 745
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998
- ↑ 3.0 3.1 3.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015
- ↑ Clyman B, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ 5.0 5.1 Journal Watch 24(11):86, 2004 Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004 Apr 10;328(7444):869. Epub 2004 Mar 23. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/15039276 <Internet> http://bmj.bmjjournals.com/cgi/content/full/328/7444/869
- ↑ Schraeder TL, Terek RM, Smith CC. Clinical evaluation of the knee. N Engl J Med. 2010 Jul 22;363(4):e5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20660399
- ↑ 7.0 7.1 Hinman RS et al Acupuncture for Chronic Knee Pain. A Randomized Clinical Trial. JAMA. 2014;312(13):1313-1322. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25268438 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1910110
- ↑ 8.0 8.1 Bennell KL, Nelligan R, Dobson F et al Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med. Feb 21, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28241215 <Internet> http://annals.org/aim/article/2605025/effectiveness-internet-delivered-exercise-pain-coping-skills-training-intervention-persons
Mandl LA Improving Symptoms in Knee Osteoarthritis: Can We Get There From Here? Ann Intern Med. Feb 21, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28241277 <Internet> http://annals.org/aim/article/2605038/improving-symptoms-knee-osteoarthritis-can-we-get-from-here