– History –
- CC: most likely will present as knee pain:
- Site: where? One or both sides? Posterior\anterior knee? Other joints? Radiates anywhere else?
- Onset: first time? When? Sudden\gradual? Continuous\intermittent? What where you doing?
- Timing: day\night? How frequent?
- Character: dull, sharp, electric-like?
- Aggravating\relieving factors: movement, rest, medications?
- Severity: 0-10 scale? Wakes you up from sleep? Interfering w\ ADL? Use of walking aids?
- Associated sx:
- Constitutional: fever, wt loss, loss of appetite, night sweats, chills, fatigue?
- Neurological: weakness, numbness, gait imbalance, urine\fecal incontinence, saddle anesthesia?
- Joint: swelling, morning stiffness, clicking, locking, giving away?
- Autoimmune ds: skin rashes, visual disturbance\dry eyes, dysuria?
- Hemarthrosis: easy bruising, bleeding?
- Chronic ds (HTN, DM, osteoporosis)
- Infections \ autoimmune ds
- Malignancy \ hematological
- Medications: OTC, steroids
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx
- Diet, exercise
– Knee Physical Exam –
- WIPE, blah blah 🙂
- “Take vital signs”
- Proper exposure: both legs
- General inspection of the patient + surroundings (walking aids)
- Assess the pt’s gait
1. Look: (from all sides, while the pt is standing)
- Skin changes (redness, discoloration, rash)
- Popliteal swelling\baker’s cyst
- Muscle wasting (quadriceps)
- Deformity (varus\valgus)
2. Feel: (first ask if they have pain?)
- Bony: patella, tibial tuberosity\platue, epicondyles, prox fibula
- Soft tissue: joint line tenderness, quadriceps, popliteal fossa
- While you’re there, palpate the popliteal A
- Bulge\milking sign (small effusion)
- Patellar tap (large effusion)
3. Move: flexion + extension
- Against resistance “comment on power”
- Passive “comment on ROM and crepitus”
4. Special tests:
- ACL\PCL: ant\post drawer test (at 90°)
- LCL\MCL: varus\valgus stress test (at 0° and 30°)
- Meniscus: McMurray’s test
- Tibial N:
- M -> planter flexion
- S -> sole of the foot
- Deep peroneal N:
- M -> foot dorsiflexion
- S -> 1st web space
- Superficial peroneal N:
- M -> foot eversion
- S -> dorum of the foot
- Ankle jerk
- Popliteal A
- Dorsalis pedis A
- Post tibial A
6. Joint above + joint below
– Differential Diagnosis –
- Degenerative OA
- Inflammatory arthritis: RA
- Seronegative arthropathies
- Gout \ pseudogout
– Investigations –
- X-ray; findings:
- Joint space narrowing
- Subchondral sclerosis
- Subchondral cysts
- Blood tests (normal in OA)
- Arthrocentesis (if signs of septic joint)
– Management –
- Weight loss
- Quadriceps physiotherapy
- Use of walking aids
- Acetaminophen (1st line)
- Intra-articular steroid injection
- Total knee replacement