Knee Pain Approach

– 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?

• PMHx:
  • Diseases:
    • Chronic ds (HTN, DM, osteoporosis)
    • Infections \ autoimmune ds
    • Malignancy \ hematological
  • Medications: OTC, steroids
  • Surgery, hospitalization, trauma
  • Blood transfusions, IV drug use, tattoos
  • Allergies

• FMHx:
  • 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)
• Scars
• Swelling\bulging
• Popliteal swelling\baker’s cyst
• Muscle wasting (quadriceps)
• Deformity (varus\valgus)

2. Feel: (first ask if they have pain?)

• Temperature
• Landmarks:
  • Bony: patella, tibial tuberosity\platue, epicondyles, prox fibula
  • Soft tissue: joint line tenderness, quadriceps, popliteal fossa
    • While you’re there, palpate the popliteal A
• Effusion:
  • Bulge\milking sign (small effusion)
  • Patellar tap (large effusion)

3. Move: flexion + extension

• Active
• 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

5. Neurovascular:

• Tibial N:
  • M -> planter flexion
  • S -> sole of the foot

• Deep peroneal N:
  • M -> foot dorsiflexion
  • S -> 1^st web space

• Superficial peroneal N:
  • M -> foot eversion
  • S -> dorum of the foot

• Reflexes
  • Patellar
  • Ankle jerk

• Pulses:
  • Popliteal A
  • Dorsalis pedis A
  • Post tibial A

6. Joint above + joint below 

 

---

– Differential Diagnosis –

• Degenerative OA
• Inflammatory arthritis: RA
• Seronegative arthropathies
• Gout \ pseudogout
• Fibromyalgia

 

– Investigations –

1. X-ray; findings:
   • Joint space narrowing
   • Osteophytes
   • Subchondral sclerosis
   • Subchondral cysts
   • Subluxation
   • Varus
2. Blood tests (normal in OA)
3. Arthrocentesis (if signs of septic joint)

 

– Management –

1. Conservative:
   • Weight loss
   • Quadriceps physiotherapy
   • Use of walking aids
2. Pharmacological:
   • Acetaminophen (1^st line)
   • NSAIDS
   • Intra-articular steroid injection
3. Operative: 
   • Total knee replacement

 

---

 

---

Download the PDF version: here