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 -> 1st 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 (1st line)
    • NSAIDS
    • Intra-articular steroid injection
  3. Operative: 
    • Total knee replacement

 


 


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