Knee pain resident survival guide
|Knee pain Resident Survival Guide Microchapters|
Synonyms and keywords: Approach to knee stiffness, Approach to knee swelling, Approach to the hot knee joint
The knee joint has the largest articular space. The knee joint supports two to five times a person's body weight depending on the physical activity. There are both traumatic and non-traumatic conditions that cause knee pain. Lifestyle modification for knee pain includes Rest, Ice, Compression, and Elevation (RICE) for ligament injuries, Exercise, heat treatment, Paracetamol, symptomatic slow-acting drugs for OA (glucosamine, chondroitin, diacerein, and avocado–soya unsaponifiables), Restorative sleep advice and Weight loss. Knee pain should be treated depending on the underlying cause.
|Anterior Knee Pain|
|Medial Knee Pain|
|Lateral Knee Pain|
|Posterior Knee Pain|
Non-Traumatic causes of knee pain
|Unilateral Knee Pain|
|Bilateral Knee Pain|
Examine the patient:
❑ HEENT signs:
❑ Range of motion:
❑ Perform knee maneuvers for examination of knee ligament injuries
Knee pain associated with trauma
Knee pain not associated with trauma
Significant knee swelling
❑ Anterior cruciate ligament (ACL) tear
❑ Large meniscus tear
❑ Intra-articular fracture
❑ Osteochondral defect
❑ Patellar dislocation
❑ Posterior lateral corner tear
❑ Posterior cruciate ligament (PCL) tear
❑ Patellar tendon tear
❑ Quadriceps tendon tear
❑ Knee (tibiofemoral) dislocation
Limited knee swelling
❑ Small or moderate meniscus tear
❑ Medial collateral ligament (MCL) strain
❑ Lateral collateral ligament (LCL) strain
❑ Patellar subluxation
❑ Partial ACL tear
❑ Partial PCL tear
❑ Patella fracture
❑ Fibular neck or head fracture
Knee joint effusion present
Knee joint effusion absent
Activity related knee pain
❑ Chronic osteochondral defect
❑ Knee osteoarthritis
Not activity related knee pain
❑ Crystal arthropathy
❑ Septic arthritis
❑ Systemic rheumatic disease
According to the focus of knee pain
Anterior knee pain
❑ Tibial tubercle apophysitis (Osgood Schlatter)
❑ Hoffa's fat pad syndrome
❑ Quadriceps and patellar tendinopathy
❑ Prepatellar or infrapatellar bursitis
❑ Plica syndrome
Vague anterior knee pain
❑ Chronic patella dislocation or subluxation
❑ Patellofemoral pain
❑ Chondromalacia patella
❑ Patella stress fracture
Medial knee pain
❑ Degenerative medial meniscal tear
❑ Saphenous nerve entrapment
❑ Pes anserine bursitis
Lateral knee pain
❑ Iliotibial band syndrome
❑ Degenerative lateral meniscal tear
Posterior knee pain
❑ Popliteal artery aneurysm
❑ Popliteal artery entrapment
❑ Popliteal (Baker's) cyst
❑ Popliteus tendinopathy
Life style modification for the knee pain depending on the condition
Knee pain due to osteoarthritis
❑ Nonpharmacologic treatment (eg, exercise, weight loss)
❑ NSAIDS as needed (alternate: acetaminophen)
❑ If symtoms persist:
Knee pain due to rheumatoid arthritis
❑ Inadequate response:
Knee pain due to systemic lupus erythematosis
General treatment: Hydroxychloroquine
Preferred regimen: Dextropropoxyphene
- US is an excellent and easily performed imaging study in the detection of knee joint effusions. However, because of its technical limitations, ultrasound (US) may only evaluate the outer bone surface and has a limited role in the detection of occult knee fractures.
- In patients with chronic knee pain, referred pain from the hip must be considered, especially if the knee radiographs are unremarkable and there is clinical evidence or concern for hip pathology.
- When an intra-articular abnormality is suspected, CT arthrography may be used instead of MRI to evaluate the menisci and articular cartilage.
- When initial radiographs are normal or reveal a joint effusion but pain persists, the next indicated study is usually MRI without IV contrast, which is more sensitive than radiography.
- Ultrasound (US) is not often useful as a screening test or a comprehensive examination. It may be appropriate to confirm a suspected effusion and to guide a potential aspiration. The US is as accurate in diagnosing a popliteal cyst and detecting cyst rupture when compared to MRI.
- Radiographs of the knee are usually appropriate for the initial imaging of chronic knee pain in patients greater than or equal to 5 years of age.
- Knee radiographs may be appropriate for the initial imaging of patients 5 years of age or older for the evaluation of a fall or acute twisting trauma to the knee when there is no focal tenderness, no effusion, and they are able to walk.
- Knee radiographs are usually appropriate as the initial imaging study of patients 5 years of age or older for the evaluation of a fall or acute twisting trauma to the knee when at least one of the following is present: focal tenderness, effusion, inability to bear weight.
- MRI knee without IV contrast is usually appropriate as the next imaging study, after radiographs did not show a fracture, of adults or skeletally mature children, for the evaluation of suspected occult knee fractures or internal derangement after a fall or acute twisting trauma to the knee.
- MRI knee without IV contrast is usually appropriate as the next imaging study after radiographs did not show a fracture, of skeletally immature children, for the evaluation of suspected occult knee fractures or internal derangement after a fall or acute twisting trauma to the knee. 
- With negative radiographs, MR arthrography is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement.
- With negative radiographs, MRA is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement.
- Ultrasound (US) is not used as the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement.
- Radionuclide bone scan is usually not indicated to evaluate patients with signs of a prior (chronic) osseous knee injury.
- Joint aspiration is usually not indicated to evaluate patients with signs of the prior (chronic) osseous knee injury.
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