Knee pain resident survival guide

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Knee pain Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]

Synonyms and Keywords: Approach to knee stiffness, Approach to knee swelling, Approach to the hot knee joint

Overview

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.

Causes

Common Causes

Traumatic and activity-related causes of knee pain

Anterior Knee Pain
Medial Knee Pain
Lateral Knee Pain
Posterior Knee Pain

Non-Traumatic causes of knee pain

Unilateral Knee Pain
Bilateral Knee Pain

Diagnosis

The approach to the diagnosis of knee pain is based on a step-wise testing strategy. Below is an algorithm summarizing the identification and laboratory diagnosis of knee pain.[1][3][2]

 
 
 
 
 
 
 
 
 
 
Seek proper history:

❑ Warmth of joint
Redness of joint
Stiffness of joint
Swelling of joint
Weakness of joint
Numbness or tingling of joint
Discoloration of fingers in the cold
Discomfort on exposure to sunlight
❑ Pain in any other joint
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

HEENT signs:

Inspection:

Palpation:

  • Look for pain on palpation

Range of motion:

Power

❑ Perform knee maneuvers for examination of knee ligament injuries

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial workup for knee pain:

Complete blood count (CBC) with differential
Erythrocyte sedimentation rate (ESR)
❑ Arthrocentesis and analysis
❑ X-ray knee anteroposterior (AP) view and lateral view
CT scan knee
MRI knee
DEXA scan
Ca++ and Vitamin-D levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 

Treatment

 
 
 
 
 
 
 
 
Life style modification for the knee pain depending on the condition
  • 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
  • Weight loss
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Knee pain due to septic arthritis
 
Knee pain due to osteoarthritis
❑ Nonpharmacologic treatment (eg, exercise, weight loss)
NSAIDS as needed (alternate: acetaminophen)

❑ If symtoms persist:

 
Knee pain due to crystal arthropathy
Gout

❑ Acute attack:

❑ Recurrent attacks (Tophi, renal uric acid stones):


Pseudogout

 
Knee pain due to rheumatoid arthritis

Methotrexate
❑ Persistent symptoms for >6 months:

❑ Inadequate response:

 
Knee pain due to systemic lupus erythematosis

General treatment: Hydroxychloroquine

  • Severe disease:

Preferred regimen:
Hydroxychloroquine and IV methylprednisolone
Alternative regimen: (1) Hydroxychloroquine and oral prednisone
(2) Mycophenolate
(3) IV cyclophosphamide
(4) IV Rituximab

  • Less severe (mild and moderate) disease:

Preferred regimen: (1) Hydroxychloroquine
(2) Prednisone
Alternative regimen: (1) Azathioprine
(2) Methotrexate
Chronic pain management:

  • Moderate pain:

Preferred regimen: Dextropropoxyphene
Alternative regimen: Co-codamol (Acetaminophene + opioid)/; Acetaminophen/codeine

  • Moderate to severe chronic pain:

(1) Hydrocodone
(2) Oxycodone
Alternative regimen: (1) MS Contin
(2) Methadone

(3) Fentanyl[9][10][11]

Do's

  • 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.[12]
  • When an intra-articular abnormality is suspected, CT arthrography may be used instead of MRI to evaluate the menisci and articular cartilage.[13]
  • 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.[14]
  • 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.[15]
  • 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.[14]
  • 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. [14]

Don'ts

References

  1. 1.0 1.1 1.2 "www.aafp.org" (PDF).
  2. 2.0 2.1 2.2 Hussain, SM; Neilly, DW; Baliga, S; Patil, S; Meek, RMD (2016). "Knee osteoarthritis: a review of management options". Scottish Medical Journal. 61 (1): 7–16. doi:10.1177/0036933015619588. ISSN 0036-9330.
  3. 3.0 3.1 Scott, David L; Wolfe, Frederick; Huizinga, Tom WJ (2010). "Rheumatoid arthritis". The Lancet. 376 (9746): 1094–1108. doi:10.1016/S0140-6736(10)60826-4. ISSN 0140-6736.
  4. Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML (2011). "Approach to septic arthritis". Am Fam Physician. 84 (6): 653–60. PMID 21916390.
  5. Taruc-Uy RL, Lynch SA (2013). "Diagnosis and treatment of osteoarthritis". Prim Care. 40 (4): 821–36, vii. doi:10.1016/j.pop.2013.08.003. PMID 24209720.
  6. Neogi, Tuhina (2011). "Gout". New England Journal of Medicine. 364 (5): 443–452. doi:10.1056/NEJMcp1001124. ISSN 0028-4793.
  7. Sidari A, Hill E (2018). "Diagnosis and Treatment of Gout and Pseudogout for Everyday Practice". Prim Care. 45 (2): 213–236. doi:10.1016/j.pop.2018.02.004. PMID 29759121.
  8. Burmester GR, Pope JE (2017). "Novel treatment strategies in rheumatoid arthritis". Lancet. 389 (10086): 2338–2348. doi:10.1016/S0140-6736(17)31491-5. PMID 28612748.
  9. Lisnevskaia L, Murphy G, Isenberg D (2014). "Systemic lupus erythematosus". Lancet. 384 (9957): 1878–1888. doi:10.1016/S0140-6736(14)60128-8. PMID 24881804.
  10. Fortuna G, Brennan MT (2013). "Systemic lupus erythematosus: epidemiology, pathophysiology, manifestations, and management". Dent Clin North Am. 57 (4): 631–55. doi:10.1016/j.cden.2013.06.003. PMID 24034070.
  11. Dörner T, Furie R (2019). "Novel paradigms in systemic lupus erythematosus". Lancet. 393 (10188): 2344–2358. doi:10.1016/S0140-6736(19)30546-X. PMID 31180031.
  12. Haviv B, Bronak S, Thein R (2013). "The complexity of pain around the knee in patients with osteoarthritis". Isr Med Assoc J. 15 (4): 178–81. PMID 23781753.
  13. Kalke RJ, Di Primio GA, Schweitzer ME (2012). "MR and CT arthrography of the knee". Semin Musculoskelet Radiol. 16 (1): 57–68. doi:10.1055/s-0032-1304301. PMID 22447237.
  14. 14.0 14.1 14.2 14.3 "acsearch.acr.org".
  15. Wick MC, Kastlunger M, Weiss RJ (2014). "Clinical imaging assessments of knee osteoarthritis in the elderly: a mini-review". Gerontology. 60 (5): 386–94. doi:10.1159/000357756. PMID 24751528.