Knee pain resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]
Synonyms and keywords: Knee stiffness, Knee swelling, Hot knee joint
Overview
Causes
Common Causes
Anterior Knee Pain |
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Medial Knee Pain |
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Lateral Knee Pain |
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Posterior Knee Pain |
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Non-Traumatic causes of knee pain
Unilateral Knee Pain |
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Bilateral Knee Pain |
Diagnosis
Shown below is an algorithm summarizing the diagnosis of [[disease name]] according to the [...] guidelines.
Seek proper history:
❑ 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:
❑ Range of motion:
❑ Power ❑ Perform knee maneuvers for examination of knee ligament injuries
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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 | 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of [[disease name]] according to the [...] guidelines.
Life style modification for the knee pain depending on the condition
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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): | Knee pain due to rheumatoid arthritis ❑ Methotrexate
❑ Inadequate response:
| Knee pain due to systemic lupus erythematosis General treatment: Hydroxychloroquine
Preferred regimen:
Preferred regimen: (1) Hydroxychloroquine
Preferred regimen: Dextropropoxyphene
(1) Hydrocodone | {{{ C06 }}} | {{{ C07 }}} | |||||||||||||||||||||||||||||||||||||||||||||||||
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.[5]
- When an intra-articular abnormality is suspected, CT arthrography may be used instead of MRI to evaluate the menisci and articular cartilage.[6]
Don'ts
- 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.
References
- ↑ 1.0 1.1 "www.aafp.org" (PDF).
- ↑ 2.0 2.1 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.
- ↑ 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.
- ↑ Neogi, Tuhina (2011). "Gout". New England Journal of Medicine. 364 (5): 443–452. doi:10.1056/NEJMcp1001124. ISSN 0028-4793.
- ↑ 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.
- ↑ 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.