Knee pain resident survival guide

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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

Traumatic and activity-related causes of knee pain

Anterior Knee Pain
  • Patellar subluxation or dislocation
  • Tibial apophysitis (Osgood-Schlatter lesion)
  • Jumper's knee (patellar tendonitis)
  • Patellofemoral pain syndrome (chondromalacia patellae)
Medial Knee Pain
  • Medial collateral ligament sprain
  • Medial meniscal tear
  • Pes anserine bursitis
  • Medial plica syndrome
Lateral Knee Pain
  • Lateral collateral ligament sprain
  • Lateral meniscal tear
  • Iliotibial band tendonitis
Posterior Knee Pain
  • A popliteal cyst (Baker's cyst) as a result of sport-related injury
  • Posterior cruciate ligament injury [1]

Non-Traumatic causes of knee pain

Unilateral Knee Pain
  • Septic Arthritis
  • Gout
  • Pseudogout (acute calcium pyrophosphate crystal arthritis)[1]
Bilateral Knee Pain
  • Osteoarthritis [2]
  • Rheumatoid Arthritis [3]
  • Systemic Lupus Erythematosis
  • Baker cyst as a result of Rheumatoid arthritis and Osteoarthritis [2]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according to the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
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

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
  • 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
 
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Do's

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. 1.0 1.1 "www.aafp.org" (PDF).
  2. 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.
  3. 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. Neogi, Tuhina (2011). "Gout". New England Journal of Medicine. 364 (5): 443–452. doi:10.1056/NEJMcp1001124. ISSN 0028-4793.
  5. 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.
  6. 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.