Knee Pain

1. Most prevalent in physically active pts

2. Hx
a. Pain characteristics- OLD CARTS; if pain is caused by acute injury, ask whether able to
continue activity/bear wt after injury or forced to cease activities immediately
b. Mechanical Sx- locking suggests meniscal tear; popping at time of injury suggests
ligamentous injury, probably complete (3rd deg) rupture; “giving way” consistent w/
knee instability and may indicate patellar subluxation or ligamentous rupture
c. Effusion- rapid onset (w/in 2hr) of large, tense effusion suggests rupture of ACL or
fracture of tibial plateau w/ resultant hemarthrosis; slower onset (24-36hr) of mild to
moderate effusion consistent w/ meniscal injury or ligamentous sprain; recurrent
effusion after activity consistent w/ meniscal injury
d. Mechanism of Injury- anterior force applied to proximal tibia w/ knee in flexion (when
knee hits dashboard in MVA) can injure PCL; lateral force to knee (clipping in football)
creates valgus stress and is most common way MCL is injured; medial blow (varus load)
injures LCL; quick stops and sharp cuts/turns cause deceleration forces that
sprain/rupture ACL; hyperextension can injure ACL or PCL; sudden twisting/pivoting
creates shear force that injures meniscus
e. Medical Hx- injury or surgery, previous attempts to Tx knee pain, Hx of gout,
pseudogout, RA or other degenerative joint dz
3. PhEx
a. Inspection and palpation- compare painful knee w/ asymptomatic knee inspecting for
erythema, swelling, bruising, and discoloration; evaluate vastus medialis for signs of
atrophy; palpate for pain, warmth, and effusion; point tenderness at patella, tibial
tubercle, patellar and quadriceps tendon, and joint lines; ROM by extending and flexing
knee as far as possible (normal ROM: extension= 0deg, flexion= 135deg)
b. Patellofemoral assessment- evaluate for effusion while pt supine and injured knee in
extension and suprapatellar pouch should be milked to check for effusion;
patellofemoral tracking assessed by observing patella for smooth motion while pt
contracts quads; check for crepitus during palpation; quadriceps angle (Q angle, fig2)
>15deg is predisposing factor for lateral patellar subluxation; patellar apprehension
(fingers at medial aspect of patella, attempt to sublux patella laterally), if reproduces
pain or “gives way”, patellar subluxation is likely cause of Sx
c. Cruciate ligaments
i. ACL- anterior drawer test (knee flexed at 90deg); Lachman test (fig3) (knee
flexed up to 30deg, lack of clear endpoint indicates (+) test)

ii. PCL- posterior drawer test (knee flexed at 90deg), posterior sag sign; posterior
displacement of tibia
d. Collateral ligaments
i. Medial collateral ligament- valgus stress test (fig4) at both 0deg (full extension)
and 30deg of knee flexion; at 0deg the PCL and articulation of femoral condyles
w/ tibial plateau stabilize knee; at 30deg valgus stress assesses laxity of MCL
ii. Lateral collateral ligament- varus stress test at 0deg and 30deg knee flexion;
firm end point indicates collateral ligament is intact; soft/absent end point
indicates complete (3rd deg) rupture of ligament
 e. Menisci- tenderness at joint line; McMurray test (fig5)- grab heel w/ one hand and knee
w/ other w/ thumb at lateral joint line and fingers at medial joint line, flex knee
maximally, to test lateral meniscus rotate tibia internally and apply valgus stress while
extending knee to ~90deg, to test medial meniscus rotate tibia externally and apply
varus stress while extending to ~90deg; (+) test produces thud or click, or causes pain in
a reproducible portion of ROM

4. Imaging- most pts w/ knee pain have soft tissue injuries hence plain-films usually NOT indicated.
Ottawa knee rules (tbl1); if radiographs required, get 3 views (AP, lateral, Merchant’s view [for
patellofemoral joint]); teen pts w/ chronic knee pain and recurrent effusion require notch or
tunnel view (posteroanterior view w/ knee flexed to 40-50deg) to detect radiolucencies of
femoral condyles (medial most common) indicating osteochondritis dissecans; if OA suspected,
standing wt-bearing radiographs should be obtained
a. Ottawa knee rule (100% sensitivity for fractures)- radiographs should be obtained after
acute injury ONLY in pts w/ one or more of the following:
i. > or = 55
ii. Isolated tenderness of patella w/ no other bony tenderness of knee
iii. Tenderness at head of fibula
iv. Inability to flex knee to 90deg
v. Inability to bear weight both immediately and in ED for 4 steps, regardless of
limp (i.e., unable to transfer wt onto each lower limb two times)
5. Labs- warmth, tenderness, painful effusion, and marked pain w/ even slight ROM consistent w/
septic arthritis or acute inflammatory arthropathy; CBC w/ diff, ESR, arthrocentesis (joint fluid
tested for cell count w/ diff, glucose, protein, bacterial cultures and sensitivity, and polarized
light microscopy for crystals); arthrocentesis may be required to differentiate simple effusion
(clear, straw-colored transudative fluid; knee sprain or chronic meniscal injury) from
hemarthrosis (ACL tear, fracture, acute tear of outer meniscus) or occult osteochondral fracture
(hemarthrosis w/ fat globules in aspirate); RA- ESR, RF in select pts

6. Children and adolescents- septic arthritis can occur at ANY age!

a. Patellar subluxation- teenage girl; “giving way” episodes of knee; Q angle >15deg;
patellar apprehension elicited by subluxing patella laterally, mild effusion usually
present; moderate to severe knee swelling may indicate hemarthrosis, suggesting
patellar dislocation w/ osteochondral fracture and bleeding
b. Tibial apophysitis (Osgood-Schlatter lesion, fig1)- teenage boy (13-14) (or 10-11y/o girl);
recently gone through growth spurt; anterior knee pain localized to tibial tuberosity;
waxing and waning knee pain for months; worsens w/ squatting, walking up or down
stairs, forceful contractions of quads; exacerbated by jumping and hurdling (stress on
insertion of patellar tendon when landing); PhEx- tibial tuberosity is tender, swollen, and
warm, pain reproduced w/ resisted active extension or passive hyperflexion; no
effusion; radiographs usually negative, rarely show avulsion of apophysis at tibial
tuberosity
 c. Patellar tendonitis- Jumper’s knee; irritation and inflammation of patellar tendon;
teenage boys during growth spurt; vague anterior knee pain for months; worsens after
walking down stairs or running; PhEx- patellar tendon is tender, pain reproduced by
resisted knee extension; no effusion; radiographs not indicated
d. Slipped capital femoral epiphysis- referred pain to knee from hip; children and
teenagers w/ poorly localized knee pain and no Hx of trauma; overweight; sits w/
affected hip slightly flexed and externally rotated; normal knee exam; hip pain elicited
w/ passive internal rotation or extension of affected hip; radiographs show
displacement of epiphysis of femoral head, (-) radiographs do NOT rule out Dx; CT
indicated
e. Osteochondritis dissecans- intra-articular osteochondrosis of unknown etiology;
Do NOT confuse this for medial meniscal
tear! degeneration and recalcification of articular cartilage and underlying bone; medial
femoral condyle most commonly affected; vague, poorly localized pain, morning
stiffness, recurrent effusions; locking or catching if loose body is present; PhEx:
quadriceps atrophy, tenderness along involved chondral surface, mild joint effusion;
plain-film: osteochondral lesion or loose body; get 4 views: AP, PA tunnel [only way to
visualize osteochondral lesions at lateral aspect of medial femoral condyle], lateral,
Merchant’s; MRI indicated in pts w/ suspected osteochondral lesion
7. Adults
a. Overuse syndromes
i. Anterior knee pain
1. Patello-femoral pain syndrome (chondromalacia patellae)- more
common in women; vague Hx of anterior knee pain occurring after
prolonged periods of sitting (“theater sign”); PhEx- slight effusion,
patellar crepitus on ROM, pain reproduced by direct pressure at
anterior aspect of patella or subluxing patella medially or laterally and
palpating superior and inferior facets of patella; radiographs NOT
indicated
ii. Medial knee pain
1. Medial plica syndrome- plica (a redundancy of joint synovium medially)
becomes inflamed w/ repetitive overuse; acute onset of medial knee
pain after increase of usual activities; PhEx- tender, mobile nodularity at
medial aspect anterior to joint line; no effusion; radiographs NOT
indicated
2. Pes anserine bursitis- tendinous insertion of sartorius, gracilis, and
semitendinosus at anteromedial aspect of proximal tibia forms pes
anserine bursa which becomes inflamed due to overuse or direct
contusion; confused w/ MCL sprain or OA; pain worsened by repetitive
flexion and extension; PhEx- tenderness at medial aspect of knee,
posterior and distal to medial joint line; no effusion; slight swelling at
insertion of medial hamstring muscles, valgus stress or resisted knee
flexion reproduce pain; radiographs NOT indicated
iii. Lateral knee pain
 1. IT band tendonitis- excessive friction b/w IT band and lateral femoral
condyle; overuse syndrome; runners and cyclists or anyone w/
repetitive knee flexion activities; predisposing factors: tightness of IT
band, excessive foot pronation, genu varum, tibial torsion; pain
aggravated by activity particularly running downhill and climbing stairs;
PhEx- tenderness at lateral epicondyle of femur ~3cm proximal to joint
line, soft tissue swelling, crepitus, NO joint effusion; radiographs NOT
indicated; NOBLE’S TEST- pt supine, thumb over lateral femoral
epicondyle as pt flexes and extends knee, pain most prominent w/ knee
at 30deg, reproduce pain of IT band tendonitis
2. Popliteus tendonitis- rare
b. Trauma
i. ACL sprain- noncontact deceleration forces (runner plants one foot and sharply
turns in opposite direction) valgus stress anterior displacement of tibia and
sprain/rupture of ligament; pt hears or feels “pop” at time of injury and ceases
activity immediately, swelling w/in 2hr indicates rupture and consequent
hemarthrosis; PhEx- joint effusion that limits ROM, (+) anterior drawer test
(could be (-) b/c of hemarthrosis and guarding by hamstrings), Lachman test
more reliable; radiographs indicated to detect possible tibial spine avulsion
fracture, MRI indicated as part of presurgical eval.
ii. Medial collateral ligament sprain- usually result of acute trama, pt reports
misstep or collision that places valgus stress on knee, followed by immediate
onset of pain and swelling at medial aspect of knee; PhEx- point tenderness at
medial joint line, valgus stress test of knee flexed to 30deg reproduces pain;
clearly defined endpoint on valgus stress test indicates grade 1 or 2 sprain,
complete medial instability indicates full rupture of ligament (grade 3 sprain)
iii. Lateral collateral ligament sprain- less common than MCL injury; results from
varus stress (runner plants one foot and turns toward ipsilateral knee); acute
onset of lateral knee pain and immediate cessation of activity; PhEx- point
tenderness at lateral joint line, instability or pain w/ varus stress at knee flexed
to 30deg; radiographs NOT indicated
iv. Meniscal tear- sudden twisting injury (runner suddenly changing directions) or
prolonged degenerative process particularly in pt w/ ACL-deficient knee;
recurrent knee pain and catching or locking especially when squatting or
twisting of knee; PhEx- mild effusion, tenderness at medial or lateral joint line,
atrophy of vastus medialis, (+) McMurray test (- test does NOT rule out meniscal
tear); plain film radiographs seldom indicated and are (-); MRI is test of choice
c. Infection- ANY AGE; more common in immunocompromised: CA, DM, alcoholism, AIDS,
corticosteroid therapy; abrupt onset of pain and swelling w/ no antecedent trauma;
PhEx- knee is warm, swollen, exquisitely tender even w/ slight motion; arthrocentesis-
turbid synovial fluid, WBC >50,000, >75% PMNs, elevated protein (>3g/dL), low glucose
(>50% lower than serum glucose), gram stain may show organism; common pathogens:
S. aureus, strep species, H. flu, N. gonorrhea; hematologic studies- elevated WBCs,
increased bands (left shift), elevated ESR (>50mm/hr)
8. Older adults
a. OA- common after age 60; knee pain aggravated by wt-bearing and relieved by rest, no
systemic Sx, morning stiffness that dissipates w/ activity, episodes of acute synovitis;
PhEx- decreased ROM, crepitus, mild joint effusion, palpable osteophytic changes at
knee joint; recommended radiographs: wt-bearing AP and PA tunnel, non-wt-bearing
Merchant’s and lateral views; joint-space narrowing, subchondral sclerosis, cystic
changes, hypertrophic osteophyte formation
b. Crystal-induced inflammatory arthropathy- acute inflammation, pain, and swelling,
absence of trauma; gout commonly affects knee, (-) birefringent MSU crystals in joint
cause intense inflammatory response; pseudogout, (+) birefringent, CPP crystals; PhEx-
swollen, erythematous, warm, tender knee joint even w/ minimal ROM; arthrocentesis-
clear or slightly cloudy fluid, WBC count 2000-75000, high protein (>32g/dL), glucose
concentration 75% of serum glucose
c. Popliteal (Baker’s) cyst- synovial cyst originating from posteromedial aspect of knee joint
at level of gastrocneio-semimembranous bursa; insidious onset of mild to moderate
pain in popliteal area; PhEx- palpable fullness at medial aspect of popliteal area or near
origin of medial head of gastrocnemius, (+) McMurray if medial meniscus is injured;
definitive Dx w/ arthrography, US, CT, or less commonly, MRI