1. Approach to Knee pain
Dr. Faisal Al Hadad
Consultant of Family Medicine
& Occupational Health
PSMMC

2. History
PAIN CHARACTERISTICS
 Onset (rapid or insidious)
 Location (anterior, medial, lateral, or posterior)
 Duration
 Severity
 Quality (e.g., dull, sharp, achy)
 Aggravating and alleviating factors
 Whether the patient was able to continue activity or
bear weight after acute injury or was forced to cease
activities immediately.

3. History
MECHANICAL SYMPTOMS
 Locking
 Popping
 Giving way
EFFUSION
 Timing (rapid/slow onset)
 Amount of joint effusion (mild/moderate/sever)

4. History
MECHANISM OF INJURY
 if the patient sustained a direct blow to the knee
 if the foot was planted at the time of injury
 if the patient was decelerating or stopping suddenly
 if the patient was landing from a jump
 if there was a twisting component to the injury
 if hyperextension occurred.

5. History
MEDICAL HISTORY
 History of knee injury or surgery.
 Previous attempts to treat knee pain, including the
use of medications, supporting devices, and physical
therapy.
 History of gout, pseudogout, rheumatoid arthritis, or
other degenerative joint disease.

6. Ottawa knee rules
A knee x-ray is only required for knee injury patients with any of
:these findings





age 55 or over
isolated tenderness of the patella (no bone tenderness of the
knee other than the patella)
tenderness at the head of the fibula
inability to flex to 90 degrees
inability to weight bear both immediately and in the casualty
department .

7. Anatomy

8. Anatomy

9. Differential Diagnosis
Children and Adolescents.
 Patellar subluxation
 Tibial apophysitis (Osgood- Schlatter lesion)
 Patellar tendonitis (Jumper’s knee)
 Slipped capital femoral epiphysis
Adults
 Overuse syndromes
 Trauma
 Infection
Older Adults
 Osteoarthritis
 Crystal-induced Inflammatory arthropathy
 Popliteal cyst (Baker’s cyst)

10. Children and Adolescents

Patellar subluxation

Tibial apophysitis (Osgood- Schlatter lesion)

Patellar tendonitis (Jumper’s knee)

Slipped capital femoral epiphysis

11. PATELLAR SUBLUXATION
 Occurs
more often in teenage girls
 Presents
knee.
 Pain
test.
with giving-way episodes of the
is reproduced by patellar apprehension

12. TIBIAL APOPHYSITIS

The typical patient is a 13- or 14-year-old boy (or a 10- or 11-yearold girl) who has recently gone through a growth spurt.

Presents with anterior knee pain localized to the tibial tuberosity.
The pain worsens with squatting, walking up or down stairs, or
forceful contractions of the quadriceps muscle.

On PE, the tibial tuberosity is tender and swollen, and may feel
warm. The knee pain is reproduced with resisted active extension
or passive hyperflexion of the knee.

Radiographs are usually negative; rarely, they show avulsion of the
apophysis at the tibial tuberosity.

13. PATELLAR TENDONITIS

Most commonly occurs in teenage boys, particularly during a
growth spurt.

The patient reports vague anterior knee pain that has persisted
for months and worsens after activities such as walking down
stairs or running.

On PE, the patellar tendon is tender, and the pain is reproduced
by resisted knee extension.

Radiographs are not indicated.

14. SLIPPED CAPITAL FEMORAL
EPIPHYSIS

Most commonly occurs in overweight teenagers

The patient usually reports poorly localized knee pain.

The affected hip is slightly flexed and externally rotated. Hip pain is
elicited with passive internal rotation or extension of the hip.

Radiographs typically show displacement of the epiphysis of the
femoral head. However, negative radiographs do not rule out the
diagnosis in patients with typical clinical findings. CT scanning is
indicated in these patients.

15. Adults
1. Overuse syndromes
 Patellofemoral pain syndrome
 Medial plica syndrome
 Iliotibial band tendonitis
2. Trauma
 Anterior Cruciate Ligament Sprain
 Medial Collateral Ligament Sprain
 Lateral Collateral Ligament Sprain
 Meniscal Tear
3. Infection

16. Patellofemoral pain syndrome

Patients typically present with a vague history of mild to moderate
anterior knee pain that usually occurs after prolonged periods of sitting
(“theater sign”).

On PE, a slight effusion may be present, along with patellar crepitus on
range of motion.

The patient’s pain may be reproduced by applying direct pressure at the
anterior aspect of the patella. Patellar tenderness may be elicited by
subluxing the patella medially or laterally and palpating the superior and
inferior facets of the patella.

Radiographs usually are not indicated.

17. Medial plica syndrome

The plica, a redundancy of the joint synovium medially, can
become inflamed with repetitive overuse

The patient presents with acute onset of medial knee pain after a
marked increase of usual activities.

On PE, a tender,mobile nodularity is present at the medial aspect
of the knee, just anterior to the joint line.

Radiographs are not indicated.

18. .Iliotibial band tendonitis

Commonly occurs in runners and cyclists, although it may develop in
any person subsequent to activity involving repetitive knee flexion.

The patient reports pain at the lateral aspect of the knee joint
aggravated by activity, particularly running downhill and climbing
stairs.

On PE, tenderness is present at the lateral epicondyle of the femur.
Noble’s test is used to reproduce the pain. With the patient in a
supine position, the physician places a thumb over the lateral
femoral epicondyle as the patient repeatedly flexes and extends the
knee.

Radiographs are not indicated.

19. Trauma
Anterior Cruciate Ligament Sprain.

Injury to the anterior cruciate ligament usually occurs because of noncontact
deceleration forces, as when a runner plants one foot and sharply turns in the
opposite direction. Resultant valgus stress on the knee leads to anterior
displacement of the tibia and sprain or rupture of the ligament.

The patient usually reports hearing or feeling a “pop” at the time of the injury, and
must cease activity or competition immediately. Swelling of the knee within two
hours after the injury indicates rupture of the ligament and consequent
hemarthrosis.

On PE, the patient has a moderate to severe joint effusion that limits range of
motion. The anterior drawer test may be positive, but can be negative because of
hemarthrosis and guarding by the hamstring muscles. The Lachman test should be
positive and is more reliable than the anterior drawer test.

Radiographs are indicated to detect possible tibial spine avulsion fracture. MRI of
the knee is indicated as part of a presurgical evaluation.

20. Trauma
Medial Collateral Ligament Sprain

The patient reports a misstep or collision that places
valgus stress on the knee, followed by immediate onset of
pain and swelling at the medial aspect of the knee.

On PE, the patient with medial collateral ligament injury
has point tenderness at the medial joint line. Valgus
stress testing of the knee reproduces the pain .

21. Trauma
Lateral Collateral Ligament Sprain

Lateral collateral ligament sprain usually results from varus stress to
the knee, as occurs when a runner plants one foot and then turns
toward the ipsilateral knee.

The patient reports acute onset of lateral knee pain that requires
prompt cessation of activity.

On PE, point tenderness is present at the lateral joint line. Instability or
pain occurs with varus stress testing of the knee.

Radiographs are not usually indicated.

22. Trauma
Meniscal Tear.

The meniscus can be torn acutely with a sudden twisting injury of the
knee, such as may occur when a runner suddenly changes direction.

The patient usually reports recurrent knee pain and episodes of catching
or locking of the knee joint, especially with squatting or twisting of the
knee.

On PE, a mild effusion is usually present, and there is tenderness at the
medial or lateral joint line. Atrophy of the the quadriceps muscle also may
be noticeable. The McMurray test may be positive, but a negative test
does not eliminate the possibility of a meniscal tear.

MRI is the radiologic test of choice because it demonstrates most
significant meniscal tears.

23. INFECTION

Infection of the knee joint may occur in patients of any age but
is more common in those whose immune system has been
weakened by cancer, diabetes mellitus, alcoholism, acquired
immunodeficiency syndrome, or corticosteroid therapy.

The patient with septic arthritis reports abrupt onset of pain and
swelling of the knee with no antecedent trauma.

On PE, the knee is warm, swollen, and exquisitely tender. Even
slight motion of the knee joint causes intense pain.

24. Synovial fluid analysis

Arthrocentesis reveals turbid synovial fluid.

Analysis of the fluid yields a WBC count higher than 50,000 per
mm3 with more than 75 percent PMN cells, an elevated protein
content , and a low glucose concentration.

Gram stain of the fluid may demonstrate the causative
organism.

Hematologic studies show an elevated WBC, an increased
number of immature PMN cells (i.e., a left shift), and an
elevated ESR.

25. Older Adults
 Osteoarthritis
 Crystal-induced
Inflammatory arthropathy
(gout or pseudogout)
 Popliteal
cyst (Baker’s cyst)

26. OSTEOARTHRITIS

The patient presents with knee pain that is aggravated by weightbearing activities and relieved by rest.

The patient usually awakens with morning stiffness that dissipates
somewhat with activity. In addition to chronic joint stiffness and
pain, the patient may report episodes of acute synovitis.

Findings on PE include decreased range of motion, crepitus, a mild
joint effusion, and palpable osteophytic changes at the knee joint.

Weight-bearing radiograph is recommended. Radiographs show
joint-space narrowing, subchondral bony sclerosis, cystic changes,
and hypertrophic osteophyte formation

27. CRYSTAL-INDUCED INFLAMMATORY
ARTHROPATHY

Patient with gout or pseudogout presents with pain, and
swelling in the absence of trauma

On PE, the knee joint is erythematous, warm, tender, and
swollen. Even minimal range of motion is exquisitely painful.

Microscopy of the synovial fluid displays negatively birefringent
rods in the patient with gout and positively birefringent
rhomboids in the patient with pseudogout.

28. (Popliteal cyst (Baker’s cyst

The patient reports insidious onset of mild to moderate
pain in the popliteal area of the knee

On PE, palpable fullness is present at the medial aspect
of the popliteal area. The McMurray test may be positive if
the medial meniscus is injured.

Definitive diagnosis of a popliteal cyst may be made with
arthrography, ultrasonography, CT scanning, MRI.

29. Thank you

30. Knee joint examination
Dr Faisal Al Hadad

31. Inspection
 Erythema
(septic arthritis, gout/pseudogout)
 Swelling(septic arthritis, gout/pseudogout,
trauma)
 Bruising (trauma)
 Posture (SCFE)
 Musculature (menisceal tear)

32. Palpation
 Tenderness
 Warmth
(septic arthritis, gout/ pseudogout)
 Effusion (anterior cruciate ligament sprain)
 Popliteal fossa (baker’s cyst)

33. Palpation
Tenderness






Patella (patellofemoral pain syndrome)
Patellar tendon (patellar tendonitis)
Tibial tubercle (tibial apophysitis)
Lateral epicondyle of the femur (illiotibial band syndrome)
Medial joint line (medial collateral ligament, medial
meniscus)
Lateral joint line (lateral collateral ligament, lateral
meniscus)

34. Movement

Range of motion (septic arthritis, gout/ pseudogout,
OA)

Crepitus (OA, patellofemoral pain syndrome)

Passive hyperflexion of knee joint (tibial apophysitis)

Resisted active extension of knee joint(tibial
apophysitis, patellar tendonitis)

Passive internal rotation of hip joint (SCFE)

35. Specific tests

Patellar apprehension test (patellar subluxation)

Anterior drawer test (anterior cruciate ligament sprain)

Lachman test (anterior cruciate ligament sprain)

Valgus test (medial collateral ligament)

Varus test (lateral collateral ligament)

McMurray (meniscal tear)

36. Lachman test

37. Varus and valgus stress test

38. McMurray test to assess the
.medial meniscus

39. Thank you