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Approach to the Adult with Knee Pain

Approach to the Adult with Knee Pain. March 2014. Objectives. Broadly categorize knee pain Identify most common differential diagnosis of knee pain. Knee Pain. Traumatic. Non –Traumatic. Intrinsic. Extrinsic. Intraarticular. Periarticular. Structural. Inflammatory. Anatomy.

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Approach to the Adult with Knee Pain

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  1. Approach to the Adult with Knee Pain March 2014

  2. Objectives Broadly categorize knee pain Identify most common differential diagnosis of knee pain

  3. Knee Pain Traumatic Non –Traumatic Intrinsic Extrinsic Intraarticular Periarticular Structural Inflammatory

  4. Anatomy http://www.aafp.org/afp/2003/0901/p907.html

  5. http://www.knee-pain-explained.com/KneeBursa.html

  6. Clinical Question • 57 yo M with PMH of Hypertension, Diabetes presents with right knee pain started 3 months ago. He noticed his knee slowly became more red and swollen. He works in an office and sits most of the day. He does not recall any trauma. He likes to walk with his wife in the evenings and occasionally does gardening on the weekends. He denies any fevers, rash or pain in other joints. On physical exam there is no click, there is full range of motion however painful and with tenderness to palpation on the medial aspect of knee. What condition does he most likely have? • Iliotibial band syndrome • Prepatellar Bursitis • Meniscal tear • Patellofemoral pain syndrome

  7. Step 1: Intrinsic vs Extrinsic Knee motion rarely aggravates referred pain If examination of knee is normal. Test hip and ankle to identify referred pain

  8. Step 2: Periarticular versus Intraarticular  • Intra-articular - structural defect or an inflammatory process • patient experiences discomfort within the knee • often a chronic effusion is present and tenderness is diffuse • Peri-articular – patient’s can localize the pain to a specific area around the knee • Specific examination maneuvers (direct palpation, valgus or varus stress) elicit a focal pain at the involved structure

  9. Varus and Valgus Stress Tests

  10. Periarticular Pain by Location

  11. Intraarticular Knee Pain: Step 3: Inflammatory vs Structural • Structural – pain is usually provoked by activity and is absent at rest • Meniscal tear, ACL tear • Inflammatory process -pain with activity AND at rest • Often presents with joint effusion and fluid analysis is needed by aspiration of the effusion

  12. Common Causes of Intra-articular Knee Pain

  13. Knee Pain Traumatic Non –Traumatic Intrinsic Extrinsic Intraarticular Periarticular Referred from other joints like hip, ankle, back Structural Inflammatory Focal pain, Ddx based on location Pain with rest and activity Pain with activity

  14. Summary Use the step wise algorithm in your approach to creating a differential diagnosis Localization of the pain can help narrow the differential

  15. References Up to Date: General evaluation of the adult with knee pain MKSAP 16 Rheumatology MKSAP 16 General Internal Medicine MedStudy 15th Edition Core curriculum Book 3 Rheumatology

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