The Family History for a Patient With Joint Pain Should Include
Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests
A more recent article on evaluation of knee pain in adults is available.
Am Fam Physician. 2003 Sep 1;68(5):907-912.
This is part I of a two-part article on knee hurting. Office Ii, "Differential Diagnosis," appears on page 917 in this issue.
Article Sections
- Abstract
- History
- Concrete Exam
- Laboratory Studies
- References
Family physicians frequently come across patients with knee joint pain. Accurate diagnosis requires a knowledge of knee anatomy, common pain patterns in genu injuries, and features of oftentimes encountered causes of knee pain, also every bit specific physical examination skills. The history should include characteristics of the patient'due south pain, mechanical symptoms (locking, popping, giving way), joint effusion (timing, corporeality, recurrence), and mechanism of injury. The physical examination should include careful inspection of the articulatio genus, palpation for betoken tenderness, cess of joint effusion, range-of-movement testing, evaluation of ligaments for injury or laxity, and assessment of the menisci. Radiographs should exist obtained in patients with isolated patellar tenderness or tenderness at the head of the fibula, inability to bear weight or flex the human knee to ninety degrees, or age greater than 55 years.
Knee hurting accounts for approximately one 3rd of musculoskeletal problems seen in primary care settings. This complaint is near prevalent in physically active patients, with every bit many as 54 percent of athletes having some caste of knee joint pain each yr.1 Articulatio genus hurting tin be a source of significant disability, restricting the power to piece of work or perform activities of daily living.
The genu is a complex structure (Figure 1),2 and its evaluation can present a challenge to the family medico. The differential diagnosis of knee pain is all-encompassing but tin exist narrowed with a detailed history, a focused physical examination and, when indicated, the selective use of appropriate imaging and laboratory studies. Function I of this two-role commodity provides a systematic approach to evaluating the genu, and office II3 discusses the differential diagnosis of articulatio genus pain.
Figure 1.
Beefcake of the knee.
Reprinted from Tandeter HB, Shvartzman P, Stevens MA. Acute knee injuries: use of determination rules for selective radiograph ordering. Am Fam Dr. 1999; 60:2600.
History
- Abstract
- History
- Physical Examination
- Laboratory Studies
- References
PAIN CHARACTERISTICS
The patient's description of knee hurting is helpful in focusing the differential diagnosis.4 It is important to clarify the characteristics of the pain, including its onset (rapid or insidious), location (inductive, medial, lateral, or posterior human knee), duration, severity, and quality (due east.g., dull, sharp, achy). Aggravating and alleviating factors also need to be identified. If knee hurting is caused by an acute injury, the dr. needs to know whether the patient was able to keep activity or bear weight after the injury or was forced to terminate activities immediately.
MECHANICAL SYMPTOMS
The patient should be asked about mechanical symptoms, such as locking, popping, or giving way of the knee. A history of locking episodes suggests a meniscal tear. A sensation of popping at the fourth dimension of injury suggests ligamentous injury, probably consummate rupture of a ligament (third-degree tear). Episodes of giving way are consistent with some degree of knee joint instability and may indicate patellar subluxation or ligamentous rupture.
EFFUSION
The timing and corporeality of joint effusion are important clues to the diagnosis. Rapid onset (inside two hours) of a big, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau with resultant hemarthrosis, whereas slower onset (24 to 36 hours) of a balmy to moderate effusion is consistent with meniscal injury or ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury.
MECHANISM OF INJURY
The patient should be questioned near specific details of the injury. It is important to know 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 all of a sudden, if the patient was landing from a leap, if in that location was a twisting component to the injury, and if hyperextension occurred.
A straight blow to the knee can cause serious injury. Anterior force applied to the proximal tibia with the knee in flexion (e.one thousand., when the human knee hits the dashboard in an automobile blow) can crusade injury to the posterior cruciate ligament. The medial collateral ligament is well-nigh commonly injured equally a result of direct lateral force to the knee joint (e.g., clipping in football game); this forcefulness creates a valgus load on the knee joint and can result in rupture of the medial collateral ligament. Conversely, a medial blow that creates a varus load can injure the lateral collateral ligament.
Noncontact forces also are an important crusade of genu injury. Quick stops and sharp cuts or turns create significant deceleration forces that can sprain or rupture the anterior cruciate ligament. Hyperextension can result in injury to the anterior cruciate ligament or posterior cruciate ligament. Sudden twisting or pivoting motions create shear forces that tin can injure the meniscus. A combination of forces tin can occur simultaneously, causing injury to multiple structures.
MEDICAL HISTORY
A history of knee injury or surgery is important. The patient should be asked about previous attempts to treat human knee pain, including the use of medications, supporting devices, and concrete therapy. The physician likewise should ask if the patient has a history of gout, pseudogout, rheumatoid arthritis, or other degenerative articulation disease.
Physical Examination
- Abstract
- History
- Physical Examination
- Laboratory Studies
- References
INSPECTION AND PALPATION
The dr. begins past comparison the painful knee with the asymptomatic human knee and inspecting the injured genu for erythema, swelling, bruising, and discoloration. The musculature should be symmetric bilaterally. In detail, the vastus medialis obliquus of the quadriceps should be evaluated to determine if information technology appears normal or shows signs of atrophy.
The articulatio genus is then palpated and checked for pain, warmth, and effusion. Point tenderness should be sought, particularly at the patella, tibial tubercle, patellar tendon, quadriceps tendon, anterolateral and anteromedial joint line, medial joint line, and lateral joint line. Moving the patient's knee joint through a brusque arc of motion helps identify the joint lines. Range of motion should be assessed by extending and flexing the articulatio genus as far as possible (normal range of move: extension, cypher degrees; flexion, 135 degrees).5
PATELLOFEMORAL ASSESSMENT
An evaluation for effusion should exist conducted with the patient supine and the injured knee in extension. The suprapatellar pouch should exist milked to determine whether an effusion is present.
Patellofemoral tracking is assessed by observing the patella for smooth motion while the patient contracts the quadriceps muscle. The presence of crepitus should be noted during palpation of the patella.
The quadriceps bending (Q angle) is determined past drawing one line from the anterior superior iliac spine through the eye of the patella and a second line from the center of the patella through the tibial tuberosity (Figure ii).vi A Q angle greater than 15 degrees is a predisposing gene for patellar subluxation (i.e., if the Q angle is increased, forceful contraction of the quadriceps muscle tin cause the patella to sublux laterally).
Figure ii.
Quadriceps angle (Q angle).
Reprinted from Juhn MS. Patellofemoral pain syndrome: a review and guidelines for treatment. Am Fam Physician 1999;lx:2014.
A patellar apprehension test is so performed. With fingers placed at the medial aspect of the patella, the doc attempts to sublux the patella laterally. If this maneuver reproduces the patient's pain or a giving-way sensation, patellar subluxation is the likely cause of the patient's symptoms.7 Both the superior and inferior patellar facets should be palpated, with the patella subluxed first medially and then laterally.
CRUCIATE LIGAMENTS
Anterior Cruciate Ligament
For the anterior drawer test, the patient assumes a supine position with the injured knee flexed to 90 degrees. The physician fixes the patient'due south pes in slight external rotation (by sitting on the foot) and and so places thumbs at the tibial tubercle and fingers at the posterior calf. With the patient'southward hamstring muscles relaxed, the dr. pulls anteriorly and assesses anterior displacement of the tibia (anterior drawer sign).
The Lachman test is some other means of assessing the integrity of the anterior cruciate ligament (Figure 3).vii The test is performed with the patient in a supine position and the injured knee joint flexed to 30 degrees. The md stabilizes the distal femur with one hand, grasps the proximal tibia in the other manus, and and then attempts to sublux the tibia anteriorly. Lack of a clear end point indicates a positive Lachman test.
FIGURE three.
Lachman examination.
Reprinted from Smith BW, Greenish GA. Acute knee joint injuries: function I. History and physical examination. Am Fam Physician 1995;51:618.
Posterior Cruciate Ligament
For the posterior drawer test, the patient assumes a supine position with knees flexed to 90 degrees. While standing at the side of the examination tabular array, the doctor looks for posterior deportation of the tibia (posterior sag sign).7,8 Next, the physician fixes the patient's foot in neutral rotation (past sitting on the human foot), positions thumbs at the tibial tubercle, and places fingers at the posterior dogie. The physician then pushes posteriorly and assesses for posterior displacement of the tibia.
COLLATERAL LIGAMENTS
Medial Collateral Ligament
The valgus stress test is performed with the patient's leg slightly abducted. The doctor places one manus at the lateral aspect of the knee joint and the other hand at the medial attribute of the distal tibia. Adjacent, valgus stress is applied to the articulatio genus at both zippo degrees (total extension) and xxx degrees of flexion (Effigy 4)7. With the knee joint at null degrees (i.east., in full extension), the posterior cruciate ligament and the articulation of the femoral condyles with the tibial plateau should stabilize the genu; with the articulatio genus at thirty degrees of flexion, application of valgus stress assesses the laxity or integrity of the medial collateral ligament.
Figure 4.
Varus and valgus stress test. The maneuvers should be performed with the knee joint unflexed and at 30 degrees of flexion.
Reprinted from Smith BW, Green GA. Acute knee injuries: part I. History and physical examination. Am Fam Medico 1995;51:617.
Lateral Collateral Ligament
To perform the varus stress examination, the physician places one hand at the medial attribute of the patient'due south knee and the other hand at the lateral aspect of the distal fibula. Next, varus stress is applied to the knee, get-go at full extension (i.e., zero degrees), then with the knee flexed to 30 degrees (Figure 4).7 A house end betoken indicates that the collateral ligament is intact, whereas a soft or absent end signal indicates consummate rupture (third-caste tear) of the ligament.
MENISCI
Patients with injury to the menisci ordinarily demonstrate tenderness at the articulation line. The McMurray test is performed with the patient lying supine9 (Figure v). The test has been described variously in the literature, but the writer suggests the following technique.
FIGURE 5.
McMurray test to appraise the medial meniscus. (Top) The test is performed with the patient supine and the knee flexed to 90 degrees. To exam the medial meniscus, the examiner grasps the patient'southward heel with one mitt to concur the tibia in external rotation, with the thumb at the lateral joint line, the fingers at the medial joint line. (Heart) The examiner flexes the patient's knee maximally to impinge the posterior horn of the meniscus against the medial femoral condyle. (Bottom) A varus stress is applied equally the examiner extends the knee.
The physician grasps the patient's heel with one hand and the knee with the other paw. The physician's thumb is at the lateral joint line, and fingers are at the medial joint line. The physician then flexes the patient's human knee maximally. To examination the lateral meniscus, the tibia is rotated internally, and the knee is extended from maximal flexion to about xc degrees; added pinch to the lateral meniscus can exist produced by applying valgus stress across the articulatio genus joint while the knee is beingness extended. To test the medial meniscus, the tibia is rotated externally, and the human knee is extended from maximal flexion to almost ninety degrees; added compression to the medial meniscus can exist produced by placing varus stress across the genu while the knee is beingness extended. A positive test produces a thud or a click, or causes pain in a reproducible portion of the range of motion.
Because virtually patients with human knee pain accept soft tissue injuries, plain-picture show radiographs generally are not indicated. The Ottawa genu rules are a useful guide for ordering radiographs of the knee10,11 (Table 1).11
Table 1
Ottawa Human knee Rules for Obtaining Radiographs in Astute Genu Injury
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If radiographs are required, 3 views are usually sufficient: anteroposterior view, lateral view, and Merchant's view (for the patellofemoral joint).7,12 Teenage patients who written report chronic knee pain and recurrent articulatio genus effusion require a notch or tunnel view (posteroanterior view with the knee flexed to forty to l degrees). This view is necessary to detect radiolucencies of the femoral condyles (virtually usually the medial femoral condyle), which indicate the presence of osteochondritis dissecans.13
Radiographs should be closely inspected for signs of fracture, particularly involving the patella, tibial plateau, tibial spines, proximal fibula, and femoral condyles. If osteoarthritis is suspected, standing weight-bearing radiographs should be obtained.
Laboratory Studies
- Abstract
- History
- Physical Examination
- Laboratory Studies
- References
The presence of warmth, exquisite tenderness, painful effusion, and marked pain with even slight range of move of the genu joint is consequent with septic arthritis or acute inflammatory arthropathy. In improver to obtaining a complete claret count with differential and an erythrocyte sedimentation rate (ESR), arthrocentesis should be performed. The joint fluid should be sent to a laboratory for a jail cell count with differential, glucose and protein measurements, bacterial civilization and sensitivity, and polarized light microscopy for crystals.
Considering a tense, painful, swollen knee may nowadays an unclear clinical picture, arthrocentesis may be required to differentiate simple effusion from hemarthrosis or occult osteochondral fracture.4 A uncomplicated articulation effusion produces articulate, straw-colored transudative fluid, every bit in a articulatio genus sprain or chronic meniscal injury. Hemarthrosis is caused by a tear of the inductive cruciate ligament, a fracture or, less commonly, an acute tear of the outer portion of the meniscus. An osteochondral fracture causes hemarthrosis, with fatty globules noted in the aspirate.
Rheumatoid arthritis may involve the knee joint. Hence, serum ESR and rheumatoid factor testing are indicated in selected patients.
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REFERENCES
testify all references
i. Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart LG. The content of convalescent medical intendance in the Usa. An interspecialty comparison. N Engl J Med. 1983;309:892–7. ...
2. Tandeter HB, Shvartzman P, Stevens MA. Acute human knee injuries: utilise of determination rules for selective radiograph ordering. Am Fam Physician. 1999;60:2599–608.
3. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: part II. Differential diagnosis. Am Fam Physician. 2003;68:917–22.
4. Bergfeld J, Ireland ML, Wojtys EM, Glaser Five. Pinpointing the cause of acute knee joint pain. Patient Intendance. 1997;31(18):100–7.
5. Magee DJ. Knee. In: Orthopedic physical assessment. 4th ed. Philadelphia: Saunders, 2002:661–763.
6. Juhn MS. Patellofemoral pain syndrome: a review and guidelines for treatment. Am Fam Physician. 1999;threescore:2012–22.
7. Smith BW, Light-green GA. Acute knee injuries: part I. History and physical exam. Am Fam Physician. 1995;51:615–21.
8. Walsh WM. Knee joint injuries. In: Mellion MB, Walsh WM, Shelton GL, eds. The team doctor's handbook. 2nd ed. St. Louis: Mosby, 1997:554–78.
nine. McMurray TP. The semilunar cartilage. Br J Surg. 1942;29:407–14.
10. Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa knee dominion for the utilize of radiography in acute knee injuries. JAMA. 1997;278:2075–9.
11. Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Caciotti T, et al. Derivation of a decision dominion for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26:405–13.
12. Sartoris DJ, Resnick D. Plain picture show radiography: routine and specialized techniques and projections. In: Resnick D, ed. Diagnosis of bone and articulation disorders. 3d ed. Philadelphia: Saunders:1–xl.
13. Schenck RC Jr, Goodnight JM. Osteochondritis dissecans. J Os Joint Surg [Am]. 1996;78:439–56.
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