Case 25: Knee Pain - Virginia Tech



Objectives:

i. Describe and be able to perform a physical examination of the knee

ii. List the differential diagnoses for knee pain

iii. Describe the incidence and consequences of knee injuries in the female athlete

iv. Describe the symptoms and signs of Lyme Disease

v. Describe the laboratory evaluation of knee pain and be able to apply this to the clinical presentation of a patient with knee pain.

vi. Describe treatment options for Chondromalacia Patella

USC Case # 8: Knee Pain

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History of Present Illness (HPI):

Scarlet O’Hara is a 19 yo black female college student who presents to your office with right knee pain. She denies any trauma but frequently participates in recreational sports activities such as basketball, running and tennis. She describes her pain as being “around my kneecap” and rates it a 4 or 5 on a scale of 10. She notes that her knee doesn’t really swell up with fluid but is sometimes a little “puffy”. She has had no locking or giving out but notes that climbing or descending stairs makes her pain worse. She does note an occasional “grinding” sensation behind her kneecap. Prolonged sitting in class makes the pain worse when she first gets up but after a few steps the pain usually gets better. She’s been taking advil over the last few weeks with some temporary relief of symptoms.

Past Medical History:

Immunizations are up to date. She denies fevers or rashes. There is no family history of lupus or rheumatoid arthritis. Father is diabetic. Mother is hypertensive. Grandmother has had a hip replacement for arthritis. She has had a previous tonsillectomy. She has had a previous ACL reconstruction during her junior year of High School on the left knee. This summer she worked as a camp counselor and on one of the hikes she thinks she was bitten by something, maybe a tick but she is not sure. It was some type of bite that was “red for a few days but got better on its own”.

Question: What is the importance of the previous ACL reconstruction on the left (asymptomatic) knee?

Answer: Previous joint injuries or operations are always a relevant part of the musculoskeletal history. Regarding this injury it is unlikely that there is a “cause and effect” relationship unless she is still symptomatic or has some weakness in the previously operated knee resulting in an “overload” of the right knee.

Question: Is gender an issue in knee injuries?

Answer: There is a four-fold to eight-fold higher incidence of knee injuries in females than males in jumping and cutting sports including basketball, soccer, volleyball and others. In female athletes knee injuries account for up to 91% of season ending injuries and 94% of those injuries requiring surgery. Season ending knee injuries occur at a rate as high as 1 in 10 female athletes annually at the intercollegiate level (i.e. 15,000 female athletes lost each year to athletic participation). At a rate of approximately 1 in 65 ACL injuries per participant annually, approximately 7000 ACL ruptures occur in high school female basketball players alone in the United States on an annual basis. Higher rate of injury in female athletes combined with dramatic increase in female participation since Title IX in 1972 has led to a geometric increase in the number of musculoskeletal injuries in female athletes over the last three decades.

Question: Is the possible tick bite relevant?

Answer: Maybe. Her history is pretty sketchy here but we will need to consider this in the differential. A tick bite with joint pain may indicate a Lyme arthritis. Lyme disease is an inflammatory disease characterized by a skin rash, joint inflammation, and flu-like symptoms, caused by the bacterium Borrelia burgdorferi transmitted by the bite of a deer tick. Lyme disease was first described in the United States in the town of Old Lyme, Connecticut in 1975, but has now been reported in most parts of the United States.

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Early localized disease refers to a red rash in the area of the tick bite. This rash shows up within a month of infection. The bite itself is usually found near the waist or belt line, or in other warm, moist areas of the body. The bite may burn, itch, or hurt. The rash usually grows over a period of days and may be in a "bulls eye" pattern, red with a white spot in the middle, or completely red.

__________

While she doesn’t describe the “classic” rash she does remember the bite area as being a little red.

Physical Examination:

She is alert, oriented and cooperative and shows appropriate concern for her injury. She is dressed in gym shorts and sneakers. You ask her to take her shoes off and watch her walk briefly in the hall. She has no limp but you note that she is “flat-footed”. You also note that she has a somewhat “valgus” knee alignment with an increased “Q” angle. Her mom states that she has been that way all of her life. When she was a toddler she wore “special shoes”. They tried some over the counter arch supports a few years ago but she found them too uncomfortable to play in. She complains that her hamstrings are “tight”.

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With respect to the knee evaluation you examine the uninvolved knee first and there is no specific abnormality noted. When examining the right knee you note no ligamentous laxity, no joint line tenderness and no effusion. She has audible and palpable subpatellar crepitation with knee flexion and extension. She has a positive “patellar grind” test and tenderness to palpation over the lateral patellar facet. Leg lengths are equal. She has bilateral hamstring tightness. With knee extension in the seated position she has a positive “inverted J sign”.

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The distal neurovascular status is intact. There are no rashes or skin changes noted.

Question: What is your differential diagnosis?

Answer: 1) Bilateral Pes Planus 2) Lyme Arthritis 3) Chodromalacia Patella 4) Patellar Tendonitis 5) Osgood Schlatter Disease

Bilateral pes planus is a correct diagnosis based on your careful observation. It is likely related to the primary diagnosis but is not the only reason for her knee pain. Her previous orthotics were uncomfortable so you recommend custom orthotics which should have a better fit than the over-the-counter type that she previously tried.

Lyme arthritis is a possibility based on her history of possible tick bite. She does not describe the “classic” bulls eye rash but does remember having a “red spot”. You order a Lyme a titer blood test which is negative making this diagnosis unlikely.

Chondromalacia Patella is a correct diagnosis and is likely the major cause of her knee pain. She has a number of positive historical clues including: grinding behind the kneecap, pain with stair climbing, and pain after prolonged sitting. Biomechanical risk factors include bilateral pes planus and increased “Q” angle (see above). From the perspective of her examination she has pain over the lateral patellar facet, subpatellar crepitation and an “inverted J sign”. This sign is characterized by lateral subluxation of the patella during terminal knee extension and can be indicative of weakness of the vastus medialis oblique muscle.

Patellar tendonitis is an incorrect diagnosis but a common cause of anterior knee pain in young athletes. This diagnosis would not cause subpatellar crepitation or an “inverted J sign”. You would also generally note pain with palpation and tenderness with direct palpation over the patellar tendon which was not present in this case.

Osgood Schlatter Disease is an incorrect diagnosis but also a common cause of anterior knee pain in young athletes. It is more common in males than females (7 to 1 ratio) and generally occurs in the 10-14 year old age group. The most characteristic finding is localized pain and swelling at the tibial tuberosity secondary to inflammation at this apophysis (growth plate).

Further Discussion and Treatment Recommendations:

Mom wants to know if an MRI is needed to make this diagnosis. You indicate to her that 90% of non-traumatic knee pain can be diagnosed based on history, physical examination and plain x-rays. MRI is seldom needed but often requested. History alone will allow an accurate diagnosis up to 70% of the time.

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Mom is satisfied with that answer but wants to know what needs to be done to “get this knee fixed”. Your recommendations include: 1) a period of “relative rest” with emphasis on non-impact aerobic activity, 2) quadriceps strengthening with emphasis on the vastus medialis oblique muscle, 3) hamstring flexibility exercise, 4) custom orthotics to address her “flat feet” and knee alignment issues, 5) icing especially after activity, 6) a short course of anti-inflammatory medication (such as ibuprofen for 10-14 days), and 7) you discuss the possible use of a knee sleeve as a temporary measure to improve her patellar tracking.

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Finally, you schedule a follow up visit for two weeks to monitor her progress.

SUMMARY AND RECOMMENDATIONS

●The history is critical to understanding the cause of an athlete or active adult’s knee pain. Important elements of the history include distinguishing between acute and chronic knee pain, identifying any trauma that may have caused the knee pain, learning the mechanism of injury if trauma was involved, and understanding what activities the patient participates in that may contribute to their symptoms. A review of useful questions to elicit the history is provided in the text.

●The physical examination of any joint is classically divided into inspection, palpation, range of motion testing, strength and neurovascular testing, and special maneuvers to assess for specific diagnoses. Special tests are selected based upon the most likely diagnostic category, which is based in turn upon the history, including the mechanism of any injury and the chronicity (acute or chronic) of pain. The knee examination is described in detail separately.

●Using information from the history, key symptoms, and findings from the basic knee examination, the clinician can usually select one of three common diagnostic categories that best fits the patient. The three major categories are:

•Acute knee pain, either from trauma or associated with overuse

•Chronic knee pain associated with overuse

•Knee pain without trauma or overuse, possibly associated with systemic symptoms

●A history of acute knee pain associated with trauma is usually clear-cut, although the precise mechanism may be difficult to establish. Such a history allows the clinician to focus on the knee-related structures most likely to have been injured. These include the collateral and anterior cruciate ligaments and the menisci. Testing the stability of these structures, identifying points of focal tenderness and the presence of an effusion, and performing special tests to confirm suspicions about the structures involved comprise the core of the initial evaluation of acute trauma-related knee pain.

●Chronic knee pain associated with overuse has typically persisted for approximately six weeks or longer and is not associated with any sudden inciting trauma. Chronic knee pain associated with overuse is progressive, becoming more painful with increasingly less intense activity over time. Typically, the knee examination reveals no structural instability. Many such patients suffer from patellofemoral pain or another condition related to the patella or surrounding soft tissues (eg, pes anserine, iliotibial band). In older patients, a degenerative meniscus or osteoarthritis must be considered.

●Patients with knee pain that developed or increased abruptly after excessive activity but who clearly have not sustained trauma of any kind often suffer from acute-on-chronic pain related to overuse (“overuse trauma”). The pain associated with overuse trauma often arises towards the end of an activity that exceeds what the athlete has trained to do or follows some change in training.

●Chronic or acute knee pain in an adult without inciting trauma or a history of overuse is a “red flag” that a more extensive evaluation is required, particularly if the pain is associated with constitutional symptoms, such as fever. The cause of such pain is much less likely to be musculoskeletal.



Readings: Rakel’s Textbook of Family Medicine pp 669 - 677

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