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					                                          Knee pain
                                                                            Mr. Harish Kurup
                                                                   Consultant in Orthopaedics
                                                                     Pilgrim Hospital, Boston

1.     General Information

Common knee problems seen in general practice are acute knee injury, degenerative meniscal
tears and osteoarthritis.

2.     Incidence/Prevalence:

Acute knee injury is more common in younger patients. Meniscal tears are more common in
middle age and osteoarthritis is a disease of older patients.

3.     Causes and Risk Factors

Acute knee injury is common in most sports and recreational activities like football, skiing etc.
Patients may present to emergency department acutely or after few days to general practitioner.
Young women are more prone to get anterior cruciate ligament injuries. Increasing number of
children (second decade) sustain these injuries due to increasing participation in injury prone
activities.

Degenerative meniscal tears are seen in patients in the age group 40- 60 years. Typically present
with mechanical symptoms related to activity like clicking and locking. The most common site
of tear is posterior horn of medial meniscus.

Osteoarthritis of knee is more common than hip arthritis but less disabling. It is commonly seen
over the age of 60 years. Primary osteoarthritis is more common in medial compartment and
patellofemoral compartment.


4.     History / symptoms

Pain: Rest pain is suggestive of arthritis. Pain with clicking sensation especially over medial
joint line is suggestive of meniscal tear. Pain worse when coming down the stairs is suggestive of
patello-femoral arthritis.

Locking: True locking is a mechanical block to knee extension. The knee is held is 20-30 degrees
of flexion and further extension is not possible. This is typically due to a displaced bucket handle
tear of medial meniscus.
Instability: Feeling of knee giving way could be suggestive of cruciate ligament injury but may
be seen in meniscal tears as well.

5.     Physical signs

Effusion: Both acute injuries and chronic arthritis can present with effusion. Acute swelling
following injury may be due to blood (hemarthrosis). Patellar tap is sensitive for moderate sized
effusions. To look for patellar tap, first empty the suprapatellar pouch (proximal to patella, under
quadriceps muscle) with one hand. Keeping the hand there, push the patella to femur with
cupped fingers of other hand.

Tenderness: Medial joint line tenderness in younger age group is suggestive of medial meniscal
tear and in older patients of medial compartment osteoarthritis. Lateral joint line tenderness
points to similar pathology on lateral side. With knee in extension, push patella towards femur.
Pain is suggestive of patello-femoral arthritis.

Lachmann’s test: For anterior cruciate ligament injury. A fully relaxed patient is a must. Patient
lying down supine on bed, flex knee to 20 degrees. Hold distal femur with one hand, hold
proximal tibia with other hand. Pull tibia forward and compare with the asymptomatic side. Too
much anterior translation is suggestive of anterior cruciate ligament rupture.

McMurray’s test: Not considered very specific for meniscal tears by most surgeons. Extending
knee from flexion, external rotation with valgus stress causes medial joint pain and clicking.

6.     Differential diagnosis

Arthritis, mono or polyarticular, may be inflammatory in origin. Both seropositive arthritis such
as rheumatoid arthritis or seronegative arthritis like Reiter’s syndrome can present with knee
swelling and pain.

Septic arthritis should be kept in mind whenever you see an acutely painful knee even with
underlying diagnosis of osteoarthritis. Monoarticular arthritis in the young can be gonococcal in
origin.

Prepatellar bursitis is more common in occupations involving kneeling. This is usually
streptococcal in origin. Intravenous antibiotics are sometimes required for these cases.

Children in the age group of 10-14 years may present osteochondritis of tibial tuberosity known
as Osgood Schlatter’s disease. This is a self limiting condition.

7.     Investigations:

Blood tests such as White cell count and CRP (C - reactive protein) are helpful in ruling out
infections.
Most knee problems require radiographs for further evaluation. Antero-posterior (standing view
to assess joint space narrowing) and lateral radiographs are usual views.

Cruciate and meniscal pathology may need MRI scan for confirmation. Refer to specialist for
further assessment.


8.     Treatment

Medications:

Analgesics: Start with Paracetamol.

Non-steroidal anti-inflammatories (NSAIDs) : The next choice is NSAIDS such as ibuprofen or
diclofenac. NSAIDs may not be suitable in patients who suffer from Asthma or peptic ulcer.
COX-2 inhibitors are also used routinely (caution: heart disease)

Opiods : such as Codeine.

Supplements: Recent research has shown that taking glucosamine sulphate (which is found in
healthy cartilage) or fish oils may have positive results.

Intra-articular injections : Steroids or hyaluronic acid injections into knee joint are usually
helpful. This may be performed by general practitioner or specialist.

Physiotherapy:

For exercises to maintain joint mobility and muscle strengthening.

Surgery:

When conservative measures fail, consider specialist referral for surgery. Meniscal and cruciate
ligament injuries need arthroscopic (keyhole) surgery. Arthritis may need joint replacement.

9.     Prevention

Patients with early arthritis should avoid types of exercise that put strain on joints such as
running and weight training. Instead, opt for exercises like swimming and cycling where joints
are better supported.

Loosing weight can delay progression of arthritis or make symptoms less severe.

				
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