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Home , Knee effusion, Plica syndrome

Carlton J. Covey, MD, FAAFP; Matthew K. Nontraumatic pain: Hawks, MD Nellis Family Residency Program, A diagnostic & treatment guide Nellis Air Force Base, Nev (Drs. Covey and Hawks); Uniformed Services University of the Health Little has been written about nontraumatic nonarthritic Sciences, Bethesda, Md in adults. This article seeks to fill that void with (Dr. Covey) practical tips and an at-a-glance resource. [email protected]

The authors reported no potential conflict of interest relevant to this article.

The opinions and assertions CASE u Jane T, age 42, comes to see you because of right knee contained herein are the Practice pain that she’s had for about 6 months. She denies any trau- private views of the authors and are not to be construed recommendations ma. Ms. T describes the pain as vague and poorly localized, as official or as reflecting the views of the US Air Force › Consider radiography for but worse with activity. She says she started a walking/ Medical Department or the a patient with patellofemoral program 9 months ago, when she was told she was US Air Force at large. pain syndrome if (body mass index, 29). She has lost 10 pounds since then, Ms. T examination reveals an says, and hopes to lose more by continuing to exercise. Upon effusion, the patient is age further review, you find that Ms. T has had increasing pain 50 years or older, or the while ascending and descending stairs and that the pain is also condition does not improve exacerbated when she stands after prolonged sitting. after 8 to 12 weeks of If Ms. T were your patient, what would you include in a phys- treatment. C ical examination and how would you diagnose and treat her? › Order plain radiography for all patients with patello­ nee pain is a common presentation in primary care. femoral instability to assess While traumatic knee pain is frequently addressed for osseous trauma/deformity; in the medical literature, little has been written consider magnetic resonance K about chronic nontraumatic nonarthritic knee pain like that imaging if you suspect significant of Ms. T. Thus, while physical exam tests often lead to the damage or the patient does correct diagnosis for traumatic knee pain, there is limited not respond to information on the use of such tests to determine the etiol- conservative . C ogy of chronic knee pain. Perform joint aspiration with This review was developed to fill that gap. In the pages analysis for that follow, we provide general guidance on the diagnosis patients with painful knee and treatment of chronic nontraumatic knee pain. The con- effusion, and provide an ditions are presented anatomically—anterior, lateral, medial, orthopedic referral without or posterior—with common etiologies, history and physi- delay when an infectious cal exam findings, and diagnosis and treatment options for joint is suspected. A each (TABLE).1-31

Strength of recommendation (SOR)

A  Good-quality patient-oriented evidence Anterior knee pain B Inconsistent or limited-quality Patellofemoral pain syndrome patient-oriented evidence C Consensus, usual practice, Patellofemoral pain syndrome (PFPS), the most com- opinion, disease-oriented mon cause of anterior knee pain, is a complex entity with an evidence, case series etiology that has not been well described.2 The quadriceps

720 The Journal of Family Practice | DECEMBER 2014 | Vol 63, No 12 Patellofemoral pain syndrome is the most common cause of anterior knee pain. Taping or bracing—along with —may help reduce the pain.

tendon, medial and lateral retinacula, ilio- of popping or crepitus in the joint. Swelling is tibial band (ITB), vastus medialis and late- not a common finding.2 ralis, and the insertion of the patellar tendon A recent meta-analysis revealed limited on the anterior tibial tubercle all play a role evidence for the use of any specific physical in proper tracking of the patellofemoral joint; exam tests to diagnose PFPS. But pain dur- an imbalance in any of these forces leads to ing squatting and pain with a patellar tilt abnormal patellar tracking over the femoral test were most consistent with a diagnosis of condyles, and pain ensues. PFPS can also be PFPS. (The patellar tilt test involves lifting the secondary to joint overload, in which exces- lateral edge of the patella superiorly while the sive physical activity (eg, running, lunges, or patient lies supine with knee extended; pain squats) overloads the patellofemoral joint with <20° of lift suggests a tight lateral reti- and causes pain. naculum). Conversely, the absence of pain z Risk factors for PFPS include strength during squatting or the absence of lateral imbalances in the quadriceps, hamstring, and retinacular pain helps rule it out.2 A physical hip muscle groups, and increased training, exam of the cruciate and collateral ligaments such as running longer distances.4,32 A recent should be performed in a patient with a his- review showed no relationship between an tory of instability. Radiography is not needed increased quadriceps (Q)-angle and PFPS, so for a diagnosis, but may be considered if ex- that is no longer considered a major risk factor.5 amination reveals an effusion, the patient is z Diagnosis. PFPS is a diagnosis of ex- age 50 years or older, or no improvement oc- clusion, and is primarily based on history curs after 8 to 12 weeks of treatment.33 and physical exam. Anterior knee pain that z Treatment. The most effective and I mage © © mage is exacerbated when seated for long periods strongly supported treatment for PFPS is of time (the “theater sign”) or by descending a 6-week physiotherapy program focusing j oe gorman oe stairs is a classic indication of PFPS.1 Patients on strengthening the quadriceps and hip may complain of knee stiffness or “giving out” muscles and stretching the quadriceps, ITB, secondary to sharp knee pain and a sensation hamstrings, and hip flexors.4,5 There is limited

jfponline.com Vol 63, No 12 | DECEMBER 2014 | The Journal of Family Practice 721 information about the use of nonsteroidal anti- z Diagnosis. Patients with PFI often pres- inflammatory drugs (NSAIDs), but they can be ent with nonspecific anterior knee pain sec- considered for short-term management.2 ondary to recurrent dislocation.13 Notable z Patellar taping and bracing have physical exam findings are: shown some promise as adjunct • a positive J sign (noted if the patella for PFPS, although the data for both are non- suddenly shifts medially during early conclusive. There is a paucity of prospective knee flexion or laterally during full randomized trials of patellar bracing and a extension) 2012 Cochrane review found limited evi- • decreased quadriceps (specifically dence of its efficacy.34 But a 2014 meta-anal- VMO) and hamstring strength and ysis revealed moderate evidence in support flexibility of patellar taping early on to help decrease • patellar , which should pain,6 and a recent review suggests that it can be no more than a quarter to a half of be helpful in both the short and long term.7 the patellar diameter bilaterally Taping or bracing may be useful when • pain during a patellar tilt test combined with a tailored physical therapy • a positive patellar apprehension test.10 program. Evidence for treatments such as (With the patient lying with the knee biofeedback, chiropractic manipulation, and flexed to 20°, place thumbs on the orthotics is limited, and they should be used medial patella and push laterally; the Older patients only as adjunctive therapy.4 patient will straighten leg with pain (mostly women) or “apprehension” prior to patellar have an CASE u When you examine Ms. T, you find dislocation.) increased risk for no swelling of the affected knee. You perform patellofemoral the tilt test, which elicits pain. Squatting causes Plain radiography should be ordered instability. some pain, as well. You diagnose PFPS and pro- in all cases to assess for osseous trauma/ vide a referral for 6 weeks of physiotherapy. deformity and to help guide surgical consid- eration. Magnetic resonance imaging (MRI) Patellar subluxation can provide additional information when or chronic dislocation significant soft tissue damage is suspected Patellofemoral instability (PFI) occurs when or the patient does not improve with conser- the patella disengages completely from the vative therapy.8,11 trochlear groove.11 PFI’s etiology also relates z Treatment. A recent Cochrane review to the complexity of the patellofemoral joint. showed that conservative treatment (VMO Here, too, stability of the joint is achieved strengthening, bracing, and propriocep- with a combination of soft tissue and bony re- tive therapy) prevented future dislocations straints. At full extension and early flexion of more effectively than surgical intervention.11 the knee, however, the mechanisms of stabil- However, is indicated when obvious ity are limited, resulting in increased instabil- predisposing anatomic conditions (osteo- ity. Other associated factors include Q-angle, chondral fracture, intra-articular deformity, lateral pull from a tight ITB, and opposing or a major tear of a medial soft tissue stabi- forces from the vastus lateralis and vastus lizer) are clearly shown on imaging.8,11 medialis obliquus (VMO).8-10 z Risk factors for PFI. The most common Patellar (jumper’s knee) predisposing factors for PFI are trochlear dys- Patellar tendinopathy, an overuse injury of- plasia, patella alta, and lateralization of the ten called “jumper’s knee” because it is asso- tibial tuberosity or patella.10,11 Older patients, ciated with high-intensity jumping sports like predominately women, have an increased risk volleyball and basketball, is an insertional for PFI.9 Patients usually have a history of pa- tendinopathy with pain most commonly at tellar subluxation or dislocation in their youth, the proximal patellar tendon.10 The with approximately 17% of those who had a of the injury is poorly understood, but is be- first dislocation experiencing a recurrence.9 A lieved to be the result of an impaired healing family history of PFI is common, as well.10 response to microtears.12,14 continued

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TABLE Nontraumatic knee pain: What to look for, how best to treat

Diagnosis History Physical exam Treatment PFPS* • Anterior pain • No effusion2 • Quad and hip strengthening • + Theater sign1 • + Patellar tilt3 • Hip flexor, hamstring, iliotibial band, and quad stretching4,5 • Descending stairs • Pain with squatting3 exacerbates • Taping/bracing may help6,7 Chronic dislocation • Anterior pain8 • + J sign • VMO strengthening11 • Snapping/feeling of • Hypermobile patella • Bracing dislocation8 • + Patellar tilt • Surgery may be needed8 • History of dislocation9 • + Patellar apprehension10 Patellar tendinopathy† • Anterior pain that worsens • Focal suprapatellar pain • Eccentric training13-15 with activity, especially (assess for tendon integrity)12 • Physical therapy jumping12 • PRP injections may be considered16 ITBS • Lateral pain that • + Noble’s test18 • Refrain from activity that causes worsens with repetitive pain/activity modification • Ober’s test18 knee flexion17 + • NSAIDs • Physical therapy • Corticosteroid injections17-19 Plica syndrome • Medial pain • + Mediopatellar plica test21 • Physical therapy20 • Catching/locking20 • Palpation of plica • Quad strengthening • NSAIDs • Corticosteroids20,22 Anserine • Medial pain • Pain with palpation at • Rest insertion of anserine complex23 • , particularly in • Cryotherapy females23 • Edema not always present • NSAIDs • DM23 • Corticosteroids • Weight loss, DM treatment, as indicated24-26 Popliteal • Posterior pain/fullness • Palpable mass in popliteal • Treat underlying condition fossa • History of other knee • Knee flexion pathology • + Foucher’s sign27,28 • Ice • NSAIDs • Aspiration/corticosteroids27

Knee effusion • Chronic knee swelling, • Red, hot, swollen knee • Joint aspiration is a must if joint possibly intermittent, worse indicates possible infection is a consideration with activity • Orthopedic referral if infection is found29,30

DM, diabetes mellitus; ITBS, ; NSAIDs, nonsteroidal anti-inflammatory drugs; PFPS, patellofemoral pain syndrome; PRP, platelet-rich plasma; VMO, vastus medialis obliquus. *Diagnosis of exclusion. †The Victorian Institute of Sport Assessment (VISA) questionnaire can be used to follow the progress and severity of patellar tendinosis.31 continued

jfponline.com Vol 63, No 12 | DECEMBER 2014 | The Journal of Family Practice 723 FIGURE 1 Suspect iliotibial band syndrome? Perform Noble’s test A B p , faaf d ey, m ey, v . co j on t : carl OF

Y S E T COUR

Os T HO P

Palpate over the lateral femoral condyle and flex/extend the knee. If the action elicits pain, the test is positive for Three weeks iliotibial band syndrome. of platelet-rich plasma injections helped z Diagnosis. Patients with patellar tendi- tions performed twice a day for 12 weeks—and 75% of patients nopathy typically present with anterior supra- physical therapy to platelet-rich plasma (PRP) with patellar patellar pain aggravated by activity. Classically, injections, sclerosing injections, and surgery, tendinopathy the pain can occur in any of 4 phases:12 are available for the treatment of patellar tendi- return to their 1. pain isolated after activity nopathy.13-15 While no specific data have proven pre-symptom 2. pain that occurs during activity but the superiority of any one therapy, expert con- activity level does not impede activity sensus recommends eccentric exercise as ini- within 90 days. 3. pain that occurs both during and af- tial therapy, performed for 12 weeks.14,15 ter the activity and interferes with It’s also interesting to note that a recently competition published study showed that 3 weekly PRP 4. a complete tendon disruption. injections helped 75% of patients—all of whom failed to respond to 4 months of eccen- Examination should include an assess- tric therapy—return to their pre-symptom ment of the patellar tendon for localized activity level within 90 days.16 Corticosteroid thickening, nodularity, crepitus, and focal su- injections should not be used to treat patel- prapatellar tenderness. The muscle-tendon lar tendinopathy due to the risk of tendon function should be evaluated by assessing rupture.15 Orthopedic referral for surgical in- knee mobility and strength of the quads via tervention should be considered for patients straight leg raise, decline squat, or single leg who fail to respond after 3 to 6 months of con- squats.12 The Victorian Institute of Sport - As servative therapy.14 sessment (VISA) questionnaire can be used to quantify the symptoms and to help track the patient’s progress throughout therapy.31 Lateral knee pain There are no proven special tests or radio- Iliotibial band tendinopathy logic studies to aid in the diagnosis of patellar Iliotibial band syndrome (ITBS) is a com- tendinopathy,14 but magnetic resonance im- mon source of lateral knee pain, particu- aging (MRI) can be used for further evalua- larly in runners, cyclists, and endurance tion when findings are equivocal.35 athletes.17-19,36,37 The exact pathophysiology z Treatment. A wide range of options, behind this diagnosis is debatable, but the from eccentric training—eg, 3 sets of 15 repeti- most accepted etiology is inflammation gen-

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FIGURE 2 Ober’s test is also useful for ITBS

A B

Patients with ITBS often Abduct and extend the affected hip with one hand and stabilize the pelvis with the other, then allow the knee to passively fall. The leg should drop to parallel as shown in B; failure to do so suggests a tight iliotibial band that can complain lead to iliotibial band syndrome. of persistent nontraumatic knee pain that erated from micro trauma to the soft tissues strain over the ITB, myofascial release via worsens with with inadequate healing time, resulting in foam rollers, and physical therapy focused on repetitive knee persistent inflammation. ITBS is often associ- stretching the iliotibial band, tensor fasciae flexion. ated with excessive overall running mileage, latae, and gluteus medius while strengthen- a sudden increase in mileage, or an abrupt ing the gluteus medius and core muscles.17 change in training.18,37 No single program has been shown to be bet- z Diagnosis. Patients often complain of ter than another. persistent nontraumatic lateral knee pain Corticosteroid injections are second- that worsens with repetitive knee flexion (eg, line therapy and have been shown to improve running or cycling).17-19,37 A physical exam pain compared with placebo up to 2 weeks will often reveal pain over the lateral femoral post injection.17,19 When symptoms persist condyle and a positive Noble’s test (FIGURE 1). for more than 6 months despite conservative A positive Ober’s test (FIGURE 2) is suggestive treatment, surgical intervention may be indi- of ITBS, as well. The sensitivity and specific- cated.18,19 Patients who experience temporary ity of these tests are not well established, but pain relief with corticosteroid injections of- in patients performing repetitive knee flexion ten respond best to surgery.36 activities with subjective lateral knee pain, pain over the lateral femoral condyle and a positive Ober’s and/or Noble’s test suggest Medial knee pain an ITBS diagnosis.18 Imaging is not indicated Medial plica syndrome initially, but MRI should be used in refractory Because of its anatomic location, the medial cases to rule out other etiologies.17,19 plica—which can be palpated in up to 84% of z Treatment. First-line therapy for ITBS the population20—is susceptible to impinge- is conservative,17-19,36,37 often involving a ment by the medial femoral condyle or the combination of techniques such as refrain- patellofemoral joint. Trauma with repetitive ing from the activity that triggers the pain, knee movement leads to inflammation and NSAIDs, activity modification to reduce the thickening of the plica, resulting in medial

jfponline.com Vol 63, No 12 | DECEMBER 2014 | The Journal of Family Practice 725 plica syndrome.20,38 Initial inflammation may with or without edema. Radiologic studies are be triggered by blunt trauma, a sudden in- not needed, but may be helpful if significant crease in activity, or transient .22 bony pathology is suspected. Ultrasound, z Diagnosis. Medial plica syndrome is computed tomography (CT), and MRI are not a challenging diagnosis. Patients generally recommended.23 have nonspecific complaints of aching me- z Treatment. Resting the affected knee, dial knee pain, locking, and catching similar cryotherapy, NSAIDs, and using a pillow at to complaints of a medial meniscal injury.20 night to relieve direct bursal pressure are rec- Evaluation should include the medio- ommended.33 Weight loss in obese patients, patellar plica test, which is performed with treatment of pes planus, and control of diabetes the patient lying supine with the knee fully may be helpful, as well. Although the literature extended. Pressure is placed over the in- is limited and dated, corticosteroid injection feromedial patellofemoral joint, creating an has been found to reduce the pain and may be impingement of the medial plica between considered as second-line treatment.24-26 the finger and the medial femoral condyle. Elimination or marked diminishing of pain with knee flexion to 90° is considered a posi- Posterior knee pain tive test.21 Popliteal (Baker’s) cyst A recent systematic review found this test The popliteal fossa contains 6 of the numer- A mediopatellar to be more diagnostically accurate than an ous bursa of the knee; the bursa beneath the plica test was MRI (sensitivity of the test is 90% and speci- medial head of the gastrocnemius muscle more accurate ficity is 89%, vs 77% and 58%, respectively, for and the semimembranosus tendon is most than an MRI MRI) for detection of medial plica syndrome. commonly involved in the formation of a in diagnosing Ultrasound is almost as accurate, with a sensi- popliteal cyst.40 It is postulated that increased medial plica tivity of 90% and specificity of 83%.39 intra-articular pressure forces fluid into the syndrome, z Treatment of medial plica syndrome bursa, leading to expansion and pain. This according centers on physiotherapy and quadriceps can be idiopathic or secondary to internal to a recent strengthening,20 augmented with NSAIDs. derangement or trauma to the knee.41 Older systematic Intra-articular corticosteroid injections are age, a remote history of knee trauma, or a co- review. considered second-line treatment.20,22 An or- existing joint disease such as , thopedics referral is indicated to consider ar- meniscal pathology, or rheumatoid throscopic plica removal for refractory cases.20,22 are significant risk factors for the develop- ment of popliteal .27 z Diagnosis. Most popliteal cysts are The anserine bursal complex, located ap- asymptomatic in adults and discovered in- proximately 5 cm distal to the medial joint cidentally after routine imaging to evaluate line, is formed by the combined insertion of other knee pathology. However, symptomat- the sartorius, gracilis, and semitendinosus ic popliteal cysts present as a palpable mass tendons,39 but the exact mechanism of pain in the popliteal fossa, resulting in pain and is not well understood. Whether the patho- limited range of motion. physiology is from an insertional tendonitis During the physical exam with the pa- or overt bursitis is unknown, and no studies tient lying supine, a medial popliteal mass have focused on prevalence or risk factors. that is most prominent with the knee fully ex- What is known is that overweight individuals tended is common. A positive Foucher’s sign and women with a wide pelvis seem to have a (the painful mass is palpated posteriorly in greater predilection and those with pes pla- the popliteal fossa with the knee fully extend- nus, diabetes, or knee osteoarthritis are at in- ed; pain is relieved and/or the mass reduced creased risk.23 in size with knee flexion to 45°) suggests a di- z Diagnosis. Medial knee pain repro- agnosis of popliteal cyst.27,28 duced on palpation of the anatomical site of Radiologic studies are generally not insertion of the pes anserine tendon complex needed to diagnose a popliteal cyst. However, supports a diagnosis of pes anserine bursitis, if diagnostic uncertainty remains after the

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history and physical exam, plain knee radio- patients without a history of trauma who can- graphs and ultrasound should be obtained. not bear weight. Systemic complaints point to This combination provides complementary an infection and, with the exception of a pos- information and helps rule out a fracture, sible low-grade fever, are not typically seen in arthritis, and thrombosis as the cause of the crystalline disease. Notable findings include pain.27 MRI is helpful if the diagnosis is still an erythematous, hot, swollen knee and pain in doubt and for patients suspected of having with both active and passive movement. significant internal derangement leading to Plain radiographs of the knee should cyst formation. Arthrography or CT is gener- be ordered to rule out significant trauma ally not needed.27,41 or arthritis as the etiology. It is important to z Treatment. As popliteal cysts are often perform joint aspiration with synovial fluid associated with other knee pathology, man- analysis. Fluid analysis should include a agement of the underlying condition often white blood cell (WBC) count with differen- leads to cyst regression. Keeping the knee in tial, Gram stain and cultures, and polarized flexion can decrease the available space and light microscopy (not readily available in an assist in pain control in the acute phase.27 outpatient setting).29 Cold packs and NSAIDs can also be used ini- Synovial fluid analysis characteristics tially. Cyst aspiration and intra-articular ste- suggestive of a septic joint include turbid roid injection have been shown to be effective quality, WBC >50,000 per mm3, an elevated for cysts that do not respond to this conser- protein content, and a low glucose concen- A prompt vative approach.27 However, addressing and tration.30 Gram stain and culture will help orthopedic managing the underlying knee pathology (eg, identify the infectious agent. Orthopedic re- referral is osteoarthritis, meniscal pathology, or rheu- ferral should not be delayed in patients with essential when matoid arthritis) will prevent popliteal cysts a suspected infectious joint. Corticosteroids you suspect an from recurring. should not be injected during aspiration if in- infectious joint. fection is being ruled out.

When the problem CASE u When Ms. T returns for a follow-up is painful knee effusion visit 8 weeks later, she states that the knee Nontraumatic knee effusion can be the prima- pain has resolved and that she has returned to ry source of knee pain or the result of under- running. She has lost an additional 8 pounds lying pathology. We mention it here because and continues to diet. And, at the advice of clinical suspicion is paramount in diagnosing her physical therapist, she is continuing her a septic joint, a serious cause of painful knee physiotherapy regimen at home to prevent a effusion that warrants prompt treatment. recurrence of PFPS. JFP As in other causes of knee pain, a detailed history of the character of the pain is essen- Correspondence Carlton J. Covey, MD, FAAFP, Nellis tial. Septic arthritis and crystalline disease Residency Program, 4700 Las Vegas Boulevard North, Nellis (, pseudogout) should be suspected in Air Force Base, NV 89191; [email protected]

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