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Carlton J. Covey, MD, FAAFP; Matthew K. Nontraumatic knee pain: Hawks, MD Nellis Family Medicine 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 knee pain 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/running Medical Department or the a patient with patellofemoral program 9 months ago, when she was told she was overweight 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 soft tissue 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 therapy. C ogy of chronic knee pain. Perform joint aspiration with This review was developed to fill that gap. In the pages synovial fluid 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 physical therapy—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 © 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 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 therapies • 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 hypermobility, 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, surgery 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 tendinopathy (jumper’s knee) predisposing factors for PFI are trochlear dys- Patellar tendinopathy, an overuse injury of- plasia, patella alta, and lateralization of the ten

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