Knee Pain & Tenderness

Adopted: 6/11/12

Knee Pain & Tenderness: Differential Diagnoses by Location

Location of pain and tenderness can often be very helpful in establishing an initial differential diagnosis. Location is based on both subjective pain (have the patient point to the pain during the history) and objective findings (e.g., point of maximum tenderness during static palpation). The specific anatomical location of pain/tenderness leading to identification of the tissues involved is very important in reaching a correct diagnosis. A discrete knowledge of anatomy is critical. This information can then be combined with other salient features from the history (e.g., mechanism of injury) and the physical (response to orthopedic testing).

Generalized or variable pain patterns

Some conditions produce generalized or variable pain. These conditions include arthritides, infections such as Lyme, joint effusions, hemarthrosis, fractures, tumors, radiculopathies & other referred pain from the back, sciatica, metastatic neoplasm, fibromyalgia (usually medial). ______

Intra-capsular Pain

Knee trauma  Meniscus**  Cruciate**  Fracture

Non-traumatic (overuse or insidious onset)  Meniscus**  Osteoarthritis**  Joint mouse  Plica  Cruciate  Inflammatory joint disease (e.g., RA)  Infection†

Note: The authors have attempted to offer guidance relative to which conditions may be more common and which rare. Prevalence statistics for many of these conditions are unknown, especially in a chiropractic setting— the annotations are the judgments of the authors.

** = A very common cause to consider, should be high on the differential. * = A common condition to consider. † = Statistically rare—but, because of its serious nature, may be important to keep in mind if only to rule out.

KNEE PAIN & TENDERNESS Page 1 of 4

Diagram by Location Anterior Knee Pain

Patellar pain Superior to patella

Trauma Non-traumatic Trauma Non-traumatic

 Contusion**  Patellofemoral  Quadriceps  Quadriceps  Dislocation* pain syndrome** contusion* tendinopathy*/ /subluxation  OA**  Tendon rupture suprapatellar effusions  Patellar  Chondromalacia*  Distal femoral  Osteoid osteoma† fracture  Prepatellar fracture  Ewing’s† bursitis  Fibrosarcoma &  Stress fracture osteosarcoma†  Dislocation/  Giant cell tumors† subluxation

Medial or lateral to patella Inferior to patella Trauma Non-traumatic Trauma Non-traumatic

 Infrapatellar  Jumpers knee**  Patellar  Symptomatic tendon tear  Osgood dislocation or synovial plica**  Tibial fractures Schlatter’s** subluxation*  Referral from hip/  Fat pad  Sinding-Larsen-  MCL sprain* SI joint or inflammation Johansson’s  Symptomatic proximal femur*  Tibial stress synovial plica  Peripatellar fractures neuritis  Fat pad

inflammation or entrapment  Infrapatellar bursitis  Osteoid osteoma†  Ewing’s and osteosarcoma’s† Medial Knee Pain

Superior to joint line Distal thigh

Trauma Non-traumatic Trauma Non-traumatic  MCL sprain*  Symptomatic plica**  Quadriceps  Semitendinosus  Patellar  Referred pain from strain,* tendinopathy** dislocation/ upper femur/hip /SI* contusions* & or strain retinacular tear*  MCL sprain myositis ossificans†  Quadriceps  Femoral fracture  Saphenous neuritis Hamstring tendon tendinopathy †   Symptomatic  Tumor tear chronic strains plica  Femoral fracture  Femoral stress fracture  Tumor Joint line Trauma Non -traumatic

Proximal leg  Meniscus  Meniscus tear** tear**  Joint surface  MCL sprains** pathology (e.g., OA)* Trauma Non-traumatic (pain crosses  Osteochondritis  Tennis leg*  Tennis leg* the joint line) dissecans  Contusions*  Tib stress fx  Joint surface  Coronary lig capsulitis injury* †  Tibia fx  Thrombophlebitis  MCL sprains † Coronary lig  Thrombophlebitis  Tumor  (pain crosses the joint sprain*  line)

Inferior to joint line

Trauma Non-traumatic

 Pes anserine  Pes anserine tendinopathy/ tendinopathy/ bursitis Bursitis*  Tibial fracture  Tibial stress fracture*  Tumor† 

KNEE PAIN & TENDERNESS Page 2 of 4

Lateral Knee Pain

Joint line Superior to joint line

Trauma Non-traumatic/ Trauma Non-traumatic/ chronic chronic

 Meniscus tear*  Contusion**  Coronary lig  Meniscus tear*  Biceps  ITB syndrome** sprain *  Coronary lig. muscle -  Biceps  LCL sprain capsulitis* tendon tear tendinopathy* (pain may cross  Discoid meniscus  Common  Tumo r† (child) joint line)* peroneal  Joint surface  Chronic lateral neuropathy injury instability (pain  Lateral condylar may cross joint † line) osteochondritis †  LCL sprain Inferior to joint line

Trauma Non-traumatic/ chronic  Peroneal neuropathy *  Proximal tib-fib  Fibular fracture joint dysfunction*,  Proximal tib-fib instability or sprain capsulitis  Biceps tendon  Peroneal strain/tear neuropathy*  Popliteus strain  Fibular stress fx  Gastrocnemius  Radiculitis (early) strain  Popliteus tendinopathy/MFTP  Biceps tendinopathy  Tumor†

Posterior Knee Pain

Posterolateral/Posteromedial Posterior Center

Trauma Non-traumatic Trauma Non-traumatic

 Hamstring strain  Gastrocnemius  Baker’s cyst  Baker’s cyst with  Gastrocnemius tendinopathy or with internal attendant internal strain/rupture myofascitis* derangement** derangement**  Hamstring  Tear posterior  Tear posterior tendinopathy horn of horn of  Osteochondritis meniscus** meniscus** dissecans  ACL tear*  Sciatica/ referred   PCL tear pain*  Posterior  DVT capsular sprain  Posterior capsulitis  Acute  Popliteus compartment tendinopathy or syndrome myofascitis  Chronic compartment syndrome †  Sarcoma †  Infections

KNEE PAIN & TENDERNESS Page 3 of 4

AUTHOR: Mike Carnes, MS, DC & Ron LeFebvre, DC Reviewed and Adopted by CSPE Committee  Daniel DeLapp, DC, DABCO, LAc, ND  Shawn Hatch, DC, DACBSP  James Strange, DC  Lorraine Ginter, DC  Owen T. Lynch, DC  Ryan Ondick, DC  Anita Roberts, DC  Michael Tarnasky, DC  Devin Williams, DC  Laurel Yancey, DC

KNEE PAIN & TENDERNESS Page 4 of 4