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 Meniscus Meniscus tear** Proximal leg 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** Coronary lig. sprain * muscle - Biceps LCL sprain capsulitis* tendon tear tendinopathy* (pain may cross Discoid meniscus Common Tumo r† joint line)* (child) peroneal Joint surface Chronic lateral neuropathy instability (pain injury 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 Copyright © 2012 University of Western States 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 .