So, let's discuss knee pain today.
I'm sure that a lot of
you at some point in your life
have experienced knee pain.
Maybe thought about it.
Maybe you didn't.
But it's certainly something we see
very commonly in our practices.
In my practice, a lot of older adults in
my brick-and-mortar clinic,
and so therefore a lot of those
patients have osteoarthritis.
But the differential for knee pain can
be far broader than osteoarthritis.
We’ll talk about that differential as well as the assessment
of patients with knee pain from physical examination
and then we’ll go into discussing
treatment as well for knee pain.
So, in the history,
I think one thing that’s really critical
is just getting an idea of the type of pain,
its exact location within the knee
and how long it's been going on.
And then, very importantly, other
associated mechanical symptoms.
Does the knee lock or does it give away,
which would obviously be a sign of
some kind of meniscal damage.
So, other elements in the history,
it's very different,
but I don't see a lot of patients.
My 75-year-olds aren't out there playing tackle football
and getting a direct blow to their –
over their tibia.
But certainly if you see that,
if you're in sports medicine on the field
or in the emergency department,
a direct blow to the knee makes
you think about a fracture,
but probably even more commonly
would be a tear of the cruciate ligament,
anterior more than posterior.
Was the foot planted
and then a twisting motion was applied
and a pop maybe was heard?
Certainly, think about meniscal injury.
And then, getting a history of previous
injury is very important because,
as I said, this is really common.
A lot of folks who tear their meniscus
or their ACL, anterior cruciate ligament,
have done so in the past.
So, getting an idea of what's happened to them before
will give you a stronger inclination
as to what's happening now.
so steps that you're familiar with.
Inspection of the knee.
First, looking for any signs of effusion,
any abnormal –
there’s a displacement of the
patella grossly, like a dislocation.
That's pretty obvious to determine as well.
Testing range of motion,
both actively and passively.
You're going to to palpate for pain,
but you also –
You also check for warmth
of the knee and signs –
other signs of an effusion.
I usually like to milk down the fluid around the joint
and see if I can actually draw out any
small effusion the patient may have.
Patellofemoral syndrome is a really
common cause of chronic knee pain
and we’ll talk about it a bit in-depth.
But one thing you can notice is when the
quadriceps contract against your resistance,
you might notice some crepitus over the knee.
So you can put your hand right
over the patella and feel that.
You’re going to check for the stability of
the cruciate and the collateral ligaments.
And oftentimes, it helps to compare
one side to the other.
And then, there are a lot of
different tests for the meniscus.
There’s a grind test and there's a lot of
different things you can try to do.
They all have a pretty poor sensitivity.
So, that's not something that
you can really hang your hat on,
particularly when it’s negative that it
rules out in any way a meniscal tear.
And we’ll talk for a minute
about meniscal tears,
but the punchline is that
if you really are going after and
think the patient has meniscal tear,
you need to do an MRI
because only that test has the
sensitivity you need to diagnose it.