Non-traumatic knee pain, Part I

Working in a physical medicine setting, a patient complaint I see on daily basis is knee pain. The knee pain complaints in this setting and that commonly present in the primary care setting are typically non-traumatic, non-emergent in nature. Before working in physical medicine, I didn’t truly appreciate how complex the knee is. There are quite a few different causes for non-traumatic knee pain, in this blog post I am going to cover iliotibial band syndrome and patellofemoral pain syndrome. 

When it comes to diagnosing non-traumatic knee pain, the history and physical examination including numerous knee orthopedic tests are paramount. Malanga and Mautner (2017) discuss that the correct diagnosis regarding knee pain was made in 83% of patients using history and physical examination alone. While MRI and x-ray are helpful in making a diagnosis, imaging should not be overused, as it can sometimes result in improper diagnosis of the mechanism of knee pain, overtreatment of knee pain and unnecessary costs. 

Iliotibial Band Syndrome

Jared, a 24-yr. old male, 5’8” at 155 lbs., comes in to see you with a complaint of daily left knee pain. Jared reports his left knee has been bothering him off and on for the last 5 months. Over the last month his knee has been getting more bothersome and the aching, burning pain (5/10) seems to go up from the outside of his knee to the outside of his thigh. He denies any injuries to his knee. The pain is worse when cycling greater than ten miles or walking long distances. The pain is relieved with rest, Advil and stretching.  The pain is interfering with his training for his first competitive bicycle race.

Physical examination shows skin- WNL, no swelling, bilateral knee ROM- WNL, muscle strength- WNL. Palpatory examination reveals moderate tenderness to lateral left femoral condyle and left IT band, trigger points noted in the IT band. Anterior and posterior drawer tests, Lachman test, valgus and varus stress tests and McMurray test are all negative.  Jared has moderate restriction in flexion at the lumbosacral area and is unable to touch his toes, bilateral hamstrings are tight and tender to palpation. This appears to be classic IT band syndrome. 

The treatment plan for Jared includes, avoid cycling for at least 6 weeks, physical therapy to work on the IT band, hamstrings and increasing flexibility. You recommend that he gets a foam roller to use at home to roll out the IT band/hamstrings and that he takes his bicycle to a shop to verify proper saddle height. Jared comes in for a follow up 8 weeks later, he reports his daily knee pain has resolved, he was able to ride thirty miles on his bike over the weekend without pain and his flexibility has increased. Success!!

Patellofemoral Pain Syndrome

Anna, a 30-yr. old female, 5’ 6” at 140 lbs., comes in to see you with a complaint of right knee pain. Anna denies any knee injuries and reports the pain has been going on for the past couple of months. Anna is a software designer and after sitting at her computer for hours, her knee becomes stiff and achy (+ Theater sign). She feels like the pain is in her knee cap and sometimes when she is going down stairs she feels her right knee popping and acts like it is going to give way. Anna reports that over the last couple of weeks she hasn’t been able to run because of the pain. This is aggravating for Anna because running is one of her passions and how she deals with life’s daily stressors. She reports she hasn’t really tried anything for her knee pain other than trying to stand more at work and not running. 

Physical examination shows skin- WNL, no swelling, bilateral knee ROM- WNL. Right knee palpatory examination reveals mild tenderness to the anterior knee cap and distal aspect of the quadriceps tendon superior to the patella. Bilateral hamstrings and IT bands are tight to palpation. Mild crepitus is felt with right knee flexion and extension.  Muscle strength- hip flexion 4/5 bilaterally, knee extension 4/5 right knee, 5/5 left knee. Squatting does elicit anterior knee pain bilaterally. Clarke sign positive and pain is felt with passive lateral patellar tilt. Anterior and posterior drawer tests, Lachman test, valgus and varus stress tests are all negative. This appears to be patellofemoral pain syndrome. 

The treatment plan for Anna includes, avoid running for at least 6 weeks, physical therapy to strengthen quadriceps and hip complex and stretch hamstrings, IT bands, hip flexors and quadriceps.  Anna comes in for a follow up 8 weeks later, she reports her knee pain has resolved, her legs feel stronger and she no longer feels her right knee wanting to give out on her when she goes down stairs. You encourage Anna to continue the exercises and stretches she learned in physical therapy so her knee pain does not reoccur. Well done!!

Treatment Take-Home Message

If you notice, a common pattern with both of these diagnoses is they are both overuse injuries. A vital part of successfully treating overuse knee injuries is identifying the culprit and eliminating and/or modifying the aggravating factor that is causing the injury. When it comes to overuse knee injuries, I usually recommend a low-impact physical activity (swimming, yoga) the patient can do while they are recovering from their knee injury in addition to their physical therapy. We need to keep our patients moving!

In a following blog post I will discuss other common non-traumatic knee injuries. Stay tuned!!

References

Malanga, G. A., & Mautner, K. (2017). Musculoskeletal physical examination an evidenced-based approach (2nd ed.). Philadelphia, PA: Elsevier

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