Knee Pain
Introduction
Knee pain can occur from direct injury to its bone, meniscus, and ligaments or can be referred from more proximal muscles and hip (Figure 12-1).
Differential Diagnosis
The differential diagnosis for knee pain includes tight hamstrings, tight quadriceps, iliotibial (IT) band syndrome, anserine bursitis, meniscal injury, anterior cruciate ligament (ACL) injury, and patellar tendon dysfunction. Conditions that are amenable to manual medicine include patellofemoral syndrome, patellar tendonitis, IT band dysfunction, and anserine bursitis with adductor dysfunction.
 Figure 12-1 • Locations of common injuries and dysfunctions of the knee. |
Acute Knee Pain
History of trauma or new activities
Differential diagnosis includes disruption of the ACL, posterior cruciate ligament (PCL), lateral or medial collateral ligaments or meniscal injuries
Diagnosis
Acute pain without trauma
Common causes: osteoarthritis, infectious (Lyme, gonorrhea), gout
General knee pain with swelling (loss of prepatellar medial and/or lateral concavities) (Figure 12-2)
If the knee swells within 2 hours after new activity, think ACL injury.
If the knee swells a few hours after a new activity, think meniscal or colateral ligament injury.
Generalized knee pain with little or no edema
Common causes: patella-femoral pain, patellar tendonitis, derangement from within the joint (from meniscal injury or cyst)
Lateral knee pain
Common causes: lateral collateral injury, IT band dysfunction, lateral meniscus injury
Pain over the lateral joint line: lateral collateral sprain or tear
Pain on palpation over the anterolateral joint space: may imply lateral meniscus injury
Pain over proximal tibia laterally: test for IT band dysfunction.
Figure 12-2 • Normal versus lost concavities. (Reprinted from Fisher RG, Boyce TH, Correa AG. Moffet’s Pediatric Infectious Diseases. Philadelphia: Wolters Kluwer; 2017 with permission.)
Medial knee pain
Common causes: medial collateral injury, osteoarthritis, medial meniscus injury, anserine bursitis.
Pain on palpation over the medial joint line: medial collateral sprain or tear or osteoarthritis
Pain on palpation anteriorly over proximal tibia: could be due to anserine bursitis or osteoarthritis
Pain on palpation over anteromedial joint line: medial meniscal injury
Treatment for suspected collateral ligament injury or partial tear, ACL/PCL injury, or meniscal injury, treat with RISE (Rest, Ice, Compression, Elevation) and refer to physical therapy for rehabilitation treatment.
X-rays are indicated if fracture is suspected. Magnetic resonance imaging is rarely initially necessary unless patient fails physical therapy.
Remember the Rules
1. Move to a position of less pain and apply trigger point care.
2. Stretch the SHORTENED muscle.
3. Treat the region (above and below pain).
4. Tape to support neutral position.
5. Support definitive treatment (physical therapy, orthopedics, neurosurgery).
GENERALIZED KNEE PAIN
Diagnosis
Patellofemoral Syndrome
Proximal/generalized patellar pain, often due to quadriceps dysfunction with tight IT band and weak vastus medialis oblique (VMO): patella track laterally and compresses into the lateral femoral condyle.
Perform patellar compression test
Position the patient supine and relaxed.
Push posteriorly on patella, and ask patient to contract the quadriceps.
If pain is elicited, patellofemoral syndrome is likely.
Patellar Tendonitis/Jumper Knee
Distal patellar pain due to distal patellar tendon inflammation, often related to tight hamstring and quadriceps, overuse, or faulty foot mechanics.
Patellar Tendonitis Test
Position the patient supine and relaxed.
Press down on the proximal aspect of the patella with your superior thumb.
Using the other hand, push under the inferior pole of the patella.
If pain occurs at the distal aspect, think patellar tendonitis.
Treatment for Patellofemoral Syndrome and Patellar Tendonitis
Treatment involves addressing tight quadriceps.
Hip Flexor Stretches
Supine
With the patient supine, place the involved leg off the end of the table.
Flex the patient’s other hip and knee.
Hold both knees stable, and ask the patient to raise the involved knee against your resistance while taking three belly breathes, then relax; move the involved leg further into an extension stretch.
Repeat these steps for three stretch-relax cycles.
Prone
With the patient prone and involved knee flexed, lift the involved leg off the table to the end point.
Ask the patient to gently bring the knee down toward the table, using 10% effort, against resistance for three belly breaths.
Have the patient relax and move the hip further into extension.
Repeat these steps for total of three cycles.
If this stretch is too painful, perform reciprocal inhibition.
Reciprocal Inhibition for Hip Flexor Tightness
With the patient supine and the involved leg hanging off the end of the table and the opposite knee and hip flexed, place one hand on the uninvolved knee and gently lift the involved thigh to the end point with the other hand.
Ask the patient to use 10% effort to try to bring the thigh down against resistance while taking three belly breaths.
Then ask the patient to relax while you move the involved leg further into hip extension to the end point (you can also add more hip flexion on the opposite side, if it makes the patient feel better.)
Repeat these steps for three stretch-relax cycles.
Kinesiology Taping for Patellar Tendonitis
Have the patient sitting with the knee flexed off the end of the table.
Measure the strip from the mid-thigh to the distal aspect of the patellar tendon, then double the length of the tape and cut.
Cut a second 6-inch strip.
Split the long piece of tape in the middle and stretch it 50% tension. Apply over the infrapatellar tendon.
Maintain 50% tension as you apply each side proximally up the medial and lateral thigh. Apply the last 2 inches on each side without tension. Rub the tape to activate the adhesive.
Split the middle of the second piece of tape and apply across the inferior patellar tendon, applying the last 2 inch without tension.
Rub to activate the adhesive.
ILIOTIBIAL BAND FRICTION SYNDROME CAUSING LATERAL KNEE PAIN
Figure 12-3 shows the anatomy of the IT band.
Diagnosis
Testing the IT Band can be done using the Noble Compression Test or the Ober Test.
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