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Differential Diagnosisof Knee PainNovember 11, 2016
Raymond H. Kim, M.D.
Colorado Joint ReplacementPorter Adventist Hospital
Denver, Colorado
Adjunct Associate Professor of Bioengineering, Department of Mechanical and Materials
Engineering, University of Denver
Clinical Associate ProfessorDepartment of Orthopaedic SurgeryJoan C. Edwards School of Medicine
at Marshall University
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Disclosures
• Consulting: DJO Surgical• Product Development: DJO Surgical• Speaker bureau: Convatec• Speaker bureau: Ceramtec• Research support: Porter Adventist
Hospital• Royalties: Innomed
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• Evaluation of knee pain
• Differential diagnosis
• Specific knee conditions
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Evaluation of Knee Pain
• Meticulous gathering of patient history• Thorough physical exam• Imaging studies• Possible laboratory studies• Possible arthrocentesis
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Most DiagnosesCan Be Made With:
• History
• Physical exam
• Plain radiographs
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History
• Age, gender• Duration of pain• Location• Quality• Alleviating factors• Exacerbating factors• History of trauma• Locking, catching,
swelling• Weight-bearing pain• Night pain
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History
• PMH– Previous surgery?
• Meds– Steroids? NSAIDs?
• Social hx– EtOH? Smoking?
• Family hx– Rheumatologic conditions?
• ROS
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Physical Exam
• Spine
• Hip
• Knee
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Spine Exam isPart of the Knee Exam!
• Physical examination of the lumbar spine
• Unexplained “knee”pain
• Referred pain from lumbar radiculopathy
• Spinal stenosis
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Hip Exam isPart of the Knee Exam!
• Physical examination of the hip
• Referred pain from the hip
• Hip arthritis• Failed THA
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Physical Examinationof the Knee
• Observation– Gait pattern (antalgia)– Spine, pelvic deformity– Muscle atrophy– Skin and prior incisions– Alignment
• Varus• Valgus
– Effusion
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Physical Exam
• Palpation– Crepitus– Tenderness
• Medial joint line• Lateral joint line• Peripatellar• Pes bursa
– Pulses
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Physical Exam
• Motion – Active motion – Passive ROM– Contractures– Fixed vs correctable
deformities
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Physical Exam
• Stability– Lachman– Anterior drawer– Posterior drawer– Pivot shift– Varus / valgus
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Physical Exam
• Strength– Quadriceps
• Extension lag?– Hamstrings
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Physical Exam
• Neurologic exam
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Differential Diagnosis
• Extra-articular
• Peri-articular
• Intra-articular
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Differential Diagnosis
• Extra-articular– Lumbar spine pathology
• Degenerative disc disease• Nerve root impingement• Spinal stenosis
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Differential Diagnosis
• Extra-articular– Hip pathology
• Arthritis• AVN• Fracture• Failed THA
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Differential Diagnosis
• Extra-articular– Vascular disease
• Insufficiency• Aneurysm • Thrombosis
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Differential Diagnosis
• Extra-articular– Psychological illness
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Differential Diagnosis
• Peri-articular– Tendonitis
• Patellar• Quadriceps• Hamstring• Iliotibial band
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Differential Diagnosis
• Peri-articular– Bursitis
• Prepatellar• Pes
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Differential Diagnosis
• Peri-articular– Cutaneous neuroma
• Saphenous neuralgia
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Differential Diagnosis
• Peri-articular– Reflex sympathetic
dystrophy
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Differential Diagnosis
• Intra-articular– OA– Meniscal pathology– Ligament compromise– Osteochondritis dissecans– AVN– SPONK– Inflammatory arthropathy
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Imaging Studies
• X-rays• MRI• CT scan• Bone scan
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Radiographs
• AP– Weight-bearing– Fracture, joint space
narrowing, OCD, loose bodies, alignment
• Lateral– Lateral decubitus with
knee flexed 30 to 45 deg, tension on tendon
– Patellar alta, baja– Patella fx
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Radiographs
• Merchant– Patellar tilt, subluxation,
dislocation– Osteochondral fx– PF osteophytes
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Additional Radiographs
• PA flexion (Rosenberg)– Flexion WB radiograph– Assessment of early
joint space narrowing– OCD
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Additional Radiographs
• Hip-to-ankle– Limb alignment– Hip pathology– Pre-op templating
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MRI
• Consider MRI when plain radiographs appear normal but need to further evaluate source of knee pain
• Reasonable for aiding in diagnosis of SPONK, AVN, meniscal tear, ligament tear
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CT Scan
• Fracture diagnosis– Occult fracture– Fracture pattern
• Patella-femoral mal-alignment
• Assess bone loss, defects
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Bone Scan
• Technetium 99m • Historically useful for
diagnosis of SPONK• Focally intense
uptake of affected condyle or tibialplateau
• Less commonly utilized with the advent of MRI
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Specific Knee Conditions
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Meniscus Tear
• Traumatic– Twisting injury– Can be associated with
ligament injury, hemarthrosis
• Degenerative– Usually complex tears– Locking, catching,
giving way, effusions– Exacerbated by
hyperflexion
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Osteochondritis Dissecans
• More common in males
• Age 15 to 20• MFC lateral aspect • Gradual onset of
symptoms• 50% trauma hx• Pain and locking if
detached fragment
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SPONK
• 3x more common in females
• Older than 60 yo• Sudden onset of pain• Worse at night• Acute phase 6 to 8
wks
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SPONK
• Focal area of severe tenderness on medial femoral condyle
• May appear locked due to pain, effusion, muscle spasm
• Usually medial fem condyle but can also be lateral fem condyle, tib plateau
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SPONK
• Stage 1 – normal x-rays, positive bone scan, bone edema on MRI T2
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SPONK
• Stage 2 – flattening of weight-bearing portion
• Stage 3 – radiolucent area, sclerotic halo
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SPONK
• Stage 4 –subchondral collapse
• Stage 5 – bony collapse with secondary degeneration
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SPONK
• Non-op rx– Crutches, NSAIDS, PT– Good results with
symptomatic rx• Operative
– Scope debridement– Osteochondral allograft– HTO– Core decompression– Arthroplasty
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Secondary Osteonecrosis
• Younger than 45 yo• Gradual onset of pain• > 80% bilateral• Multiple lesions• Often have
concomitant hip involvement
• Steroids, EtOH, SLE, sickle cell anemia, Gaucher’s, caisson
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Secondary Osteonecrosis
• Non-op rx– Crutches, NSAIDS, PT– POOR results with
conservative rx• Operative
– Scope debridement– Osteochondral allograft– HTO– Core decompression– Arthroplasty
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Inflammatory Arthritis
• Systemic conditions– Rheumatoid arthritis– Psoriatic arthritis– Reactive arthritis– Colitis-associated
arthritis– Undifferentiated
spondyloarthropathy– Lupus– Sarcoidosis– Behcet’s disease
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Inflammatory Arthritis
• Crystal-associated– Gout– Calcium pyrophosphate
disease– Calcium oxalate
disease
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Arthrocentesis
• Inflammatory
• WBC 2000 - 75,000 • PMN > 50%• Crystals - present?• Culture - negative
• Septic
• WBC > 100,000• PMN > 75%• Crystals - none• Culture - positive
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Inflammatory Arthritis
• Treatment– NSAIDs
• COX-2 selective inhibitors
– Corticosteroids
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Inflammatory Arthritis
• Treatment– Disease-Modifying Anti-
rheumatic Drugs• Hydroxychloroquine,
sulfasalazine, methotrexate, leflunomide, etanercept, infliximab, akakinra, adallimumab
– Biological Response Modifiers
• TNFa antagonist• IL-1 antagonist
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Summary
• A thorough history, physical exam, and plain x-rays can establish diagnosis in most cases
• Differential diagnosis should include extra-articular, peri-articular, and intra-articular etiologies
• Ancillary testing / imaging may be helpful in equivocal cases
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Thanks for your attention
Colorado Joint ReplacementPorter Adventist Hospital
Denver, Colorado