This document provides an overview of knee pain, including different causes, symptoms, and diagnostic approaches based on age. It discusses common conditions that cause knee pain in children/adolescents, adults, and older adults. For each, it outlines key symptoms, mechanisms of injury, differential diagnoses, and examination findings. Common ligament injuries, meniscal tears, and overuse injuries in adults are described. Diagnostic tests including imaging and physical exams are also summarized. The document aims to guide physicians in evaluating and diagnosing the underlying cause of a patient's knee pain.

1. Approach to Knee Pain
Dr.RAJAT JANGIR
Consultant Arthroscopy and Sports Injury
MS Ortho (Ahmedabad)
Fellow Arthroscopy( South Korea)
Dip Sports Med IOC (UK)

3. 22

4.  Fibrocartilaginous structures
Vascular periphery (2-3 mm)
Medial meniscus
Cresent-shaped
Lateral meniscus
Circular

5.  MCL
 LCL
 ACL
 PCL
 MPFL
Meniscofemoral
ligament

6. History
PAIN CHARACTERISTICS
 Onset (rapid or insidious)
 Location (anterior, medial, lateral, or posterior)
 Duration
 Severity
 Quality (e.g., dull, sharp, achy)
 Aggravating and alleviating
 Able to continue activity or bear Immediately.

7. History
MECHANICAL SYMPTOMS
 Locking
 Popping
 Giving way
EFFUSION
 Timing (rapid/slow onset)
 Amount of joint effusion (mild/moderate/severe)

8. History
MECHANISM OF INJURY
 direct blow to the knee
 foot was planted
 decelerating or stopping suddenly
 landing from a jump
 Twisting injury
 hyperextension

9. Ottawa knee rules
• Age 55 or over
• Isolated tenderness of the patella
• Tenderness at fibular head,
• Inability to flex to 90 degrees
• Inability to bear weight

10. Differential Diagnosis
Children and Adolescents.



Patellar subluxation
Tibial apophysitis (Osgood- Schlatter lesion)
Patellar tendonitis (Jumper’s knee)
Adults



Overuse syndromes
Trauma
Infection
Older Adults



Osteoarthritis
Crystal-induced Inflammatory arthropathy
Popliteal cyst (Baker’s cyst)

11. Children and Adolescents
 Patellar subluxation
 Tibial apophysitis (Osgood- Schlatter lesion)
 Patellar tendonitis (Jumper’s knee)

12. PATELLAR SUBLUXATION
 Occurs more often in teenage girls
 giving-way episodes of knee.
 Pain on patellar apprehension test.

14. TIBIAL APOPHYSITIS
• 13-14 year old boy (10-11yr girl)-
growth spurt
• Anterior knee pain TT
• squatting, walking up or down stairs
• TT is tender & swollen
• Radiographs are usually negative, rarely show
avulsion of apophysis at TT.

16. PATELLAR TENDONITIS
 Teenage boys- growth spurt.
 Vague anterior knee pain persisted for months and worsens
after activities
 Patellar tendon tender, and pain is reproduced by resisted
knee extension.
 Radiographs are not indicated.

17. Adults
1. Overuse syndromes



Patellofemoral pain syndrome
Medial plica syndrome
Iliotibial band tendonitis
2. Trauma




Anterior Cruciate Ligament Sprain
Medial Collateral Ligament Sprain
Lateral Collateral Ligament Sprain
Meniscal Tear
3. Infection

18. Patellofemoral pain syndrome

Anterior knee pain occurs after prolonged periods of sitting
(“theater sign”).
 Slight effusion, Patellar crepitus.
 Pain may be reproduced by applying direct pressure at anterior
aspect of patella.
 Radiographs usually are not indicated.

20. Medial plica syndrome
 The plica, a redundancy of the joint synovium medially, can
become inflamed with repetitive overuse
 Acute onset of medial knee pain after a marked increase of
usual activities.
 Tenderness MFC
 Radiographs are not indicated.

22. Iliotibial band tendonitis
 Runners & cyclists

Pain at lateral aspect of knee aggravated by activity, particularly
running downhill and climbing stairs.

Tenderness -lateral epicondyle
Noble’s test – supine position, pain when physician places thumb
on lateral epicondyle as the patient repeatedly flexes and extends
the knee.
 Radiographs are not indicated.

24. Trauma
ACL
 Noncontact deceleration forces

“Pop” at the time of the injury
must cease activity or competition immediately.
Swelling of the knee within two hours.

Joint effusion
Anterior drawer test
Lachman test

25. Anterior Cruciate Ligament
 Most common knee injury among
athletes
 AM fibers taut in flexion
 Check anterior displacement
 PL fibers taut in extension
 Check rotation
 Hyperextension, internal rotation
– rarely isolated injury from
contact force
 Intersubstance (70%)
(LEFT KNEE)

26. ACL Diagnosis: Examination
 large hemarthrosis
 Anterior drawer test
 NOT RELIABLE BY
ITSELF
 Lachman test
 Knee only flexed 30
 Pivot shift

27.  X-ray
 Segond fracture of
lateral tibial condyle
 Tibial spine avulsion
in young patients
 MRI – 95%
accuracy
Normal ACL Torn ACL
ACL: Diagnosis: Imaging

28. Posterior Cruciate Ligament
 Broader, longer, stronger
 PM and AL fiber bundles
 Receives better vasc. from
MGA, synovial membrane
 Tears much less frequently
 Only in isolation when
“dashboard knee” injury
 Hyperextension in sports,
especially
Posterior view
Anterior view
Medial
femoral
condyle

29. PCL: Diagnosis
 Posterior drawer test
 Neutral start vital!
 Gravity or sag test
 X-ray to confirm sag test
 MRI
negative positive

30. Trauma
Medial Collateral Ligament Sprain
 Collision that places valgus stress on knee
 Immediate onset of pain and swelling at medial aspect of
knee
 Point tenderness at the medial joint line
 Valgus stress test

31. Varus and valgus stress test

32. Trauma
Lateral Collateral Ligament Sprain
 varus stress to the knee
 lateral knee pain that requires prompt cessation of
activity.
 Point tenderness
Varus stress test
 MRI

33. Trauma
Meniscal Tear
 Acute- Twisting injury
Chronic- Degenarative
 Recurrent knee pain
catching or locking
especially with squatting or twisting of knee.

Tests
 MRI

34. McMurray test to assess the
.medial meniscus

35. INFECTION
 any age
but is more common immunodeficiency
cancer, diabetes mellitus, corticosteroid
 Warm, swollen, and exquisitely tender.

36. Older Adults
 Osteoarthritis
 Crystal-induced Inflammatory arthropathy
(gout or pseudogout)
 Popliteal cyst (Baker’s cyst)

37. OSTEOARTHRITIS
 knee pain aggravated by weight- bearing activities and relieved
by rest.
 morning stiffness that dissipates somewhat with activity
Acute flare
 Decreased ROM, crepitus, mild joint effusion, and palpable
osteophytes

39. CRYSTAL-INDUCED INFLAMMATORY ARTHROPATHY
 Gout or pseudogout presents with pain, and swelling in the
absence of trauma
 Redness, warm, tender, and swollen.
Even minimal range of motion is exquisitely painful.

Microscopy
negatively birefringent gout
positively birefringent pseudogout

40. Popliteal cyst -Baker’s cyst
 Insidious onset of mild to moderate pain in the popliteal area
 palpable fullness
 MRI USG

42. Take home message
• Age
• Injury
• Loaction
• Tests

43. Thank you and
Questions?