Diagnosis of Knee sprain
Knee sprain Diagnosis: Book Excerpts
Tests and diagnosis discussion for Knee sprain:
A thorough
examination is needed to determine the kind and extent of the injury. To
diagnose a collateral ligament injury, the doctor exerts pressure on the
side of the knee to determine the degree of pain and the looseness of
the joint. An MRI is helpful in diagnosing injuries to these
ligaments.
(Source: excerpt from Questions and Answers About Knee Problems: NIAMS)
Diagnostic Tests for Knee sprain: Online Medical Books
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KNEE PAIN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it transient? Transient knee pain may be due to rheumatic fever, sarcoidosis, palindromic rheumatism, or trauma.
- Is it unilateral or bilateral? Unilateral knee pain would suggest gout, septic arthritis, bursitis, hemophilia, pseudogout, osteogenic sarcoma, and traumatic conditions such as torn meniscus, hemarthrosis, sprain of collateral ligaments, and fracture.
- Is there a history of trauma? History of trauma would suggest a sprain, torn meniscus, bruise, or fracture.
- Are there prominent systemic symptoms? If there are prominent systemic symptoms, one should consider lupus erythematosus, Reiter's disease, rheumatoid arthritis, other collagen disease, scurvy, and rheumatic fever.
- What is the age of the patient? Younger patients are more likely to have traumatic conditions such as fracture, sprains, bruises, or a torn meniscus. Osgood-Schlatter disease would be more typical of patients in their early teens. Patients in their twenties are more likely to have rheumatoid arthritis, Reiter's disease, and lupus erythematosus, whereas patients in the fourth or fifth decade and older would be more likely to have osteoarthritis, gout, and pseudogout.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, ASO titer, ANA, CRP, urinalysis, chemistry panel, arthritis panel, and x-rays of the involved joint. X-rays may show a fracture, osteoarthritic changes, and punched-out lesion of gout or chondrocalcinosis (suggesting pseudogout). It is also wise to do a bone survey. Synovial fluid analysis and culture may be done if there is sufficient joint fluid. A trial of therapy can be initiated and may be diagnostic.
If further diagnostic workup needs to be done at this point, it is most cost-effective to refer the patient to a rheumatologist or orthopedic surgeon before ordering MRI or other studies. He may want to do an arthroscopic examination before proceeding with other tests for arthritic conditions. For further workup of knee pain, see
page 279
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
KNEE SWELLING:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it painless? Painless swelling of the knee is probably a Charcot's joint.
- Is it unilateral or bilateral? Unilateral knee swelling is most likely due to trauma, gout, pseudogout, hemophilia, septic arthritis, tuberculosis, osteogenic sarcoma, torn meniscus, or osteomyelitis. Bilateral swelling of the knee is more commonly seen in osteoarthritis, lupus erythematosus, Reiter's disease, and rheumatoid arthritis.
- Is there fever? The presence of fever suggests septic arthritis, rheumatic fever, rheumatoid arthritis, osteomyelitis, lupus erythematosus, and Reiter's disease.
- Are there systemic symptoms? Systemic symptoms suggest lupus erythematosus, rheumatoid arthritis, and Reiter's disease, as well as rheumatic fever.
- What is the age of the patient? Knee swelling in younger patients is more likely to be due to rheumatic fever, septic arthritis, lupus erythematosus, Reiter's disease, and rheumatoid arthritis. Older patients are more likely to be affected with gout, pseudogout, and osteoarthritis. Osteogenic sarcoma seems to occur between the ages of 5 and 25 years in most cases.
DIAGNOSTIC WORKUP
Routine diagnostic tests include CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel, VDRL test, and x-rays of the involved joint or joints. A bone survey should probably also be done. If there is significant swelling, an arthrocentesis for synovial fluid should be done and the fluid analyzed and cultured. A therapeutic trial may be initiated at this point and can assist in the diagnosis.
If there is still doubt about the diagnosis, referral to a rheumatologist or orthopedic surgeon should be made before ordering MRI or expensive diagnostic tests. An orthopedic surgeon may perform fiberoptic arthroscopy to diagnose the problem. Additional diagnostic tests to order in cases of knee swelling may be found on
page 279
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Knee Pain/Swelling:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Degenerative joint disease (osteoarthritis)
-
Ligamentous injury
–ACL: Positive Lachman (more sensitive) and anterior drawer test
–PCL: Positive thumb sign (more sensitive) and posterior drawer test
–MCL: Pain and/or increased laxity with valgus stress
–LCL: Pain and/or increased laxity with varus stress -
Meniscus tear
–Patient may complain of pain and locking; positive McMurray circumduction test
-
Patellofemoral syndrome
- Iliotibial band syndrome
–Pain along the lateral aspect of the knee accompanied by a palpable or audible snapping
–Occurs almost exclusively in runners
- Pes anserine bursitis
–Patients complain of pain along the medial aspect of the knee (at pes anserinus insertion)
–Caused by repetitive movement that creates an inflammatory response
-
Joint effusion
–May be secondary to osteoarthritis, inflammatory arthritis, ligament injury, gout, pseudogout, or infection -
Joint infection (septic joint)
–Staphylococcus aureus is most common
–Neisseria gonorrhoeae is common in
adolescents and young adults
–Salmonella is common in sickle cell patients
–Haemophilus influenzae is common in children -
Osteochondritis dissecans (OCD)
–Osteonecrosis of subchondral bone
–Most commonly seen in the knee
–Patient reports a gradual onset of pain
–Exam reveals tenderness of the affected
area with manipulation
-
In the pediatric population, consider Osgood-Schlatter disease, physeal injury, and discoid meniscus
-
Hip or foot/ankle disease with referred pain to the knee
-
Malignancy
-
Osteomyelitis
Workup and Diagnosis
- History and physical examination are often diagnostic
–Inspect the patient's gait for limitations of motion or other abnormalities
–Visually assess symmetry between the knees: Note
swelling, deformity, erythema, and muscle atrophy
–Palpate: Note tenderness, warmth, and crepitus
–“Milk the joint” to elicit an effusion
–Test for range of motion (active and passive)
–Perform McMurray circumduction test and ligament
testing (e.g., Lachman test, anterior/posterior drawer tests, thumb sign, varus/valgus stress tests)
-
X-rays are often indicated
–AP, lateral, and merchant or sunrise films of both knees
–When possible, also obtain weight-bearing A/P films
–Merchant and sunrise X-rays of the patella are used to
evaluate alignment and injury to the patella
–On occasion, tunnel views of the knee are useful (e.g., for OCD)
-
Joint aspiration should be performed in patients with joint effusions; fluid analysis includes cell count with differential, crystals, Gram stain, and culture
-
MRI may not be necessary during initial evaluation, but may help with confirmation of specific injuries and surgical planning (e.g., PCL tear, meniscus tear, OCD)
-
Bone scan may be used to evaluate malignancy or infection
-
In some cases, blood work may include CBC, ESR, C-reactive protein, alkaline phosphatase, and uric acid
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Knee Pain:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Septic arthritis
–Characterized by redness, swelling or effusion, warmth, pain with active and passive ROM, fever or chills
–Requires urgent evaluation and diagnosis
- Osgood-Schlatter disease (OSD)
–Repetitive microtrauma to the bone-tendon junction where patellar tendon inserts into the secondary ossification center of the tibial tubercle
–Onset at early adolescence, more often in athletes
- Sinding-Larsen-Johansson disease
–Similar to OSD, except localized to distal pole of the patella
- Meniscal pathology
–Meniscal tears are usually associated with acute trauma, and involve pain and swelling with mechanical symptoms such as popping, clicking, or locking
–Discoid meniscus: Mechanical symptoms and plain X-rays show squaring, widening, and cupping
- Ligamentous injury
–Medial collateral ligament sprain via overuse injury or valgus force to knee
–Anterior cruciate ligament tear associated with sport noncontact pivoting injury, associated with a “pop” and immediate swelling
–Posterior cruciate tear associated with direct trauma to anterior tibia or hyperflexion with plantar flexed foot
–Lateral collateral ligament injury is rare
-
Osteochondritis dissecans
–Trauma resulting in separation of subchondral bone and cartilage at lateral aspect of medial femoral condyle
-
Patellar subluxation/dislocation
–Lateral displacement of patella associated with increased Q angle, genu valgum, and femoral anteversion (more common in women)
-
Bursitis
–Chronic friction over pes anserine, iliotibial band, or capsular bursa leads to inflammation and thickening of the bursa
-
Bipartite patella
–Common variant of patellar ossification
Workup and Diagnosis
-
History
–Specific location, duration, onset, aggravating or alleviating factors, and pain characteristics
–Previous trauma, preceding illness, or associated symptoms
–Past medical history and family history including bone, hematologic, or metabolic disorders
-
Physical exam
–Bilateral hip, knee, and ankle exam
–Redness, warmth, effusion, active and passive ROM
–Palpate joint line, patella, tibial tubercle, pes anserine,
and medial/lateral ligaments
–Patella tracking or apprehension, varus/valgus stress, Lachman, and anterior posterior drawer tests
–Crepitus along the flexion arc and McMurray test
-
Labs
–Often not needed unless concerned about infection
–CBC with differential, platelets, PT/INR, ESR, CRP
–Knee aspirate for cell count and differential with Gram stain, culture, and crystals
-
Radiography
–Plain X-ray: Screening knee films include AP, lateral, Merchant views
–AP pelvis and frog-leg lateral of the pelvis or femur films if indicated by exam findings
-
MRI to show soft tissues such as meniscus and ligaments
–May demonstate joint effusion in synovitis/infection, marrow edema in osteomyelitis, ligament rupture
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Knee Pain:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Age and etiology. The patient’s age is an important factor in determining the likelihood of certain knee problems. Because of stronger ligaments, avulsion fracture (anterior intercondylar eminence of the tibia, tibia tubercle) is more common in younger age groups, whereas ligamentous rupture occurs in older persons. Patellar dislocations and apophysitis are more likely in growing adolescents.
B. Trauma. Understanding the mechanism of injury and estimating the acceleration or deceleration and torsional forces across the knee joint, predict the likelihood of occult fractures and internal derangement. Patients describing a popping sensation during a rotational or twisting injury, followed by an immediate swelling, usually have internal derangement of either meniscal or ligamentous components, or both. Locking of the knee suggests a “bucklehandle” meniscal tear obstructing normal hingejoint activity of the femoraltibial joint.
C. Alleviating or exacerbating factors. Patellofemoral syndrome (PFS) or chrondromalacia patella is associated with anterior knee pain that worsens going up or down stairs or with prolonged sitting. Morning stiffness that improves with mild activity, but worsens as the day progresses, is typical of degenerative arthritis (osteoarthritis). The stiffness of rheumatoid arthritis (RA) generally does not improve with activity. Patients with multiple joint pains should be questioned about fever or skin rash to rule out infectious or inflammatory joint disease.
Physical examination
Both knees, as well as the hip, ankle, and foot on the affected side, should be examined. The knees are inspected for symmetry, signs of quadriceps or calf wasting, and any obvious swellings, discoloration, or pallor. Thigh, knee, calf circumference, and leg length are measured to document any asymmetry. Measurement of the quadriceps or Q angle (normal <15°) is important to evaluate anterior knee pain. Inability to perform full knee flexion and extension will highlight any effusion. Neurovascular supply should also be evaluated.
In nonacute circumstances, the suprapatellar bursa is milked to determine if effusion is present. The patellar apprehension test may detect patellar dislocation; the patellar grind test is used to detect PFS. Evaluation of patellofemoral tracking within the femoral groove also helps make the latter diagnosis as the patella will track laterally in PFS, leading to the characteristic “jockey cap” patella. The knee should be carefully palpated for tenderness of the patellotibial insertion (Osgood-Schlatter’s disease), the body of the infrapatellar tendon (tendinitis), the insertion of the tendon on the patella (Sinding-Larsen-Johannson disease), medial and lateral joint line (potential meniscal pathology), pes anserine bursa (bursitis), or iliotibial band insertion. Plica, a painful, thickened band of exuberant synovium, can also be diagnosed by palpitation of the medial and lateral joint lines.
Ligamentous testing is done next. Test the posterior cruciate ligament through the posterior drawer sign. Use the Lachman test for the anterior cruciate ligament, or, in obese patients, the anterior drawer sign. The medial collateral ligament is tested in zero and 15° of flexion by applying a valgus stress to the knee. The lateral collateral ligament is tested similarly using a varus stress. McMurray’s test may detect a meniscal tear. A duck walk test can also be used to look for a posterior meniscal tear. The patient’s gait is observed, specifically looking for forefoot varus and heel valgus, Morton’s foot deformity, and femoral anteversion, all of which can accentuate valgus stress on the knee and lead to a painful overuse syndrome.
>
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Acute Knee Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Osteoarthritis
❑ Patellofemoral pain
❑ Collateral ligament sprain
❑ Meniscal tear
❑ Anterior cruciate tear
❑ Infrapatellar quadriceps tendinitis
❑ Acute monoarticular arthritis
❑ Prepatellar bursitis
❑ Anserine bursitis
❑ Hamstring injury
❑ Baker cyst
❑ Septic joint
❑ Iliotibial band syndrome
❑ Hemarthrosis
❑ Patellar fracture
❑ Patellar dislocation
❑ Osteochondritis desiccans
❑ Osteonecrosis
Diagnostic Approach
Careful questioning about the mechanism of injury is most important. Overuse injury or undue stress caused by unbalanced walking is a common source. A sensation of “giving away” on stepping down is a symptom of posterior horn meniscus or anterior cruciate tear. Joint line pain is seen in osteoarthritis, high-grade collateral ligament injury, meniscal tear, and tibial plateau fracture. Pain located medially several centimeters below this is due to anserine bursitis or low-grade medial collateral ligament injury. Anterior knee pain is found in injury to the quadriceps mechanism or large joint effusions. Popliteal pain is usually due to a large knee effusion.
Systematically stress the knee in each direction, looking for pain and/or laxity, comparing with the contralateral side. The range of motion may be limited by effusion, by a meniscal tear, or by a loose body. True locking, with ability to flex but not extend fully, occurs 10 degrees short of full extension. A McMurray maneuver is performed by rotating the tibia on the femur medially with the knee flexed at 90 degrees and then extending the knee, then repeating the process with lateral rotation. A painful “clunk” with medial rotation indicates a lateral meniscus tear, and the same finding with lateral rotation suggests a medial meniscus tear. An anterior drawer sign is elicited as pain and a laxity when the tibia is pulled forward with the knee at 90 degrees, indicating anterior cruciate injury. A Lachman manuver, performed at 15 degrees flexion, is more sensitive. With effusion the hollows of the knee are filled, and a transmitted fluid wave can be elicited.
In acute knee injury, the Ottawa Knee Rule minimizes the number of x-rays without missing a significant fracture. Obtain an x-ray if: (a) age is >54, (b) there is tenderness at the head of the fibula, (c) there is isolated patellar tenderness, (d) there is an inability to flex the knee to 90 degrees, or (e) there is an inability to bear weight immediately and take four steps in the E.R.
Palpable clicks are not necessarily pathologic; they may be caused by the semitendinosus tendon slipping over the medial condyle or the iliotibial band slipping over the lateral condyle.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
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