Finding, the exact location of a patient's pain (when possible) and correlating it to potential abnormalities or specific anatomic structures is an essential part of the physical exam. We recommend that a standard systematic exam be followed in every patient and that the area of maximal tenderness be palpated last to prevent the patient from guarding due to pain during the exam.
Joint Line Pain:
Joint line pain can be indicative of a tear of the lining of the joint (the
capsule), a meniscus tear, or may indicate abnormalities with the bone or
cartilage at the joint line (chondromalacia, arthritis, osteochondritis dissecans,
etc). In the evaluation of joint line pain, we perform this concurrent with
either a varus or valgus
stress test. While we are applying a stress across the joint, we place
our fingers directly over the joint line to assess for joint line pain, a
clunk (which may indicate a peripheral meniscal
tear), or intraarticular crepitation (which may indicate cartilage damage
or a meniscal tear). We try to work with
the patient to determine if the pain is just under our fingers (which may
indicate an injury to the joint line capsule) or deeper inside the joint.
Tibial Tuberosity:
Tenderness at the tibial tuberosity is primarily due to Osgood-Schlatter's
syndrome, or its residual, or deep infrapatellar bursitis. A bony
prominence over the tibial tubercle may indicate either ongoing Osgood-Schlatter's
irritation in an adolescent with open growth plates, or the residual of Osgood-Schlatter's
in adults. In adults, the most common cause of continued pain after Osgood-Schlatter's
syndrome is a bony ossicle in the patellar tendon or in the deep infrapatellar
bursa. The deep infrapatellar bursa is located slightly proximal to the patella
tendon attachment on the tibial tubercle (LaPrade, 1998). It is most easily
palpated on the lateral aspect of the bursa just proximal to the tibial tubercle.
Tenderness in either of these two locations usually goes hand in hand with
tight hamstrings.
Palpation of a possible suprapatella plica.
Tenderness of the semimembranosus direct arm
insertion on the posteromedial aspect of the knee. A
bursa just proximal to the insertion is often inflammed
in patients with tight hamstrings.
Tenderness of the biceps femoris- FCL bursa on the
lateral aspect of the knee. A bursa is located at the
point where the anterior arm of the long biceps crosses
lateral to the fibular collateral ligament (LaPrade, 1997)
Patellofemoral Joint:
There are multiple anatomic reasons for patellofemoral joint pain. The majority
of these can be palpated during a physical examination to help differentiate
the source of pain. This in turn may be useful in choosing the proper rehabilitation
protocol for a patient. Suprapatellar
plica irritation is the most common finding we will see in patients with
patellofemoral pain. Pain at the pes anserine bursa, semimembranosis bursa,
deep infrapatellar bursa (LaPrade, 1998), or the FCL-biceps femoris bursa
(LaPrade and Hamilton, 1997) usually indicates that a patient has associated
tight hamstrings and the sequelae from the extra stress on the joint. Pain
at the inferior pole of the patella is usually indicative of patellar tendonitis.
Pain at the quadriceps insertion on the proximal patella may indicate a partial
quadriceps tendon tear, quadriceps tendonitis, or the residual of a previous
injury or surgery. We do not believe that one can palpate the medial or lateral
facets of the patella independent of pushing on the plica (or associated joint
retinaculum). Our belief is that the term chondromalacia patella is
a wastebasket term for anterior knee pain without breaking down the individual
anatomic components. One of my Hughston Society colleagues has gone so far
as to have his knee arthroscoped to determine the source of pain in an unanesthetized
knee. He found that his previously undiagnosed chondromalacia of his patella
surface was non-painful to direct palpation with an arthroscopic probe (Scott
Dye, American Journal of Sports Medicine, 1999). For this reason, we discourage
the use of the term chondromalacia patella except in those patients who have
been found via MRI or arthroscopy to have a well-localized cartilage lesion
to their patella which is causing pain or in those patients who have an associated
bone scan which shows increased uptake around this area.
Deep Joint Pain:
Pain deep inside the joint can be either due to a posterior horn meniscal
tear, a Baker's cyst, a fabella syndrome (on the lateral side of the joint),
ganglion cysts of the cruciate ligaments, pigmented villnodular synovitis,
lipoma arborescens (LaPrade, et al, 1995) or other pathology. Pain deep inside
the knee with maximal knee flexion is very useful to help determine if there
is a posterior horn meniscal tear. Pain at the posteromedial aspect of the
joint just above the direct arm attachment of the semimembranosis and its
intersection with the medial head of the gastrocnemius is usually indicative
of a Baker's cyst. Pain along the lateral aspect of the posterior joint,
in the region of a fabella, which is accentuated with ankle dorsiflexion,
may be indicative of a fabella syndrome or irritation due to arthritis of
the fabellofemoral joint.
Superficial Joint Pain:
A superficial infection may be painful and is usually accompanied by
increased warmth and redness of the region. Superficial pain over the anterior
aspect of the joint may be indicative of a prepatellar bursitis. Pain over
the anteromedial aspect of the joint, just distal to the joint line, may be
indicative of an irritation of the infrapatellar branch of the saphenous
nerve in a patient with a previous contusion or surgery in this area.
Pain over the lateral or posterolateral aspect of the joint just distal to
the fibular head may be indicative of a common peroneal nerve irritation.
This could indicate either localized nerve entrapment or potentially a herniated
disk pushing on a nerve root.
Other:
Tenderness at the joint line upon flexion of the
knee.
Pain deep inside the knee with maximal knee flexion is
most often indicative of a posterior horn meniscal tear.
Pain over the anterior aspect of the knee with deep
knee flexion is usually found in patients with
patellofemoral dysfunction. In these patients, they
may have pain from plical irritation, patellofemoral
chondromalacia, or other anterior joint pathology.
