Rehab Protocols
Interactive Knee Exam
Viscosupplementation

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.