Nontraumatic knee pain: A diagnostic &amp; treatment guide

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Applied Evidence

Nontraumatic knee pain: A diagnostic & treatment guide

J Fam Pract. 2014 December;63(12):720-728

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References

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Pes anserine bursitis

The anserine bursal complex, located approximately 5 cm distal to the medial joint line, is formed by the combined insertion of the sartorius, gracilis, and semitendinosus tendons,³⁹but the exact mechanism of pain is not well understood. Whether the pathophysiology is from an insertional tendonitis or overt bursitis is unknown, and no studies have focused on prevalence or risk factors. What is known is that overweight individuals and women with a wide pelvis seem to have a greater predilection and those with pes planus, diabetes, or knee osteoarthritis are at increased risk.²³

Diagnosis. Medial knee pain reproduced on palpation of the anatomical site of insertion of the pes anserine tendon complex supports a diagnosis of pes anserine bursitis, with or without edema. Radiologic studies are not needed, but may be helpful if significant bony pathology is suspected. Ultrasound, computed tomography (CT), and MRI are not recommended.²³

Treatment. Resting the affected knee, cryotherapy, NSAIDs, and using a pillow at night to relieve direct bursal pressure are recommended.³³Weight loss in obese patients, treatment of pes planus, and control of diabetes may be helpful, as well. Although the literature is limited and dated, corticosteroid injection has been found to reduce the pain and may be considered as second-line treatment.^24-26

Posterior knee pain

Popliteal (Baker’s) cyst

The popliteal fossa contains 6 of the numerous bursa of the knee; the bursa beneath the medial head of the gastrocnemius muscle and the semimembranosus tendon is most commonly involved in the formation of a popliteal cyst.⁴⁰It is postulated that increased intra-articular pressure forces fluid into the bursa, leading to expansion and pain. This can be idiopathic or secondary to internal derangement or trauma to the knee.⁴¹Older age, a remote history of knee trauma, or a coexisting joint disease such as osteoarthritis, meniscal pathology, or rheumatoid arthritis are significant risk factors for the development of popliteal cysts.²⁷

Diagnosis. Most popliteal cysts are asymptomatic in adults and discovered incidentally after routine imaging to evaluate other knee pathology. However, symptomatic popliteal cysts present as a palpable mass in the popliteal fossa, resulting in pain and limited range of motion.

During the physical exam with the patient lying supine, a medial popliteal mass that is most prominent with the knee fully extended is common. A positive Foucher’s sign (the painful mass is palpated posteriorly in the popliteal fossa with the knee fully extended; pain is relieved and/or the mass reduced in size with knee flexion to 45°) suggests a diagnosis of popliteal cyst.^27,28

Radiologic studies are generally not needed to diagnose a popliteal cyst. However, if diagnostic uncertainty remains after the history and physical exam, plain knee radiographs and ultrasound should be obtained. This combination provides complementary information and helps rule out a fracture, arthritis, and thrombosis as the cause of the pain.²⁷MRI is helpful if the diagnosis is still in doubt and for patients suspected of having significant internal derangement leading to cyst formation. Arthrography or CT is generally not needed.^27,41

Treatment. As popliteal cysts are often associated with other knee pathology, management of the underlying condition often leads to cyst regression. Keeping the knee in flexion can decrease the available space and assist in pain control in the acute phase.²⁷Cold packs and NSAIDs can also be used initially. Cyst aspiration and intra-articular steroid injection have been shown to be effective for cysts that do not respond to this conservative approach.²⁷However, addressing and managing the underlying knee pathology (eg, osteoarthritis, meniscal pathology, or rheumatoid arthritis) will prevent popliteal cysts from recurring.

When the problem is painful knee effusion

A prompt orthopedic referral is essential when you suspect an infectious joint. Nontraumatic knee effusion can be the primary source of knee pain or the result of underlying pathology. We mention it here because clinical suspicion is paramount in diagnosing a septic joint, a serious cause of painful knee effusion that warrants prompt treatment.

As in other causes of knee pain, a detailed history of the character of the pain is essential. Septic arthritis and crystalline disease (gout, pseudogout) should be suspected in patients without a history of trauma who cannot bear weight. Systemic complaints point to an infection and, with the exception of a possible low-grade fever, are not typically seen in crystalline disease. Notable findings include an erythematous, hot, swollen knee and pain with both active and passive movement.

Plain radiographs of the knee should be ordered to rule out significant trauma or arthritis as the etiology. It is important to perform joint aspiration with synovial fluid analysis. Fluid analysis should include a white blood cell (WBC) count with differential, Gram stain and cultures, and polarized light microscopy (not readily available in an outpatient setting).²⁹