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If the knee is swollen and red and warm to the touch when compared to the other knee, a doctor may be concerned about inflammation due to rheumatoid arthritis or a crystalline arthritis, such as gout or pseudogout, or joint infection. Besides sending the joint fluid to a laboratory for analysis, blood tests may requested to determine a white blood cell count, erythrocyte sedimentation rate, and perhaps the level of C-reactive protein or uric acid. If blood tests reveal Lyme disease antibodies forming, the condition may be attributed to it.
An X-ray is useful to verify that there is no break or dislocation when there is a history of trauma. May show signs of osteoarthritis.
It is possible to prevent the onset of prepatellar bursitis, or prevent the symptoms from worsening, by avoiding trauma to the knee or frequent kneeling. Protective knee pads can also help prevent prepatellar bursitis for those whose professions require frequent kneeling and for athletes who play contact sports, such as American football, basketball, and wrestling.
The diagnosis of patellofemoral pain syndrome is made by ruling out patellar tendinitis, prepatellar bursitis, plica syndrome, Sinding-Larsen and Johansson syndrome, and Osgood–Schlatter disease.
Patients can be observed standing and walking to determine patellar alignment. The Q-angle, lateral hypermobility, and J-sign are commonly used determined to determine patellar maltracking. The patellofemoral glide, tilt, and grind tests (Clarke's sign), when performed, can provide strong evidence for PFPS. Lastly, lateral instability can be assessed via the patellar apprehension test, which is deemed positive when there is pain or discomfort associated with lateral translation of the patella.
There are no set standards for the diagnosis of suspected transient synovitis, so the amount of investigations will depend on the need to exclude other, more serious diseases.
Inflammatory parameters in the blood may be slightly raised (these include erythrocyte sedimentation rate, C-reactive protein and white blood cell count), but raised inflammatory markers are strong predictors of other more serious conditions such as septic arthritis.
X-ray imaging of the hip is most often unremarkable. Subtle radiographic signs include an accentuated pericapsular shadow, widening of the medial joint space, lateral displacement of the femoral epiphyses with surface flattening (Waldenström sign), prominent obturator shadow, diminution of soft tissue planes around the hip joint or slight demineralisation of the proximal femur. The main reason for radiographic examination is to exclude bony lesions such as occult fractures, slipped upper femoral epiphysis or bone tumours (such as osteoid osteoma). An anteroposterior and frog lateral (Lauenstein) view of the pelvis and both hips is advisable.
An ultrasound scan of the hip can easily demonstrate fluid inside the joint capsule (Fabella sign), although this is not always present in transient synovitis. However, it cannot reliably distinguish between septic arthritis and transient synovitis. If septic arthritis needs to be ruled out, needle aspiration of the fluid can be performed under ultrasound guidance. In transient synovitis, the joint fluid will be clear. In septic arthritis, there will be pus in the joint, which can be sent for bacterial culture and antibiotic sensitivity testing.
More advanced imaging techniques can be used if the clinical picture is unclear; the exact role of different imaging modalities remains uncertain. Some studies have demonstrated findings on magnetic resonance imaging (MRI scan) that can differentiate between septic arthritis and transient synovitis (for example, signal intensity of adjacent bone marrow). Skeletal scintigraphy can be entirely normal in transient synovitis, and scintigraphic findings do not distinguish transient synovitis from other joint conditions in children. CT scanning does not appear helpful.
About 25% of people over the age of 50 experience knee pain from degenerative knee diseases.
Knee MRIs should be avoided for knee pain without symptoms or effusion, unless there are non-successful results from a functional rehabilitation program.
X-ray images (normally during weightbearing) can be obtained to rule out other conditions or to see if the patient also has osteoarthritis. The menisci themselves cannot be visualised with plain radiographs. If the diagnosis is not clear from the history and examination, the menisci can be imaged with magnetic resonance imaging (an MRI scan). This technique has replaced previous arthrography, which involved injecting contrast medium into the joint space. In straightforward cases, knee arthroscopy allows quick diagnosis and simultaneous treatment. Recent clinical data shows that MRI and clinical testing are comparable in sensitivity and specificity when looking for a meniscal tear.
There are several types of inflammation that can cause knee pain, including sprains, bursitis, and injuries to the meniscus. A diagnosis of prepatellar bursitis can be made based on a physical examination and the presence of risk factors in the person's medical history; swelling and tenderness at the front of the knee, combined with a profession that requires frequent kneeling, suggest prepatellar bursitis. Swelling of multiple joints along with restricted range of motion may indicate arthritis instead.
A physical examination and medical history are generally not enough to distinguish between infectious and non-infectious bursitis; aspiration of the bursal fluid is often required for this, along with a cell culture and Gram stain of the aspirated fluid. Septic prepatellar bursitis may be diagnosed if the fluid is found to have a neutrophil count above 1500 per microliter, a threshold significantly lower than that of septic arthritis (50,000 cells per microliter). A tuberculosis infection can be confirmed using a roentgenogram and urinalysis.
Pain in or around the hip and/or limp in children can be due to a large number of conditions. Septic arthritis (a bacterial infection of the joint) is the most important differential diagnosis, because it can quickly cause irreversible damage to the hip joint. Fever, raised inflammatory markers on blood tests and severe symptoms (inability to bear weight, pronounced muscle guarding) all point to septic arthritis, but a high index of suspicion remains necessary even if these are not present. Osteomyelitis (infection of the bone tissue) can also cause pain and limp.
Bone fractures, such as a toddler's fracture (spiral fracture of the shin bone), can also cause pain and limp, but are uncommon around the hip joint. Soft tissue injuries can be evident when bruises are present. Muscle or ligament injuries can be contracted during heavy physical activity —however, it is important not to miss a slipped upper femoral epiphysis. Avascular necrosis of the femoral head (Legg-Calvé-Perthes disease) typically occurs in children aged 4–8, and is also more common in boys. There may be an effusion on ultrasound, similar to transient synovitis.
Neurological conditions can also present with a limp. If developmental dysplasia of the hip is missed early in life, it can come to attention later in this way. Pain in the groin can also be caused by diseases of the organs in the abdomen (such as a psoas abscess) or by testicular disease. Rarely, there is an underlying rheumatic condition (juvenile idiopathic arthritis, Lyme arthritis, gonococcal arthritis, ...) or bone tumour.
Diagnosis is by examination. A Baker's cyst is easier to see from behind with the patient standing with knees fully extended. It is most easily palpated (felt) with the knee partially flexed. Diagnosis is confirmed by ultrasonography, although if needed and there is no suspicion of a popliteal artery aneurysm then aspiration of synovial fluid from the cyst may be undertaken with care. An MRI image can reveal presence of a Baker's cyst.
An infrequent but potentially life-threatening complication, which may need to be excluded by blood tests and ultrasonography, is a deep vein thrombosis (DVT). Quick assessment of the possibility of DVT may be required where a Baker's cyst has compressed vascular structures, causing leg edema, as this sets up conditions for a DVT to develop.
A burst cyst commonly causes calf pain, swelling and redness that may mimic thrombophlebitis.
Magnetic resonance imaging (MRI) can be helpful in assessing for a ligamentous injury to the medial side of the knee. Milewski et al. has found that grade I to III classification can be seen on MRI. With a high-quality image (1.5 tesla or 3 tesla magnet) and no previous knowledge of the patient’s history, musculoskeletal radiologists were able to accurately diagnose medial knee injury 87% of the time. MRI can also show associated bone bruises on the lateral side of the knee, which one study shows, happen in almost half of medial knee injuries.
Knee MRIs should be avoided for knee pain without mechanical symptoms or effusion, and upon non-successful results from a functional rehabilitation program.
This test can see various warning signs that predict if OSD might occur. Ultrasonography can detect if there is any swelling within the tissue as well as cartilage swelling. Ultrasonography's main goal is to identify OSD in the early stage rather than later on. It has unique features such as detection of an increase of swelling within the tibia or the cartilage surrounding the area and can also see if there is any new bone starting to build up around the tibial tuberosity.
Anterior-posterior (AP) radiographs are useful for reliably assessing normal anatomical landmarks. Bilateral valgus stress AP images can show a difference in medial joint space gapping. It has been reported that an isolated grade III sMCL tear will show an increase in medial compartment gapping of 1.7 mm at 0° of knee flexion and 3.2 mm at 20° of knee flexion, compared to the contralateral knee. Additionally, a complete medial ligamentous disruption (sMCL, dMCL, and POL) will show increased gapping by 6.5 mm at 0° and 9.8 mm at 20° during valgus stress testing. Pellegrini-Stieda syndrome can also be seen on AP radiographs. This finding is due to calcification of the sMCL (heterotopic ossification) caused by the chronic tear of the ligament.
OSD may result in an avulsion fracture, with the tibial tuberosity separating from the tibia (usually remaining connected to a tendon or ligament). This injury is uncommon because there are mechanisms that prevent strong muscles from doing damage. The fracture on the tibial tuberosity can be a complete or incomplete break.
Type I: A small fragment is displaced proximally and does not require surgery.
Type II: The articular surface of the tibia remains intact and the fracture occurs at the junction where the secondary center of ossification and the proximal tibial epiphysis come together (may or may not require surgery).
Type III: Complete fracture (through articular surface) including high chance of meniscal damage. This type of fracture usually requires surgery.
A meniscal tear can be classified in various ways: by anatomic location, by proximity to blood supply, etc. Various tear patterns and configurations have been described. These include:
- Radial tears;
- Flap or parrot-beak tears;
- Peripheral, longitudinal tears;
- Bucket-handle tears;
- Horizontal cleavage tears; and
- Complex, degenerative tears.
These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.
The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:
- Age/strength
- Activity level
- Tear pattern
- Chronicity of the tear
- Associated injuries (anterior cruciate ligament injury)
- Healing potential
Laximetry is a reliable technique for diagnosing a torn anterior cruciate ligament.
Segond and reverse Segond fractures are characterized by a small avulsion, or "chip", fragment of characteristic size that is best seen on plain radiography in the anterior-posterior plane. The chip of bone may be very difficult to see on the plain x-ray exam, and may be better seen on computed tomography. MRI may be useful for visualization of the associated bone marrow edema of the underlying tibial plateau on fat- saturated T2W and STIR images, as well as the associated findings of ligamentous and/or meniscal injury.
Early stages may be treated conservatively using the R.I.C.E methods.
1. Rest
2. Ice
3. Compression
4. Elevation
Exercises involving eccentric muscle contractions of the quadriceps on a decline board are strongly supported by extant literature. A physical therapist may also recommend specific exercises and stretches to strengthen the muscles and tendons, eg. cycling or swimming. Use of a strap for jumper's knee and suspension inlays for shoes may also reduce the problems.
Should this fail, autologous blood injection, or platelet-rich plasma injection may be performed and is typically successful though not as successful as high volume saline injection (Crisp "et al."). Uncommonly it may require surgery to remove myxoid degeneration in the tendon. This is reserved for patients with debilitating pain for 6–12 months despite conservative measures. Novel treatment modalities targeting the abnormal blood vessel growth which occurs in the condition are currently being investigated.
New research shows that knee operations in most cases have no better effects than exercise programs, and that most knee operations thus can be avoided.
There is no specific test for this condition. Diagnosis is based on signs and symptoms, and exclusion of other conditions.
In the absence of cartilage damage, pain at the front of the knee due to overuse can be managed with a combination of RICE (rest, ice, compression, elevation), anti-inflammatory medications, and physiotherapy.
Usually chondromalacia develops without swelling or bruising and most individuals benefit from rest and adherence to an appropriate physical therapy program. Allowing inflammation to subside while avoiding irritating activities for several weeks is followed by a gradual resumption. Cross-training activities such as swimming, strokes other than the breaststroke, can help to maintain general fitness and body composition. This is beneficial until a physical therapy program emphasizing strengthening and flexibility of the hip and thigh muscles can be undertaken. Use of nonsteroidal anti-inflammatory medication is also helpful to minimize the swelling amplifying patellar pain. Treatment with surgery is declining in popularity due to positive non-surgical outcomes and the relative ineffectiveness of surgical intervention.
This condition is usually curable with appropriate treatment, or sometimes it heals spontaneously. If it is painless, there is little cause for concern.
Correcting any contributing biomechanical abnormalities and stretching tightened muscles, such as the iliopsoas muscle or iliotibial band, is the goal of treatment to prevent recurrence.
Referral to an appropriate professional for an accurate diagnosis is necessary if self treatment is not successful or the injury is interfering with normal activities. Medical treatment of the condition requires determination of the underlying pathology and tailoring therapy to the cause. The examiner may check muscle-tendon length and strength, perform joint mobility testing, and palpate the affected hip over the greater trochanter for lateral symptoms during an activity such as walking.
The MRI is perhaps the most used technique for diagnosing the state of the Anterior Cruciate Ligament but it not always the most reliable. In some cases the Anterior Cruciate Ligament can indeed not be seen because of the blood surrounding it.
Future research into posterolateral injuries will focus on both the treatment and diagnosis of these types of injuries to improve PLC injury outcomes. Studies are needed to correlate injury patterns and mechanisms with clinical measures of knee instability and laxity.