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People often describe pain as being “inside the knee cap.” The leg tends to flex even when relaxed. In some cases, the injured ligaments involved in patellar dislocation do not allow the leg to flex almost at all.
Osgood–Schlatter disease causes pain in the front lower part of the knee. This is usually at the ligament-bone junction of the patellar ligament and the tibial tuberosity. The tibial tuberosity is a slight elevation of bone on the anterior and proximal portion of the tibia. The patellar tendon attaches the anterior quadriceps muscles to the tibia via the knee cap.
Intense knee pain is usually the presenting symptom that occurs during activities such as running, jumping, squatting, and especially ascending or descending stairs and during kneeling. The pain is worse with acute knee impact. The pain can be reproduced by extending the knee against resistance, stressing the quadriceps, or striking the knee. Pain is initially mild and intermittent. In the acute phase, the pain is severe and continuous in nature. Impact of the affected area can be very painful. Bilateral symptoms are observed in 20–30% of people.
Patients often complain of pain and swelling over the medial aspect of the knee joint. They may also report instability with side-to-side movement and during athletic performance that involves cutting or pivoting.
Subacromial bursitis often presents with a constellation of symptoms called impingement syndrome. Pain along the front and side of the shoulder is the most common symptom and may cause weakness and stiffness. If the pain resolves and weakness persists other causes should be evaluated such as a tear of the rotator cuff or a neurological problem arising from the neck or entrapment of the suprascapular nerve. The onset of pain may be sudden or gradual and may or may not be related to trauma. Night time pain, especially sleeping on the affected shoulder, is often reported. Localized redness or swelling are less common and suggest an infected subacromial bursa. Individuals affected by subacromial bursitis commonly present with concomitant shoulder problems such as arthritis, rotator cuff tendinitis, rotator cuff tears, and cervical radiculopathy (pinched nerve in neck).
Impingement may be brought on by sports activities, such as overhead throwing sports and swimming, or overhead work such as painting, carpentry, or plumbing. Activities that involve repetitive overhead activity, or directly in front, may cause shoulder pain. Direct upward pressure on the shoulder, such as leaning on an elbow, may increase pain.
The primary symptom of prepatellar bursitis is the swelling of the area around the kneecap. It generally does not produce a significant amount of pain unless pressure is applied directly to the swelling. The area of swelling may be red (erythema), warm to the touch, or surrounded by cellulitis, particularly if the area has become infected. In such cases, the bursitis is often accompanied by fever. Unlike arthritis, prepatellar bursitis generally does not affect the range of motion of the knee, though it may cause some discomfort when the knee is completely flexed. Flexion and extension of the knee may cause crepitus.
Patients often complain of pain and instability at the joint. With concurrent nerve injuries, patients may experience numbness, tingling and weakness of the ankle dorsiflexors and great toe extensors, or a footdrop.
Osgood–Schlatter disease (OSD), also known as apophysitis of the tibial tubercle, is inflammation of the patellar ligament at the tibial tuberosity. It is characterized by a painful bump just below the knee that is worse with activity and better with rest. Episodes of pain typically last a few months. One or both knees may be affected and flares may recur.
Risk factors include overuse, especially sports which involve running or jumping. The underlying mechanism is repeated tension on the growth plate of the upper tibia. Diagnosis is typically based on the symptoms. A plain X-ray may be either normal or show fragmentation in the attachment area.
Pain typically resolves with time. Applying cold to the affected area, stretching, and strengthening exercises may help. NSAIDs such as ibuprofen may be used. Slightly less stressful activity may be recommended.
About 4% of people are affected at some point in time. Males between the ages of 10 and 15 are most often affected. After growth slows, typically age 16 in boys and 14 in girls, the pain will no longer occur despite a bump potentially remaining. The condition is named after Robert Bayley Osgood (1873–1956), an American orthopedic surgeon and Carl B. Schlatter, (1864–1934), a Swiss surgeon who described the condition independently in 1903.
Jacobson previously described the common problems to medial knee surgery. It was stressed that adequate diagnosis is imperative and all possible injuries should be evaluated and addressed intraoperatively. Damage to the saphenous nerve and its infrapatellar branch is possible during medial knee surgery, potentially causing numbness or pain over the medial knee and leg. As with all surgeries, there is a risk of bleeding, wound problems, deep vein thrombosis, and infection that can complicate the outcome and rehabilitation process. The long term complication of arthrofibrosis and heterotopic ossification (Pellegrini-Stieda syndrome) are problems that are best addressed with early range of motion and following defined rehabilitation protocols. Failure of graft due to intrinsic mechanical forces should be prevented with preoperative alignment assessment (osteotomy treatment) and proper rehabilitation.
A predisposing factor is tightness in the tensor fasciae latae muscle and iliotibial tract in combination with a quadriceps imbalance between the vastus lateralis and vastus medialis muscles can play a large role. However individuals with larger Q angles are genetically more predisposed to this type of injury due to the increased lateral angle at which the femur and tibia meet.
Another cause of patellar symptoms is "lateral patellar compression syndrome", which can be caused from lack of balance or inflammation in the joints. The pathophysiology of the kneecap is complex, and deals with the osseous soft tissue or abnormalities within the patellofemoral groove. The patellar symptoms cause knee extensor dysplasia, and sensitive small variations affect the muscular mechanism that controls the joint movements.
24% of people whose patellas have dislocated have relatives who have experienced patellar dislocations.
An individual may feel or hear a "pop" in their knee during a twisting movement or rapid deceleration, followed by an inability to continue participation in the sport and early swelling from hemarthrosis. This combination is said to indicate a 90% probability of rupture of the anterior cruciate ligament.
An individual may experience instability in the knee once they resume walking and other activities, and they may feel their knee is "giving out". Loss of full range of motion, and discomfort along the joint line are also common symptoms of an ACL injury.
A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci. When doctors and patients refer to "torn cartilage" in the knee, they actually may be referring to an injury to a meniscus at the top of one of the tibiae. Menisci can be torn during innocuous activities such as walking or squatting. They can also be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged 'wear and tear' called a degenerative tear.
Tears can lead to pain and/or swelling of the knee joint. Especially acute injuries (typically in younger, more active patients) can lead to displaced tears which can cause mechanical symptoms such as clicking, catching, or locking during motion of the knee joint. The joint will be in pain when in use, but when there is no load, the pain goes away.
A tear of the medial meniscus can occur as part of the unhappy triad, together with a tear of the anterior cruciate ligament and medial collateral ligament.
As the name implies, movement of the shoulder is severely restricted in people with a "frozen shoulder". This condition, which doctors call adhesive capsulitis, is frequently caused by injury that leads to lack of use due to pain. Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally lubricates the gap between the arm bone and socket to help the shoulder joint move. It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident, are at a higher risk for frozen shoulder. The condition rarely appears in people under the age of 40.
The most common symptoms in impingement syndrome are pain, weakness and a loss of movement at the affected shoulder. The pain is often worsened by shoulder overhead movement and may occur at night, especially if the patient is lying on the affected shoulder. The onset of the pain may be acute if it is due to an injury or may be insidious if it is due to a gradual process such as an osteoarthritic spur. The pain has been described as dull rather than sharp, and lingers for long periods of a time, making it hard to fall asleep at night. Other symptoms can include a grinding or popping sensation during movement of the shoulder.
The range of motion at the shoulder may be limited by pain. A painful arc of movement may be present during forward elevation of the arm from 60° to 120°. Passive movement at the shoulder will appear painful when a downwards force is applied at the acromion but the pain will ease once the downwards force is removed.
Follow-up studies by Levy et al. and Stannard at al. both examined failure rates for posterolateral corner repairs and reconstructions. Failure rates repairs were approximately 37 – 41% while reconstructions had a failure rate of 9%.
Other less common surgical complications include deep vein thrombosis (DVTs), infection, blood loss, and nerve/artery damage. The best way to avoid these complications is to preemptively treat them. DVTs are typically treated prophylactically with either aspirin or sequential compression devices (SCDs). In high risk patients there may be a need for prophylactic administration of low molecular weight heparin (LMWH). In addition, having a patient get out of bed and ambulate soon after surgery is a time honored way to prevent DVTs. Infection is typically controlled by administering 1 gram of the antibiotic cefazolin (Ancef) prior to surgery. Excessive blood loss and nerve/artery damage are rare occurrences in surgery and can usually be avoided with proper technique and diligence; however, the patient should be warned of these potential complications, especially in patients with severe injuries and scarring.
Symptoms of gamekeeper's thumb are instability of the MCP joint of the thumb, accompanied by pain and weakness of the pinch grasp. The severity of the symptoms are related to the extent of the initial tear of the UCL (in the case of Skier's thumb), or how long the injury has been allowed to progress (in the case of gamekeeper's thumb).
Characteristic signs include pain, swelling, and ecchymosis around the thenar eminence, and especially over the MCP joint of the thumb. Physical examination demonstrates instability of the MCP joint of the thumb.
The patient will often manifest a weakened ability to grasp objects or perform such tasks as tying shoes and tearing a piece of paper. Other complaints include intense pain experienced upon catching the thumb on an object, such as when reaching into a pants pocket.
Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying coraco-acromial ligament, acromion, coracoid (the acromial arch) and from the deep surface of the deltoid muscle. The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.
Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain.
Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune inflammatory conditions such as rheumatoid arthritis; crystal deposition disorders such as gout or pseudogout; calcific loose bodies, and infection. More commonly, subacromial bursitis arises as a result of complex factors, thought to cause shoulder impingement symptoms. These factors are broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury.
In 1983 Neer described three stages of impingement syndrome. He noted that "the symptoms and physical signs in all three stages of impingement are almost identical, including the 'impingement sign'..., arc of pain, crepitus, and varying weakness." The Neer classification did not distinguish between partial-thickness and full-thickness rotator cuff tears in stage III. This has led to some controversy about the ability of physical examination tests to accurately diagnose between bursitis, impingement, impingement with or without rotator cuff tear and impingement with partial versus complete tears.
In 2005, Park et al. published their findings which concluded that a combination of clinical tests were more useful than a single physical examination test. For the diagnosis of impingement disease, the best combination of tests were "any degree (of) a positive Hawkins-Kennedy test, a positive painful arc sign, and weakness in external rotation with the arm at the side," to diagnose a full thickness rotator cuff tear, the best combination of tests, when all three are positive, were the painful arc, the drop-arm sign, and weakness in external rotation.
A shoulder fracture that occurs after a major injury is usually accompanied by severe pain. Within a short time, there may be redness and bruising around the area. Sometimes a fracture is obvious because the bones appear out of position.
(However this occur in non-involved dislocations and separations.) Both diagnosis and severity can be confirmed by x rays.
Anterior cruciate ligament injury is when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. Injuries are most commonly complete tears. Symptoms include pain, a popping sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours. In approximately 50% of cases other structures of the knee such as ligaments, cartilage, or meniscus are damaged.
The underlying mechanism often involves a rapid change in direction, sudden stop, landing following jumping, or direct contact. It is more common in athletes, particularly those who participate in alpine skiing, soccer, football, or basketball. Diagnosis is typically by physical examination and maybe support by magnetic resonance imaging (MRI).
Prevention is by neuromuscular training and core strengthening. Treatment recommends depend on desired level of activity. If there will be low levels of future activity, bracing and physiotherapy may be sufficient. In those with high activity levels, arthroscopic repair via anterior cruciate ligament reconstruction is often recommended. Surgery, if recommended, is generally not carried out until the initial inflammation from the injury has resolved.
As of 2009, about 200,000 people are affected per year in the United States. In some sports, females have a higher risk while in others, both sexes are equally affected. Without surgery, in those with a complete tear, many are unable to play sports and develop osteoarthritis.
An unhappy triad (or terrible triad, "horrible triangle", O'Donoghue's triad or a "blown knee") is an injury to the anterior cruciate ligament, medial collateral ligament, and medial meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, acute tears of the medial meniscus always present with a concomitant lateral meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.
Prepatellar bursitis is an inflammation of the prepatellar bursa at the front of the knee. It is marked by swelling at the knee, which can be tender to the touch but which does not restrict the knee's range of motion. It is most commonly caused by trauma to the knee, either by a single acute instance or by chronic trauma over time. As such, prepatellar bursitis commonly occurs among individuals whose professions require frequent kneeling.
A definitive diagnosis of the condition can usually be made once a clinical history and physical examination have been obtained, though determining whether or not the bursitis is septic is not as straightforward. Treatment of prepatellar bursitis depends on the severity of the symptoms. Mild cases may only require rest and icing of the knee. A number of different treatment options have been used for severe septic cases, including intravenous antibiotics, surgical irrigation of the bursa, and bursectomy.
A sprain is a type of acute injury which results from the stretching or tearing of a ligament. Depending on the severity of the sprain, the movement on the joint can be compromised since ligaments aid in the stability and support of joints. Sprains are commonly seen in vulnerable areas such as the wrists, knees, and ankles. They can occur from movements such as falling on an outstretched hand, or a twisting of the ankle or foot.
The severity of a sprain can also be classified:
Grade 1: Only some of the fibers in the ligament are torn, and the injured site is moderately painful and swollen. Function in the joint will be unaffected for the most part.
Grade 2: Many of the ligament fibers are torn, and pain and swelling is moderate. The functionality of the joint is compromised.
Grade 3: The soft tissue is completely torn, and functionality and strength on the joint is completely compromised. In most cases, surgery is needed to repair the damage.
Movement of the shoulder is severely restricted, with progressive loss of both active and passive range of motion. The condition is sometimes caused by injury, leading to lack of use due to pain, but also often arises spontaneously with no obvious preceding trigger factor (idiopathic frozen shoulder). Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limitation similar to frozen shoulder. Intermittent periods of use may cause inflammation.
In frozen shoulder, there is a lack of synovial fluid, which normally helps the shoulder joint, a ball and socket joint, move by lubricating the gap between the humerus (upper arm bone) and the socket in the shoulder blade. The shoulder capsule thickens, swells, and tightens due to bands of scar tissue (adhesions) that have formed inside the capsule. As a result, there is less room in the joint for the humerus, making movement of the shoulder stiff and painful. This restricted space between the capsule and ball of the humerus distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder.
One sign of a frozen shoulder is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. The movement that is most severely inhibited is external rotation of the shoulder.
People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion, or if bumped. A physical therapist, osteopath or chiropractor, physician, physician assistant, or nurse practitioner may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.
The normal course of a frozen shoulder has been described as having three stages:
- Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.
- Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
- Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.
Pes anserine bursitis is an inflammatory condition of the medial (inner) knee at the anserine bursa, a sub muscular bursa, just below the pes anserinus.
Shoulder impingement syndrome, also called subacromial impingement, painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder, is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder.