1) Patellofemoral Arthralgia – anterior knee pain, nonspecific ache, burning, sometimes a sharp pain, pain worse on climbing stairs and squatting, knee bending, hiking, squatting, pain while being seated for sometime, pain on direct compression of the patella against the femoral condyles with the knee in full extension, tenderness on palpation of the posterior surface of the patella, pain on resisted knee extension, pain on isometric quadriceps contraction against suprapatellar resistance with the knee in slight flexion, abnormal Q angle (N on Patellofemoral assessment), abnormal patellar tracking (N on Patellofemoral assessment), patellar instability (N on Patellofemoral assessment), look for following conditions which predispose for Patellofemoral pain : increased Q angle, femoral anteversion, tibial torsion, hyperpronation of foot, vastus medialis atrophy and or weakness preventing the normal medial movement of patella in knee flexion, tight lateral retinaculum, patella alta, patella baja, patellar subluxation, tightness of CHIQ complex (ie. Calf muscles, Hamstrings, Iliotibial band, Quadricpes management of which is stretching the individual muscles of the complex), general ligamentus laxity,.wide pelvic girdle, pes planus, muscle tightness, genu recurvatum, Mx – look for correctible causes among the above predisposing factors for patellofemoral pain, activity modification, ice therapy in the acute stage of pain (See notes under strains and sprains for management), muscle strengthening exercise for quadriceps with short-arc quadriceps, knee presses, isometric quadriceps sets, straight leg raises with legs rotated externally, hamstring stretches, vastus lateralis stretches, iliotibial band stretches, retinacular expansion stretches, patellofemoral bracing with a patella cut-out and lateral stabilizer, medial taping of the patella, arch supports and foot orthotics for foot problems.
2) Jumper’s knee – also known as patellar tendonitis, quadriceps tendonitis, anterior knee pain, mostly with jumping and running, initially pain with activities, then pain persists after the offending activity, finally pain with poor performance of the offending activity, point tenderness at the inferior pole of patella, point tenderness at the superior pole of patella, point tenderness at the tibial tuberosity, resisted extension of knee painful and weak, Mx – look for predisposing factors like hamstring tightness, quadriceps tightness, obesity, genu varum, genu valgum, increase Q angle, patella alta, patella baja and limb length inequality with a view for correcting then where possible, activity modification, ice application in acute stage, stretching exercises for hamstrings, gastrocnemius, iliopsoas, rectus femoris, adductors, quadriceps, gluteals, iliotibial band and patellar retinaculum, strengthening exercises using single leg squats, NSAIDS for pain at acute stage, orthopedic referral for tendon repair if conservative measures fail
3) Medial plica syndrome – anterior knee pain, medial knee pain, acute onet, triggered by an increase in high impact knee activity, pain worsened with stairs climbing, squatting, jogging and running, pain can continue for long periods if untreated, point tenderness at plica point (ie. 1-2 fingerbreaths medial to the medial edge of patella), mobilem nodularity at the plica point, at plica point suprapatellar pliac can be rolled between fingers, patient’s symptoms can be reproduced by rolling the plica with fingers at he plica point, predisposing factors include patellfemoral dysfunction, patellar subluxation, tight hamstring (as assessed by changes in hamstring-popliteal angle), poor quadriceps tone, therefore assess for these in the physical, Mx – closed chain quadriceps kinetic exercises (ie exercise bike, leg presses, straight leg raises, minisquats), hamstring stretches, activity modification, on failed conservative treatment refer for arthroscopy and for further orthopaed management.
4) Acute arthritis – acute red, hot, swollen joint, all movements are limited or almost absent, any movement is very painful, the patient moves the joint with heavy guarding, other signs and symptoms depend on the underlying cause of arthritis, in case of traumatic arthritis there will be an initiating trauma, Mx – NSAIDS, treatment of the underlying cause,
5) Osteoarthritis – knee pain with activity with weight bearing, morning stiffness more than 30 mts, knee giving way, varus def, valgus def, recurrent episodes of synvitis (knee pain and swelling lasting few days), decreased range of motion, crepitus on active motion, varus or valgus deformity, palpable osteophytes, bony enlargement of knee, Mx – active range of motion exercise for knee (long sitting position extend the knee from mid-flexion to the end point of extension, long sitting position flex the knee from mid-flexion to end point of flexion, two 30 second repetitions with 3 sec hold at the end of range), muscle strengthening exercises for knee and hip, muscle stretching for the lower limbs (standing calf stretches, supine hamstring stretch, prone quadriceps stretch each 3 repetitions with 30 sec hold), riding stationery bike, all exercises should be painless or very minimally painful, should not cause increase in pain, swelling of joint, warmth over the joint, objective signs of improvemnent wih above regime are reduction in pain, stiffness, disability and improvement in the distance walked in 6 minutes.
6) Gout and pseudogout - acute red, hot, swollen joint, nontraumatic afebrile, very painful knee joint movements, limited range of movements,
7) Seropositive arthritis
8) Seronegative arthritis
9) Septic joint - acute red, hot, swollen joint
10) Haemarthrosis - acute red, hot, swollen joint
11) Periarthritis
12) Prepatellar bursitis – red, painful, tender swelling over the knee, knee joint movements normal and painless, direct trauma or RSI criteria (N) present,
13) Infrapatellar bursitis – extremes of both flexion and extension of knee joint painful, minimal swelling on either side of the patellar tendon, point tenderness on either side of the patellar tendon,
14) Anserine bursitis – obesity, abnormal gait, osteoarthritis of the knee, long-distance running, valgus knee defect, hyperpronated feet, tight hamstrings (flex the hip to 90* and then extend the leg passively to assess the hamstring popliteal angle), medial knee pain, point tenderness over a point 5 cm below the joint margin at the site of the tibial tubercle and just medial to the tubercle (alternatively anserine bursa point is at a point just distal to the tibial tubercles and about 2 fingerbreaths medial to it), pain worsens with climbing stairs, extremes of flexion and extension painful, Mx – look for predisposing factors, correct those which are correctible, hamstring stretches, closed chain quadriceps strengthening exercises, cutting back on offending activity, ice massage.
15) CPPDD (calcium pyrophosphate deposition disease)
16) Meniscal tears – twisting or flexing injury with a click, knee pain, knee clicks, knee locking, recurrent attacks of knee pain and clicks and locking, precipitated by knee twisting and squatting, McMurray test (N) positive, Apley’s compression test positive (N), synovial effusion may be seen in the acute stage, Mx – MRI is the investigation of choice and orthopedic referral for further evaluation.
17) Recurrent dislocation of patella – apprehension test positive (See Notes under patellofemoral assessment)
18) Myofascial pain syndrome - anterior knee pain spreading up and down the leg and thigh in adductor longus, brevis MFPS, popliteal fossa pain and spreading up posterior thigh in biceps femoris MFPS, anterior knee pain spreading to the anterior thigh in rectus femoris MFPS, anterior thigh pain, anterior knee pain in vastus medialis MFPS. See notes under myofascial pain syndrome for diagnostic criteria and treatment.
19) Medial collateral ligament strain – knee trauma with a valgus strain on the knee, immediate onset pain and swelling at the medial knee, point tenderness at the joint line medially, valgus stress at knee 30* flexion reproduces patient’s pain, lack of clearly defined end point on valgus stress testing denotes full rupture of a MCL and requires orthopedic referral.
20) Iliotibial Band Syndrome – lateral knee pain, initially activity related, later even at rest, point tenderness at 2 cm proximal to the joint line, while standing flexing the affected knee to 30* reproduce the patient surgical technique symptoms, signs and symptoms of MFPS may also be seen, weakness of knee flexors extensors, hip abductors commonly associated, Ober’s test positive (patient lies down on the unaffected side keeping the ipsilateral knee and hip 90* flexd. Examiner while keeping the pelvis steady, abducts and extends the affected leg at the hip and then lowers the limb into adduction. If the leg remains abducted and the patient experiences lateral pain at the knee iliotibial band is tight and has tendinitis), Mx – activity modification, massage, stretching and strengthening, stretching of the iliotibial band, hip flexors, and plantar flexors, once the stretching can be done without pain, start the muscle strengthening program focusing mainly on the gluteus medius muscle.