Clinically, it can be difficult to
differentiate articular from nonarticular knee pain. Most patients with
articular knee pain have a relatively diffuse pain that is not well localized
to one area of the knee. Physical examination shows loss of motion, crepitus
(in osteoarthritis), warmth (in inflammatory arthritis), or the presence of
effusion. If knee pain is localized or if the knee has full range of motion
without warmth, crepitus, or effusion, one of the following nonarticular
syndromes should be considered: infrapatellar tendinitis, Osgood-Schlatter
disease, prepatellar bursitis, anserine bursitis, anterior knee pain syndromes,
and restless legs syndrome.
Infrapatellar tendinitis, or jumper's knee,
causes anterior knee pain below the patella and is often related to athletic
activities. Tenderness is localized to the infrapatellar tendon, with no
associated swelling, and conservative measures almost always result in
resolution of symptoms.
Osgood-Schlatter disease is characterized by
pain and swelling over the tibial tubercle at the tendon insertion point. This
condition is seen predominantly in adolescent males and is thought to represent
a traumatic avulsion injury. Symptoms usually resolve with temporary
immobilization and slow resumption of activities.
Prepatellar bursitis, or housemaid's knee,
causes pain and swelling in the anterior knee superficial to the patella and
infrapatellar tendon. An area of localized fluid collection is usually
detectable; aspiration is often needed for diagnosis. As in olecranon bursitis
of the elbow, prepatellar bursitis may be associated with trauma, localized
bacterial infection, and, less commonly, gout, rheumatoid arthritis, and
atypical infections. The differentiation between trauma and infection is
particularly important for initiation of appropriate therapy.
Anserine bursitis, which is caused by irritation
of the bursa near the attachment of the sartorius and hamstring muscles at the
medial tibial condyle, is a common cause of medial knee pain. Patients with
this condition complain of pain at night or when climbing stairs, and an area
of localized tenderness can be found on examination. Coexistent osteoarthritis
of the knee joint is present in many patients, and relief with local heat or
injection of glucocorticoids and anesthetic may be helpful both diagnostically
and therapeutically.
Anterior knee (patellofemoral) pain syndromes
usually manifest themselves as pain and crepitus associated with activities
that require knee flexion under load conditions (e.g., stair climbing).[45] Physical findings that
help with diagnosis include (1) reproduction of pain with pressure over the
patella during knee motion and (2) tenderness over the medial surface of the
patella. The cause of most anterior knee pain syndromes is uncertain, but the
pain may be related to misalignment of the quadriceps with lateral patellar
subluxation, patella alta, hypermobility, or findings of chondromalacia of the
patella on arthroscopic evaluation. Local measures and an exercise program that
emphasizes isometric quadriceps strengthening is helpful in most patients. Some
patients require arthroscopic intervention to diagnose and correct articular
irregularities or patellar misalignment.
Restless legs syndrome is characterized by
unpleasant, deep-seated paresthesia in both legs that usually occurrs during
rest and that is relieved by movement.[46] Most patients with this syndrome have
associated disturbance of sleep, and many have abnormal periodic leg movements
during sleep [see 11:XIII Disorders of Sleep]. Although idiopathic in
most patients, restless legs syndrome has been associated with iron deficiency,
uremia, pregnancy, diabetes, and polyneuropathies. Patients with severe
symptoms may respond to levodopa-carbidopa. However, some patients may require
treatment with bromocriptine, carbamazepine, clonidine, benzodiazepines, or
opioids.
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