Case Analysis: Knee Pain

Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

FOCUSED SOAP NOTE:15-year-old with knee pain

 

Patient information:

Initials SB

Age: 15

Sex: male

Race: white

S.

Cc (chief complaint): “I feel dull pain in both knees.”

Hpi:

Mr. S.B., a 15-year-old white male, came to the facility with complaints of dull pain in both knees for the past few days. He reports the pain to be accompanied by clicking sounds and a ‘catching’ sensation on the patella. He denies any aggravating factors that preceded the symptoms. SB also denies any recent trauma, falls and is otherwise healthy with no significant medical complaints.

Current medications:

None

Allergies: No known history of food or drug allergy.

Pmhx:

No history of hospitalization

no history of blood transfusion

no history of chronic health conditions in the family.

Soc & substance hx:

No history of alcohol or substance use

Fam hx:  third, born in a family of four.

Surgical hx: No history of surgical intervention

Mental hx: No history of chronic mental health issues in the family.  

Violence hx: No history of arrest.

Reproductive hx: Single, heterosexual

Ros:

General: Denies weight loss, chills, or weakness.

Heent: Eyes: No diplopia, visual loss, or blurred vision. Ears, nose, and throat: No hearing loss, congestion, sneezing, sore throat, or runny nose.

Skin: No rash or itching.

Cardiovascular: No palpitations, chest pain, or chest discomfort.

Respiratory: No breathing shortness, cough, or sputum.

Gastrointestinal: No nausea, vomiting, anorexia, or diarrhea.

Genitourinary: No pain or itchiness on urination.

Neurological: No headache, dizziness, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

Musculoskeletal: Knee pain, clicking, catching sensation.

Hematologic: No anemia, bleeding, or bruising.

Lymphatics: No history of hepatosplenoctomy or enlarged nodes.

Psychiatric: No history of anxiety or depression.

Endocrinologic: No polydipsia, polyuria or cold, or heat intolerance. Reproductive: heterosexual.

Allergies: No known food or drug allergy.

Diagnostic results: n/a

A.

Differential diagnoses:

  • Patellofemoral pain syndrome is associated with pain around or beneath the patella (kneecap) (Gaitonde et al., 2019). It commonly occurs due to problems with alignment, tracking, and function of the patella within the femoral groove of the thigh bone. It typically affects adolescents and young adults with excessive knee flexion (Pereira et al., 2022). This is a likely diagnosis as the patient presents with anterior knee pain, clicking, and a catching sensation.
  • Chondromalacia patella is a condition associated with softening and degeneration of the cartilage on the patella (Damgaci et al., 2020). It is caused by muscle overuse, abnormal patellar, and trauma. Symptoms include knee pain and swelling, especially when performing knee flexion activities. However, it was ruled out as the patient did not present with swelling.
  • Meniscal injury is associated with damage to the meniscus, which acts as a shock absorber, thus stabilizing the knee (Adams et al., 2021). such injury is common among sporting individuals that engage in activities that twist the knee. However, this condition is ruled out as the patient has no cracked meniscus.

The plan includes requesting a leg x-ray to rule out the possibility of a fracture. Referring the patient to a physical therapist for strengthening exercises and interventions to improve patellar tracking and alleviating symptoms. The provider should also prescribe nonsteroidal anti-inflammatory drugs like ibuprofen for pain relief. SB should also be advised against strenuous activities involving excessive kneeling or high impact. A follow-up appointment will be scheduled after a week to check the patient’s progress and evaluate the need for further interventions.

Health promotion and disease prevention

The health promotion plan will emphasize the need to maintain a healthy weight and exercise regularly to strengthen muscles around the knee joint and promote joint stability (Tramontano et al., 2020). As a 15-year-old, Mr. SB will likely engage in strenuous activities like running or playing football. HenceHence educating him on proper body ergonomics and connecting him to programs focusing on physical therapy will improve his health outcomes. The provider should advise family and friends to be supportive and create a safe environment that caters well being. This overall process should respect and acknowledge Mr. SB’s preferences, cultural backgrounds, and beliefs about life.

Reflection

This case demonstrates the importance of taking a comprehensive health history and physical examination, which help formulate the correct diagnosis. The patient’s concerns about knee pain and feeling a catching sensation raise concern for the musculoskeletal system. Additionally, the case has shown the importance of health promotion to prevent poor disease prognosis and improve overall health outcomes.

REFERENCES

Adams, B. G., Houston, M. N., & Cameron, K. L. (2021). The Epidemiology of Meniscus Injury. Sports medicine and arthroscopy review29(3), e24–e33. https://doi.org/10.1097/JSA.0000000000000329

Damgacı, L., Özer, H., & Duran, S. (2020). Patella-patellar tendon angle and lateral patella-tilt angle decrease in patients with chondromalacia patella. Knee surgery, sports traumatology, arthroscopy: official journal of the ESSKA28(8), 2715–2721. https://doi.org/10.1007/s00167-020-06065-7

Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral pain syndrome. American family physician99(2), 88–94. https://www.aafp.org/pubs/afp/issues/2019/0115/p88.html?utm_medium=email&utm_source=transactionLinks to an external site.

Pereira, P. M., Baptista, J. S., Conceição, F., Duarte, J., Ferraz, J., & Costa, J. T. (2022). Patellofemoral Pain Syndrome Risk Associated with Squats: A Systematic Review. International Journal of environmental research and public health19(15), 9241. https://doi.org/10.3390/ijerph19159241Links to an external site.

Tramontano, M., Pagnotta, S., Lunghi, C., Manzo, C., Manzo, F., Consolo, S., & Manzo, V. (2020). Assessment and Management of Somatic Dysfunctions in Patients With Patellofemoral Pain Syndrome. The Journal of the American Osteopathic Association120(3), 165–173. https://doi.org/10.7556/jaoa.2020.029

 

Answer

Knee Pain Case Analysis

The patient is a 15-year-old white male who has come with complaints of bilateral dull knee pain that has been present for the last few days. He reports that the pain is accompanied by clicking sounds and a ‘catching’ sensation on the patella. The are no aggravating factors associated with the pain. He has no history of trauma prior to the pain and has been healthy. There are no diagnostic tests available after his evaluation.

Differential Diagnosis

Patellofemoral Pain Syndrome (PFS)

It is a common cause of anterior knee pain. Patients report generalized knee pain anteriorly that is worsened by loading a knee that is flexed, such as running or climbing stairs (Bump & Lewis, 2020). It mostly affects adolescents and adults who are in their second and third decades of life. PFS accounts for 25-40% of the knee pathologies documented in sports medicine (Bump & Lewis, 2020). It is a diagnosis of exclusion that is only considered after all intra-articular or peripatellar pathologies have been ruled out. Etiological factors include malalignment, muscular imbalance, overactivity and overload, and trauma. To diagnose a patient with PFS, a comprehensive and accurate history taking and physical examination should be conducted (Bump & Lewis, 2020). Patients may report that the symptoms are unilateral or bilateral. The patient will report that the knee pain worsens with squatting, prolonged sitting, running, or climbing stairs. The pain is poorly localized, achy, and in some cases, it may be sharp. The pain can be described as around or behind the patella bone. Some patients report that there is a feeling of something giving way or a catching sensation in the knee (Bump & Lewis, 2020). In the evaluation of SB, he has no history of any trauma to the knee; he describes the pain as dull, a catching sensation is felt on the patella, and his age bracket fits under the epidemiological population of people who are affected by PFS. Therefore, this is the most appropriate diagnosis for SB.

Diagnostic Tests

PFS is a clinical diagnosis that entails thorough history taking and physical examination. Investigative modalities are only done if there is a failure of response to any therapy intervention that has been initiated after a duration of one to two months. In most cases, the treatment intervention is conservative. Plain radiographs can only then be taken where symptom resolution fails. However, it should be noted that the radiographic picture may not correlate with the complaint the patient is raising, and the affected versus non-affected sides may be difficult to differentiate based on the X-ray result. Since it is a diagnosis of exclusion, a plain radiograph will help rule out other differential causes of knee pain, such as bipartite patella, loose bodies, osteoarthritis, and occult fractures (Bump & Lewis, 2020). There is no role of advanced imaging modalities in this condition, such as magnetic resonance imaging (MRI), musculoskeletal ultrasound, and computerized tomography (CT scan) (Bump & Lewis, 2020). These only come in handy when other pathologies are being evaluated.

Chondromalacia Patella

This is an affliction of the hyaline cartilage of the knee joint. It causes the hyaline cartilage to soften, tearing, fissuring, and erosion. The etiology of chondromalacia patella arises from malalignment of the lower limb and mal tracking of the patella, muscular weakness, and patella lesions (Habusta & Griffin, 2020). Patients will report anterior knee pain or vaguely diffuse posterior or anterior patellar pain. It affects women more attributed to their Q angles. Factors worsening the pain include squatting, running, or kneeling. Diagnostic imaging modalities include conventional radiographs, CT scans, MRI scans, or arthrography with plain radiography or CT arthrography (Habusta & Griffin, 2020). Management is mostly operative.

Meniscal Injury

Meniscal injuries result from rotational or shearing forces exerted on the tibiofemoral joint, particularly when the menisci have an increased axial load (Raj & Bubnis, 2019). It may be due to trauma where patients report a pop sensation with immediate knee effusion. This mainly involves the anterior cruciate ligament and may associate with medial meniscus injury. Symptoms include low-grade effusions and stiffness that develop gradually (Raj & Bubnis, 2019). Pain is reported that involves anteromedial or anterolateral joint lines. Other symptoms include locking, catching, clicking, giving way sensation, and inability of full knee extension (Raj & Bubnis, 2019). Diagnostic imaging modalities include anteroposterior (AP), oblique, lateral, sunrise, and weight-bearing views to assess for any other pathologies that may be present.

Different Possible Conditions

Osteoarthritis

This is an inflammatory condition that affects joints and results in cases of permanent disability (Aboulenain & Saber, 2023). Typically, the condition causes pain that is worse with use and improves with inactivity (Aboulenain & Saber, 2023). Osteoarthritis can affect other joints in different parts of the body. Patients will report dull, aching, and throbbing joint pain that is persistent and predictable. There may be accompanying stiffening of the joint and immobilization (Aboulenain & Saber, 2023). This is a less likely differential in this patient owing to his age but should be ruled out due to the bilateral presentation.

Loose Bodies

Loose bodies are defined as small bone or cartilage fragments that break off and float inside the knee joint cavity (Zmerly et al., 2021). The effects associated with them include pain in the knee region, selling, and locking (Zmerly et al., 2021). They may be attributed to injury of cartilage sustained during sports or traumatic incidences, inflammatory conditions of the knee, or Charcot’s disease.

Occult Fractures

According to Ma et al. (2020), occult fractures are those that cannot be picked by a plain radiograph or show minute abnormalities that were not detected by the initial radiograph. The fracture may, however, be detected by other different imaging modalities. They may present with knee pain.

Bipartite Patella

Patella injury may be caused by direct or indirect traumatic injuries. Most of the injuries affect the male gender. The patient will report having sustained high trauma injuries, and therefore, the clinician should take a comprehensive history and perform an extensive musculoskeletal exam. With closed injuries, crepitus may be palpated, fracture gaps, or the joint may be swollen due to hemarthrosis. Evaluation is through AP and lateral knee radiographs.

Cruciate Ligament Injury

Cruciate ligament injuries may be anterior cruciate ligament or posterior cruciate ligament injuries. Injuries are most commonly due to traumatic injuries. Raj & Varacallo (2020) reports that patients with cruciate ligament injuries will complain of knee pain localized on the posterior region, swelling, and associated instability.

References

Aboulenain, S., & Saber, A. Y. (2023). Primary Osteoarthritis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557808/#:~:text=Primary%20Osteoarthritis%20-%20StatPearls%20-%20NCBI%20Bookshelf%20Osteoarthritis

Bump, J. M., & Lewis, L. (2020, May 24). Patellofemoral Syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557657/

Habusta, S. F., & Griffin, E. E. (2020). Chondromalacia Patella. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/

Ma, Q., Jiao, Q., Wang, S., Dong, L., Wang, Y., Chen, M., Wang, S., Ying, H., & Zhao, L. (2020). Prevalence and Clinical Significance of Occult Fractures in the Extremities in Children. Frontiers in Pediatrics, 8. https://doi.org/10.3389/fped.2020.00393

Raj, M. A., & Bubnis, M. A. (2019, March 21). Knee Meniscal Tears. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431067/

Raj, M. A., & Varacallo, M. (2020). Posterior Cruciate Ligament (PCL) Knee Injuries. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430726/

Zmerly, H., Moscato, M., & Akkawi, I. (2021). Assessment and Management of Loose Bodies in the Knee Joint and Related Disease: A Narrative Review. Current Rheumatology Reviews, 17. https://doi.org/10.2174/1573397117666211021165807

 

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