Background
The patient is 22 years old. Previously healthy. A student and plays football in his free time. He consults his general practitioner due to increasing pain (VAS 5) in the right knee joint and can no longer play football. There have been some hard tackles in matches over the past six months. Six months ago, the patient had a twist with temporary swelling. The coach said it was a ligament strain. The patient has not fully recovered since the incident.
The pain is located at the front of the knee joint, sometimes with swelling around the patella. Over the last two months, the pain has increased to VAS 6. Exercise and walking down stairs worsen the symptoms. The patient also experiences more pain with prolonged sitting with the knee bent, for example on the bus and in lectures. There have been no locking episodes. The patient has not used painkillers.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I have been having more and more pain in my right knee, and now I can no longer play football.
- Doctor
How long have you had these complaints?
- Patient
It has built up over time, but it has become noticeably worse over the last two months.
- Doctor
Has there been any injury?
- Patient
There have been some hard tackles in the last six months. And six months ago I twisted my knee and got some swelling afterward.
- Doctor
What did you hear that time?
- Patient
The coach said that it was probably just a sprain in a ligament. But I haven't fully recovered from it.
- Doctor
Where is the pain mostly located?
- Patient
At the front of the knee. And sometimes it swells a bit around the kneecap.
- Doctor
What makes it worse?
- Patient
Training makes it worse. And it is especially painful when I go down stairs.
- Doctor
Does it hurt when you are sitting still?
- Patient
Yes, if I sit for a long time with my knee bent, for example on the bus or at school, it starts to hurt.
- Doctor
Has the knee locked up?
- Patient
No, it has not locked up.
- Doctor
Have you taken painkillers?
- Patient
No, I haven't really taken anything for it.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Patellofemoral pain syndrome.
- Differential diagnoses are patellar tendon pathology, injury to the medial collateral ligament, and medial meniscus injury.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Passive extension in the knee joint
Doctor
I want to move your knee a little. Let me know if it hurts.
Patient
With full passive extension, the recognizable pain increases a little.
Yes, right at the very edge there I feel it in the front of the knee.
Findings
- Slightly increased pain with full passive extension in the knee joint.
- The pain is located over the lower part of the patella and at the front of the knee joint, somewhat medially.
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2. Palpation of the patellar tendon attachment at the apex of the patella
Doctor
I feel a little here on the front of the knee. Indicate where it is tender.
Patient
Clearly indicates local pain at the attachment area on the apex of the patella.
Yes, right down there on the kneecap it hurts.
Findings
- Localized pain on palpation at the attachment of the patellar tendon on the apex of the patella.
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3. Grinding test
Doctor
Now I will do a test of the kneecap. Let me know if it triggers the pain you feel.
Patient
Indicates recognizable pain at the front of the knee.
Yes, it hurts at the front of the knee.
Findings
- Pain at the front of the knee joint during the Grinding test.
-
4. Lateral stability and medial collateral ligament
Doctor
I will test the ligaments on the side of your knee.
Patient
Presents pain on the inside of the knee during valgus stress.
It hurts on the inside when you test there.
Findings
- Pain on the inside of the knee joint when testing the medial collateral ligament.
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5. Cruciate ligament tests
Doctor
I also check the cruciate ligaments.
Patient
No obvious pain or sense of laxity beyond normal examination discomfort.
It goes fine.
Findings
- The cruciate ligament tests are normal.
-
6. Meniscus test
Doctor
Now I am testing the meniscus. Let me know if you feel pain, clicking, or if it locks.
Patient
Reports slight discomfort medially in the front of the knee joint.
It is slightly uncomfortable on the inside in the front, but it does not click.
It does not lock.
Findings
- Slight discomfort in the medial anterior part of the knee joint during meniscus test.
- No clicking sensation and no tendency to lock.
-
7. Valgus test at 30 degrees flexion
Doctor
I also test the knee in a slightly bent position.
Patient
Indicates pain in the medial joint space, but the examination does not show instability.
It hurts on the inside, but it does not feel like it gives way.
Findings
- Some pain in the medial joint space during valgus test at 30 degrees flexion.
- No instability in valgus test.
Learning points
- 1 Anterior knee pain in a young, active patient.
- 2 Worsening with load, especially going down stairs and during prolonged sitting with a bent knee.
- 3 Relationship between pain provocation during Grinding test and localized tenderness at the patellar tendon attachment on the apex of the patella.
- 4 Differential diagnoses can be screened with tests of the collateral ligaments, meniscus, and cruciate ligaments.