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Probability diagnosis

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Ligament strains and sprains ± traumatic synovitis

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Osteoarthritis

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Patellofemoral syndrome

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Prepatellar bursitis

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Serious disorders not to be missed

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Vascular disorders:

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  • deep venous thrombosis

  • superficial thrombophlebitis

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Neoplasia/cancer:

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  • primary in bone

  • metastases

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Infection:

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  • septic arthritis

  • tuberculosis

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Rheumatic fever

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Rheumatoid arthritis

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Acute cruciate ligament tear

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Juvenile chronic arthritis

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Pitfalls (often missed)

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Referred pain: back or hip disease

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Foreign bodies

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Intra-articular loose bodies

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Osteochondritis dissecans

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Osteonecrosis

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Synovial chondromatosis

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Osgood–Schlatter disorder

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Meniscal tears

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Fractures around knee

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Pseudogout (chondrocalcinosis)

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Gout → patellar bursitis

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Ruptured popliteal (Baker’s) cyst

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Rarities:

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  • sarcoidosis

  • Paget disease

  • spondyloarthropathy

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Masquerades checklist

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Depression

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Diabetes

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Spinal dysfunction (referred)

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Is the patient trying to tell me something?

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Psychogenic factors relevant, especially with possible injury compensation.

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Key history

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The history helps diagnosis, especially evaluating the nature of the injury. Define whether the pain is acute or chronic, dull or sharp, continuous or recurring. Keep in mind age-related causes and past history.

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Key examination

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The provisional diagnosis may be evident from a combination of the history and simple inspection of the joint but the process of testing palpation, movements (active and passive) and specific structures of the knee joint helps pinpoint the disorder.

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Key investigations

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Consider:

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  • FBE/ESR

  • connective tissue antibodies

  • blood culture

  • plain X-ray including special views

  • bone scan

  • ultrasound

  • arthrography: CT scan, MRI (excellent for investigating internal ‘derangement’)

  • arthroscopy

  • aspiration of fluid for culture or crystal examination.

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Diagnostic tips

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Examine the hip and lumbosacral spine if examination of the knee is normal but knee pain is the complaint.

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Acute haemarthrosis following an injury should be regarded as an anterior cruciate ligament tear until proved otherwise.

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