Publication Date: March 2024 (Volume 27, Number 3)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 03/01/2028.
Authors
Vanica Guignard, MD
Assistant Professor of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL
John Kiel, DO, MPH, FACEP, CAQSM
Associate Professor of Emergency Medicine, Associate Professor of Sports Medicine, University of South Florida Morsani College of Medicine, Tampa, FL
Diego Riveros, MD
Attending Physician, Emergency Medicine, Tampa General Hospital, Tampa, FL
Peer Reviewers
Daniel Eraso, MD, FACEP
Assistant Professor, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, FL
Michael P. Jones, MD
Professor of Emergency Medicine, Vice Chair for Education, Residency Director, Albert Einstein College of Medicine, Jacobi + Montefiore, Bronx, NY
John Munyak, MD
Urgent Care Sports Medicine Physician, New York Bone and Joint Specialists, New York, NY
Abstract
Knee pain is a common presenting complaint in the emergency department, and although the major etiologies are overuse and degenerative, inflammatory and infectious causes must be ruled out. This issue reviews the potential causes of knee pain from the history and physical examination, symptom location-based differential, clinical clues, and special testing strategies. Evidence on the uses of x-ray and ultrasound for diagnostic imaging is reviewed. For suspected infectious causes, procedures for palpation-guided and ultrasound-guided arthrocentesis are outlined. Treatment strategies are summarized, with evidence on the effectiveness of weight loss, physical therapy, orthotics, medication therapies, joint injections, and nerve blocks considered.
Case Presentations
CASE 1
A 19-year-old woman presents with knee pain that she says becomes worse when she is running…
Her vital signs are: temperature, 37°C; heart rate, 72 beats/min; blood pressure, 114/68 mm Hg; and respiratory rate, 14 breaths/min. You note that she has a low body mass index and a history of amenorrhea.
On examination, she has no joint effusion, but her knee is quite tender on the medial femoral condyle.
She has been waiting some time for radiographic studies, and you wonder: does she really need that knee x-ray?
CASE 2
A 70-year-old woman presents with knee pain that she says has been present for several months…
She says there has been no trauma, and the pain has gotten progressively worse with ambulation.
Her vital signs are: temperature, 36.8°C; heart rate, 88 beats/min; blood pressure, 136/80 mm Hg; and respiratory rate, 12 breaths/min.
On examination, she is tender along both the medial and lateral joint lines, with a trace effusion. You note that both of her knees seem to have overt degenerative changes.
The physician assistant with you at bedside asks whether a knee immobilizer would be appropriate…
CASE 3
A 32-year-old man is brought in by EMS with fever and knee pain…
His vital signs are: temperature, 39°C; heart rate, 108 beats/min; blood pressure, 120/82 mm Hg; and respiratory rate, 16 breaths/min.
When you ask him about risk factors, he says that he is an IV drug user.
Although the patient is currently hemodynamically stable, he looks very uncomfortable. There is effusion in his right knee, it is warm, and he has extreme pain with any range of motion.
You consider the high likelihood that this patient has a septic knee joint, and wonder: is bedside ultrasound best-practice for aspirating a septic joint? What are the current laboratory cutoff levels for making a diagnosis of septic arthritis?
Accreditation:
EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
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