menuSymptoms In Detail
Pain
In principle the site, nature, character and severity of pain are determined by specific questions.
General Questions:
Location (vague widespread suggesting patella-femoral source or localised to medial or lateral joint line)
Nature (sharp, burning, dull ache etc)
Exacerbating features (activity related or at rest)
Pain radiation
Progress over time (getting worse or better)
Specific Scenarios:
Pain on medial aspect of knee on deep squatting: indicates a meniscal tear
Joint pain radiating down leg: indicates arthritic aching process
Pain at rest: usually indicates severe arthritis
Pain at night: indicates inflammatory cause
Pain worse on sitting for prolonged periods or on climbing/descending stairs: indicates patello-femoral problems
Pain in multiple sites: indicates either a generalised problem or may indicate inappropriate pain response
Swelling
Swelling usually indicates that there is a significant problem in the knee
General questions:
Relation to onset of symptoms (earlier or late).
Exacerbating features
Relieving features
Specific Scenarios:
Swelling occurring within four hours from pivoting injury: indicates torn anterior cruciate ligament
Swelling occurring greater than four hours after twisting injury: usually indicates a meniscal tear
Swelling with activity: usually indicates a degenerative process
Localised hard swelling on lateral joint line after activity: indicates lateral meniscal cyst from a tear
Extra articular swelling: indicates a bursa
Non specific onset: indicates an inflammatory problem
A very tense and painful swelling following injury: usually means haemarthrosis and a more significant injury
Locking
This means the transient inability of the leg to go out straight rather than difficulty in flexing the knee. It is important to distinguish this from pseudo locking following medial collateral injury where extension is limited by pain.
General Questions:
Exacerbating factors (squatting, twisting etc)
Relieving factors
Exact description of locking (asking the patient what they mean by locking)
Permanently blocked or intermittent
True meniscal locking or false patella catching
Specific Scenarios:
Intermittent locking of the knee relieved by shaking the leg or a trick manoeuvre: indicates a loose body
Inability to fully straighten the leg at any time following trauma: indicates a meniscal tear, osteochondral fragment or ACL stump blocking full extension
Transient locking on standing: may indicate catching of the worn arthritic surfaces
Giving Way
Giving way can also be described as buckling, not trusting the knee or giving out.
General Questions:
Movements associated with the giving way (pivoting movements, straight line activities or descending stairs)
Description of giving way sensation (twisting knuckles sign or patella giving way)
Relation to pain (pain before or after giving way)
Specific Scenarios:
Rotational giving way mimicked by twisted knuckles: indicates ACL deficiency
Knee giving way on pivoting to one side and feeling of patella jumping: indicates patella dislocation
Knee giving way on squatting associated with medial pain: indicates meniscal tear
Knee giving way on stairs with falling over: indicates patella dislocation. With ACL type giving way the patient is usually able to catch themselves
Giving way after pain: usually due to quads inhibition associated with pain from the catching of worn surfaces
Additional clinical features to elicit
Other specific detail is required to lead to an action plan and these include:
Noises and sensations in the joint:
A feeling of something moving around indicates a loose body
A painful grating sensation indicates crepitus and possible damage to the joint surface
A thudding clunk usually indicates a meniscal tear catching or relocating
Severity of the symptoms in relation to lifestyle:
For the active individual this means sporting aims and desired activity levels.
For the arthritic assessment this means walking distance, ability to climb stairs, night waking and interference with quality of life.
