48
Hip and Knee Pain
JAMES I. HUDDLESTON • STUART GOODMAN
KEY POINTS
The clinician should be able to narrow the differential
diagnosis of hip or knee pain down to two to three diagnoses
after the history and physical examination.
Imaging studies should be used to confirm the diagnosis.
Conventional radiographs should usually be the initial
imaging study ordered.
Many of the vital structures in the knee can be palpated
easily or examined with provocative tests.
A knee effusion is often associated with internal
derangement.
The clinician should suspect a torn meniscus if a patient has
an effusion, joint line tenderness, and pain with
hyperextension and hyperflexion.
envelope around the knee and the fact that knee
pain is rarely referred, the pain generators around the knee
can often be elucidated with a complete history and thorough physical examination. Diagnosis of hip pain may be
more challenging because the joint is deeper and the
region is not infrequently the site of referred pain from the
spine. An understanding of the basic biomechanics of these
joints is also important in formulating a differential diagnosis because certain activities are likely to cause specific
injuries.
This chapter focuses on the important aspects of the
history, physical examination, and imaging modalities
involved in evaluating patients with complaints of knee and
hip pain. An appropriate, thorough workup of these patients
will allow the clinician to formulate an accurate differential
diagnosis in an efficient manner.
Patients with osteoarthritis often complain of stiffness and
pain with activity.
Inflammatory arthritis should be considered when a patient
continues to experience pain despite resting the joint.
Groin pain with internal rotation of the hip is due to hip
pathology until proven otherwise.
Concurrent hip and lumbosacral pathology is common.
It is estimated that musculoskeletal pain affects one-third
to one-half of the general population.1,2 Disease is occurring as the baby boomers have reached middle age and
beyond. This is exemplified by the increasing prevalence
of hip and knee replacement operations, which rose by
16.2% to 884,400 procedures annually in the United States
between 2002 and 2004.3 Furthermore, the prevalence of
total knee and total hip arthroplasty is expected to double
by 2016 and 2026, respectively.4 The hip and knee joints
are two of the most commonly affected sites of musculoskeletal pain, with the prevalence of hip pain ranging from
8% to 30% in persons 60 years of age and older5,6 and
the prevalence of knee pain ranging from 20% to 52% in
persons 55 years of age or older. In general, women experience more musculoskeletal pain than men.7 There are also
geographic and ethnic variations in the rates of both hip
and knee pain. For example, there tends to be significantly
less hip and knee pain with decreasing latitude, as well as
significantly less hip pain and osteoarthritis in China than
in the United States.8-15
When evaluating complaints of knee or hip pain, knowledge of the anatomy of these joints is necessary for formulating a differential diagnosis. Given the thin soft tissue
KNEE PAIN
History
A detailed history is perhaps the most important step in
accurately diagnosing the cause of knee pain. Knee complaints generally fall into two broad categories, pain or
instability. Pain may arise from injury to the articular surfaces (e.g., osteoarthritis, inflammatory arthritis, osteochondral defects, osteochondritis dissecans), torn menisci,
quadriceps and patella tendon tears, bursitis, nerve damage,
fractures, neoplasia, or infection. Referred pain from the hip
or spine is less common. Instability is usually episodic and
stems from injuries to the quadriceps-patellar extensor
mechanism, collateral ligaments, or cruciate ligaments. It is
important to distinguish true instability from the common
complaint of “giving way” because the latter is usually due
to a robust pain response rather than specific structural
pathology.
Patients in certain age groups tend to experience similar
injuries. In patients younger than 40 years, ligament injuries, acute meniscus tears, and patellofemoral problems are
frequently encountered. In contrast, degenerative conditions such as osteoarthritis and degenerative meniscal
lesions tend to occur more frequently in older patients.
The location and character of the pain are particularly
important when evaluating knee pain because many of the
structures vital to proper knee function are subcutaneous
and can be palpated easily. We prefer to conceptualize the
knee as three separate compartments—medial, lateral, and
patellofemoral. Each compartment should be examined
separately. The patient should be able to point to the exact
area where the pain is most severe. The onset of the pain
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should be determined. Osteoarthritis and inflammatory
arthritis tend to have an insidious onset, whereas injuries to
menisci and ligaments are usually associated with a traumatic event. Knowing the details of a traumatic event will
be helpful. For example, a twisting injury, especially one
sustained with a flexed knee, suggests a meniscus tear,
whereas a noncontact knee injury associated with change
of direction is more likely to produce a tear of the anterior
cruciate ligament (ACL). Pain from degenerative arthritis
tends to be associated with stiffness, is generally worse with
ongoing activity during the day, and is exacerbated by exercise, stair climbing, getting up from a chair, getting in and
out of a car, and so on.
The presence or absence of knee swelling is an important
part of the history because knee effusions (fluid in the knee
joint) usually accompany internal derangement. An effusion may also be present with synovitis, osteoarthritis,
inflammatory arthritis, fractures, infection, and neoplasm.
Distinguishing among soft tissue swelling around the knee,
synovial thickening, and a true knee effusion is critical (see
later). The timing or onset of the swelling is also important
for determining the diagnosis. An acute cruciate or collateral ligament injury or osteochondral fracture will usually
present with an acute hemarthrosis (occurring within an
hour), whereas an effusion associated with arthritis tends to
be more insidious in nature.
Complaints of “locking” are common. In a younger
patient, locking may be due to a displaced meniscal tear. In
older patients with degenerative arthritis, complaints of
locking are often due to loose bodies. It is important to
distinguish between true locking and diminished range of
motion due to pain (so-called pseudolocking) because this
distinction will determine which imaging studies are most
appropriate.
Timing of the pain with activity is also important for
making the correct diagnosis. Meniscus tears and ligament
injuries leading to instability will be particularly troublesome with activities such as walking on uneven surfaces,
stairs, and movements requiring knee flexion and pivoting.
Osteoarthritis tends to be exacerbated by all load-bearing
activities and relieved by rest.
The clinician should also explore the patient’s exercise
tolerance and ability to perform activities of daily living.
These details may give insight into the severity of the injury
and will also guide treatment. Important details include the
use of ambulatory assist devices (cane, crutches, walker,
brace, and wheelchair), walking tolerance, and capability
for other exercises (physical therapy).
A history of any previous treatments rendered should
also be recorded. One’s response to physical therapy, analgesics, nonsteroidal anti-inflammatories, nutritional supplements (such as glucosamine and chondroitin), intra-articular
injections of corticosteroids or hyaluronic acid derivatives,
and any operative treatments will lend further insight into
the accurate diagnosis and have implications for treatment
once the diagnosis has been confirmed.
At the end of taking a detailed history, the clinician
should be able to formulate a differential diagnosis with a
short list of potential conditions. This information should
then allow the physician to concentrate on specific aspects
of a focused physical examination that will lead to confirmation of the diagnosis.
Physical Examination
General
After a brief overall assessment of the patient, the physical
examination should begin with observation of the patient’s
lower extremity coronal alignment and leg lengths. We
prefer to have the patient stand with legs slightly apart
while he or she faces the examiner (Figure 48-1). A goniometer is then used to measure the varus/valgus alignment
of the knees. Evaluation of leg lengths should be performed
with step blocks of known sizes. The total height of the
blocks needed to make the iliac crests level with the floor
is equivalent to the leg-length discrepancy (Figure 48-2).
Gait is examined next. Although a comprehensive discussion of gait analysis is beyond the scope of this chapter,
all clinicians should routinely make a few basic observations
when evaluating the patient with a knee problem. Antalgic
gaits (shortened stance phase) and thrusts are commonly
seen. Any disorder that causes lower extremity pain may
cause an antalgic gait. Seen in the stance phase of gait,
thrusts may be due to a progressive angular deformity secondary to degenerative changes or chronic ligamentous
instability. Medial thrusts result from medial collateral ligament and/or posteromedial capsular laxity. Lateral thrusts
arise from lateral collateral ligament or posterolateral corner
laxity (Figure 48-3). Patients may also thrust into recurvatum (so called back-knee deformity) due to posterior capsular
laxity or quadriceps weakness.
The patient should then transfer to the examination
table for evaluation in a comfortable supine position. The
examination should proceed with inspection and palpation
before performing any provocative maneuvers. A pillow
should be placed under the knee if full extension is not
possible due to pain (e.g., fractures, displaced meniscus
tears, large effusion). If there is no known pre-existing
pathology, the contralateral knee can serve as an adequate
control. The lower extremity should be inspected for any
Figure 48-1 Assessment of coronal alignment.
CHAPTER 48 A
B
| Hip and Knee Pain
685
C
Figure 48-4 A-C, Large effusions can be detected by “ballotting” the
patella with the knee in extension.
Figure 48-2 The total height of the blocks needed to make the iliac
crests level is equal to the length discrepancy.
skin lesions, areas of ecchymosis, or surgical scars. Quadriceps atrophy should be noted, and a tape measure should be
used to record thigh circumference. It is good practice to
measure the thigh circumference at the same distance from
the patella or joint line in each knee. The presence of an
effusion should be noted. This will be seen as fullness or
swelling in the suprapatellar pouch. The effusion should be
confirmed by ballottement of the patella (Figure 48-4).
Small effusions will require “milking” of the fluid upward
into the suprapatellar pouch. This will allow for quantification of the amount of fluid (Figure 48-5). The active and
A
passive range of motion of both knees should be recorded
with a goniometer.
The examiner should then proceed with palpation of all
structures of the knee. It is important to do this in a systematic manner to ensure completeness. Palpation should be
gentle but firm enough to detect subtle pathology. Structures to be palpated include the quadriceps tendon, the
patella (superior and inferior poles), the pes anserinus bursa,
the medial (Figure 48-6A) and lateral (Figure 48-6B) joint
lines, the origins and insertions of the collateral ligaments,
the tibial tubercle, and the popliteal fossa. Fullness in the
posterior knee may be indicative of a Baker’s cyst.
Ligaments
Injuries to the collateral or cruciate ligaments may lead to
knee instability. It is important to mention that for each
B
Figure 48-3 The femur shifts medially during a medial thrust (A) and
laterally during a lateral thrust (B).
Figure 48-5 Small effusions can be appreciated by the “milking” of
fluid into the suprapatellar pouch.
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PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
A
Figure 48-7 The anterior drawer test is performed by subluxating the
tibia anteriorly with the knee in 90 degrees of flexion. The amount of
anterior translation (mm) is noted. The end point is characterized as
“soft” or “hard.”
B
Figure 48-6 Palpation of the medial (A) and lateral (B) joint lines.
translational and rotational motion of the knee, there are
both primary and secondary restraints. When a primary
restraint is disrupted, motion will be limited by the secondary restraint. If a secondary restraint is injured and the
primary restraint remains intact, then motion will not be
abnormal. For example, the ACL is the primary restraint to
anterior translation of the tibia, while the medial meniscus
is the secondary restraint. ACL disruption will lead to a
significant increase in anterior tibial translation. This translation will be increased if the patient had a prior medial
menisectomy.16
The collateral ligaments can be examined with stress
applied in the coronal plane. They should be examined in
full extension and in 30 degrees of flexion to remove the
influence of the cruciate ligaments and the capsular
restraints. With the patient in a supine position, a varus
force is applied across the knee to test the lateral collateral
ligament and a valgus force is applied across the knee to
evaluate the medial collateral ligament.
The ACL is one of the most frequently injured structures
in the knee. ACL insufficiency is also common in advanced
osteoarthritis. Common mechanisms of injury include a
direct blow to the lateral side of the knee (the “clipping”
injury in football causing the triad of medial collateral ligament, ACL, and medial meniscus injuries17), as well as
noncontact injuries that occur during cutting, pivoting, and
jumping.18 Patients often report an audible “pop” accompanied by the acute onset of knee swelling. Multiple tests have
been described to evaluate the ACL. The most sensitive
tests for diagnosis of an ACL injury include the anterior
drawer, Lachman,19 and pivot-shift tests.20,21 All three tests
are performed with the patient in the supine position. The
anterior drawer test is performed with the knee flexed to 90
degrees. The examiner places his or her hands on the posterior surface of the proximal tibia and subluxates the tibia
anteriorly (Figure 48-7). Any gross movement of the tibia
that is different from the contralateral side is considered
abnormal. The Lachman test is performed with the knee in
30 degrees of flexion (to remove the contribution of secondary restraints). The examiner applies an anterior force on
the tibia while stabilizing the femur with his or her contralateral hand. Any increase in anterior tibial translation relative to the contralateral side is considered abnormal (Figure
48-8). The pivot-shift test is performed with the knee in
extension. The examiner holds the tibia in slight internal
Figure 48-8 The Lachman test is performed by applying an anterior
force on the tibia while stabilizing the femur with the knee in 30 degrees
of flexion.
CHAPTER 48 A
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687
B
Figure 48-9 A and B, The pivot-shift test is positive if the tibia reduces with a “clunk” or a “glide” at 20 to 40 degrees of flexion.
rotation and applies a valgus stress while the knee is slowly
flexed. This combination of forces should cause the tibia to
subluxate anteriorly if the ACL is injured. The test is positive if the tibia reduces with a “clunk” or a “glide” at 20 to
40 degrees of flexion (Figure 48-9).
The posterior cruciate ligament (PCL) is the strongest
ligament in the knee,22,23 and thus injuries to the PCL are
usually a result of significant knee trauma. The “dashboard”
injury is a common mechanism for PCL injury and occurs
during a motor vehicle accident when the flexed knee
strikes the dashboard (Figure 48-10). The PCL can be evaluated with the posterior drawer, posterior sag, and quadriceps active tests. All tests are performed with the patient in
the supine position. The posterior drawer test is performed
with the knee in 90 degrees of flexion. The examiner applies
a posteriorly directed force to the tibia. Placement of one’s
thumb tips at the anterior joint line will allow for quantification of any abnormal translation (Figure 48-11). The
posterior sag test is positive when the tibia subluxates posteriorly with the knee at 90 degrees of flexion. Loss of the
medial tibial step-off at the joint line should alert the examiner to a PCL injury (Figure 48-12).22 This test is usually
positive in the chronic setting or under anesthesia in the
acute setting. The quadriceps active test is performed
with the knee in 60 degrees of flexion. The patient is asked
to extend the knee while keeping his or her foot on the
examination table. One will see reduction of the tibia in a
positive test.24
Figure 48-10 An injury to the posterior cruciate ligament can occur
when the tibia strikes the dashboard, causing the tibia to subluxate posteriorly on the femur.
Figure 48-11 The posterior drawer test is performed by subluxating
the tibia posteriorly with the knee in 90 degrees of flexion. The amount
of posterior translation (mm) is noted. The end point is characterized as
“soft” or “hard.”
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external rotation at both 30 degrees and 90 degrees of
flexion suggests combined PCL and posterolateral corner
injuries.
Menisci
Figure 48-12 The posterior sag test is positive when the tibia subluxates posteriorly with the knee at 90 degrees of flexion.
Injuries to the PCL are often accompanied by injuries to
the posterolateral corner, a complex structure that functions
as both a static and dynamic stabilizer of the knee.23 It is
composed of the lateral collateral ligament, the popliteofibular ligament, the popliteomeniscal attachment, the
arcuate ligament, and the popliteus tendon and muscle.25
Injuries to the posterolateral corner and/or the PCL can be
examined with the “dial test” (Figure 48-13). The posterolateral corner structures restrain external rotation at 30
degrees of flexion, while the PCL restrains external rotation
at 90 degrees of flexion. An increase of external rotation
at 90 degrees of flexion without an increase in external
rotation at 30 degrees of flexion suggests an isolated PCL
injury. An increase of external rotation at 30 degrees of
flexion without an increase at 90 degrees of flexion suggests
an isolated injury to the posterolateral corner. Increased
A
Traumatic and degenerative meniscal injuries are among
the most common knee injuries. The menisci are considered
the “shock-absorbing” cartilages of the knee. They also
provide rotational and translational restraint. The medial
meniscus tends to be more bean shaped and is both larger
and less mobile than the lateral meniscus. The lateral
meniscus tends to be more C shaped. These anatomic differences have implications for the different injury patterns
seen in these two structures.
Meniscal tears usually occur with rotation of the flexed
knee as it moves into extension. Tears of the medial meniscus are more common than tears of the lateral meniscus,
likely due to the relative lack of mobility of the medial
meniscus.26 Patients will frequently complain of “locking”
and “clicking” or of something “wrong” with the knee, and
this usually results from displacement of the torn meniscus
during motion. Common physical findings include pain
with hyperflexion and with hyperextension, joint line tenderness, and an effusion. Many provocative tests have been
described to diagnose meniscal tears. The McMurray27 and
Apley compression28 tests are frequently performed, though
they do lack sensitivity and specificity. The flexion McMurray test is performed with the patient supine and the hip
and knee flexed to 90 degrees. A compressive and rotational
force is applied to the knee as it is moved from a flexed to
an extended position. The test is positive if the patient
complains of pain (Figure 48-14). The Apley compression
test is performed with the patient prone and the knee flexed
to 90 degrees. In a positive test, the patient will complain
of pain with rotation of the tibia. An arthroscopic
B
Figure 48-13 A and B, The degree of tibial external rotation is measured in the “dial” test.
CHAPTER 48 | Hip and Knee Pain
689
Figure 48-16 An extensor lag due to a complete tear in the quadriceps
tendon.
Figure 48-14 A positive flexion McMurray test may indicate a torn
meniscus.
photograph in Figure 48-15 shows a tear in the posterior
horn of the medial meniscus.
prevalence of quadriceps tendon rupture after total knee
arthroplasty is a rare (0.1%) but devastating complication.29
Patients usually present with intense anterior knee pain
after experiencing an eccentric quadriceps contraction
during a fall or twisting injury. Physical examination reveals
a palpable defect in the tendon, an effusion due to hemarthrosis, and hypermobility of the patella. Patients will
usually not be able to fully extend their knee (Figure 48-16).
Quadriceps Tendon
Injuries to the quadriceps tendon are most common in the
sixth and seventh decades of life. Patients with systemic
lupus erythematosus, renal failure, endocrinopathies, diabetes, and various other systemic inflammatory and metabolic
diseases tend to be at a higher risk for these injuries. The
Patella Tendon
Problems with the infrapatellar tendon include tendinitis
and rupture. Tendinitis is usually an overuse injury and is
often associated with jumping, changes in activity level,
and eccentric contractions during falls. Patients will exhibit
tenderness at their tibial tubercle or at the inferior pole of
their patella. Rupture of the patella tendon usually occurs
in patients younger than 40 years of age and is associated
with chronic patella tendinitis. Patients usually present
with anterior knee pain and the inability to extend their
knee.
Patellofemoral Pain
A
B
Figure 48-15 Arthroscopic photograph of a tear in the posterior horn
of the medial meniscus before (A) and after (B) debridement.
Anterior knee pain is a common complaint seen by many
orthopedic surgeons. It is more common in women, and it
accounts for up to 25% of all sports-related knee injuries.30
A variety of factors contribute to the biomechanics of the
patellofemoral joint and include overuse, the depth of
the trochlea, the shape of the patella, quadriceps strength,
the line of pull of the quadriceps relative to the patella
tendon (the Q angle), the length of the patella tendon, the
shape of the femoral condyles, and the articular cartilage.
Abnormalities of any of these factors may contribute to this
pain syndrome, and successful treatment is possible only
with correct identification of any contributing factors.
Physical examination of the patellofemoral joint begins
with an analysis of coronal alignment of the knee because
any valgus deformity may contribute to lateral subluxation.
The height of the patella relative to the tibial tubercle
should be noted (patella alta or baja). The J sign is present
when the patella slides laterally at terminal extension,
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indicating excessive pull of the vastus lateralis. The vastus
medialis obliquus is the primary stabilizer against lateral pull
by the vastus lateralis. With the knee extended and the
quadriceps relaxed, the examiner should make note of any
patellar tilt. Any crepitus, either audible or palpable, should
be noted as well. Crepitus is common in osteoarthritis. A
Q angle greater than 15 degrees in females and greater than
8 degrees to 10 degrees in males is considered abnormal.30
Patellar mobility should be assessed using a quadrant system
for passive mediolateral displacement of the patella relative
to the trochlear groove. The normal patella should not be
displaced medially or laterally beyond the second quadrant.
Any abnormality in mobility may stem from changes in the
tightness of the retinaculum. The apprehension test is performed by attempting to subluxate the patella with the knee
in extension. The test is positive when it elicits pain and
an unwillingness to allow the examiner to move the patella
laterally (Figure 48-17).
At the conclusion of the history and physical examination, the astute clinician should have formulated a short list
of possible diagnoses. With this list in mind, the appropriate
imaging studies can now be obtained. The goal of the initial
imaging studies should be to confirm the diagnosis with the
most appropriate and least expensive study. Advanced
imaging studies should not replace a thorough history and
physical examination.
Imaging
Conventional Radiographs
Conventional roentgenograms are usually the first study
obtained after knee injury and should be read in a systematic
fashion. Soft tissues should be evaluated before examining
the bony structures. Findings should be described in terms
of radiolucent and radiopaque lines. Only after the findings
Figure 48-17 The apprehension test is positive when subluxation of
the patella causes pain.
have been described should the interpretation phase
begin. It is the natural tendency to bypass the description
and proceed directly to interpretation. If this is done, it is
likely that certain findings will be missed or dismissed
prematurely.
The basic radiographic evaluation of the knee consists
of standing anteroposterior (AP) weight-bearing, lateral,
and Merchant’s views. The AP view allows for evaluation
of coronal alignment and height of the tibiofemoral joint
spaces. The normal coronal alignment of the knee should
be 5 to 7 degrees of anatomic (tibiofemoral) valgus. The
lateral tibiofemoral joint space should be wider than the
medial tibiofemoral joint space in a normal knee. The presence of marginal osteophytes, joint space narrowing, subchondral sclerosis, and cystic change will be seen in the
presence of osteoarthritis (Figure 48-18). Periarticular
A
C
B
Figure 48-18 Standing anteroposterior (A), lateral (B), and Merchant’s (C) views of an osteoarthritic knee.
CHAPTER 48 | Hip and Knee Pain
691
Computed Tomography
Computed tomography (CT) has largely been replaced by
magnetic resonance imaging (MRI) in evaluation of routine
knee problems. CT is now used primarily for detection of
bony tumors and in the trauma setting for detection of
subtle fractures that are not easily visualized with conventional radiographs, as well as for a more thorough evaluation
of intra-articular fractures. In cases of distal femoral or proximal tibia fractures, CT is used to help the surgeon plan
operative treatment. CT is also used to assess axial alignment of the femoral and tibial components in cases of the
painful total knee arthroplasty.33,34
Ultrasound
A
B
C
Figure 48-19 Standing AP (A), lateral (B), and Merchant’s (C) views of
the knee in a patient with rheumatoid arthritis.
osteopenia, concentric joint space narrowing, and a paucity
of osteophytes are commonly seen in inflammatory arthritis
(Figure 48-19). The lateral radiograph allows for evaluation
of an effusion, patella tendon length, and the quadriceps
tendon. The Merchant’s view is taken tangential to the
patellofemoral joint.31 It allows for detection of patellofemoral arthritis and malalignment.
Additional views include a posteroanterior (PA) standing view with the knees flexed approximately 45 degrees,
the tunnel or intercondylar notch view, and the 36-inch AP
standing view of bilateral lower extremities. The flexed PA
standing view is taken with the radiographic beam directed
10 degrees caudad from anterior to posterior. This allows for
evaluation of the posterior femoral condyles for joint space
narrowing.32 The tunnel view is obtained with the knee
flexed and the radiographic beam directed inferiorly at an
angle perpendicular to the tibial plateau. It is useful in
detecting posterior tibiofemoral joint space narrowing,
tibial spine fractures, loose bodies, and osteochondral lesions
on the medial aspect of the femoral condyles. The 36-inch
standing view is used for determining the mechanical axis
of the lower extremity and evaluating any deformity that
may be present. The normal mechanical axis is a straight
line joining the center of the hip, knee, and ankle joints.
Surgeons use it for preoperative planning and postoperative
evaluation in total knee arthroplasty, as well for the planning of distal femoral and proximal tibia osteotomies in
arthritis surgery.
The use of ultrasound has become more common in the
diagnosis of knee disorders due to recent improvements in
transducer technology. Ultrasound is an attractive imaging
modality because of its low cost, real-time capabilities, and
portability. The ability to perform provocative maneuvers
during sonography is particularly appealing. Ultrasound can
easily and reliably detect joint effusions, as well as quadriceps and patella tendon disruptions. It has been reported
that ultrasound can detect a 1-mm increase in joint fluid.35
Nuclear Scintigraphy
Nuclear scintigraphy is sensitive but not specific, and it is
used to detect areas of increased osseous remodeling. It
requires clinical correlation and should be used in conjunction with other imaging modalities. Technetium phosphate
compounds are injected intravenously. Approximately 50%
of the tracer is excreted by the kidneys, and the remainder
is taken up in areas of increased osseous turnover. Imaging
of the skeleton is typically performed 2 to 3 hours after
injection because this allows for maximum contrast between
the soft tissues and the skeletal structures while still providing for an adequate photon count.36
Three-phase bone scanning can yield additional information. The three phases include an angiographic pool,
followed by blood pool and bone imaging. The angiographic
phases allow for detection of regional hyperemia. This technique has been reported to have greater specificity and can
be used in cases of suspected osteomyelitis, osteonecrosis,
stress fracture, and implant loosening.36 It has been reported
that increased radionuclide uptake can be seen for up to 12
to 18 months after total knee arthroplasty. Asymmetric
uptake in one area around the prosthesis should raise the
question of loosening or periprosthetic fracture (Figure
48-20).37,38 Addition of labeled leukocytes to the technetium 99m sulfur colloid yields an 80% sensitivity and 100%
specificity for diagnosing infection.39
Magnetic Resonance Imaging
MRI has supplanted many imaging modalities due to its
direct multiplanar capabilities and superior soft tissue contrast. Although conventional radiographs remain the gold
standard for defining osseous structures, MRI provides
excellent visualization of articular cartilage, the cruciate
ligaments, the collateral ligaments, the patella tendon, the
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ANT
POST
RT MED L LAT
L MED RT LAT
Figure 48-20 A bone scan reveals increased uptake of radiotracer around the distal femur in this patient with an infected total knee arthroplasty
and septic loosening of his femoral component.
quadriceps tendon, and the menisci (Figure 48-21). It is also
highly sensitive for detecting bone marrow edema (contusion), stress fractures, and mass lesions. Use of the “two-slice
touch” rule has improved the sensitivity and specificity of
MRI in accurately diagnosing meniscal tears. This rule classifies a meniscus as torn if there are two or more magnetic
resonance (MR) images with abnormal findings and as possibly torn if there is only one MR image with an abnormal
finding. Using fast spin-echo imaging, the sensitivity and
specificity for diagnosing medial and lateral meniscal tears
was 95% and 85%, and 77% and 89%, respectively. This
translates to a positive predictive value of 91% to 94% for
medial meniscus tears and 83% to 96% for lateral meniscus
tears.40
Common Disorders in the Differential Diagnosis
of Knee Pain
General
Though many diseases may involve the knee, a limited
number are encountered frequently. In evaluating the complaint of knee pain, the clinician should be familiar with
osteoarthritis; rheumatoid arthritis; inflammatory arthritis
associated with the seronegative spondyloarthropathies;
tears of the menisci, ligaments, and tendons; osteochondritis dissecans; osteochondral fractures; fractures; referred
pain from the hip (such as with slipped capital femoral
epiphysis in adolescents); vascular claudication; neurogenic
claudication; complex regional pain syndrome; sarcoma;
metastases; and infection.
Bursitis
The prepatellar bursa lies between the retinaculum and the
subcutaneous fat and runs from the patella to the tibial
tubercle. The bursa may become inflamed and fill with fluid
when exposed to a direct blow or repetitive microtrauma
(kneeling). Patients with prepatellar bursitis present with
anterior knee pain on flexion and a fluctuant mass over the
anterior knee. If the area becomes warm, tender to palpation, and erythematous, septic bursitis should be ruled out
with aspiration. The pes anserinus bursa, located over the
insertions of the sartorius, gracilis, and semitendinosus
muscles on the proximal medial tibia, can also be a source
of knee pain if inflamed.
Neoplasia
Figure 48-21 This sagittal magnetic resonance image shows linear
signal change extending to the meniscal surface consistent with a tear
in the posterior horn of the medial meniscus.
Tumors around the knee are often diagnosed after trauma
prompts medical evaluation. Pain at night, pain at rest,
and constitutional symptoms should alert the clinician
CHAPTER 48 to consider the appropriate workup. Some of the benign
tumors seen around the knee include enchondroma, pigmented villonodular synovitis, osteochondromatosis, and
giant cell tumor. Malignant tumors seen around the knee
include, but are not limited to, metastases, osteosarcoma,
Ewing’s sarcoma, chondrosarcoma, and malignant fibrous
histiocytoma.
Popliteal Cysts
A popliteal cyst, originally called Baker’s cyst, is a synovial
fluid-filled mass located in the popliteal fossa. The most
common synovial popliteal cyst is considered to be a distention of the bursa located beneath the medial head of the
gastrocnemius muscle. Usually, in an adult patient, an
underlying intra-articular disorder (osteoarthritis) is present.
In children, the cyst can be isolated and the knee joint
normal. Patients usually present with episodic posterior
knee pain.41 The diagnosis is made by ultrasonography or
MRI. Treatment options include benign neglect, aspiration,
surgical excision, or removal of the underlying pathology
(arthritis) with knee arthroplasty.
HIP PAIN
History
Taking an accurate history is an important initial step in
formulating a differential diagnosis for patients who present
with a complaint of hip pain. In general, more conditions
should be considered in the differential diagnosis for hip
pain than for knee pain because the hip is a common site
for referred pain from lumbosacral and intrapelvic pathology. A detailed, comprehensive history will direct the clinician to a focused physical examination.
Most patients who present with hip pathology will complain of pain. It is important to define the exact location of
the pain because “hip” pain may refer to discomfort in the
groin, lateral thigh, or buttock. Pain in the groin or medial
thigh region is most often due to hip disease and is believed
to arise from irritation of the capsule and/or synovial
lining.42 Pain generated in the lumbosacral spine may be
referred to the buttocks and/or lateral thigh.43 Lateral thigh
pain may stem from so-called trochanteric bursitis (usually
abductor tendinitis) as well. Activities or positions that
aggravate and relieve the pain should be explored. The
severity, frequency, and patterns of radiation of the pain
should also be evaluated. It is not uncommon for knee pain
to be generated from the hip joint. Metastatic and primary
tumors that occur in the pelvic and proximal thigh regions
should always be included in the differential diagnosis.
Intrapelvic pathology from the prostate, seminal vesicles,
hernias, ovaries, gastrointestinal (GI) system, and vasculature should also be considered.44,45
Knowledge of the patient’s general level of functioning
is important because this will lend insight into the severity
of disease and may influence treatment. Patients with hip
pathology may have difficulty trimming their toenails,
donning shoes and socks, and using stairs. Walking tolerance and use of assist devices should also be recorded. The
Harris Hip Score and WOMAC Osteoarthritis Index are
two rating scales that are widely used to assess function in
this patient population.46,47
| Hip and Knee Pain
693
The patient should be asked about any hip problems that
he or she encountered in childhood. Diseases such as developmental dysplasia, slipped capital femoral epiphysis, LeggCalvé-Perthes disease, polio, and trauma may lead to
osteoarthrosis later in life.48-50 Any treatment rendered for
these diseases should be asked about as well.
Osteoarthritis and inflammatory arthritis are two
common causes of hip pain. In general, pain from osteoarthritis will be exacerbated by activity and relieved by rest.
Mild arthritis of the hip may not become symptomatic until
a certain activity level is reached. Stiffness (usually from
synovitis) is also a common complaint with both degenerative and inflammatory arthritis. When the hip pain continues despite a trial of rest, an underlying inflammatory or
infectious process should be considered. The American
Rheumatism Association revised their classification of rheumatoid arthritis in 1988. The current criteria include 1 hour
of morning stiffness for 6 weeks, symmetric joint swelling in
at least three joints, subcutaneous nodules, typical radiographic changes, and a positive rheumatoid factor.51
Any previous treatments for hip pain should be discussed.
The patient’s response to nonsteroidal anti-inflammatory
medications, nutritional supplements (e.g., chondroitin
and glucosamine), physical therapy, corticosteroid injections, local anesthetic injections, hyaluronic acid injections, ultrasound, and operative interventions should be
recorded. Lastly, a more general medical history should be
explored. The physician should be aware of alcoholism,
neuromuscular disorders, smoking history, and general
support systems.
Physical Examination
The physical examination of the patient with hip pain
begins as the clinician watches the patient for the first time.
Ease of chair rise, postures, and walking speed all provide
insight into the extent of a patient’s disability. A general
evaluation of the patient’s spine, lower extremity alignment, and leg lengths comes next. With the examiner
behind the patient, the spine is examined for coronal and
sagittal balance. The patient is asked to touch his or her
toes. A rib hump indicates the presence of scoliosis. Any
gross deformity of the spine will alert the examiner to the
potential of a pelvic obliquity and resultant leg-length discrepancy. The overall coronal alignment of the lower
extremities is evaluated next. If a leg-length discrepancy is
detected, blocks can be used, as discussed previously, to
determine the amount of apparent inequality. If the leglength discrepancy is due to a fixed pelvic obliquity from
lumbosacral disease, blocks may not be able to level the
pelvis. Previous surgical scars about the hip are noted. Palpation of the bony landmarks (iliac crest, anterior superior
iliac spine, posterior superior iliac spine, ischial tuberosity,
coccyx, spinous processes, and greater trochanter) should be
performed (Figure 48-22). The femoral neck is located
approximately three fingerbreadths below the anterior superior iliac spine.
A basic evaluation of gait should be performed. Though
gait analysis is a complex science, all clinicians should feel
comfortable evaluating for common abnormalities. The
patient with hip pain may present with an antalgic gait. The
severity of the limp should be classified as mild, moderate,
or severe. Mild limps can only be detected by trained
694
PART 6 Iliac
crest
| DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
Anterior
superior
iliac spine
Greater
trochanter
Ischial
tuberosity
Spinous
process
Posterior
superior
iliac spine
process
Coccyx
Figure 48-22 Diagram of the bony landmarks on the pelvis that can
be palpated during physical examination.
observers. Moderate limps will be noticed by the patient. A
severe limp will be readily apparent and have a significant
impact on speed of ambulation. Common causes of limp
include pain and abductor (gluteus medius and gluteus
minimus) weakness. Differentiating between these two
etiologies of limp is an important part of the physical
examination.
The patient with abductor dysfunction will likely have
an abductor, or Trendelenburg lurch.52 With a Trendelenburg lurch, the patient compensates for abductor dysfunction by leaning over the involved hip to shift the body’s
center of gravity in that direction (Figure 48-23). If the
patient has a Trendelenburg lurch, we proceed to evaluate
for a Trendelenburg sign. A positive Trendelenburg sign
A
B
occurs when the pelvis tilts toward the unsupported side
during one-legged stance. This test is best performed with
the examiner behind the patient. Causes of abductor
weakness are numerous and may include a contracted or
shortened gluteus medius, coxa vara, fracture, dysplasia,
neurologic conditions (e.g., superior gluteal nerve injury,
radiculopathy, poliomyelitis, myelomeningocele, spinal
cord lesions), and slipped capital femoral epiphysis.
The patient is then asked to lay supine on the examination table. The range of motion of both hips should be
evaluated by recording flexion, extension, adduction, abduction, internal rotation in extension, and external rotation
in extension. Hip extension is best evaluated with the
patient in the prone position. Normal range of motion
values include 100 to 135 degrees for flexion (knee should
be flexed to relax the hamstrings), 15 to 30 degrees for
extension, 0 to 30 degrees for adduction, 0 to 40 degrees for
abduction, 0 to 40 degrees for internal rotation, and 0 to
60 degrees for external rotation. Motion is often limited
in cases of deformity (such as limited internal rotation in
slipped capital femoral epiphysis) and advanced osteoarthritis. Internal rotation and abduction are usually the first
motions to be limited in osteoarthritis. Motion will be
painful in patients with synovitis as well. Areas that are
painful should be palpated.
A series of special tests can be performed to evaluate for
subtle muscle contractures and limitation of motion. The
presence of a hip flexion contracture is common in patients
with moderate to severe hip pathology and can be quantified with the Thomas test (Figure 48-24).53 This test is
performed by having the patient bring his or her thighs to
their chest while in the supine position. This allows for
flattening of the spine, and the hip to be evaluated is allowed
to extend to neutral. If the patient is unable to reach neutral,
the amount of flexion contracture is recorded. The Ober
test measures tightness of the iliotibial band. The patient
lies on the unaffected side and the examiner helps the
patient abduct the hip with the hip extended and the knee
C
Figure 48-23 Physical examination of abductor function: A, Normal
single-legged stance. B, Positive Trendelenburg lurch and negative Trendelenburg sign. C, Positive Trendelenburg lurch with pelvic obliquity and
leaning over the involved hip to shift the body’s center of gravity.
Figure 48-24 In the Thomas test, a hip flexion contracture is measured
by flexing the contralateral hip to eliminate compensatory lumbar lordosis. The ipsilateral hip is then allowed to extend with gravity. The angle
between the examination table and the thigh is the degree of flexion
contracture.
CHAPTER 48 flexed to 90 degrees. The leg is slowly released from abduction to neutral, and the hip will remain abducted if there is
contracture of the iliotibial band. Ely’s test will detect a
tight rectus femoris. The knee is passively flexed with the
patient in the prone position. If the rectus femoris is tight,
the ipsilateral hip will spontaneously flex. If the rectus
femoris is normal, the hip will remain flush with the examination table.
Patients will occasionally complain of a “snapping” sensation in their hip. Although it may be difficult for the clinician to reproduce snapping, patients may be able to
demonstrate this by flexing and internally rotating their hip.
Extra-articular causes of hip snapping include a thickened
iliotibial band snapping over the greater trochanter, the
iliopsoas tendon gliding over the iliopectineal eminence,
the long head of the biceps tendon rubbing on the ischial
tuberosity, and the iliofemoral ligament rubbing on the
femoral head. Intra-articular causes of snapping hip syndrome include loose bodies and large labral tears.
In addition to using blocks with the patient standing, leg
lengths can be measured while the patient is in the supine
position (Figure 48-25). The apparent leg length is the distance from the umbilicus to the medial malleolus. The true
leg length is measured from the anterior superior iliac spine
to the medial malleolus. Pelvic obliquity and abduction/
adduction of the hip will create an apparent leg-length
discrepancy.
Sacroiliac disease should be included in the differential
diagnosis of hip pain. Although multiple provocative tests
have been described to elicit sacroiliac disease, the flexion
in abduction and external rotation (FABER) test (also
known as Patrick’s test) can help distinguish between hip
and sacroiliac joint pathology. With the patient supine, the
clinician has the patient place his or her hip in the flexion,
abduction, and externally rotated position. The clinician
then presses the flexed knee and the contralateral anterior
superior iliac spine toward the floor. Pain in the buttocks
suggests sacroiliac joint disease, whereas pain in the groin
A
B
| Hip and Knee Pain
695
points to hip pathology. If the sacroiliac joint is implicated,
it is recommended that multiple other provocative tests be
performed. It has been shown that by using a combination
of the distraction, thigh thrust, compression, sacral thrust,
Gaenslen’s, and FABER tests, sacroiliac joint pathology is
the likely pain generator when three or more of the tests
are positive.54,55
The acetabular labrum is drawing attention as a previously underappreciated cause of hip pain. Clinical presentation of a labral tear of the acetabulum may be variable, and
the diagnosis is often delayed. Patients usually see multiple
providers before the diagnosis is confirmed. In a series of
66 patients with arthroscopically confirmed tears of the
acetabular labrum, 92% of the patients complained of groin
pain, 91% of the patients had activity-related pain, 71% of
the patients complained of night pain, 86% of the patients
described the pain as moderate to severe, and 95% of the
patients had a positive impingement sign. The authors recommended that a diagnosis of acetabular labral tear be suspected in young, active patients complaining of groin pain
with or without trauma.56 The positive impingement test
helps confirm the diagnosis of labral tear. The test is positive
if the patient experiences groin pain with the hip flexed,
adducted, and internally rotated. The positive predictive
value of this test has been shown to range from 0.91 to 1.00
in six different studies.57-62
A thorough evaluation of the neurovascular system
should be completed after the musculoskeletal portion of
the physical examination for the hip or knee is completed.
This should include palpation or Doppler evaluation of the
femoral, popliteal, dorsalis pedis, and posterior tibial arteries, as indicated. Strength testing with resisted isometric
movements for each muscle in the lower extremity is performed, with 5 being normal strength, 4 being full motion
against gravity and against some resistance, 3 being fair
motion against gravity, 2 being movement only with gravity
eliminated, 1 being evidence of muscle contraction but no
joint motion, and 0 being no evidence of contractility.
C
Figure 48-25 Measurement of leg lengths: A, The apparent leg length is the distance from the umbilicus to the medial malleolus. B, Pelvic obliquity
causing an apparent leg-length discrepancy. C, The true leg length is the distance from the anterior superior iliac spine to the medial malleolus.
696
PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
Figure 48-26 An anteroposterior pelvis demonstrates the characteristic joint space narrowing, cystic changes, and osteophytes seen in
osteoarthritis.
Sensation in the lower extremity should be evaluated by
assessing for light touch and/or appreciation of pin prick in
a dermatomal distribution. Patellar and ankle reflexes
should be tested. Lastly, the examiner should test for any
abnormal clonus and Babinski reflexes as indicated.
Imaging
Figure 48-27 An anteroposterior hip demonstrating the characteristic
concentric joint space narrowing, paucity of osteophytes, and periarticular osteopenia seen in rheumatoid arthritis.
Nuclear Scintigraphy
The role of bone scanning in the evaluation of hip pathology is similar to its role in the assessment of knee pain. It
should always be used in conjunction with other imaging
modalities due to its limited specificity (Figure 48-30).
Conventional Radiographs
Plain radiographs remain the primary diagnostic imaging
tool for the evaluation of hip pathology. All other imaging
modalities should be viewed as complementary to conventional radiographs. Our standard screening series includes a
low anteroposterior (AP) pelvis (Figure 48-26), an AP hip
(Figure 48-27), a frog-lateral view, and a cross-table lateral
view. The frog-lateral view provides a lateral of the proximal
femur and is useful for detecting femoral head collapse (as
seen in osteonecrosis, Figure 48-28). Numerous other special
radiographs of the hip exist including Judet 45-degree
oblique views and the false profile view. Judet views allow
for easier visualization of the anterior (obturator oblique)
and posterior (iliac oblique) columns. The false profile view
allows for evaluation of anterior bony coverage of the
femoral head in cases of acetabular dysplasia. Developmental dysplasia of the hip (DDH) is common, and we do not
recommend the routine use of any special views before referral to an orthopedic surgeon (Figure 48-29).
Magnetic Resonance Imaging
MRI provides unprecedented detail of the soft tissues around
the hip joint. Its use is now common for diagnosis of osteonecrosis, labral pathology, neoplasia, effusion, synovitis,
loose bodies, tendinitis, transient osteoporosis of the hip,
Computed Tomography
Computed tomography (CT) is used for assessment of acetabular fractures, acetabular nonunions, femoral head fractures, subtle femoral neck fractures, neoplasia, and bone
stock in the revision total hip arthroplasty setting. Due to
its limited soft tissue contrast, CT has largely been replaced
by MRI for detailed evaluation of the soft tissues around
the hip.
Figure 48-28 A frog-lateral radiograph demonstrating femoral head
collapse from osteonecrosis.
CHAPTER 48 Figure 48-29 An anteroposterior hip radiograph demonstrates osteoarthrosis from developmental dysplasia. The up-sloping lateral edge of
the acetabulum is characteristic for developmental dysplasia of the hip.
occult femoral neck fractures, bone edema, gluteus medius
tendon avulsions, and nerve injury. MR arthrography of the
hip joint is useful for identifying gluteus medius tendon
avulsion after total hip arthroplasty (Figure 48-31) and
for detecting labral tears. One study showed a 92% sensi­
tivity for the detection of labral tears using MR arthrography.63 Delayed gadolinium-enhanced MRI of cartilage, a
| Hip and Knee Pain
697
Figure 48-31 This short tau inversion recovery coronal magnetic resonance image shows a complete avulsion of the gluteus medius tendon
from its insertion on the greater trochanter. Note the signal change
along the lateral aspect of the greater trochanter, consistent with accumulation of intra-articular gadolinium at the site where the gluteus
medius tendon should be.
technique designed to measure early arthritis in the hip
joint, is now being used clinically in the management of hip
dysplasia.64 Despite the tremendous diagnostic capabilities
of MRI, its ability to detect bony pathology is limited. As
such, conventional radiographs remain the imaging modality of choice for the screening of hip pathology.
ANT blood pool
POS blood pool
LAT RT hip
ANT hips
POS hips
LAT LT hip
Figure 48-30 This bone scan shows increased radiotracer uptake at the proximal femur. The patient presented with activity-related thigh pain 1 year
after primary cementless total hip arthroplasty. History, physical examination, and conventional radiographs suggested failure of osseointegration. At
the time of surgery the femoral component was found to be grossly loose.
698
PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
Hip Arthrography
Hip arthrography is useful for detecting avulsions of the
gluteus medius tendon from the greater trochanter and for
differentiating intra-articular hip pathology from lumbosacral disease. In one study, intra-articular anesthetic injection was 90% accurate in predicting intra-articular pathology
as confirmed by hip arthroscopy.65 Anesthetic arthrogram of
the hip has shown a 95% positive predictive value and a
67% negative predictive value for pain relief after total hip
arthroplasty in patients with concurrent hip and lumbar
osteoarthritis.66
Common Disorders in the Differential Diagnosis
of Hip Pain
Numerous common causes of hip pain exist, and a detailed
discussion of these is beyond the scope of this chapter.
The differential diagnosis of hip pain should include osteoarthrosis (most frequently from developmental dysplasia,
Legg-Calvé-Perthes disease, or slipped capital femoral
epiphysis); inflammatory arthritis; osteonecrosis; fractures
(acetabulum, femoral head, femoral neck, intertrochanteric,
or subtrochanteric); trochanteric bursitis; femoroacetabular
impingement; tears of the acetabular labrum; transient
osteoporosis of the proximal femur; infection; snapping
hip syndrome; osteitis pubis; neoplasia (osteosarcoma,
chondrosarcoma, pigmented villonodular synovitis, osteochondromatosis, malignant fibrous histiocytoma, or metastases); inguinal hernia; or referred pain (lumbosacral spine,
sacroiliac joint, prostate, seminal vesicles, uterus, ovaries,
lower GI tract). This list can be efficiently narrowed
down by taking a detailed history, performing a compre­
hensive examination of the musculoskeletal and neur­
ovascular systems, and obtaining the appropriate imaging
studies.
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The references for this chapter can also be found on www.expertconsult.com.