Version June 2024
| Condition | Mechanism & historical features | Common symptoms | Key examination findings | Additional comments |
| Anterior knee pain | ||||
| Conditions with focal pain | ||||
| Common in athletes in early to mid teens whose sports involve cutting and jumping. Often occurs during growth spurt while athlete is very active. Pain increases with activity and decreases with rest. | Pain around tibial tubercle or inferior pole of patella. | Tenderness at tibial tubercle or inferior pole of patella. Focal swelling & warmth directly over apophysis. Knee stable and motion normal. | Apophysitis at tibial tubercle (Osgood Schlatter) is far more common than apophysitis at inferior pole of patella (Sinding Larsen Johansson). Plain radiographs show open apophysis, often with fragmentation. US shows open apophysis & fluid over tuberosity. |
| Caused by painful edema within fat pad. | Anterior knee pain. Pain increases with kneeling, walking, squatting, or running. | Tenderness along either side of patella tendon (not tendon proper). Asymmetric swelling adjacent to patellar tendon. | May contribute to patellofemoral maltracking. |
| History of overuse, typically involving sports with jumping or sprinting and sudden direction change. Gradual onset of pain that steadily increases over time if ballistic activity continues. | Pain at tendon or inferior pole of patella (patellar tendinopathy) or superior pole of patella (quadriceps tendinopathy) with ballistic movements (eg, jumping, sprinting, cutting). | Tendon tender at inferior pole of patella (most common), along tendon, at tibial tuberosity, or at superior pole of patella. Tendon may feel thick compared to normal (contralateral) one. Often associated with tight quadriceps and/or hip flexors. Knee motion normal. Squat or hop reproduces pain. | US shows characteristic changes of tendinopathy. Patellar tendinopathy more common than quadriceps. In skeletally immature, consider apophysitis. |
| Swelling develops over days just anterior or inferior to patella. History of continual pressure on affected area (eg, laborer working while kneeling); not typically associated with acute trauma, but prior puncture wound may be reported. | Pain and swelling just anterior to or below patella. | Swollen boggy bursa: Early swelling anterior to or below patella; gradually swelling increases. Overlying skin erythematous. Knee motion normal. | US shows fluid collection; fluid extends into soft tissues as swelling increases. Aspiration may be needed to rule out septic bursitis. |
| History of trauma to medial peripatellar area or dislocation/subluxation of patella. Runners with genu valgus ("knock knees") at risk. | Pain around medial patella that increases with movement (knee flexion and extension). | Thickened plica palpable under medial patella. Patella tracks abnormally during knee flexion-extension. Audible pop from medial patella area during flexion-extension. | US shows thickened plica. |
| Conditions without focal pain | ||||
| Pivoting or sudden change in direction produces acute episodes, which recur. | Knee "out of place" (typically lateral). Many episodes reduce spontaneously prior to presentation. | Tenderness often present along medial patellar border. Effusion may be present after acute dislocation. | Patients with hypermobility may have recurrent dislocation with milder symptoms and physical findings. More common among young females. |
| History of overuse, often involving running. | Diffuse, anterior peri-patellar pain. Knee may feel "unstable". Pain increases with squatting, prolonged sitting, running (especially downhill), climbing or descending stairs. | Patellar undersurface may be tender (medial or lateral). Weak terminal knee extension and VMO atrophy common. Weak hip flexion, abduction, & external rotation common. Hamstring tightness common. Patellofemoral compression test may be positive. Normal knee motion. Effusion rare. | Patellofemoral pain accounts for 70% of outpatient visits for knee pain. Structural intra-articular injury must be ruled out if recurrent effusions or unusual findings (eg, abnormal knee motion or laxity detected) present. Patient may describe knee weakness (or "giving out"), likely due to reflex inhibition of quadriceps from pain. Chondromalacia patella presents with similar history and examination, but advanced imaging reveals pathologic changes. |
| As with patellofemoral pain above. | As with patellofemoral pain above. | As with patellofemoral pain above. | MRI typically not necessary, but reveals pathologic changes in articular cartilage on underside of patella. |
| History may be unclear; pain likely insidious in onset. Most common in active people training in ballistic sports. Athletes who have increased training volume and/or intensity over past weeks to months. | Anterior knee pain made worse by activity, particularly ballistic movements (jumping). | Patella tenderness (depends on severity of fracture). Normal knee motion. | Fracture may not be apparent in plain radiographs; MRI or CT may be required for diagnosis. |
| Medial knee pain | ||||
| Develops over years and presents in older adults, usually without inciting trauma. | Symptoms often mild but may complain of baseline discomfort. Pain with pivoting or knee twisting. Knee may catch or lock. | Medial joint line tenderness. Knee motion may not be smooth and range may be limited. Provocative tests (eg, Thesaly, McMurray) usually positive. Pain increases with deep squat. | US may show calcifications, fraying of peripheral meniscus, and cysts in regions of swelling. MRI generally accurate and diagnostic. |
| Pain may be caused by typically benign stimuli or movement. Pain radiates along course of saphenous nerve. | Pain increases with palpation or tapping (Tinel sign) at site of entrapment. | US may show thickened nerve or surrounding fluid. Nerve block relieves symptoms. | |
| Associated with repeated valgus knee strain (genu valgus). | Anteromedial knee pain in area of pes anserine tendon insertion. | Swelling at proximal anteromedial tibia. Area of bursa tender. Resisted knee flexion or hip adduction elicits pain at area of bursa. | US may reveal characteristic changes of bursitis (eg, fluid collection), or pes anserine tendinopathy. |
| Lateral knee pain | ||||
| Insidious onset of lateral knee pain related to overuse. Occurs primarily in runners, but also in cyclists. In runners, pain can vary with pace & increases on sloped surfaces. Pain increases over time if activity continues. | Pain where ITB crosses lateral femoral condyle. Pain increases with prolonged exercise but may persist afterwards. | Tender ITB where it crosses lateral femoral condyle. Weak hip abduction is common. | Generally two patient types:
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| Develops over years and presents in older adults, typically without inciting trauma. | Symptoms often mild but may complain of baseline discomfort. Pain with pivoting or knee twisting. Knee may catch or lock. | Lateral joint line tenderness. Knee motion may not be smooth and range may be limited. Provocative tests (eg, Thesaly, McMurray) usually positive. Pain increases with deep squat. | US may show calcifications, fraying of peripheral meniscus, and cysts in regions of swelling. MRI generally accurate and diagnostic. |
| Posterior knee pain | ||||
| Typically occurs in older individuals with cardiovascular risk factors. | Small aneurysms may be asymptomatic. Claudication symptoms with activity. | Pulsatile mass may be palpable in popliteal fossa. | US can identify aneurysm; can compare with contralateral knee. Associated with abdominal aortic aneurysm. |
| Not associated with risk factors for cardiovascular disease. | Pain deep in calf or popliteal fossa. Claudication symptoms with vigorous activities involving repeated ankle dorsi- and plantar flexion. Asymptomatic at rest. | Resting physical examination unremarkable. | Rare cause of knee pain. More common in young male athletes. |
| Damaged protruding posterior knee capsule with many potential causes. | Posterior knee pain and tightness. | Palpable swollen cystic structure in popliteal fossa. | Often associated with intra-articular pathology or knee osteoarthritis. If cyst ruptures, knee pain & tightness typically resolve; fluid may track into calf causing swelling. US shows compressible fluid-filled mass, typically medial to vascular bundle. |
| Gradual onset of posterolateral knee pain. Often caused by excessive running (especially downhill) or sprinting, also by hiking downhill. | Posterior knee pain. Pain increases when runner is "braking" or trying to prevent acceleration while running downhill. | Tenderness at posterior aspect of lateral femoral condyle (palpate popliteal tendon with patient in figure-of-4 position). Resisted tibial external rotation may elicit pain. | US reveals characteristic changes of tendinopathy. |
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