knee pain

Respond to at of your colleagues . Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

Mallory Bisher
Review of Case Study 3 (Knee Pain)
COLLAPSE
Case Study: Knee Pain

Patient Information:

Patient Name: JS Age: 15 Gender: Male Race: Caucasian

S.

CC: Dull pain in both knees

HPI: John Smith is a 15-year-old Caucasian male who presents to the clinic today with his mother due to dull pain in both knees. John reports that the pain started approximately a month ago; however, has worsened the past 2 days. John reports that at times one or both knees click, and there is a catching sensation under the patella. John reports swelling of the knees but denies any other symptoms. John reports that the pain is exacerbated by physical activity, including running, and going up and down the stairs. John reports that elevation, ice, and ibuprofen his pain. John reports his current pain level is a 5/10 and 8/10 at its worst (on a scale of 1-10, 10 being the worst).

Current Medications:

Multivitamin once daily
Ibuprofen 200mg PO every 4 to 6 hours as needed for pain

Allergies: No known drug, food, or environmental allergies.

PMHx: Reports receiving all necessary childhood immunizations. Reports receiving COVID vaccine in January 2022, denies receiving booster. Reports receiving annual flu shot on 10/1/22. Denied previous hospitalizations or surgery. Denies any chronic medical conditions.

Soc Hx: Lives at home with his parents and younger brother. Full-time student. Engaged in extracurricular activities including cross country and track. Enjoys hanging out with friends. Negative for previous or current tobacco use. Denies exposure to secondhand smoke. Denies alcohol and illicit drug use.

Fam Hx:

Father: No diagnosed health conditions; several knee surgeries due to football related injuries
Mother: Generalized anxiety disorder; asthma
Sister (age 12): Asthma
Paternal Grandfather: Deceasedlung cancer
Paternal Grandmother: HTN; Generalized anxiety disorder
Maternal Grandfather: HTN
Maternal Grandmother: Deceasedbrain tumor
ROS:

General: Denies fever, chills, fatigue, and weight loss/gain.

Skin: Reports acne. Denies rashes or moles. Denies history of skin cancer.

Cardiovascular: Denies chest pain or discomfort. Denies palpitations.

Respiratory: Denies shortness of breath, wheezing, and cough. No sputum.

Gastrointestinal: Denies anorexia, nausea, vomiting, and diarrhea. Denies abdominal pain.

Musculoskeletal: Reports dull pain and swelling in bilateral knees. Reports occasional clicking and catching sensation in bilateral knees. Denies back pain. Denies pain in upper extremities. Denies history of arthritis. Denies loss of range of motion.

Neurological: Denies recent loss of consciousness. Denies syncope. Denies falls or seizures. Denies problems with balance and coordination.

Hematologic/Lymphatics: Denies easy bruising and bleeding. Denies history of anemia. Denies any swollen glands.

O.

Physical exam:

Vital signs: BP: 124/80, right arm, sitting, small cuff; P: 76 and regular; T: 98.6 orally; RR: 17, non-labored; Wt: 104; Ht: 51; BMI: 19

General: Alert and oriented X4. Speech is clear and appropriate. Appears well nourished. Appears mildly uncomfortable.

Skin: Normal turgor, no rash, or lesions. No cyanosis, pallor, or jaundice.

Cardiovascular: S1 and S2 sounds audible. No gallops, murmur, friction, or rubs.

Respiratory: Breath sounds clear to auscultation in all lung fields. No crackles or wheezing. Chest wall is symmetrical. Respirations are non-labored.

Abdomen: Soft, nondistended, and nontender. No splenomegaly. Normoactive bowel sounds.

Musculoskeletal: Fully weight-bearing. No spine curvature. Joints and muscles are symmetrical with no redness or deformity. Swelling of bilateral knees. Full range of motion in upper extremities. Reduced range of motion in bilateral knees. Normal muscle tone. Negative for crepitus. Negative for edema.

Neurological: Alert and oriented X4. Cranial nerves II-XII grossly intact. Intact deep tendon reflexes.

Diagnostic results:

Ballottement examination
Vastus medialis coordination test; Patellar apprehension test; Waldron’s test; Clarke’s test; Eccentric step test (Nijs et al., 2006)
McMurray test
Bulge sign
X-ray
MRI scan
A.

Differential Diagnoses:

Patellar tendinitis (Jumpers knee)

Patellofemoral pain syndrome (Runners knee)
According to Bump and Lewis (2022), patellofemoral pain syndrome is one of the most common causes of anterior knee pain. The specific etiology of patellofemoral pain syndrome is unknown but it is believed to be multifactorial and secondary to physical training (Bump & Lewis, 2022). Symptoms of patellofemoral pain syndrome may be unilateral or bilateral and acute or gradual (Bump & Lewis, 2022). The pain associated with patellofemoral pain syndrome is often described as achy and typically worsens with running, squatting, and climbing stairs (Bump & Lewis, 2022). Additionally, some individuals may experience a catching sensation in the knee (Bump & Lewis, 2022). Although JS has the signs and symptoms associated with patellofemoral pain syndrome, there are more consistencies with patellar tendinitis.

Bursitis
Bursitis is inflammation of the bursa (Ball et al., 2019). Bursitis can occur in several locations including the knee, hip, elbow, and shoulder (Ball et al., 2019). Individuals who have bursitis commonly experience pain and stiffness surrounding the joint around the inflamed bursa (Ball et al., 2019), which is the knee in this case. In general, when someone has bursitis, they may experience increased pain during activity. Objective data for bursitis may include reduced range of motion due to swelling, pain on movement, point tenderness, and warmth at the site (Ball et al., 2019). Additionally, pain and soreness may radiate to tendons at the site (Ball et al., 2019). JS reports symptoms that are consistent with bursitis; however, is negative for point tenderness, warmth at site, and pain radiation. JSs symptoms appear more consistent with patellar tendinitis.

Osgood-schlatter disease
According to Dains et al. (2019), Osgood-schlatter disease is a common condition in adolescent males and may result from strenuous activity. Osgood-schlatter disease is characterized by painful swelling of the anterior portion of the tibial tubercle (Dains et al., 2019). In addition to painful swelling, individuals with Osgood-schlatter disease will often limp and experience increased pain with stair climbing and kneeling (Dains et al., 2019). Physical examination may reveal swelling, warmth, and tenderness of the tibial tubercle (Dains et al., 2019). JSs assessment reveal signs and symptoms consistent with Osgood-schlatter disease; however, is negative for a limp, warmth, and tenderness of the knee.

Medial meniscus tear
According to Dains et al. (2019), medial meniscus injuries occur after a twisting injury to the knee. Signs and symptoms of medial meniscus tear may include pain, trouble flexing the knee, difficulty bearing weight, clicking or catching in the knee joint, swelling of the knee joint, and tenderness (Dains et al., 2019). Due to JSs reported symptoms, it is imperative to rule out medial meniscus tear. Although JS has several signs and symptoms consistent with medial meniscus tear, JS does not have difficulty bearing weight or tenderness. Additionally, JS denies having suffered an injury.

Primary Diagnosis:

Patellar tendinitis (Jumpers knee)
According to Santana et al. (2022), patellar tendinitis is a painful condition of the knee caused by small tears in the patellar tendon. Patellar tendinitis may result from repetitive actions associated with physical activity (Ball et al., 2019). Dains et al. (2019) indicated that patellar tendinitis occurs more frequently in individuals who engage in physical activities such as running and jumping. Individuals who have patellar tendinitis complain of dull, achy pain and may have associated clicking (Dains et al., 2019). Additionally, patellar tendinitis may cause reduced range of motion in the affected joint (Ball et al., 2019). JSs subjective report and assessment results are most consistent with patellar tendinitis.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier Mosby.

Bump, J., & Lewis, L. (2022). Patellofemoral syndrome. StatPearls. StatPearls Publishing

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Nijs, J., Van Geel, C., Van der auwera, C., & Van de Velde, B. (2006, February). Diagnostic value of five clinical tests in patellofemoral pain syndrome. Manual Therapy, 11(1), 6977. https://doi.org/10.1016/j.math.2005.04.002

Santana, J., Mabrouk, A., & Sherman, A. (2022). Jumpers knee. StatPearls. StatPearls Publishing

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