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Non-Traumatic Anterior Knee Pain Care Pathway

Date of last update: September, 2024

4. Differential Diagnosis Requiring Medical Attention

 

Red Flags: Immediate Referral to Emergency Care:

1. Deep Vein Thrombosis (DVT)

  • Pain Location: Throbbing pain in calf or thigh.

  • Signs/Symptoms/Red Flags: Active cancer, paralysis/paresis/recent plaster immobilization of lower extremity, recently bedridden for 3 days, major surgery within 12 weeks requiring general anesthesia, previous DVT, shortness of breath, chest pain.

  • Physical and Neurological Examination: Warmth, localized tenderness along distribution of deep veins, entire leg swollen, no neurological deficits.

  • Action: Immediate referral to emergency care.

 

2. Infection (i.e., Septic arthritis)

  • Pain Location: Localized pain in the knee area.

  • Signs/Symptoms/Red Flags: Severe acute pain; erythema, warmth, and edema around knee joint; night sweats; night pain, recent trauma/surgery, intravenous drug use, fever, chills, reduced joint mobility.

  • Physical and Neurological Examination: Diffuse tenderness, warmth to touch, edema, no neurological deficits.

  • Action: Immediate referral to emergency care.

Refer to Medical Provider:

 

1. Peripheral Arterial Disease (PAD)

  • Pain Location: Leg pain/cramping while walking, often in calves.

  • Signs/Symptoms: Cold lower extremities; history of coronary heart disease, cerebrovascular disease, diabetes, hypertension, hypercholesterolemia; family history of PAD; smoking; previous vascular problems; cancer; COPD; previous thromboembolic events.

  • Physical and Neurological Examination: Absent/weak pulses in lower extremities, skin colour changes, sores on feet, leg numbness/ weakness.

  • Action: Referral to appropriate medical provider.

 

2. Inflammatory Arthritides (rheumatoid arthritis, reactive arthritis, gout)

1. Rheumatoid Arthritis

  • Pain Location: Various joints, often symmetrical, including the knee.

  • Signs/Symptoms: Morning stiffness > 1 hour; symmetrical joint pain; joint swelling and deformity; systemic symptoms such as fatigue or malaise..

  • Physical and Neurological Examination: Swollen, tender joints; deformities in severe cases; no neurological deficits.

  • Action: Referral to appropriate medical provider.

2. Reactive Arthritis

  • Pain Location: Various joints, often including the knee.

  • Signs/Symptoms: Joint pain and swelling following an infection; symptoms may include conjunctivitis and urethritis; systemic symptoms such as fatigue.

  • Physical and Neurological Examination: Swollen, tender joints; no neurological deficits.

  • Action: Referral to appropriate medical provider.

 

3. Gout

  • Pain Location: Typically affects the big toe but can also involve the knee and other joints..

  • Signs/Symptoms: Sudden onset of severe pain; redness; swelling; warmth in the affected joint; recurrent attacks; history of hyperuricemia.

  • Physical and Neurological Examination: Extremely tender, swollen, and warm joint; red or purplish skin around the affected joint; no neurological deficits.

  • Action: Referral to appropriate medical provider.

3. Referred Pain

1. Slipped Capital Femoral Epiphysis (SCFE)

  • Pain Location: Referred knee pain from hip joint pathology.

  • Signs/Symptoms: Pain with activity and relief with rest; typically occurs in adolescence or late childhood.

  • Physical and Neurological Examination: Walking or running with a limp, toe-out gait, or leg length discrepancy; no neurological deficits.

  • Action: Referral to appropriate medical provider.

 

2. Hip Osteoarthritis

  • Pain Location: Referred knee pain from the hip.

  • Signs/Symptoms: Hip pain and stiffness; groin pain; pain with weight-bearing activities.

  • Physical and Neurological Examination: Reduced range of motion in the hip; antalgic gait; no neurological deficits.

  • Action: Referral to appropriate medical provider.

3. Lumbar Radiculopathy

  • Pain Location: Referred pain from the lower back to the knee.

  • Signs/Symptoms: Lower back pain; radiating pain to the knee; numbness or tingling in the leg.

  • Physical and Neurological Examination: Positive straight leg raise test; neurological deficits such as weakness or altered sensation.

  • Action: Referral to appropriate medical provider.

4. Tumor (e.g., Giant cell tumor)

  • Pain Location: Knee or surrounding areas.

  • Signs/Symptoms: Noticeable lump; pain that worsens with movement; swelling.

  • Physical and Neurological Examination: Palpable mass; tenderness over the affected area; no neurological deficits.

  • Action: Referral to appropriate medical provider.

5. Peripheral Neuropathy

Saphenous nerve (i.e., Saphenous Neuritis or Gonalgia Paresthetica)

  • Pain Location: Anterior or medial knee pain.

  • Signs/Symptoms: Occasionally described as pain to touch along the nerve. Can be activity-related pain or pain at rest.

  • Physical and Neurological Examination: Aggravated by limb movements that tension the nerve; sensory deficits along the distribution of the saphenous nerve.

  • Action: Referral to appropriate medical provider.

Back to care pathway

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

All content and media on the Canadian Chiropractic Guideline Initiative (CCGI) website is created and published online for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. Always seek the guidance of a qualified health professional with questions, concerns or management regarding your health.

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