Lincoln Mayhew: A 25-Year-Old Male With Right Anteroinferior Knee Pain and Swelling

Learning Objectives

•

Learn the common causes of knee pain.
•

Develop an understanding of the unique anatomy of the knee joint.
•

Develop an understanding of the bursae of the knee.
•

Develop an understanding of the ligaments of the knee.
•

Develop an understanding of the tendons of the knee.
•

Develop an understanding of the differential diagnosis of knee pain.
•

Learn the clinical presentation of jumper’s knee.
•

Learn how to examine the knee and associated ligaments.
•

Learn how to use physical examination to identify jumper’s knee.
•

Develop an understanding of the treatment options for jumper’s knee.

Lincoln Mayhew

Lincoln Mayhew is a 25-year-old male track star with the chief complaint of “my right knee keeps swelling up and hurting.” Lincoln stated that over the past few weeks, his right knee has become increasingly swollen and painful, especially after his workout. “Doc, as an elite athlete, I have to stay in shape—you know, sprints, hurdles, and laps. I can’t miss a day.” Lincoln noted that he was competing in a regional qualifier and he landed “kind of funny” on his right knee. His knee was a little sore that night, but he thought he would just work through it, so he didn’t alter his routine. He tried the whirlpool, analgesic balm, an elastic wrap, and Motrin, but in spite of all this, his knee pain got worse and it started to swell.

“Doctor, I’ve got to get my knee better. Can you just give me a shot or something? I have a big meet coming up and I don’t know how I can compete like this.” I asked Lincoln about any previous injuries to the right knee and he said that both of his knees could be sore after a heavy workout, but he had never had anything like this.

I asked Lincoln what made his symptoms worse and he said, “Anytime I put weight on my right knee, I’m in trouble. I have trouble walking, and have been sleeping on the couch because it’s so hard trying to walk upstairs to my bedroom. Between the couch and the knee pain, my sleep is really off.”

I asked Lincoln to point with one finger to show me where the pain was and he pointed to the area in front of his right knee just below the patella and said, “It hurts right here, Doc.”

On physical examination, Lincoln was afebrile. His respirations were 16 and his pulse was 65 and regular. His blood pressure was 120/70. Lincoln’s head, eys, ears, nose, and throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal, as was his abdominal examination. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the right knee revealed a large effusion, which I confirmed with the ballottement test (see Fig. 2.2 ). The area over the anterior knee was warm but did not appear to be infected. There was significant tenderness with palpation of the superior and inferior poles of the patella as well as with palpation of the patellar tendon ( Fig. 5.1 ). Examination of the bursae of the knee revealed no obvious bursitis, but the swelling of the knee could have hidden subtle findings. I performed the single-leg decline squat test, which was markedly positive on the right and negative on the left ( Fig. 5.2 ). Range of motion of the knee joint, especially resisted extension of the joint, reproduced Lincoln’s pain. The left knee examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper and lower extremities revealed that there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

■

Onset of right knee pain and swelling of the right knee following landing wrong after jumping a hurdle
■

Significant swelling of the right knee
■

Pain localized to the anterior knee
■

Difficulty walking stairs
■

No other specific traumatic event to the area identified
■

No fever or chills
■

Sleep disturbance

The Physical Examination

■

The patient is afebrile
■

There is no ecchymosis over the anterior knee
■

There is significant swelling of the knee
■

Tenderness to palpation of the patellar tendon on the right
■

Tenderness to palpation of the superior and inferior poles of the patella on the right
■

No evidence of infection
■

Pain on resisted extension of the affected right knee
■

The single-leg decline squat test was positive on the right (see Fig. 5.2 )

Other Findings of Note

■

Normal HEENT examination
■

Normal cardiovascular examination
■

Normal pulmonary examination
■

Normal abdominal examination
■

No peripheral edema
■

Normal upper and lower extremity neurologic examination, motor and sensory examination
■

No evidence of bursitis
■

Examinations of other joints other than the right knee were normal

What Tests Would You Like to Order?

The following tests were ordered:

■

Plain radiographs of the right knee
■

Ultrasound of the right knee
■

Magnetic resonance imaging (MRI) of the right knee

Test Results

The plain radiographs of the right knee were reported as normal. Ultrasound examination of the right knee revealed tendinopathy of the patellar tendon and a large joint effusion ( Figs. 5.3 and 5.4 ). MRI examination of the right knee demonstrates significant patellar tendinopathy consistent with jumper’s knee ( Fig. 5.5 ).