Knee pain

Knee pain- This is a sign of pathological processes affecting the cartilage, bone or soft tissue structures of the femoral-tibial and femoral-patellar joints. Arthralgia can be based on trauma, inflammatory and degenerative diseases of the joint apparatus and periarticular structures. Patients may complain of sharp, painful, burning, throbbing, and other types of pain that occur at rest or when moving, maintaining, bending, and stretching the leg at the knee. Diagnosis of causal pathology includes instrumental imaging methods (Rg, ultrasound, CT or MRI, arthroscopy), puncture of the joint capsule, biochemical and immunological analyzes. Until the diagnosis is clarified, rest, immobilization of the joints, NSAIDs and analgesics are recommended.

Causes of knee pain

Traumatic injury

They are usually the result of domestic trauma, common in athletes: runners, jumpers, sports participants. It develops when falling, hitting or twisting the leg. Manifested with sharp pain at the time of injury. In the future, the pain syndrome becomes less pronounced, accompanied by increasing edema. Abrasions and bruises are possible. As the frequency increases, the following injuries are identified:

• Knee injury. . . Occurs when a knee falls or hits directly. At first the pain is sharp, hot, sometimes burning, but bearable, later - dull, painful, worse with movement. Bruises are possible. The support of the legs is preserved. Sometimes the knee injury is complicated by hemarthrosis, in such cases the joint gradually increases in volume, becomes spherical, a feeling of pressure or rupture is added to the pain syndrome.
• Ligament rupture.It is detected after twisting the leg, forcing it to twist, bend or unfold in an unphysiological position. Painful sensations are stronger than bruising; at the same time as pain appears, one can feel something tearing (similar to how ordinary tissue is torn). Accompanied by significant restriction of movement, support, torsion of the limb, rapidly increasing hemarthrosis.
• Intra-articular fractures. . . They are found when hitting, falling and twisting the legs. In case of injury, a person feels very sharp, often unbearable sharp pain, sometimes a squeak is heard. Patients with an intra-articular fracture themselves describe their feelings as follows: "the pain is such that it darkens in the eyes, the world ceases to exist, you do not understand anything. ", movement is almost completely restricted, and edema and hemarthrosis progress rapidly.
• Dislocation.This is the result of a blow or fall to the knee. At the moment of dislocation of the patella, sharp pain appears, accompanied by a feeling of bending the leg and displacement in the knee. No movement possible, reference function can be saved. On the anterior surface of the knee a pronounced deformation is seen, which is subsequently smoothed out due to the increasing swelling. Sometimes hemarthrosis joins.
• Pathological fractures.They develop in minor injuries, are a consequence of reduced bone strength in osteoporosis, osteomyelitis, tuberculosis, bone tumors. The pain is painful, dull, reminiscent of the bruise pain syndrome. Signs of a pathological fracture include limitation or inability to support the leg, a feeling of instability in the knee, sometimes deformity, crunching of the bones during movement.
• Damage to the menisci.Ruptures of the meniscus are formed by twisting, impact, intense forced bending or stretching of the knee, a sharp bend with a fixed leg. At first, one feels a special click and a sharp shooting pain in the depth of the joint. Then the pain decreases somewhat, but becomes diffuse, sometimes - burning, popping, intensified when trying to support and move. The volume of the knee increases due to swelling and hemarthrosis. Support becomes impossible, movements are severely limited.

Inflammatory pathologies

They can be infectious and non-infectious (post-traumatic, toxic-allergic, metabolic, post-vaccine). The abundant blood supply to the synovial membrane and periarticular tissues promotes the rapid development of inflammation in response to direct and indirect effects, and a large number of nerve endings cause a pronounced pain response. The inflammatory process is often accompanied by synovitis (accumulation of aseptic fluid in the joint), with infection may accumulate pus.

• Arthritis.Gonarthritis occurs after injuries, sometimes complicates infectious diseases, is found in rheumatic diseases. It can be acute or chronic. Knee pain is usually dull, painful, pressing or pulling. In the beginning the pain is not intense and periodic, it intensifies in the evening or after physical activity. The initial pain then joins, the intensity and duration of the pain syndrome increase. The joint swells, the skin above it becomes red, its temperature rises. With synovitis, the contours of the knee are smoothed, there is a feeling of rupture. With suppuration, the severity of the pain increases sharply, they tremble, deprive of sleep.
• synovitis.It is not an independent disease, it complicates many acute and chronic pathologies of the joint. It is formed within a few hours or days. Initially, the pain is insignificant or absent, the feeling of fullness prevails. The knee is spherical, with a large amount of fluid, the skin is shiny. The movement is a bit limited. When infected, the pain becomes pronounced, throbbing, trembling, intensifies at the slightest movement and touch.
• bursitis.Inflammation of the joint capsules located in the patella and popliteal fossa usually occurs when the knee is overloaded and has multiple injuries (for example, with constant knee support). In bursitis the pain is local, dull, not intense, appears in a certain position of the limb, after a characteristic load, decreases when changing the position of the leg, massaging the affected area. If the back bag is affected, painful sensations are possible when climbing or descending stairs. Minor local edema is sometimes detected. When the bursa is purulent, the pain becomes sharp, trembling, burning, combined with hyperemia, swelling of the affected area, symptoms of general intoxication.
• Tendinitis.It is usually found in overweight men and athletes, affects the ligament of the patella. Initially, the pain syndrome occurs only during very intense exercise, then during standard sports activities, then during daily physical activity or at rest. The pain in tendinitis is localized in front just below the knee, dull, pulling, with the progression of the disease, sometimes paroxysmal, in some cases accompanied by slight redness and swelling, aggravated by pressure. The movement is usually full, rarely slightly limited. Rupture or rupture of the ligament is possible due to a decrease in its strength.
• Lipoarthritis.Hoff's disease affects the layers of adipose tissue under the patella. It is observed in case of constant overload of the knee or results from an old trauma. More often it affects athletes, older women. One complains of dull pain in combination, some limitation of extension. With the worsening of the pathology, the pain begins to bother at night, there is a feeling of instability of the knee, bending of the leg. When pressed on the side of the patella, a soft crackling or creaking is heard.

Autoimmune processes

The cause of diseases in this group is the production of antibodies to normal cells of the body with the development of immunocomplex aseptic inflammation of the synovial membrane and cartilage, the phenomena of vasculitis. Pathologies in most cases are chronic, without treatment are prone to progression and are often the cause of disability.

• Rheumatoid arthritis.The defeat is usually bilateral. With minimal activity of the autoimmune process, the pain is mild or moderate, intermittent, pulling, pressing, accompanied by morning stiffness. In moderate activity, the patient complains of intermittent prolonged pain, pressing or bursting pain of moderate intensity, not only during movement but also at rest. There is stiffness for many hours, moderate recurrent synovitis. With high activity of rheumatoid arthritis, the pain is strong, diffuse, exhausting, wavy, intensifies in the morning. The stiffness becomes constant, a large amount of fluid accumulates in the knees, and contractures form over time.
• Systemic lupus erythematosus.Arthralgias are often symmetrical, although one joint may be affected. They can occur at any stage of the disease; in a recurrent course of SLE, they resemble rheumatoid arthritis. At low activity of the process the pain is short-lived, non-intense, local, painful, pulling. In severe cases, the pain syndrome progresses, the pain is wavy, disturbs night sleep, becomes prolonged, diffuse, increases with movement, combined with synovitis, edema, hyperemia.
• Rheumatism.Joint pain is one of the first manifestations of rheumatic fever, occurs 5-15 days after an acute infection, affects several joints at once (usually paired). The pain is rather short-lived, but intense, migrating from one joint to another, varying in nature from pulling or pushing to burning or throbbing. The knees are swollen, hot, the skin above them is red. Movement is severely restricted. After a few days, the severity of the pain decreases, the movements are restored. In some patients, the residual effects in the form of moderate or mild dull pain persist for a long time.
• Reactive arthritis.It more often occurs 2-4 weeks after intestinal and urogenital infections, usually affects one or two joints of the lower extremities, combined with urethritis, conjunctivitis. The development of reactive arthritis is preceded by increased urination, pain and burning sensation in the urethra, tearing and spasms in the eyes. Knee pain is severe or moderate, constant, wavy, painful, pulling, twitching, combined with limited movement, worsening of the general condition, fever, severe swelling and redness of the affected area. Painful sensations and signs of inflammation last from 3 months to 1 year and then gradually disappear.

Degenerative-dystrophic processes

They develop as a result of metabolic disorders in the structures of the joints and surrounding soft tissues. They have a chronic course that progresses over many years. It is often accompanied by the formation of calcifications, cysts and osteophytes, deformation of the knee surface. With significant destruction of the joint surfaces, they lead to severe impairment of movement and support function, cause disability and require the installation of an endoprosthesis.

• Osteoarthritis.It develops for no apparent reason or against the background of various injuries and diseases, mainly in the elderly and middle-aged. Initially, the pain is mild, short-lived, usually pulling or aching, occurs with prolonged exertion and disappears at rest, often accompanied by crunch. Gradually, the pain syndrome intensifies, the knees begin to ache "in time", and at night there is a restriction of movement. Distinctive features of gonarthrosis are initial pain (pain until it "disperses"), periodic attacks of sharp cutting, burning or shooting pain due to blockade. During periods of exacerbation, synovitis often occurs, in which the pain becomes permanent, pressing, bursting.
• Meniscopathy. . . It is usually found in athletes, people whose work involves significant loads on the knee joint. It is manifested by unilateral local deep pain inside the knee at the level of the joint space, more often in the outer half of the knee. The pain intensifies during movement and subsides at rest, it can be dull, oppressive or pulling. As it progresses, sharp shooting pains appear when trying to move. On the anterior surface of the joint in the projection of pain is sometimes felt a small painful formation.
• Tendopathies. . . The tendons near the knees are affected. In the initial stage, they are manifested by short-term local superficial pain at the peak of physical activity. Subsequently, painful sensations appear at moderate, and then light loads, limiting the usual daily activity. The pain is pulling or painful, directly related to active movements, is not detected by passive unfolding and bending of the knee, sometimes accompanied by crunching or cracking. In the area of the lesion, it is possible to examine the site of the most severe pain. Local signs of inflammation (edema, hyperemia, hyperthermia) are insignificant or absent.
• Osteochondropathy.Children and young people are more often affected, the duration of the disease is several years. They usually begin gradually with a slight lameness or periodic, non-intense dull pain, intensifying with exertion, disappearing at rest. With the progression of osteochondropathy, the pain becomes strong, constant, pressing, burning or burning, accompanied by severe lameness, restricted movement and difficulty supporting the limb. Then the pain gradually decreases, the maintenance function is restored.
• Chondromatosis.It is usually diagnosed in older men, less often in infants. Chondromatosis of the joints is manifested by moderate dull wavy pain, which often worsens at night and in the morning. Movement is limited, accompanied by crunch. Occasionally there are blockages characterized by sudden sharp shooting pain, inability or severe restriction of movement. With the development of synovitis, the pain acquires a spraying character, combined with an increase in the volume of the knee, swelling of the soft tissues and a local increase in temperature.

Tumors and tumor-like formations

The pain syndrome can be caused by a cyst, a benign or malignant tumor that directly affects the joints or periarticular tissues. In addition, knee pain can serve as an alarm signal for hypertrophic arthropathy, paracancrotic polyarthritis - paraneoplastic syndromes characteristic of lung cancer, breast cancer and other oncological processes.

• Baker's cyst.It is a hernial protrusion in the popliteal fossa. In the initial stages it manifests itself as unpleasant sensations or mild local pain in the back of the knee. Against the background of an increase in Baker's cyst due to compression of nearby nerves, burning or shooting pains, tingling or numbness in the sole area may occur. The symptoms are worse when you try to bend the knee as much as possible. An elastic, slightly painful tumor-like formation is sometimes felt in the popliteal fossa.
• Benign tumors.Includes chondromas, osteochondromas, non-notifying fibroids and other neoplasms. They are characterized by a prolonged asymptomatic or asymptomatic course, may be manifested by vague and intermittent local non-intense pain. In large neoplasms, a solid formation is felt, sometimes synovitis develops.
• Malignant neoplasms.The most common malignancies affecting the joint area are synovial sarcoma, osteosarcoma and chondrosarcoma. They are manifested by dull local vague pain, sometimes with a certain circadian rhythm (worse at night). The intensity of pain increases, they become sharp, cutting, burning or twitching, spreading to the knee and adjacent tissues, accompanied by deformity, edema, synovitis, varicose veins, violation of the general condition, the formation of contracture. On palpation, a painful tumor-like formation is detected. At the start of the process, the pain is excruciating, unbearable, exhausting, deprives you of sleep and is not eliminated by non-narcotic analgesics.

Invasive operations and manipulations

The pain syndrome is triggered by damage to the knee tissue during invasive procedures. The severity of the pain directly depends on the trauma of the manipulations on the knee joint. With the penetration of pathogenic microbes in the joints, the pain is caused by inflammatory changes.

• Manipulation.The most common procedure is a puncture. The pain after a puncture is short-lived, not intense, quickly subsides, localized in the projection of the puncture, which is usually performed on the outer surface of the knee. After a biopsy, the pain may be shaky at first, then become dull and disappear after a few days.
• Operations.After arthroscopy the pain is moderate, at first quite sharp, then dull, disappears after a few days or 1-2 weeks. After an arthrotomy, the pain syndrome is more intense, lasting up to several weeks due to significant tissue damage. Usually in the first 2-3 days after the interventions the patients are prescribed analgesics, after which the pain becomes weak and gradually disappears.

Psychosomatic states

Sometimes arthralgia in the knees occurs in the absence of an organic basis (trauma, inflammation, destruction, etc. ) under the influence of psychological factors. Such pain is believed to play a protective role as it helps reduce emotional stress by transforming experiences into physical sensations. A distinctive feature of such pain is their indeterminate nature, inconsistency, lack of visible changes, a clear connection with physical activity and other objective provoking factors. Meteopathic arthralgias occur in people who are sensitive to changes in atmospheric pressure.

In addition, irradiation of knee pain is possible in coxarthrosis, lumbar osteochondrosis, Perthes disease, fibromyalgia, sciatic nerve neuropathy. However, in these pathologies, pain syndromes with another location usually come to the fore. Additional risk factors that increase the likelihood of injury and disease of the knee joint include overweight, occupational sports, hypovitaminosis, metabolic disorders, and old age. Hypothermia, stress, exercise, and dietary disorders can be provoking factors in exacerbating chronic pain.

Research

The diagnostic search algorithm is based on taking into account the nature of the pain syndrome, its duration, identification of concomitant symptoms and events preceding the onset of knee pain. At the first visit to a doctor (traumatologist-orthopedist, surgeon, rheumatologist) a visual examination and palpation of the knee is performed, assessment of the volume of active and passive movements. Taking into account the data obtained, in the future the patient may be assigned:

• Laboratory blood tests. . . Complete blood count helps to identify hematological changes characteristic of acute infectious and inflammatory process (leukocytosis, increased ESR), eosinophilia, typical of an allergic reaction. Biochemical and serological tests are most informative for autoimmune diseases, which are characterized by the formation of specific proteins in the acute phase and immunoglobulins (CRP, rheumatoid factor, ASL-O, CEC, antibodies against DNA, etc. ).
• Radiography.The main diagnostic method is an X-ray of the knee joint in 2 projections. The presence of pathology is indicated by changes in the contours of the joint head and cavity, narrowing of the joint space, changes in the thickness of the end plates, the presence of edge defects in the joint ends of the bones, osteolysis and bone destruction. In some diseases (meniscus trauma, Baker's cyst), contrast arthrography demonstrates the greatest sensitivity.
• Arthrosonography. . . Knee ultrasound is a fast, inexpensive, affordable and highly informative diagnostic method. Allows to assess the presence of effusion and free bodies in the joint cavity, to identify injuries and pathological changes in the periarticular soft tissues (signs of calcification, hemorrhage, etc. ). They help to distinguish with high accuracy the etiology of joint pain.
• CT and MRI. . . They are the methods of choice for arthropathy of any genesis. They are used for a more detailed assessment of the nature and extent of pathological changes, to identify signs characteristic of traumatic, inflammatory and tumor lesions of bone structures and soft tissues. CT and MRI of the joints are usually used with limited information content from other instrumental studies.
• Puncture of the joints. . . It is performed when there is an indication of accumulation of exudate or transudate in the joint capsule. As part of the differential diagnosis of inflammatory, degenerative and tumor diseases, cytological, bacteriological or immunological examination of the synovial fluid is performed. To diagnose autoimmune damage to the knee joint, tuberculous arthritis, synovioma, it is extremely important to perform a biopsy of the synovial membrane.
• Arthroscopy. . . The purpose of invasive endoscopic diagnosis may be to take a biopsy, clarify the necessary diagnostic information during a visual examination of joint elements. In some cases, diagnostic arthroscopy develops into therapeutic (atroscopic removal of intra-articular bodies, meniscectomy, autoplasty of ligaments, etc. ).

Symptomatic treatment

The treatment of the causes of knee pain is differentiated, taking into account the identified disease. At the same time, symptomatic care is an essential part of the overall treatment process aimed at reducing discomfort and improving quality of life. Immediately after the injury, it is recommended to apply a cold compress to the knee area - this will help reduce the sensitivity to pain. Ethyl chloride has a local cooling and anesthetic effect. In all cases, resting the knee helps reduce pain. It is necessary to limit movement, to give the legs a position in which pain is minimal. When walking, a fixative bandage is applied to the knee, immobilization of the limb is possible with the help of a plaster bandage.

In the acute period of injury or illness, it is strictly forbidden to massage the knee, apply warm compresses and wear high heels. The main classes of drugs used for the symptomatic treatment of pain and inflammation are analgesics and NSAIDs in the form of ointments, tablets and injections. These measures can only temporarily reduce pain, but do not eliminate the root cause of arthralgia. Therefore, all cases of knee pain require qualified diagnosis and treatment, and some conditions (fractures, sprains, hemarthrosis) require urgent medical attention. You can not postpone the visit to the doctor if the pain is combined with a change in the shape of the knee (swelling, smoothing of the contours, asymmetry), inability to perform flexion-extensor movements, runoff of the patella, impaired limb support.