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Duong V, Oo WM, Ding C, Culvenor AG, Hunter DJ. Evaluation and Treatment of Knee Pain: A Review. JAMA 2023; 330:1568-1580. [PMID: 37874571 DOI: 10.1001/jama.2023.19675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Importance Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain. Observations Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise therapy is first-line treatment; surgery is not indicated even in the presence of mechanical symptoms (eg, locking, catching). Conclusions and Relevance Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management.
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Affiliation(s)
- Vicky Duong
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Win Min Oo
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Physical Medicine and Rehabilitation, Mandalay General Hospital, University of Medicine, Mandalay, Mandalay, Myanmar
| | - Changhai Ding
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Clinical Research Centre, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Adam G Culvenor
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Australia
| | - David J Hunter
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Rheumatology Department, Royal North Shore Hospital, St Leonards, Australia
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Barton CJ, De Oliveira Silva D, Morton S, Collins NJ, Rathleff MS, Vicenzino B, van Middelkoop M, Crossley KM, Callaghan MJ, Selfe J, Holden S, Lack S, Macri EM, Bazett-Jones DM, Earl-Boehm JE, Riel H, Powers CM, Davis IS, Morrissey D. REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies. Br J Sports Med 2021; 55:1135-1143. [PMID: 34127482 DOI: 10.1136/bjsports-2020-103700] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 12/12/2022]
Abstract
Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.
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Affiliation(s)
- Christian J Barton
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia .,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Danilo De Oliveira Silva
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Sarah Morton
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Natalie J Collins
- Physiotherapy, The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, Queensland, Australia
| | - Michael Skovdal Rathleff
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Centre for General Practice, Aalborg University, Aalborg, Denmark.,Department of Occupational therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark
| | - Bill Vicenzino
- Physiotherapy, The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, Queensland, Australia
| | - Marienke van Middelkoop
- Department of General Practice, Erasmus MC Medical University Center, Rotterdam, The Netherlands
| | - Kay M Crossley
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Michael J Callaghan
- Medical Department, Manchester United Football Club Ltd, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - James Selfe
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Sinead Holden
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Centre for General Practice, Aalborg University, Aalborg, Denmark
| | - Simon Lack
- Sports and Exercise Medicine, Queen Mary University of London, London, UK.,Pure Sports Medicine, London, UK
| | - Erin M Macri
- Department of Orthopaedics and Sports Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Jennifer E Earl-Boehm
- Department of Kinesiology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Henrik Riel
- Centre for General Practice, Aalborg University, Aalborg, Denmark
| | | | - Irene S Davis
- Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK.,Physiotherapy Department, Barts Health NHS Trust, London, UK
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