Author: David Liddle, MD
Co Author #1: David J. Petron, University of Utah Department of Orthopedics

Patient Presentation:
A 29-year-old female presents with a nine month history of insidious and gradual onset of intermittent left anterior knee pain that has been worsening in the last two months.

History:
Six months ago she did have one episode of popping with an acute onset of pain and she believes she may have had swelling. She denies redness or warmth. She has minimal pain with daily activity. She does have pain walking up and downstairs, down more than up. She is frustrated that her pain is keeping her from being able to work-out. She has gained approximately 50 pounds in five years. She has tried ibuprofen treatment. She has no prior history of knee problems. She denies any other joint pain.

PMH, Social History, Family History, and ROS unremarkable.

During her initial evaluation, her knee was aspirated revealing normal synovial fluid. She also received a cortisone injection and was started on a rehabilitation program. On follow up one month later she reported marked improvement in her symptoms. She was treated with continued physical therapy and encouraged to start a regular exercise routine and appropriate diet plan.

She returned to clinic five months later complaining that her symptoms had again gradually and insidiously worsened. She now described swelling and she reported two episodes of her knee “locking� with intense pain. An MRI was ordered. The images were reviewed and the patient was than evaluated by an orthopedic surgeon.

Physical Exam:
Her vital signs are normal. She is 5 foot 6 inches tall and weighs 217 pounds. She is not ill appearing with normal cardiovascular, respiratory, abdominal, neurologic, and skin exams. On her left knee: There is a small effusion. There is no erythema. There is no anterior, posterior, varus, or valgus laxity. No joint line tenderness. She has a negative McMurray’s test. She is tender with palpation on the articular aspect of the patella. The patella is not hypermobile. She is tender with patellar grind. It was more difficult for her to do a one-legged squat and this reproduced pain. Strength is 5/5 and symmetric.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.