Author: Trenton Schmale, DO
Co Author #1: Margaret E Gibson, MD
Co Author #2: Kevin Gray, MD
Senior Editor: Marc Hilgers, MD, PhD, FAMSSM
Editor: Kevin Gray, MD

Patient Presentation:
29 year old female referred for evaluation of bilateral knee pain

History:
Pain started about 8 months ago when she started gaining weight while she was pregnant. During her pregnancy she gained about 50 lbs. Stopped exercising due to the pain with the concern that she was going to make things worse.The pain is intermittent. No pain at rest, but worse with standing, walking, anytime she bends her knees, and most severe pain is going down stairs. The pain is all in the front of her knees. There is no radiation and pain has been about the same since it started, even after delivery and weight loss. Knees feel unstable. She has never had pain like this before, and denies any trauma, or surgeries on her knees. She has taken acetaminophen without substantial symptomatic improvement.

Physical Exam:
BMI 27.5, vitals normal.
Examination of bilateral knees:
Inspection: Patellae appear irregularly narrow; no swelling, asymmetry, erythema, or ecchymosis.
Range of motion: Full active range of motion in flexion and extension.
Palpation: No palpable patellae, instead, a rubbery feeling present where the patella should be. Tenderness to palpation around both medial femoral condyles. No warmth to palpation, no tenderness at the joint lines, MCL, LCL, or pes anserine bursa, and no effusion.
Strength: 4/5 hip flexion, 5/5 hip extension, 5/5 knee flexion; 4/5 knee extension; 4+/5 hip abduction; 5/5 hip adduction; 5/5 ankle dorsiflexion, plantarflexion, EHL.
Special Testing: Bilaterally, negative anterior drawer, Lachman's, posterior drawer, McMurray's, patellar apprehension test. Positive Clarke’s test. Positive forefoot pronation, dynamic knee valgus and tibial internal rotation with single leg squat.
Neurovascular: Sensation intact to light touch about the entire foot and lower leg. 2+ Dorsalis Pedis and Posterior Tibialis pulses. Brisk capillary refill distally. Absence of finger and toenails.

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