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.
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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: David J. Hunter, MD, PhD, Rheumatology Department, Royal North Shore Hospital, and Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia (email@example.com).
Accepted for Publication: September 12, 2023.
Author Contributions: Drs Duong and Oo contributed equally as joint first authors and Drs Culvenor and Hunter served as co–senior authors.
Conflict of Interest Disclosures: Dr Hunter reported being the codirector of the Sydney Musculoskeletal Health Flagship; being editor of the osteoarthritis section for UpToDate and co–editor in chief of Osteoarthritis and Cartilage; and providing consulting advice on scientific advisory boards for Pfizer, Lilly, TLCBio, Novartis, TissueGene, and Biobone. No other disclosures were reported.
Funding/Support: Dr Ding received grants from the National Natural Science Foundation of China (awards 82373653 and 81974342). Dr Culvenor is a recipient of a National Health and Medical Research Council (NHMRC) of Australia Investigator Grant (award GNT2008523). Dr Hunter is employed by the University of Sydney and Royal North Shore Hospital; his salary support for the University of Sydney is supported by Arthritis Australia and an NHMRC Investigator Grant Leadership 2 (award 1194737).
Role of the Funder/Sponsor: The supporters had no role in preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.
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