Case 25: Knee pain

Last updated: May 25, 2021

Examinee instructionstoggle arrow icon

Opening scenario

Ashley Stone, a 47-year-old female; , comes to the physician's office because of pain in her right knee.

Vital signs

  • Temperature: 100.04°F (37.8°C)
  • Blood pressure: 115/80 mm Hg
  • Heart rate: 68/min
  • Respirations: 16/min
  • BMI: 32 kg/m2

Examinee tasks

Patient encountertoggle arrow icon

Patient instructions

  • You have a bandage around your right knee so that the skin is not visible. If the examinee asks you to remove it, do so.
  • When the examinee asks you to move your right lower leg, say that it hurts.
  • When the examinee presses your right calf, say that it hurts.
  • When the examinee presses on your right knee, say that it hurts on the right side (outside) of the knee.
  • When the examinee pushes your right foot toward your nose, say that it hurts.
  • You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
  • Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Do you think my condition is dangerous?”

Focused historytoggle arrow icon

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

  • Chief complaint
  • I have pain in my knee.
  • Location
  • My right knee.
  • Intensity (on a scale from 0–10)
  • It is a 6.
  • Quality
  • It is a dull pain.
  • Onset
  • The pain started 3 days ago.
  • Precipitating events
  • I fell on my knee 3 days ago after slipping on the stairs at work. It hurt a lot, so I put on a bandage.
    • Other injuries sustained in the fall
    • I only have a few scratches on my hands, but nothing else.
    • Loss of consciousness
    • No.
  • Progression/constant/intermittent
  • The pain is getting worse.
  • Previous episodes
  • Never.
  • Radiation
  • My whole calf hurts, too.
  • Alleviating factors
  • It does not hurt as much if I do not move my leg. And I took some ibuprofen, which helped.
  • Aggravating factors
  • Moving my leg and walking.
  • Associated symptoms
  • My calf has also felt swollen since yesterday evening.

Review of systems specific to knee pain and leg pain and swelling

  • Recent travel
  • Well, the day before I fell I was on the road all day visiting customers who were interested in buying artwork. But because my leg has been hurting so bad, I have not moved much for the past 2 days.
  • Fever/chills
  • No.
  • Rash/skin changes
  • I am not sure. I have this bandage on over my knee. But my calf is not red and I have not noticed a rash.
  • Chest pain
  • No.
  • Cough
  • No.
  • Shortness of breath
  • No.
  • Pain in joints
  • Apart from the pain in my knee, no.
  • Urinary problems
  • None.
  • Weight changes
  • Hmm, no. I know I am overweight, I have always had a hard time with my weight.
  • Recent infections
  • No.
  • Dizziness
  • No.
  • Warmth of lower extremity
  • No, I do not think so.
  • Weakness/numbness/tingling
  • No.

In every case of suspected DVT, it is important to ask about possible signs of pulmonary embolism, including cough, dyspnea, chest pain, and dizziness.

Past medical history, family history, and social history

Focused physical examinationtoggle arrow icon

Communication and interpersonal skillstoggle arrow icon

Patient interaction

  • Examinee knocked on the door.
  • Examinee introduced him- or herself and identified his/her role.
  • Examinee correctly used the patient's name.
  • Examinee asked open-ended questions.
  • Examinee listened attentively (did not interrupt the patient).
  • Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
  • Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
  • Examinee did not repeat painful maneuvers during physical examination.
  • Examinee discussed initial diagnostic impressions with the patient.
  • Examinee explained the management plan.
  • Examinee used non-medical terms and provided reasons for planned steps in management.
  • Examinee evaluated the patient's agreement with the next diagnostic steps.
  • Examinee asked about concerns or questions.

Counseling and challenge

Suggested response to challenge: “Mrs. Stone, I can understand your concern. At this point in time, I don't know what exactly is causing your knee and calf pain. You could have a blood clot in one of the veins of your leg, or you might have hurt your knee or the muscles of your leg during your fall at work. I would like to run some tests and do some imaging of your knee and the blood vessels in your leg to determine what exactly is causing your symptoms and to make sure we give you the appropriate treatment. I can assure you we have a very experienced team at this hospital and will provide you with the best possible care. What do you think about that?”

Patient notetoggle arrow icon

Further discussiontoggle arrow icon

Patient note

Differential diagnoses

  1. Deep vein thrombosis (DVT): This patient's progressive calf pain, history of calf swelling following a lower extremity injury, and subsequent immobilization of the leg for 2 days should raise concern for DVT. This patient's positive Homan test, subfebrile temperature, and risk factors for DVT (smoking, obesity) support this diagnosis. Because the patient only has a score of 1 according to the Wells criteria for DVT (localized tenderness along the deep venous system), D-dimer levels should be evaluated and, if abnormal, followed up by compression ultrasound with Doppler.
  2. Gastrocnemius strain (muscle strain): Calf pain, possibly radiating to the knee, swelling, and a positive Homan sign (calf pain on dorsiflexion of the foot) are all also consistent with a gastrocnemius strain. However, the injury is usually associated with ecchymosis and usually occurs while jumping, rather than during a fall.
  3. Lateral collateral ligament tear (LCL injury): Knee pain and tenderness over the lateral joint line of the knee following a fall are consistent with an LCL injury. Although the injury can cause mild pain in the lower leg, it would not sufficiently explain this patient's calf pain, swelling, or subfebrile temperature, making it the least likely differential diagnosis here.

Diagnostic studies

Other differential diagnoses to consider

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