Case Report: Hip arthritis presenting as knee pain

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BMJ Case Rep. 2015; 2015: bcr2014208625.

Published online 2015 Feb 19. doi: 10.1136/bcr-2014-208625

Case Report

¹ and ²

Author information Article notes Copyright and License information Disclaimer

A 68-year-old man with a history of left total knee replacement presented to his general practitioner with left knee pain. He reported pain onset after a fall in the garden. An X-ray of the knee was arranged but showed no abnormality to explain the pain. He was treated with simple analgesia. However, he reattended with the same knee pain. A further X-ray of the knee was requested, but again showed no abnormality. On his fourth presentation in 6 months, a further musculoskeletal examination was undertaken. This time the hip was also examined and showed that maximal pain was in fact on rotation of the hip joint. A subsequent X-ray of the hip showed severe osteoarthritis of the left hip with complete joint space loss and flattening of the femoral head. The patient was referred to an orthopaedic surgeon for a left hip replacement.

A patient with symptoms of hip osteoarthritis will usually initially present to their general practitioner (GP). A thorough history, clinical examination and an X-ray is usually all that is required to make a straightforward diagnosis. However, the pain of hip arthritis can also be confusing and misleading. This is due, in part, to the distribution of the pain. Pain from the hip is often felt in the groin area, lower back and over the front of the thigh. Ipsilateral knee pain, especially anterior knee pain, is also a generally accepted component of hip pain.¹ Owing to this wide distribution of pain, which could originate from other adjacent structures such as the lumbosacral spine or knee, a general musculoskeletal examination is essential to avoid unnecessary investigations and a delay in diagnosis.

Isolated knee pain as the only symptom of hip arthritis is conceptually difficult to appreciate and therefore, as in this case, can cause delay in diagnosis. This case serves as a reminder to the clinician of the pain distribution of hip arthritis and also of the importance of a thorough general musculoskeletal examination to avoid being misled.

A 68-year-old man with a history of asthma, osteoarthritis, total left knee replacement (16 years ago) and deep vein thrombosis presented to his GP after a mechanical fall onto grass in his garden. Following the fall he presented with pain and stiffness in his left knee limiting his walking. The knee joint was examined, which revealed anterior knee swelling and tenderness. The concern was that the knee replacement had been compromised and an X-ray was requested. However, the X-ray showed the total knee replacement (TKR) in situ with satisfactory appearance and no obvious adverse features to explain the pain (). He was treated with simple analgesia. Over the coming months, he repeatedly attended the GP practice with ongoing knee pain increasing in severity with significant impact on his daily life. A further isolated knee examination was undertaken and a further X-ray was requested to again check the appearance of the knee replacement, which again was reported as normal. On his fourth attendance in 6 months, a generalised musculoskeletal examination (inclusive of the hip) was undertaken, which revealed an antalgic gait with an unwillingness to weight bear on the left side. The examination was limited by pain but showed that maximal pain was in fact not in the knee joint itself but on internal and external rotation of the left hip joint.

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X-ray of the left knee showing total knee replacement in situ, with no adverse features.

An X-ray of the pelvis was requested and reported as showing severe bilateral osteoarthritis worse on the left where there was complete obliteration of the joint space, subarticular sclerosis and flattening of the femoral head ().

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X-ray of the pelvis showing severe bilateral osteoarthritis which is worse on the left where there is complete obliteration of the joint space, subarticular sclerosis and flattening of the femoral head.

Owing to the previous X-rays showing a satisfactory TKR with no radiological evidence to explain the pain and the significant features of the hip X-ray allied with the clinical examination, osteoarthritis of the hip was diagnosed as the source of the isolated knee pain.

The patient was referred to an orthopaedic surgeon for a left hip replacement.

The author plans to follow-up this patient in 6 months and 1 years’ time to assess knee pain postoperatively.

Referred pain is pain perception distant from the site of the stimulus, the mechanism of which is poorly understood. Referred pain is a well-recognised feature of osteoarthritic hip pain. This is likely to be due to the nerve anatomy of the pelvis and leg. The knee joint is innervated by branches of the femoral and sciatic nerves anteriorly and posteriorly by branches of the sciatic, obturator and saphenous nerves.²

Khan et al investigated the lower limb distribution of pain in 60 patients awaiting hip arthroplasty. They found that not only is anterior knee pain reported in 69% of patients, but pain below the knee was also reported in 47% cases, highlighting that the distribution of hip pain can be unexpected.¹ Wang et al, in a diagnostic study, assessed 255 patients with hip disease and ipsilateral knee pain before and after hip arthroplasty. They observed that hip disease is commonly associated with ipsilateral knee pain which improved after hip arthroplasty. ³

Although knee pain as a presentation of hip pain is recognised in the literature and understood, in part, by the anatomy, delay in diagnosis is still a problem due to failure to appreciate this known phenomenon. Yilmaz et al present a case of hip pain presenting as isolated knee pain, with normal knee radiological investigations resulting in a 9-month delay in diagnosis of a cortical defect of the left femoral head.⁴ Emms et al present an extraordinary case of a 71-year-old patient seen by seven different specialists over a period of 4 years with knee pain. He was intensively investigated including with knee MRI and knee arthroscopy. The patient was requiring 160 mg MST daily for pain control. Correct diagnosis was finally made by returning to the beginning—by undertaking a thorough clinical examination and a plain pelvic film, which showed severe degenerative changes of his ipsilateral hip joint. The patient was pain free following hip arthroplasty. ⁵

The presentation of this present case (a fall onto the knee and associated knee pain and swelling) explains why the focus was on the knee joint with a concern about the joint replacement. However, the basics of history coupled with a generalised clinical examination appears to have been forgotten. An X-ray showing a well-preserved knee joint should have prompted an earlier interrogation of the original diagnosis rather than subsequently repeating a normal test, with a fixation on the knee joint. A generalised musculoskeletal examination was not undertaken until the patient’s fourth presentation, causing a 6-month delay in diagnosis. This is the diagnostic lesson. We should always return to the principal of good clinical examination and not be afraid to interrogate an original diagnosis, especially with a reattending patient with worsening pain.

Patient’s perspective

• “After my fall in the garden I suspected that I had damaged my left knee replacement so I went to see my GP. I was given an appointment for a knee X-ray and cream to rub in for the pain. Although the X-ray came back as normal I was in so much pain so, after many weeks, I returned again to see my GP. I was sent for another knee X-ray, but it still came back as normal. I carried on as best I could but could not put up with the pain any longer so I went back again. This time another doctor gave me a very thorough examination of my hip area as well as my knees and came to the conclusion that this pain was being caused by my hip, which a hospital X-ray proved right.”

Learning points

• Knee pain can be the predominant pain symptom of hip arthritis.

• Examination of a patient presenting with knee pain is not complete without an examination of the hip joint.

• Always be prepared to reassess an original diagnosis.

Contributors: SL wrote the initial draft. VA made recommendations which were included in the final version.

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

1. Khan A, McLoughlin E, Giannakas K.
Hip osteoarthritis: where is the pain?
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Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group

Knees ache? it could be your hips’ fault

Howard shuffles slowly into his physician’s office, complaining of persistent pain in his right foot. An examination reveals that his foot is fine, but that he has a pinched nerve in his neck and that’s what is making his foot hurt.

Meanwhile, a few blocks down the street, Mary Ann limps into her doctor’s examining room, almost in tears over the relentless ache in her left knee. It turns out that both of her knees are in perfect shape. The doctor, however, informs her that the pain in her knee might be a sign of a hip disorder, and subsequent examination confirms this to be the case.

What both patients are experiencing is a phenomenon known as “referred pain,” which Daniel Mazanec, M.D., a rheumatologist and director of the Spine Center at Cleveland Clinic, describes simply as “pain in an area of the body that is distant from the source of the pain,” according to the Cleveland Clinic’s Arthritis Advisor. A classic example of referred pain, he notes, is the distress experienced in the left arm by a person in the midst of a heart attack. And for some people with acute appendicitis, the first warning sign will not be in the abdomen but in the right shoulder.

Referred pain is not to be confused with radiated pain. “If you have a herniated disk,” Dr. Mazanec explains, “you’ll have pain in your back and you’re also likely to have it in your leg, because that’s where the nerve that’s irritated happens to travel and the pain can be expected to radiate along that pathway. Referred pain, on the other hand, travels along unexpected pathways.”

Shared ‘wiring’ system

In describing the complex neurologic processes that are associated with referred pain, Dr. Mazanec says, “Think of innervation the nervous system that serves a muscle or an organ as an interconnected wiring network that travels throughout the body. A liver abscess can result in shoulder pain, for example, because the liver is situated below the diaphragm, and the ‘wires’ (nerves) from the diaphragm enter the spinal cord at the same point as the wires (nerves) from the shoulder. They share the same neurologic pathways to the brain, and sometimes the electrical signals become intermingled.”

This intermingling of pathways is not an abnormality, he notes. Rather, it results from the normal emergence of the nervous system in the embryonic stage, when the development of all of the body’s “wiring” proceeds in close proximity. “Over time,” says Dr. Mazanec, “the pathways serve different parts of the body, but they continue to share the innervation they shared in the embryo, when they were geographically in the same location.”

Arthritic pain

Patients with arthritis can also experience referred pain. “It almost always occurs in the joints,” says Dr. Mazanec, “and it is most frequently observed in people with hip osteoarthritis. It’s not unusual for patients with this condition to experience pain in the groin. But there may also be discomfort or pain in the front of the thigh that runs all the way down to the knee.”

Knee pain that accompanies hip osteoarthritis may intensify over time, Dr. Mazanec explains, and worsening discomfort will result from movement of the hip rather than from overuse of the knee, since the hip-to-knee referral of pain does not go both ways.

Another example of referred pain would be evident in a patient with cervical (neck) arthritis. “In this case,” says Dr. Mazanec, “you can experience what we call nerve entrapment, and the pain caused by the pinched nerve can radiate down the arm. But if you have an arthritic problem in the joints of the neck and there is no nerve entrapment, that pain can be perceived in the upper back.”

If a patient complains of persistent knee pain, it is by no means assumed that the hip is responsible for the problem, since knee osteoarthritis is common. “We would examine the knee,” says Dr. Mazanec, “but we would also look at the hip. If we conclude that the knee joint is normal, we would assess the patient’s mobility. We might then suspect that hip osteoarthritis is the source of the knee pain.

“We wouldn’t immediately conclude that it’s a case of referred pain from the hip,” says Dr. Mazanec. “We would confirm our diagnosis with an X-ray.” In some cases, he adds, the examination may yield “confusing” results, in which case the patient might be given a hip-joint injection of a novocaine-like drug. “If this eliminates the knee pain,” says Dr. Mazanec, “it would confirm that the problem is in the hip.”

Treatment options

If knee pain is found to have its source in an arthritic hip, therapy would center primarily on treatment of the hip, ranging from the use of nonsteroidal anti-inflammatory drugs, to physical therapy, to hip replacement.

Dr. Mazanec points out that referred pain is not an imaginary phenomenon. It is real and may signal the presence of a serious underlying condition affecting a remote part of the body. “If you experience any kind of pain,” he advises, “don’t wait a month to see if it goes away. If it persists, see your doctor.”

What You Can Do

Keep track of your pain’s characteristics and communicate this information to your physician. If the site of your pain appears normal, have an X-ray of other body components that may be causing the pain.

Talk to your doctor about treatment options drug therapy, physical therapy, or replacement.

how to relieve pain in the knee joint – diagnosis, causes, methods of treatment

Knee pain is a pathological condition that torments many people of different ages. The causes of the pain syndrome can be very diverse: from a minor injury, which will pass on its own in a few days, to serious inflammatory diseases. Why does the knee hurt, how to alleviate your condition at home and prevent discomfort in the future? Let’s find out in this article!

Content:

1. Knee joint device
2. Causes of knee pain
   1. sports injuries
   2. Household injuries
   3. Diseases of the knee joint
3. How does knee pain feel?
   1. Aching pain in the knee joint
   2. Acute pain in the knee joint
   3. Pain in the knee joint when bending
   4. Pain in the knee joint when walking
4. What to do if your knee hurts
5. How to treat knee joints
6. How to relieve knee pain at home
7. Prevention for knee joints

Knee Joint Device

Among the largest joints in the human body, the knee stands out. It provides 2 types of movements – rotation and flexion / extension.

How is the knee joint arranged? Stand out:

• patella;
• meniscus;
• articular bag;
• joint;
• end of femur and tibia;
• muscles;
• vessels;
• nerves;
• bundles.

Due to disease or injury, any structural part of the knee can become inflamed and painful.

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Causes of knee pain

Most often, pain in the knee joints is caused by injuries, diseases of the connective tissue and bone structures, complications of neurological pathologies, and malignant tumors. You should not try to diagnose yourself: the best thing you can do is to seek medical help from a professional in a timely manner. An experienced traumatologist will conduct a diagnostic study and determine the cause of the pain, prescribe conservative or surgical treatment.

Sports injuries

Many people have heard of the so-called runner’s knee. In fact, this is an injury that is typical for people involved in running at a professional or amateur level. The pain syndrome can be localized around the patella, increase with bending and descending the stairs. There is also often a clicking or crunching sound in the calyx. Also, athletes-athletes are characterized by a torn meniscus. As a rule, it occurs due to excessively intense loads, tucking of the lower leg.

Domestic injuries

Unfortunately, knee pain often occurs in everyday life. No one is immune from falls and other injuries that entail:

• Knee injury. A very common injury. The injured knee is characterized by swelling and redness, the local temperature rises slightly.
• Ligament rupture. The cause of the injury is too much eversion of the thigh or lower leg in an unnatural direction. Accompanied by severe pain.
• Fracture of the knee joint. This injury includes damage to soft tissues, bones, cartilage, ligaments. Causes excessive mobility of the knee and its deformation.

Diseases of the knee joint

Many people in Ukraine and in the world suffer from joint pathologies. If the joints are affected, then their mobility decreases, an acute or aching pain syndrome occurs. There is a very large load on the knees, therefore, due to illness, they are quickly destroyed.

The most common diseases of the knee joint are:

• Arthritis is an inflammatory process that occurs after injury or metabolic disorders.
• Bursitis – leads to swelling and inflammation of the joint capsule, causes excruciating pain and discomfort during movement.
• Periarthritis – inflammation of the muscles, tendons and ligaments. Especially unpleasant sensations become if the leg is bent at the knee.
• Chondropathy – leads to the gradual destruction of the joint and cartilage.
• Osteoporosis – characterized by weakening of bone structures, aching intense pain in the knee.

Pain in the knee area and discomfort when walking are also provoked by pathological conditions of the central nervous system. With neuritis, the nerve becomes inflamed in one or more areas, and the patient’s leg may involuntarily contract at the knee. A pinched nerve is characterized by burning sharp pain, numbness, and in some cases paralysis of the limb.

Important!

Pathology of the knee joint can be caused by diseases of various nature, including influenza and tuberculosis. A common complication of such diseases is infection in the joint bag.

How knee pain feels

You can try to determine the cause of the disease, based on how exactly the pain is felt. We remind you once again: only a doctor specializing in this field can prescribe an accurate diagnosis and subsequent treatment!

Aching pain in the knee joint

Aching pain may indicate various pathologies – osteoporosis, bursitis. Note that most often at first they are weak, mild, but over time they disturb a person more and more.

Acute pain in the knee joint

Most often due to neuritis and pinched nerve. Acute pain is accompanied by all joint injuries – from bruising to dislocation and fracture. If you hurt your knee or fell on it and feel severe, sharp pain, seek immediate help from a traumatologist.

Pain in the knee joint when bending

If the leg becomes painful to bend, the knee cartilage is most likely damaged. This symptomatology can also indicate tendon deformity, arthritis, ligament damage, inflammation of the periarticular bag. You should also be alerted by a crunch in the knees.

Pain in the knee joint when walking

Many patients who come to our clinic for medical care are concerned about pain in the knee that occurs during movement. A similar phenomenon is typical for arthrosis, osteoporosis, chronic meniscus injuries.

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What to do if your knee hurts

Unfortunately, most people seek help from a traumatologist only if they have injured their knee. But if the calyx or patella starts to hurt not because of an injury, most people prefer to endure it to the end and make an appointment with the doctor when the disease progresses rapidly and causes severe pain.

Remember – neglect of knee problems and self-medication is fraught with the following consequences:

• A sharp deterioration in well-being, increased pain in a state of activity and rest.
• Strengthening of the inflammatory process, possible addition of a secondary infection.
• Weakening of immunity due to uncontrolled use of drugs.
• Damage to other parts of the musculoskeletal system due to improper load distribution.

Important!

Arthritis of the knee, not diagnosed in time, is especially dangerous, which leads to severe deformation of the joint and the leg as a whole. Also, due to the progression of the disease, the muscle frame is restructured and the bones are bent, the limb is shortened.

How to relieve pain in the knee joint? If the pain syndrome is sudden, appeared after heavy exertion and is not associated with an injury, no medication should be taken. Most likely, these are muscle pains that will pass after rest. But if your knees hurt and swell, you should definitely contact a specialist.

How to treat knee joints

Knee joints can be treated conservatively and surgically. If the disease at the initial stage or the injury did not lead to a violation of the integrity of the structures of the knee, therapy is indicated.

The most effective methods:

• The use of anti-inflammatory and analgesic drugs, as well as vitamins and special substances that improve blood circulation and nutrition of connective and bone tissues.
• The use of ointments and compresses designed to reduce the intensity of pain and minimize swelling.
• Massage, physiotherapy, manual therapy – improve the general well-being of the patient and lead to a speedy recovery.

If the constituent parts of the knee, in particular the cartilage and the joint, are out of order, surgery is recommended. Most often required:

• knee arthroscopy;
• knee arthroplasty.

How to relieve pain in the knee joint at home

How to relieve acute pain in the knee joint? We strongly discourage self-medication. The best thing to do is to make an appointment with a doctor. But to improve your well-being, you can take advantage of:

• Anti-inflammatory ointments that contain an analgesic component.
• Ice compresses (their use is especially important after injury).
• Painkillers based on ibuprofen or paracetamol.

Also, do not forget that the injured knee must be kept calm. Try to move less and rest more.

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Knee Prophylaxis

Any pathology is easier to prevent than to cure. Therefore, it is better to try to keep your knees healthy by following the recommendations of traumatologists:

• Watch your weight, move a lot, try to avoid stress and overwork.
• Do not engage in traumatic sports.
• Wear properly fitting orthopedic shoes.
• Introduce sufficient amounts of foods rich in polyunsaturated fatty acids and collagen into the diet.

We hope the article was useful and interesting. May your knees always be healthy!

Pain under the knee – how to treat pulling pain when bending and walking

A common reason for visiting a doctor in orthopedic practice is pain under the knee from behind. Patients in this case also often complain of swelling, impaired mobility of the lower limb and redness. Pain in this area may be associated with damage to various anatomical structures, so instrumental and laboratory diagnostics will be required. An experienced doctor will prescribe an up-to-date examination method for pulling pain under the knee, and prescribe an adequate treatment. Depending on the established etiology, therapeutic measures can be conservative, surgical or complex.

Causes of back pain behind the knee

If an adult or a child has pain and pulling behind the knee, the causes are mainly associated with an inflammatory process or trauma. In this area is located the popliteal cavity, which forms the inner bend of the knee. It hurts because of damage to muscle tissue, nerves, ligaments, tendons, knee and calyx, tibia or fibula.

Pain behind the knee at the back when bending or at rest is also due to the following reasons:

• degenerative disease of the knee
• inflammation of the tissues of the knee joint
• contusion of the lower limb
• intra-articular or extra-articular fracture
• pinched nerve

Soft tissues often swell when inflamed. At the same time, the victims say that they have a pulsing under the knee at the back. The causes are associated with the clinical manifestations and symptoms of the disease, so doctors carefully assess the patient’s condition.

Varieties

Usually, during the examination, the doctor asks the patient to describe in detail the discomfort for preliminary diagnosis. For example, the popliteal cavity may burn, swell, twitch, tighten, or shoot. Often, pain radiates to other anatomical regions. For example, in the foot, heel or thigh. It is important to understand which side of the lower limb is affected.

Main varieties of symptom:

• sharp
• chronic

Specifying the type of discomfort helps to quickly diagnose and start treatment.

Acute pain

In men and women, severe pain under the knee behind the knee when walking or at rest develops due to infection or acute inflammation. In this case, soft tissues swell, and the skin turns red.

Additional features:

• pulsation
• Increased pain when flexing or extending the leg
• skin burning
• increase in body temperature
• weakness

In most cases, pyogenic bacterial cells enter this area as a result of trauma. They can also spread to the popliteal cavity from other anatomical structures through the blood or lymph.

Chronic pain

If a patient has persistent abscesses in the right or left posterior popliteal region, the doctor will first suspect a degenerative lesion of the bone joint. It could be arthritis or arthrosis. Autoimmune reactions, in which the body’s defense system damages healthy cells, are often accompanied by pain.

Which doctor to contact

If it hurts behind the knee, it is recommended to start the examination with a visit to the surgeon. This specialist will exclude the pathological process in his profile and refer the patient to another specialist. You may need to consult a rheumatologist, orthopedist or traumatologist.

Diagnostic methods

Back pain under the knee requires clarification of the cause and timely treatment. The doctor will interview the victim to collect anamnestic information and identify risk factors. The next step is inspection and palpation. In the process, the doctor will pay attention to sharp or moderate pain, swelling of the popliteal fold, the spread of discomfort in the foot or other parts of the body.

Instrumental and laboratory diagnostics:

• ultrasonography
• computed tomography or magnetic resonance imaging
• articular puncture with laboratory examination of the obtained fluid
• endoscopy
• radiography
• general and biochemical blood tests

After studying the results of the examination, the doctor will be able to conclude that the person has pain in the ligaments under the knee or other tissues.

Treatment of soreness behind the knee

Often, conservative treatment is sufficient to eliminate the pathological condition causing such a symptom. The doctor may prescribe anti-inflammatory, antibacterial and pain medications. Sometimes medicines must be given by injection. In an acute infection with pus formation, surgery will be required to remove the exudate, treat the area with an antiseptic solution, and install a drain. Daily dressings will be needed. If the pyogenic flora is inside the joint, it is possible to perform a puncture or an endoscopic procedure.

Additional treatment measures:

• physiotherapeutic procedures to eliminate unpleasant symptoms and relieve inflammation
• immobilization of the leg with a cast or bandage
• therapeutic exercise with a specific training program during the recovery phase

After treatment, rehabilitation should be carried out in order to restore motor function and improve well-being. Many people forget the importance of this event.

Rehabilitation

Restorative procedures are aimed at the complete elimination of the pathological process and the normalization of lower limb mobility. Therapeutic exercise is the main method. The specialist selects individually exercises to improve muscle condition and coordination.