Radiologic evaluation of the chronically painful knee in adults
- Shahla Modarresi, MD
Shahla Modarresi, MD
- Associate Clinical Professor of Radiology
- David Geffen School of Medicine at UCLA
- Cecilia Matilda Jude, MD
Cecilia Matilda Jude, MD
- Clinical Professor of Radiology
- David Geffen School of Medicine at UCLA
The knee is one of the largest and most complex joints in the body. It is lined by synovium and consists of two hinge-type joints between the femoral condyles and the medial and lateral tibial plateaus, and a gliding-type joint between the patella and the trochlear groove of the anterior distal femur (figure 1) . The major stabilizers of the joint are the extensor tendons (quadriceps and patellar tendons), medial and lateral collateral ligament complex, and cruciate ligaments. The menisci are fibrocartilaginous structures that distribute the stress over the articular cartilage, absorb the shock in axial loading, stabilize the joint in flexion and extension, and have a role in joint lubrication .
For the purposes of this discussion, “chronic knee pain” is defined as pain of at least three months’ duration. Imaging modalities used to evaluate adults with chronic knee pain and the appropriateness of particular studies in different clinical scenarios will be reviewed here. The history and physical examination, which are necessary to develop a differential diagnosis prior to the selection of imaging tests; a general review of imaging tests that are used in the evaluation of bone and joint pain; and radiologic evaluation of adults with acute knee pain are presented separately. (See "Approach to the adult with unspecified knee pain" and "Imaging techniques for evaluation of the painful joint" and "Radiologic evaluation of the acutely painful knee in adults".)
Chronic knee pain is most commonly caused by arthritis, bursitis and cystic lesions around the joint, tendon pathology, cartilage pathology, chronic infection, osteonecrosis (avascular necrosis), stress fractures, and avulsion injuries.
Referred pain is an important clinical consideration in the patient with chronic knee pain; however, knee pain that is referred from other anatomic sites is beyond the scope of our discussion and is discussed elsewhere.
The use of imaging in the assessment of children and adolescents with knee pain is also presented elsewhere. (See "Approach to acute knee pain and injury in children and skeletally immature adolescents", section on 'Imaging' and "Approach to chronic knee pain or injury in children or skeletally immature adolescents", section on 'Imaging'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Frick MA, Wenger DE, Adkins M. MR imaging of synovial disorders of the knee: an update. Radiol Clin North Am 2007; 45:1017.
- Fox MG. MR imaging of the meniscus: review, current trends, and clinical implications. Radiol Clin North Am 2007; 45:1033.
- Epis O, Iagnocco A, Meenagh G, et al. Ultrasound imaging for the rheumatologist. XVI. Ultrasound-guided procedures. Clin Exp Rheumatol 2008; 26:515.
- Kijowski R, Blankenbaker DG, Stanton PT, et al. Radiographic findings of osteoarthritis versus arthroscopic findings of articular cartilage degeneration in the tibiofemoral joint. Radiology 2006; 239:818.
- Kijowski R, Stanton P, Fine J, De Smet A. Subchondral bone marrow edema in patients with degeneration of the articular cartilage of the knee joint. Radiology 2006; 238:943.
- Guermazi A, Niu J, Hayashi D, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ 2012; 345:e5339.
- Vlad V, Iagnocco A. Ultrasound of the knee in rheumatology. Med Ultrason 2012; 14:318.
- Conaghan PG, Felson D, Gold G, et al. MRI and non-cartilaginous structures in knee osteoarthritis. Osteoarthritis Cartilage 2006; 14 Suppl A:A87.
- Hayes CW, Jamadar DA, Welch GW, et al. Osteoarthritis of the knee: comparison of MR imaging findings with radiographic severity measurements and pain in middle-aged women. Radiology 2005; 237:998.
- Kornaat PR, Bloem JL, Ceulemans RY, et al. Osteoarthritis of the knee: association between clinical features and MR imaging findings. Radiology 2006; 239:811.
- Hunter DJ, Zhang Y, Niu J, et al. Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis. Arthritis Rheum 2006; 54:1529.
- Felson DT, Niu J, Guermazi A, et al. Correlation of the development of knee pain with enlarging bone marrow lesions on magnetic resonance imaging. Arthritis Rheum 2007; 56:2986.
- Ding C, Martel-Pelletier J, Pelletier JP, et al. Meniscal tear as an osteoarthritis risk factor in a largely non-osteoarthritic cohort: a cross-sectional study. J Rheumatol 2007; 34:776.
- Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum 2003; 48:2178.
- Bhattacharyya T, Gale D, Dewire P, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am 2003; 85-A:4.
- Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 2008; 359:1108.
- Eckstein F, Cicuttini F, Raynauld JP, et al. Magnetic resonance imaging (MRI) of articular cartilage in knee osteoarthritis (OA): morphological assessment. Osteoarthritis Cartilage 2006; 14 Suppl A:A46.
- Raynauld JP, Martel-Pelletier J, Berthiaume MJ, et al. Quantitative magnetic resonance imaging evaluation of knee osteoarthritis progression over two years and correlation with clinical symptoms and radiologic changes. Arthritis Rheum 2004; 50:476.
- Cicuttini F, Hankin J, Jones G, Wluka A. Comparison of conventional standing knee radiographs and magnetic resonance imaging in assessing progression of tibiofemoral joint osteoarthritis. Osteoarthritis Cartilage 2005; 13:722.
- Brem MH, Pauser J, Yoshioka H, et al. Longitudinal in vivo reproducibility of cartilage volume and surface in osteoarthritis of the knee. Skeletal Radiol 2007; 36:315.
- Flemming DJ, Hash TW 2nd, Bernard SA, Brian PS. MR imaging assessment of arthritis of the knee. Magn Reson Imaging Clin N Am 2014; 22:703.
- Forslind K, Larsson EM, Eberhardt K, et al. Magnetic resonance imaging of the knee: a tool for prediction of joint damage in early rheumatoid arthritis? Scand J Rheumatol 2004; 33:154.
- Nakagomi D, Ikeda K, Okubo A, et al. Ultrasound can improve the accuracy of the 2010 American College of Rheumatology/European League against rheumatism classification criteria for rheumatoid arthritis to predict the requirement for methotrexate treatment. Arthritis Rheum 2013; 65:890.
- Wakefield RJ, Green MJ, Marzo-Ortega H, et al. Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis 2004; 63:382.
- Jones EA, Manaster BJ, May DA, Disler DG. Neuropathic osteoarthropathy: diagnostic dilemmas and differential diagnosis. Radiographics 2000; 20 Spec No:S279.
- Rettenbacher T, Ennemoser S, Weirich H, et al. Diagnostic imaging of gout: comparison of high-resolution US versus conventional X-ray. Eur Radiol 2008; 18:621.
- Brower AC. Gout. In: Arthritis in Black and White, 2nd, Brower AC, Flemming DJ (Eds), WB Saunders Company, Philadelphia 1997.
- Gerster JC, Landry M, Dufresne L, Meuwly JY. Imaging of tophaceous gout: computed tomography provides specific images compared with magnetic resonance imaging and ultrasonography. Ann Rheum Dis 2002; 61:52.
- Knobe K, Berntorp E. Haemophilia and joint disease: pathophysiology, evaluation and management. J Comorbidity 2011; 1:51.
- Krudwig WK, Schulte KK, Heinemann C. Intra-articular ganglion cysts of the knee joint: a report of 85 cases and review of the literature. Knee Surg Sports Traumatol Arthrosc 2004; 12:123.
- Beaman FD, Peterson JJ. MR imaging of cysts, ganglia, and bursae about the knee. Radiol Clin North Am 2007; 45:969.
- Vande Berg BC, Lecouvet FE, Poilvache P, et al. Assessment of knee cartilage in cadavers with dual-detector spiral CT arthrography and MR imaging. Radiology 2002; 222:430.
- Sanghvi DA, Iyer VR, Deshmukh T, Hoskote SS. MRI features of tuberculosis of the knee. Skeletal Radiol 2009; 38:267.
- Fayad LM, Carrino JA, Fishman EK. Musculoskeletal infection: role of CT in the emergency department. Radiographics 2007; 27:1723.
- Lotke PA, Nelson CL, Lonner JH. Spontaneous osteonecrosis of the knee: tibial plateaus. Orthop Clin North Am 2004; 35:365.
- Soucacos PN, Johnson EO, Soultanis K, et al. Diagnosis and management of the osteonecrotic triad of the knee. Orthop Clin North Am 2004; 35:371.
- Yates PJ, Calder JD, Stranks GJ, et al. Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee 2007; 14:112.
- Crawford DC, Safran MR. Osteochondritis dissecans of the knee. J Am Acad Orthop Surg 2006; 14:90.
- Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am 2002; 40:313.
- Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005; 235:553.
- García-Valtuille R, Abascal F, Cerezal L, et al. Anatomy and MR imaging appearances of synovial plicae of the knee. Radiographics 2002; 22:775.
- Mohr A. The value of water-excitation 3D FLASH and fat-saturated PDw TSE MR imaging for detecting and grading articular cartilage lesions of the knee. Skeletal Radiol 2003; 32:396.
- Hayirlioglu A, Doganay H, Yilmabasar G. The evaluation of the association between patella. Int J Diagn Imaging 2015; 2:21.
- Rao SK, Sripathi Rao P. Clinical, radiologic and arthroscopic assessment and treatment of bilateral discoid lateral meniscus. Knee Surg Sports Traumatol Arthrosc 2007; 15:597.
- Calcium pyrophosphate deposition disease
- Rheumatoid arthritis
- Psoriatic arthritis and reactive arthritis
- Ankylosing spondylitis
- Neuropathic arthropathy
- Gouty arthritis
- Hemophilic arthropathy
- BURSITIS AND CYSTS
- - Popliteal bursitis
- - Prepatellar bursitis
- - Pes anserinus bursitis
- - Ganglion cyst
- - Meniscal cyst
- TENDON PATHOLOGY
- ARTICULAR CARTILAGE PATHOLOGY
- MENISCAL CARTILAGE PATHOLOGY
- CHRONIC INFECTION
- Chronic infectious arthritis
- Chronic osteomyelitis
- OSTEONECROSIS (AVASCULAR NECROSIS OF BONE)
- Osteochondritis dissecans
- STRESS AND INSUFFICIENCY FRACTURES
- KNEE TUMORS
- PLICA SYNDROME
- CHONDROMALACIA PATELLAE
- DISCOID MENISCUS