Adopted: 6/11/12

Knee Pain & Tenderness: Differential Diagnoses by Location

Location of pain and tenderness can often be very helpful in establishing an initial differential
diagnosis. Location is based on both subjective pain (have the patient point to the pain during the
history) and objective findings (e.g., point of maximum tenderness during static palpation). The
specific anatomical location of pain/tenderness leading to identification of the tissues involved is very
important in reaching a correct diagnosis. A discrete knowledge of anatomy is critical. This
information can then be combined with other salient features from the history (e.g., mechanism of
injury) and the physical (response to orthopedic testing).

Generalized or variable pain patterns

Some conditions produce generalized or variable pain. These conditions include arthritides, infections
such as Lyme, joint effusions, hemarthrosis, fractures, tumors, radiculopathies & other referred pain
from the back, sciatica, metastatic neoplasm, fibromyalgia (usually medial).
_______________________________________________________________________________________

Intra-capsular Pain

Knee trauma
 Meniscus**
 Cruciate**
 Fracture

Non-traumatic (overuse or insidious onset)

 Meniscus**
 Osteoarthritis**
 Joint mouse
 Plica
 Cruciate
 Inflammatory joint disease (e.g., RA)
 Infection†

Note: The authors have attempted to offer guidance relative to which conditions may be more common and
which rare. Prevalence statistics for many of these conditions are unknown, especially in a chiropractic setting—
the annotations are the judgments of the authors.

** = A very common cause to consider, should be high on the differential.

* = A common condition to consider.
†
= Statistically rare—but, because of its serious nature, may be important to keep in mind if only to rule out .

KNEE PAIN & TENDERNESS Page 1 of 4

 Diagram by Location
Anterior Knee Pain

Patellar pain Superior to patella

Trauma Non-traumatic Trauma Non-traumatic

 Contusion**  Patellofemoral  Quadriceps  Quadriceps

 Dislocation* pain syndrome** contusion* tendinopathy*/
/subluxation  OA**  Tendon rupture suprapatellar effusions
 Patellar  Chondromalacia*  Distal femoral  Osteoid osteoma†
fracture  Prepatellar fracture  Ewing’s†
bursitis  Fibrosarcoma &
 Stress fracture osteosarcoma†
 Dislocation/  Giant cell tumors†
subluxation

Medial or lateral to patella

Inferior to patella
Trauma Non-traumatic Trauma Non-traumatic

 Infrapatellar  Jumpers knee**  Patellar  Symptomatic

tendon tear  Osgood dislocation or synovial plica**
 Tibial fractures Schlatter’s** subluxation*  Referral from hip/
 Fat pad  Sinding-Larsen-  MCL sprain* SI joint or
inflammation Johansson’s  Symptomatic proximal femur*
 Tibial stress synovial plica  Peripatellar
fractures neuritis
 Fat pad
inflammation or
entrapment
 Infrapatellar
bursitis
 Osteoid osteoma†
 Ewing’s and
osteosarcoma’s†
Medial Knee Pain
Superior to joint line
Distal thigh
Trauma Non-traumatic
Trauma Non-traumatic
 MCL sprain*  Symptomatic plica**
 Quadriceps  Semitendinosus  Patellar  Referred pain from
strain,* tendinopathy** dislocation/ upper femur/hip /SI*
contusions* & or strain retinacular tear*  MCL sprain
myositis ossificans†  Quadriceps  Femoral fracture  Saphenous neuritis
 Hamstring tendon tendinopathy  Symptomatic  Tumor†
tear chronic strains plica
 Femoral fracture  Femoral stress
fracture
 Tumor
Joint line
Trauma Non-traumatic

Proximal leg  Meniscus

tear**
 Meniscus tear**
 Joint surface
 MCL sprains** pathology (e.g., OA)*
Trauma Non-traumatic (pain crosses  Osteochondritis
 Tennis leg*  Tennis leg* the joint line) dissecans
 Contusions*  Tib stress fx  Joint surface  Coronary lig capsulitis
injury* †
 Tibia fx  Thrombophlebitis  MCL sprains
 Thrombophlebitis  Coronary lig (pain crosses the joint
 Tumor†
 sprain* line)

Inferior to joint line

Trauma Non-traumatic

 Pes anserine  Pes anserine

tendinopathy/ tendinopathy/
bursitis Bursitis*
 Tibial fracture  Tibial stress
fracture*
 Tumor†


KNEE PAIN & TENDERNESS Page 2 of 4

 Lateral Knee Pain

Joint line Superior to joint line

Trauma Non-traumatic/ Trauma Non-traumatic/

chronic chronic
 Meniscus tear*  Contusion**
 Coronary lig  Meniscus tear*  Biceps  ITB syndrome**
sprain*  Coronary lig. muscle-  Biceps
 LCL sprain capsulitis* tendon tear tendinopathy*
(pain may cross  Discoid meniscus  Common  Tumor†
joint line)* (child) peroneal
 Joint surface  Chronic lateral neuropathy
injury instability (pain
 Lateral condylar may cross joint
† line)
osteochondritis †
 LCL sprain Inferior to joint line

Trauma Non-traumatic/
chronic
 Peroneal
neuropathy*  Proximal tib-fib
 Fibular fracture joint dysfunction*,
 Proximal tib-fib instability or
sprain capsulitis
 Biceps tendon  Peroneal
strain/tear neuropathy*
 Popliteus strain  Fibular stress fx
 Gastrocnemius  Radiculitis (early)
strain  Popliteus
tendinopathy/MFTP
 Biceps
tendinopathy
 Tumor†

Posterior Knee Pain

Posterolateral/Posteromedial Posterior Center

Trauma Non-traumatic Trauma Non-traumatic

 Hamstring strain  Gastrocnemius  Baker’s cyst  Baker’s cyst with

 Gastrocnemius tendinopathy or with internal attendant internal
strain/rupture myofascitis* derangement** derangement**
 Hamstring  Tear posterior  Tear posterior
tendinopathy horn of horn of
 Osteochondritis meniscus** meniscus**
dissecans  ACL tear*  Sciatica/ referred
  PCL tear pain*
 Posterior  DVT
capsular sprain  Posterior capsulitis
 Acute  Popliteus
compartment tendinopathy or
syndrome myofascitis
 Chronic
compartment
syndrome
†
 Sarcoma
†
 Infections

KNEE PAIN & TENDERNESS Page 3 of 4

Copyright © 2012 University of Western States

AUTHOR: Mike Carnes, MS, DC & Ron LeFebvre, DC

Reviewed and Adopted by CSPE Committee
 Daniel DeLapp, DC, DABCO, LAc, ND
 Shawn Hatch, DC, DACBSP
 James Strange, DC
 Lorraine Ginter, DC
 Owen T. Lynch, DC
 Ryan Ondick, DC
 Anita Roberts, DC
 Michael Tarnasky, DC
 Devin Williams, DC
 Laurel Yancey, DC

KNEE PAIN & TENDERNESS Page 4 of 4