Review Question - QID 219969

The patient presents with a chief complaint of knee pain in the setting of a benign physical examination of the knee. However, discomfort is elicited with passive range of motion at the hip. In this scenario, radiographs of the hip should be obtained to rule out hip osteoarthritis (OA) as the source of pain (Answer 4).

Hip OA can sometimes present with referred pain to the anterior thigh or knee. In a patient presenting with this complaint and a benign evaluation of the knee, potential sources of referred pain should be assessed. Pain with motion at the hip can be indicative of OA and should prompt plain radiographic evaluation of the hip as part of the initial workup.

Metcalfe et al. performed a systematic review to assess and quantify the accuracy of clinical findings in diagnosing hip OA. They found that patients most likely to have OA demonstrated the following on physical examination: posterior pain with a squat, pain with passive abduction or adduction, abductor weakness, and decreased hip adduction or internal rotation. The authors concluded that pain elicited with passive range of motion is most helpful in detecting the potential presence of hip OA during a physical examination.

Nieuwenhuijse et al. provided an editorial on the interplay between symptoms and radiographic evaluation in the management of hip OA. They cited existing literature demonstrating a substantial discordance between patients with hip pain and radiographic evidence of OA and vice versa. They therefore stressed the importance of considering the patient’s symptoms foremost and using subsequent radiographic evaluation to either support or refute a potential contributory diagnosis. The author concluded that radiographs should be obtained in a patient presenting with hip pain that cannot be readily attributed to an alternative diagnosis such as trochanteric bursitis or iliotibial band syndrome.

Figures A and B are AP and lateral radiographs of a left knee with no obvious fractures, normal alignment, and maintained joint spaces.

Incorrect Responses:
Answer 1: The patient has a negative McMurray test and no joint line tenderness, making a meniscal injury less likely.
Answer 2: The patient has no tenderness surrounding the knee and maintained pain-free range of motion making a diagnosis of occult fracture less likely. Given the discomfort with passive range of motion at the hip, the next most appropriate step would be radiographs of the hip to evaluate for OA.
Answer 3: Full active and passive knee range of motion that is pain-free makes a diagnosis of septic joint less likely.
Answer 5: The patient has pain with hip range of motion in the setting of reported knee pain. The next most appropriate imaging study would assess for hip OA.