Presenting Problem
A twenty-six-year-old female presented to the first contact physiotherapy clinic with the onset of right knee pain worsening over several months, having had no mechanism of trauma or injury sustained. Additionally, she is experiencing back pain and bilateral elbow/forearm pain symptoms, as well as some neck pain.
Location / Aggravating Factors
The main complaint of pain is around the front of the knee and sometimes at the back. It is described as a constant throbbing ‘toothache’ pain with occasional sharp pains. Pain on visual analogue scale is mostly around an eight or nine out of ten.
She has no complaint of stiffness in the morning. Symptoms tend to be worse after standing for prolonged periods and she feels she cannot perform a deep squat when symptoms are ‘excruciating’.
The aching and throbbing sensations later in the day can stop her getting to sleep.
Relevant History
The patient’s history of multiple joint pains started over the last year. Additionally, she has experienced intermittent lower back pain for the last two years, which fluctuates depending on activity and exertion.
When questioned about inflammatory arthritis, she reported that her grandmother has a history of osteoarthritis and bone density issues.
The patient stated that she has no personal history of irritable bowel conditions such as Crohn’s disease or colitis, nor has she experienced any swelling in her hands or feet, enthesitis, or tendonitis.
Although she’s had psoriasis in the past, with reported scalp tenderness, she has not experienced the joint tenderness in the proximal or distal interphalangeal joints of her fingers often associated with psoriatic arthritis.
Red Flags / Past Medical History
At the time of assessment, no red flags were identified regarding the lumbar spine. The patient reported normal bladder and bowel control, no saddle anesthesia, no significant bilateral leg weakness, and no balance issues or gait ataxia.
Additionally, there were no joint-specific red flags like swelling, redness, heat, or inflammation. She is in generally good health, with no comorbidities, no history of cancer, and no recent fevers or infection.
Social History
The patient works shifts within the warehouse as an administrative officer; however, her job role can vary at times, including manual tasks.
Her role is mostly full-time night shifts, and during the day she is studying for her English GCSE.
She used to go to the gym but now prefers going out walking, although she is struggling to manage longer distances. This is a primary aggravating factor for the knee pain symptoms.
Objective Assessment
On objective examination, the patient demonstrated full active range of movement in her right knee joint. However, she had complaint of pain when squatting and during passive flexion of the knee. Significant pain was also elicited during resisted extension, particularly in the inner range of quadriceps activation.
Lumbar and hip active range of movement were fine, with no symptoms provoked. Ligament and meniscus tests revealed no abnormalities. The Hoffa’s fat pad test appeared positive, with increased pain on palpation in the extended knee position.
The Hoffa’s fat pad test involves supporting the posterior tibia at approximately 60 degrees of knee flexion with one hand, while applying pressure to the medial and lateral aspects of the anterior joint line. The test is considered positive if pain increases when the same pressure is applied in a fully extended knee position. However, this test should not be used as a standalone assessment of anterior knee pain—it must be performed alongside ligament and meniscus tests, as well as a thorough palpation of the joint line.
A brief postural assessment of the knee revealed significant hyperextension in standing. Further evaluation of joint mobility confirmed a Beighton score of 9 out of 9. Considering the patient’s back pain and bilateral elbow and forearm discomfort, these symptoms may be linked to generalised joint hypermobility as a possible underlying cause.
Diagnosis
Infrapatellar fat pad pain syndrome / Benign joint hypermobility.
Management Plan
Following this assessment, a person-centred approach was used to discuss a working diagnosis with the patient and to provide effective reassurance.
Since she found most of her pain was provoked by prolonged standing and walking whilst at work, I was able to give to her an allied health fitness to work form, advising on recommendations for amended duties which might include more desk-based administrative responsibilities. This approach was more appropriate than offering her a MED3 sickness form at this stage because she can functionally carry out amended duties. The patient agreed with this plan, demonstrating a collaborative decision-making process in the management plan.
Given her report of multiple joint issues, history of psoriasis, and scalp tenderness, I requested a routine blood test for inflammatory markers. However, based on the minimal subjective indicators when using the standard SCREEDEM methods for rheumatoid arthritis, questions, I anticipate these results will likely come back negative.
Due to the lack of funding within the CCG for an ultrasound scan, I advised the patient to begin with home exercises and self-management. The goal here is to see how her pain responds to changing the load on the fat pad. This also gives the patient time to get the blood tests done and to screen for inflammatory markers, which will help us determine if her multiple joint pains are part of a broader systemic issue.
Discussion
For this patient, I advised on exercise and self-management strategies to help offload the anterior knee. Most importantly, I was able to address the aggravating factors by advising her to spend less time spent on her feet at work, avoid activities that provoked her pain, and change her footwear to include a slight heel raise to minimise infrapatellar fat pad loading.
To help manage her pain, I suggested that she continue using over-the-counter analgesics and non-steroidal anti-inflammatories. Additionally, ice massage applied to the anterior knee has been shown to effectively reduce pain during acute flare-ups of anterior knee pain, reducing nociceptive pain (Hannon et al 2016; Dubois and Esculier 2020).
I recommended a six-to-eight week home exercise programme to improve load tolerance and allow the patient to gradually return to normal daily activities. Through experience, I would expect the patient to make progress during this period if she adheres to the structured daily routine.
Given this ‘watch and wait’ approach, if the patient returns to the FCP clinic without improvement in her symptoms, I would then refer her to the specialist MSK clinical assessment team. At that point, I would recommend further investigation of the knee joint, potentially including an MRI scan.
