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Histories

Knee Pain | MRCS Part B OSCE Revision

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Clinical Scenario

A 58-year-old former footballer attends clinic with worsening right knee pain. He injured the knee playing football 30 years ago and had an operation on it at the time, though he cannot recall the details. The pain has been present for several years but has worsened over the last 4 months and is now limiting his daily activities. He has come in now because he has been moved onto light duties at work, can no longer manage the stairs to his first-floor flat, and wants to know whether he can have a new knee.

Take a focused history from this patient and be ready to discuss your differential diagnosis with the examiner.

Related Differentials · Same Topic
The examiner could set this station around a different diagnosis within the same presenting complaint. Know how each would change the history.
Differential What would point to it in the history Management in brief
Osteoarthritis (this case)Mechanical pain worse with use and at the end of the day, crepitus, brief (<30 min) morning stiffness, previous joint injury or surgeryConservative: weight loss, therapeutic exercise/physiotherapy, topical then oral NSAID with PPI, intra-articular steroid for flares. Surgical: osteotomy, uni- or total knee replacement when conservative treatment fails
Rheumatoid arthritisProlonged morning stiffness (>30–60 min) that eases with activity; symmetrical small-joint involvementConservative: rheumatology referral, early DMARDs ± biologics, physiotherapy, NSAIDs. Surgical: synovectomy or arthroplasty for established joint destruction
Meniscal / ligamentous injuryLocking (meniscus) or giving way (ligament instability); often a clearer trauma historyConservative: physiotherapy and rehabilitation for most tears. Surgical: arthroscopic repair or partial meniscectomy for true locking; ACL reconstruction for disabling instability
Septic arthritisAcute onset, hot/red/swollen joint, fever, systemically unwellSurgical emergency: urgent joint aspiration for microscopy and culture before antibiotics → IV antibiotics → arthroscopic or open washout and lavage
Gout / pseudogoutEpisodic attacks of exquisite pain and swelling over hours, settling in days; may coexist with OAConservative only: aspiration to confirm crystals and exclude sepsis, NSAID or colchicine for the attack, allopurinol for prophylaxis once settled. No surgical role
Referred spinal / hip pathologyBack pain, leg numbness or weakness accompanying the knee symptomsTreat the source — Conservative: physiotherapy, analgesia. Surgical: hip arthroplasty or spinal decompression directed at the primary pathology
Reactive / enteropathic arthritisRecent diarrhoeal illness, rash, red eye, or known IBDConservative: NSAIDs, treat the underlying infection or bowel disease, rheumatology referral. Surgery has no role

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