Aggravating Factors

For Medical Students

What It Tests

Asking what makes the pain worse tests which loading pattern provokes it, and loading patterns map onto structures.

This is the question where biomechanics meets the history. Section 3 established what each activity loads, and this question asks the patient which of those hurts. 3.3.12 covers stair climbing.

It is more informative than the site of pain, because an activity is specific and a region is shared.

How It Is Performed

Ask for activities rather than movements. Stairs, slopes, squatting, kneeling, sitting for long periods, getting out of a car, running, and turning.

Ask about stairs up and stairs down separately, because they load differently and the answer differs.

Ask how soon the pain comes on: immediately, after a distance, or the following day.

Ask whether the activity has to be stopped or merely hurts, since the two are different severities.

What a Positive Means

Pain on stairs, squatting, kneeling and rising from sitting points to the patellofemoral joint, which is loaded in flexion. 4.15.9 covers it.

Pain on turning and pivoting points to rotational structures and to the menisci.

Pain on walking distance with relief on stopping points to degenerative disease.

Pain descending stairs or slopes specifically points to the extensor mechanism or the posterior cruciate. 4.11.6 covers the posterior version.

Pain the following day rather than during the activity suggests a reactive synovitis rather than a mechanical catch. 4.8.9 covers synovitis.

MRCS Level

What a Positive Means

At this level the reasoning runs from the activity to the compartment via the mechanics rather than by recall.

Deep flexion raises patellofemoral joint reaction force substantially, which is why squatting and stair descent provoke patellofemoral pain and level walking does not. 3.12.3 covers contact pressures.

A pivot loads the anterior cruciate and the anterolateral structures, so pain or apprehension on turning implicates them.

Prolonged sitting with the knee flexed loads the patellofemoral joint statically, which is why the complaint of pain after a long drive is patellofemoral until proven otherwise.

Weight bearing through a varus knee concentrates medial load, which is why walking distance is the limiting activity in medial degenerative disease. 3.13.3 covers varus alignment.

How Good It Is

This is among the strongest questions in the knee history for localisation, and it outperforms the patient's report of where the pain is.

The reason is that an activity is an unambiguous fact and a region is an interpretation.

It performs best for the patellofemoral joint, where the provoking activities are characteristic and consistent.

It performs worst in a knee with several problems, where every activity hurts and the pattern is lost. That answer is itself informative and points towards a reactive or diffusely degenerate joint rather than a single lesion.

FRCS Level

How Good It Is

The decision this question informs is whether the loading that provokes the symptom is loading the operation would change.

An osteotomy changes medial load, so it addresses a symptom provoked by weight bearing distance in a varus knee. It does not address a symptom provoked by deep flexion. 4.18.3 covers varus disease.

A patellofemoral procedure addresses flexion loading and does not address walking distance.

A meniscal procedure addresses a mechanical event and does not address diffuse load-related pain.

Matching the provoking activity to the operation's mechanism is one of the most reliable ways to predict whether a patient will be satisfied, and it is available from the history alone.

Where It Misleads

The commonest error is accepting that everything hurts without pursuing what hurts most and first. Even in a diffusely painful knee there is usually a hierarchy.

The second is missing avoidance. A patient who no longer uses stairs will report that stairs do not hurt, and the question has to be whether they use them.

The third is attributing an activity-provoked symptom to a structure that activity does not load, which is where the Section 3 mechanics are a protection rather than an ornament.

And in an obese patient every weight bearing activity is provocative and the pattern compresses, which makes the non-weight bearing questions more informative. 4.23.4 covers the assessment.

Fellowship Level

Where It Misleads

After surgery the provoking activities frequently change, and a change in the pattern is more informative than the pattern itself.

A reconstruction that has relieved instability but produced new flexion-provoked anterior pain has usually produced a patellofemoral or harvest site problem rather than a graft problem. 4.20.1 covers the assessment.

An arthroplasty painful on stair descent with a stable knee raises the patellofemoral articulation, the extensor mechanism or component position rather than loosening.

An osteotomy that relieved walking pain and introduced lateral pain has transferred load, which is the intended mechanism behaving excessively rather than a complication of a different kind. 4.20.4 covers osteotomy assessment.

The discipline is to establish the pre-operative provoking pattern before interpreting the post-operative one, and that is frequently not recorded.

No figure here supports these patterns; they are standard teaching, under decision 023.