Anterior knee pain exacerbated by running, jumping, or cycling

Pain on climbing or descending stairs or hills

Pain with prolonged sitting with knees flexed (i.e., “theater sign”)

Patellofemoral malalignment

“J” sign (i.e., curvilinear lateral tracking of the patella with contraction of quadriceps)

Tenderness along patellofemoral facets and pain with patellar compression

Crepitus with active extension

Radiography (sunrise or merchant view) often normal but may show lateral tilt or subluxation of patella

Computed tomography and MRI usually not indicated but may reveal patellar malalignment or chondromalacia

Lateral knee pain exacerbated by running, cycling, or hiking

May be aggravated by prolonged hill running, running on a slanted road shoulder, or too much unidirectional running around a track

Tenderness along lateral femoral condyle or approximately 2 cm above lateral joint line

Tight iliotibial band with Ober's test (i.e., passive adduction of hip and leg, with patient lying on unaffected side and knee slightly flexed)

Imaging usually not indicated when diagnosis is strongly suspected on clinical examination

Radiography typically normal

MRI may show thickened iliotibial band and associated edema

Activity-associated shin pain described as dull ache along mid- to distal tibia

Tenderness along posteromedial border of the mid- to distal tibia for several centimeters

Focal tenderness over anterior tibia suggests stress fracture

Radiography typically normal

MRI or bone scan may determine nature of injury if stress fracture is suspected or patient has poor response to rest and treatment

Gradual onset of pain in Achilles tendon

More common in middle-aged athletes

Acute injury with sensation of being struck in back of heel suggests rupture

Tenderness along Achilles tendon 2 to 6 cm proximal to attachment, often with thickened, tender nodules

Crepitus suggests acute tenosynovitis

Perform Thompson's test if rupture is suspected (i.e., assess passive ankle plantarflexion with calf squeeze; no response indicates tear)

Radiography usually not indicated but may show thickening of Achilles tendon or calcification at the insertion

MRI helpful if rupture is suspected and clinical evaluation is equivocal, although careful examination is usually diagnostic

Ultrasonography may be useful

Pain in plantar heel or arch that is worse with first few steps in the morning

Pain may subside with warm-up and activity, only to become stiff and sore after activity

Tenderness at medial plantar calcaneal tuberosity and along medial arch

Pain with passive dorsiflexion of the toes

Pes planus or pes cavus

Radiography usually not necessary but may show calcaneal spurring or calcifications within the plantar soft tissue

Presence or absence of heel spur does not change management

Progressive pain over a bony structure that is worse with weight-bearing activity

Pain at rest in some cases

Physicians should maintain high suspicion of stress fracture in long distance runners with musculoskeletal pain

Focal tenderness over bony structure

Overlying edema may be present

In femoral neck stress fracture, pain with passive hip range of motion

Radiography often negative early in course of injury (less than two to four weeks)

May show cortical thickening, periosteal reaction, or fracture line

MRI and bone scan are more sensitive and should be performed if high-risk stress fracture (e.g., femoral neck or navicular fracture) is suspected

Dual energy x-ray absorptiometry may be indicated if osteoporosis is suspected