What is the diagnosis and management for a 22-year-old patient with intermittent cold sensation in both knees, despite a normal X-ray?

Intermittent Cold Sensation in Both Knees with Normal X-ray

Primary Recommendation

This presentation is atypical for osteoarthritis and requires further evaluation with MRI to exclude underlying pathology such as osteochondritis dissecans, bone marrow edema, early cartilage lesions, or other soft tissue abnormalities that would not be visible on plain radiographs. 1

Diagnostic Approach

Why This is an Atypical Presentation

• A 22-year-old patient with bilateral intermittent "cold into bone" sensation does not fit the typical osteoarthritis profile (age >40, usage-related pain, short morning stiffness) 1, 2
• In atypical presentations, imaging beyond plain radiographs is recommended to confirm or exclude diagnoses and identify alternative pathology 1
• The unusual symptom description ("cold into bone") warrants investigation for conditions affecting bone marrow, subchondral bone, or neurovascular structures 1

Next Steps in Imaging

• MRI without contrast is the appropriate next imaging modality when radiographs are normal but symptoms persist or are atypical 1, 3
• MRI can detect:
  • Bone marrow edema patterns 1, 3
  • Early osteochondritis dissecans lesions (particularly relevant in this age group) 1, 4
  • Occult stress fractures or bone contusions 1
  • Cartilage abnormalities not visible on radiographs 1, 3
  • Synovitis or joint effusion 3

Physical Examination Priorities

• Assess for joint effusion, which may accompany underlying pathology even with unusual symptom descriptions 4, 3
• Evaluate for joint line tenderness, crepitus, and range of motion limitations 3, 2
• Check for mechanical symptoms (locking, catching, giving way) that would suggest meniscal or cartilage pathology 1, 4
• Document any popping or clicking sensations, as these may indicate osteochondritis dissecans or other structural abnormalities 4

Management Algorithm

If MRI Reveals Pathology

• Osteochondritis dissecans: Management depends on skeletal maturity and lesion stability; may require activity modification, protected weight-bearing, or surgical intervention for unstable lesions 1, 4
• Bone marrow edema: Consider stress reaction, early osteonecrosis, or inflammatory conditions; may require activity modification and follow-up imaging 1
• Cartilage lesions: Treatment ranges from conservative management to surgical intervention depending on severity 1

If MRI is Normal

• Consider persistent physical symptoms (medically unexplained symptoms) as a diagnosis of exclusion 5, 6
• Provide validation and biopsychosocial explanation using person-centered communication 6
• History contributes 73-94% of diagnostic information, but atypical symptoms require imaging to exclude serious pathology before attributing to functional causes 7

Critical Pitfalls to Avoid

• Do not dismiss atypical symptoms in a young patient as "normal" without advanced imaging 1
• Do not assume bilateral symptoms exclude serious pathology—osteochondritis dissecans and other conditions can be bilateral 1
• Avoid routine follow-up imaging without clinical indication, but do obtain baseline MRI when presentation is atypical 1
• Do not delay MRI if symptoms progress rapidly or change character, as this may indicate evolving pathology 1

Prognosis Considerations

• Most symptoms improve within weeks to months, but 20-25% become chronic or recurrent 7
• Serious causes not apparent on initial evaluation (including MRI) seldom emerge during long-term follow-up 7
• If osteochondritis dissecans is identified, there is risk of developing early osteoarthritis if not appropriately managed 1