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Water on the Knee on Steroids

Water on the Knee
Knee effusions or “water on the knee” is a common problem seen in athletes. With increased participation in sports, this problem is now being widely seen in sports clinic all over the country. Water on the knee can occur in every type of sports activity and can affect both genders at all ages. When the swelling in the knee occurs spontaneously without any injury, in most cases the fluid is serous (water like) but can be blood. The most common cause of knee swelling in athletes is due to what is called the overuse syndrome.

Water on the knee generally begins gradually and is readily noticeable. In the beginning, there may be no symptoms except for an abnormal contour of the knee. As the water swelling progresses, pain of varying intensity may occur. Associated with the pain may also be a slight decrease in the range of motion.

Knee Anatomy

The knee is joint is somewhat complex. It is made up of 4 strong ligaments which are essential for support of the knee. The anterior and posterior cruciate ligaments provide stability and are exceptionally strong. On either side of the knee are the medial and lateral collateral ligaments which provide lateral stability and limit stress to the joint. On top of the knee joint is a large sesamoid bone known as the patella. It provides mechanical advantage during knee extension. The inner part of the joint is covered with articular cartilage (meniscus) which acts like shock absorbers within the knee joint. The medical meniscus is less mobile than the lateral meniscus and thus is more likely to be injured.


The causes of water on the knee in athletes are numerous. They include:

  • knee fracture
  • ligamentous injuries
  • meniscal injury
  • infections
  • blood coagulation disorders
  • overuse syndromes
  • arthritis
  • synovitis

Symptoms & Signs

Symptoms of water on the knee may present with the following features:

Water on the Knee Exam
  • abnormal contour of the knee. One knee may typically appear larger than the other.
  • pain which often occurs while weight bearing and subsides with rest. The pain usually does not occur with minimal amount of water.
  • if an infection is present, the individual may present with a fever. The knee will be tender, swollen, warm and there may be signs of redness
  • if bleeding is the cause of knee swelling, the skin may show signs of ecchymosis or bruising
  • as the swelling progresses, the joint may become stiff and limit the range of motion.
  • walking may be difficulty and some individuals may limp on one knee

When water swelling occurs in the knee, the decision to see a physician depends on what caused it. Some individuals with mild degree of knee swelling may attempt home therapy at home and this may help in a few cases. However, one needs to see a health care professional if the knee swelling occurs after:

  • an injury
  • if self care measures have failed
  • the knee feels warm and hot to touch
Knee Injury & Water on the Knee


When knee swelling occurs, a physical examination is essential by a health care professional. The entire leg is examined for stability, sensory and motor function, integrity of blood supply and alignment of the joint. The assessment begins with a through inspection to look for lacerations, bruising or bleeding. If active motion can not be carried out, passive motion of the knee is attempted. The swollen knee is best examined with the patient lying down and with the knee in the 90 degree position. Palpation may reveal presence of tenderness, crepitus (noise in the knee while bending) and swelling.


X-rays are usually the first imaging study of choice when an individual presents with knee swelling. While x rays are not required in all individuals, patients who are unable to weight bear, have signs of bleeding, fever or have severe pain should have an x-ray. Plain x-rays do not reveal much about ligament of meniscal injury except for a fracture.

The best test to evaluate a patient with a swollen knee is MRI. MRI is very accurate in diagnosing ligament and Meniscal injury.

Some physicians will perform an aspiration of the swollen knee with a needle. This will immediately reveal if the swelling in the knee is from blood or due to an infection. Draining the knee of fluid also provides relief from pain and allows for proper examination.

The fluid aspirated from the knee is always analyzed for infection and presence of crystals.

Overuse syndrome

Athletes who develop water on the knees usually are diagnosed with an overuse syndrome of the knee. This condition is very common in athletes and is generally treated in a supportive fashion. The pain is usually treated with over the counter pain killers and rest. The swelling typically occurs in the weight bearing joint or one that may have sustained prior injury. The onset of overuse injury is gradual but the course is progressive. Sometimes effusion can be recurrent and may be due to small meniscal tear. All types of testing and X rays are generally negative in over use syndrome.

Water on the knee can be a chronic condition. If no cause of the condition is found, then one can alter lifestyle measures to prevent worsening of the condition.

Prevention and Treatment of Overuse Syndrome

Wearing a brace may help individuals who have recurrent build up of fluid. The brace may also help to support the knee and decrease the pain.

If you are overweight, perhaps start a weight loss program may help reduce pressure on the knee joint. Weight loss also prevents the development of osteoarthritis.

One should select an activity that does not place continuous weight bearing stress on the knee joint.

If the knee develops acute swelling, then rest is a must. The rest should be continued until the pain and swelling subside.

For acutely swollen knees, one can elevate the knee and apply ice. The ice only helps during the acute stage of the disorder.

Those individuals who have weak thigh muscles should see a physical therapist or enter a program to strengthen the hamstrings.


Koplas M, Schils J, Sundaram M. The painful knee: choosing the right imaging test. Cleve Clin J Med 2008 May; 75(5):377-84.

Pavlovich R, Goldberg SH, Bach BR. Adolescent ACL injury: treatment considerations.
J Knee Surg 2004 Apr; 17(2):79-93.

Panush RS, Schmidt C, Caldwell JR, et al. Is running associated with degenerative joint disease? JAMA 1986 Mar 7; 255(9):1152-4.

Saal JA. Common American football injuries. Sports Med 1991 Aug; 12(2):132-47.

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