Vol. 9, Issue 4, Part A (2025)

Persistent knee pain in the presence of normal magnetic resonance imaging findings presents a diagnostic and therapeutic dilemma for orthopaedic clinicians. Magnetic resonance imaging is widely regarded as the gold standard non-invasive modality for evaluating intra-articular knee pathology; however, it may fail to detect subtle chondral lesions, synovial abnormalities, early degenerative changes, or small meniscal tears. In such cases, knee arthroscopy remains the definitive diagnostic modality, allowing direct visualization of intra-articular structures and simultaneous therapeutic intervention. This practical review examines the diagnostic value of knee arthroscopy in patients who continue to experience knee pain despite normal MRI findings. Evidence from clinical studies suggests that a significant proportion of these patients demonstrate pathologies at arthroscopy that were not evident on preoperative imaging. Conditions such as focal cartilage defects, plica syndrome, synovitis, early osteoarthritic changes, and occult meniscal injuries are commonly identified during arthroscopic evaluation. The review highlights the sensitivity limitations of MRI, particularly in early-stage or low-grade lesions, and discusses factors influencing diagnostic discordance, including imaging quality, interpretation variability, and patient-related characteristics. Additionally, the role of arthroscopy in improving patient-reported outcomes through targeted interventions is explored. While arthroscopy is invasive and carries procedural risks, its judicious use in carefully selected patients with persistent symptoms can provide diagnostic clarity and guide effective management. The review emphasizes the importance of correlating clinical findings with imaging results rather than relying solely on MRI. Understanding when to proceed to arthroscopy is crucial for optimizing outcomes, reducing diagnostic delays, and addressing patient dissatisfaction. This article supports the continued relevance of diagnostic knee arthroscopy as a complementary modality in cases of unexplained knee pain with normal MRI findings, reinforcing its role in comprehensive orthopaedic evaluation.