History

  • Age
  • Acute or chronic pain
  • Duration/Frequency
  • Sport/Mechanism
  • Pop/Tear
  • Swelling (Rapid?)
  • ROM deficit
  • Instability
  • Weight-bearing immediately
  • Location of pain
  • Mechanical symptoms
  • Attempted treatment (RICE?)

Physical Exam

Inspection

  • Joint Effusion, ecchymosis
  • Skin integrity - abrasion/laceration etc
  • Alignment - Genu Varum/Valgum/Femoral anteversion
  • Gait/ability to bear weight (Walking, running, squatting, etc)

ROM

  • Extension/Flexion

Palpation

  • Effusion vs extra-articular STS
  • Physis-Tibia-Fibula, Femur
  • Patella/patello femoral compression
  • Joint lines/meniscus
  • Ligaments-Collateral/Medial Patellofemoral
  • Tendons (Patella, Quad, hamstring, ITB)

Special Maneuvers

  • Patellar apprehension
  • Lachman /Drawer
  • Valgus/Varus testing - collaterals
  • Active straight leg raise
  • McMurray

Neurovascular exam

Adjacent Joints

  • Clear the hip

Imaging

Radiographs Indications

  • Deformity, acute effusion, not weight bearing, instability, tender physis, chronic pain not improving
  • Standard trauma - AP, lateral, oblique
  • Orthopedic standard AP, Lat, Sunrise, Tunnel

MRI Indications

  • Radiographs fail to clarify the problem (consider with effusion)
  • To confirm your clinical suspicion (To answer a specific clinical question - Is there an ACL tear in the knee?)
  • Pain failing conservative care

Differential Diagnosis by Anatomic Location

Diffuse/Global Pain

  • Fracture, acute trauma, immediate dec ROM

Anterior Knee Pain

  • Patellofemoral Pain
  • Patellar subluxation/dislocation
  • Patellar tendonitis (Jumpers Knee)
  • Apophysitis (Osgood-Schlatter, Sindig)

Medial Knee Pain

  • MCL Sprain
  • Medial Meniscal Tear
  • Hamstring Strain
  • Osteochondritis Dissecans MFC
  • Medial Plica Syndrome

Lateral Knee Pain

  • Lateral Meniscal Tear
  • TB Syndrome
  • Osteochondritis Dissecans LFC
  • Hamstring Strain

Posterior Knee Pain

  • Baker’s/Popliteal Cyst
  • Gastrocnemius/Hamstring Strain
  • Posterior Capsule Sprain

Management

R-Rest
I-Ice
C-Compression
E-Elevation

  • Pain Control
  • Crutches
  • Splint/Brace
  • Limit use of knee immobilizer to < 1 week to avoid knee stiffness
  • Rehabilitation Early ROM

When to Refer

  • Failure to improve with conservative care
  • Hemarthrosis
  • Instability
  • Potential surgical conditions (suspected ACL, OCD, patellar dislocation)
  • Physis Injury
  • Parental Concern
  • Return to play concerns