Knee Pain Assessment and Management in Urgent Care

Patients presenting with knee pain in the Urgent Care setting should be classified into 2 groups: acute (<2 months) vs. chronic (>2months). Acute or chronic knee pain is further classified as traumatic vs. non-traumatic. Patient history should focus on the place, quantity, quality, radiation of pain, associated symptoms, and mitigating and exacerbating factors and treatments to date. When assessing the place of pain, it should be noted if the pain is around the kneecap (parapatellar), in front of the kneecap (anterior), behind the kneecap (posterior), below the kneecap (inferior), above the kneecap (superior), or localized to the inner portion of the knee (medial) or the outer portion of the knee (lateral). Pain presenting around the kneecap may be consistent with patellofemoral pain syndrome, osteoarthritis, or tendinitis of the quadriceps or patella.  

Pain in the front of the kneecap is oftentimes consistent with patellofemoral pain syndrome, osteoarthritis, or prepatellar bursitis. Pain behind the kneecap is likely consistent with patellofemoral pain syndrome, osteoarthritis, Baker’s cyst. Pain presenting below the kneecap may be consistent with patellofemoral pain syndrome, osteoarthritis, patellar tendinitis, or pes anserine bursitis. Pain presenting above the kneecap is often consistent with patellofemoral pain syndrome, osteoarthritis, or quadriceps tendinitis.  Pain localized to the inner knee may be consistent with patellofemoral pain syndrome, osteoarthritis, medial meniscus tear, medial collateral ligament (MCL) sprain, or pes anserine bursitis. Pain localized to the outer portion of the knee is likely due to patellofemoral pain syndrome, osteoarthritis, lateral meniscus tear, lateral collateral ligament (LCL) sprain, or iliotibialband (ITB) syndrome.  

The quantity of pain can be classified on a 1-10 scale, as mild, moderate, or severe.  Pain quantity should be documented at rest, standing, walking. The quality of pain can be classified as achy, dull, stiff, sharp, numb, pins and needles. Associated symptoms such as the presence of knee instability (locking, catching, buckling), knee swelling, knee bruising/skin discoloration, or the presence of other symptoms (fever, chills, sweats, weight loss, nausea, headache, back pain, rash) should be assessed. Mitigating factors and exacerbating factors should also be noted and may provide clues to the cause of the knee pain. Treatments that have been attempted to date should be documented. Common treatments for knee pain include rest, ice, heat, compression, elevation, supportive bracing, crutches, Tylenol, NSAIDs (I.e. Advil, Ibuprofen, Aleve, Aspirin), injection therapy (cortisone injections, viscosupplementation), physical therapy, acupuncture, surgery.

Physical examination should assess the patient’s gait, knee range-of-motion (normal 0-130), strength (knee extension/flexion), swelling, discoloration, crepitus (clicking of the knee), point tenderness, ligamentous laxity of the ACL, PCL, MCL, LCL, or mechanical issues with either the medial or lateral meniscus. Patients presenting in severe pain and/or with a traumatic mechanism of injury and have findings on exam concerning fracture or significant knee instability should have X-rays of the knee performed and should have protected weight-bearing and supportive bracing. Rest, ice, compression, elevation (RICE), and Tylenol or NSAIDs may be considered as well. Ultimately, these patients should be referred to ORTHO for further evaluation and management.

Patients presenting in mild-moderate pain and/or without findings on exam concerning fracture or significant knee instability can be initially managed conservatively with rest, ice, compression, elevation (RICE) approach with a trial of Tylenol or NSAIDs. Pain that fails to improve with such measures over a 1-2 week period should have knee X-rays performed and referred to ORTHO for further evaluation and management.