Immediate Management: Obtain Knee Radiographs and Assess for Patellar Dislocation
For a forceful planting injury with pain above and medial to the patella, you should immediately obtain anteroposterior and lateral knee radiographs to rule out patellar dislocation or fracture, as this presentation is consistent with acute patellar subluxation or dislocation. 1
Initial Clinical Assessment
Focus your examination on these specific findings:
- Patellar position: Check if the patella is high-riding or laterally displaced
- Patellar apprehension: Test for lateral patellar instability
- Effusion: Presence suggests intra-articular injury
- Ability to bear weight: Critical for determining imaging necessity
- Bony tenderness: Palpate the patella, femoral condyles, and tibial plateau
- Knee range of motion: Note if the patient can flex to 90 degrees
Imaging Algorithm
Step 1: Plain Radiographs (Initial Study)
Obtain radiographs immediately if ANY of the following Ottawa Knee Rule criteria are present 1:
- Focal tenderness at the patella or elsewhere
- Joint effusion
- Inability to bear weight (cannot take 4 steps)
Required views:
- Anteroposterior
- Lateral (at 25-30 degrees flexion)
- Add patellofemoral (sunrise) view given your suprapatellar pain location 1
The lateral view will show if the patella is dislocated superiorly (rare but possible with forceful planting) or if there's an effusion. The patellofemoral view is essential for detecting patellar subluxation, dislocation, or fracture 1.
Step 2: If Radiographs Are Negative but Clinical Suspicion Remains High
Proceed to MRI without IV contrast 1 to evaluate for:
- Medial patellofemoral ligament (MPFL) tear
- Bone marrow contusions (lateral femoral condyle and medial patella facet are classic for patellar dislocation)
- Osteochondral injuries
- Meniscal tears
- Medial collateral ligament injury
Immediate Treatment Based on Findings
If Patellar Dislocation Is Present:
Perform immediate closed reduction 2, 3:
- Provide analgesia (intramuscular or intravenous)
- Extend the knee while applying gentle medial pressure to the patella
- Success rate is >90% with minimal complications 2
- Immobilize in knee immobilizer or posterior splint for 2-3 weeks 4, 3
If No Dislocation but Suspected Instability:
Initiate conservative management 5:
- Knee immobilizer for comfort (1-2 weeks)
- Ice and NSAIDs for pain control
- Begin knee-targeted exercise therapy once acute pain subsides
- Education about the injury and recovery expectations
Critical Pitfalls to Avoid
Don't miss superior patellar dislocation: This rare variant presents with a high-riding patella and inability to extend the knee. The patella becomes locked above the femoral condyle 6, 4. Your "pain above patella" description raises this concern.
Don't assume spontaneous reduction means no injury: Many patellar dislocations reduce spontaneously before evaluation. The medial pain suggests MPFL injury, which occurs in most patellar dislocations.
Don't skip the patellofemoral view: Standard AP and lateral views can miss patellar pathology 1.
Don't delay vascular assessment: While uncommon with isolated patellar injuries, any knee dislocation (tibiofemoral) requires immediate neurovascular examination and potential vascular imaging 1, 7, 8.
Definitive Management Planning
Once imaging confirms the diagnosis:
For confirmed patellar dislocation/instability 5:
- Primary intervention: Knee-targeted exercise therapy (quadriceps strengthening, especially vastus medialis obliquus)
- Consider adding: Hip-targeted exercises if hip weakness is identified
- Education: Explain the 15-44% recurrence risk and importance of rehabilitation
- Adjunctive options based on individual factors:
- Patellar taping for symptom control
- Prefabricated foot orthoses if foot mechanics contribute
- Manual therapy for restricted motion
Surgical referral indications:
- Large osteochondral fragments
- Irreducible dislocation
- Recurrent dislocations despite conservative management
- Associated ligamentous injuries requiring repair