What is the recommended treatment for a child with knee clicking?

Pediatric Knee Clicking: Recommended Management

In most children with isolated knee clicking without pain, swelling, locking, or functional limitation, reassurance and observation are appropriate as this is typically a benign finding that does not require treatment.

Clinical Assessment

The key distinction is whether the clicking is symptomatic or asymptomatic:

Asymptomatic Clicking (Most Common)

• Isolated clicking, popping, or snapping sounds without pain, swelling, instability, or functional impairment represent normal joint sounds and require no intervention 1, 2
• These sounds often result from ligament or tendon movement over bony prominences, synovial fluid cavitation, or normal joint mechanics 3
• Parents should be reassured that this is a common, benign finding that typically resolves spontaneously with growth 1, 2

Symptomatic Clicking (Requires Further Evaluation)

If clicking is accompanied by any of the following red flags, proceed with diagnostic workup:

• Pain (localized or diffuse) 4
• Swelling or effusion 4
• Locking (true mechanical locking, not just stiffness) 4
• Catching or giving way 4, 3
• Tenderness on examination 4
• Loss of motion 4
• Inability to bear weight 4

Diagnostic Approach for Symptomatic Cases

Initial Imaging

Obtain radiographs (AP, lateral, sunrise/Merchant, and tunnel views) as the first imaging study when any of the above symptoms are present 4. This is particularly important for:

• Children ≥5 years old with focal tenderness, effusion, or inability to bear weight 4
• Suspected osteochondritis dissecans (OCD), which can present with clicking and intermittent symptoms 4

Advanced Imaging

MRI without IV contrast is appropriate as the next study after normal radiographs if internal derangement is suspected (meniscal tears, ligamentous injury, OCD lesion characterization) 4. This should be performed in:

• Skeletally immature children with persistent symptoms despite normal radiographs 4
• When concomitant pathology such as meniscal tears or ligament injuries is suspected 4

Management Algorithm

For Asymptomatic Clicking:

1. Reassure parents and patient that isolated clicking is benign 1, 2
2. No restrictions on activity are necessary 1
3. No imaging or treatment required 1, 2
4. Advise return if symptoms develop (pain, swelling, locking, instability) 3

For Symptomatic Clicking:

1. Obtain radiographs first 4
2. If radiographs show pathology (OCD, fracture), manage accordingly with orthopedic consultation 4
3. If radiographs are normal but symptoms persist, obtain MRI to evaluate for soft tissue pathology 4
4. Consider orthopedic referral for persistent symptoms, positive imaging findings, or diagnostic uncertainty 3

Common Pitfalls to Avoid

• Do not obtain imaging for isolated, asymptomatic clicking - this leads to unnecessary radiation exposure and potential overdiagnosis of incidental findings 4, 1
• Do not dismiss clicking accompanied by pain or mechanical symptoms - these may indicate significant pathology like OCD or meniscal tears that require treatment 4, 3
• Do not assume all clicking is benign in adolescent athletes - they have higher rates of meniscal tears and OCD lesions that can present with clicking 3
• Avoid MRI as the initial imaging study - radiographs should always be obtained first as they are sufficient for most diagnoses and avoid unnecessary advanced imaging 4

When to Refer to Orthopedics

Immediate referral is warranted for:

• Radiographic evidence of OCD, fracture, or other bony pathology 4
• True mechanical locking (inability to fully extend the knee) 4
• Acute traumatic injury with significant swelling and inability to bear weight 4, 3
• MRI findings of meniscal tears, ligament injuries, or unstable OCD lesions 4, 3

Routine referral is appropriate for:

• Persistent symptoms despite 3 months of conservative management 4
• Diagnostic uncertainty after initial workup 3
• Patient/family anxiety requiring specialist reassurance despite benign findings 1