What is the plan of care for a patient presenting with knee pain and popping?

Plan of Care for Knee Pain and Popping

Initial Assessment and Diagnostic Workup

Begin with a focused physical examination documenting weight-bearing ability (minimum 4 steps), knee flexion to 90 degrees, and presence of joint effusion, as these findings directly determine management urgency. 1

Key Physical Examination Elements:

• Weight-bearing status: Have patient take at least 4 steps to assess functional capacity 1
• Range of motion: Document if knee flexes to 90 degrees 1
• Joint effusion: Palpate for swelling, which suggests intra-articular pathology requiring imaging 2, 1
• Mechanical symptoms: Assess for locking, catching, or giving way that accompanies the popping 3
• Tenderness location: Identify specific areas of pain (medial, lateral, anterior, or posterior) 3

Imaging Strategy:

• Obtain plain radiographs (AP, lateral, Merchant, and tunnel views) if: pain has persisted >6 weeks, joint effusion is present, or mechanical symptoms (locking/giving way) accompany the popping 2, 1, 3
• Reserve MRI for: persistent symptoms despite adequate conservative treatment, normal radiographs with ongoing symptoms, or when surgery is being considered 4, 1, 3

Initial Conservative Management (First 6 Weeks)

Start acetaminophen up to 4g/day combined with knee-targeted exercise therapy and patient education for all patients without urgent surgical indications. 1

Pharmacological Management:

• First-line: Acetaminophen up to 4g/day due to superior long-term safety profile 1
• Second-line: Topical NSAIDs or capsaicin if acetaminophen ineffective 1
• Third-line: Oral NSAIDs with gastroprotection if gastrointestinal risk factors present 4, 1
• Ice therapy: Apply through wet towel for 10-minute periods multiple times daily for short-term pain and swelling reduction 2

Exercise Therapy Protocol:

• Knee-targeted exercises: Initiate eccentric strengthening as pain allows, progressing based on tissue tolerance to load 2, 4
• Add hip strengthening: If patient demonstrates poor tolerance to loaded knee flexion 4
• Neuromuscular training: Incorporate balance, agility, and coordination exercises to improve performance-based function 4
• Pacing principle: "Small amounts often" linked to daily activities to establish routine 4

Patient Education (Essential Component):

• Explain: Pain does not correlate with tissue damage, particularly in chronic presentations 4
• Clarify: Expected recovery timeframes and load management strategies 4, 2
• Address: Fear avoidance behaviors and build confidence for functional tasks 4
• Promote: Autonomy and self-management skills 4

Weight Management:

• Recommend sustained weight loss if patient is overweight or obese, as this improves both pain and function 4, 1

Supporting Interventions (Adjuncts to Exercise)

Prefabricated Foot Orthoses:

• Prescribe when: Patient responds favorably to treatment direction tests (symptom improvement during functional task with orthoses in place) 4
• Customize: Modify density and geometry for comfort 4

Taping:

• Consider when: Rehabilitation is hindered by elevated symptom severity, irritability, or high fear of movement 4
• Discontinue: If no favorable outcomes after 6 weeks 4

Manual Therapy:

• Use in addition to exercise: May improve pain and function when symptoms are severe 4

Advanced Interventions (If Conservative Management Fails After 6 Weeks)

Intra-articular Corticosteroid Injection:

• Indicated specifically for: Pain flares accompanied by joint effusion 1
• Note: Provides only short-term relief without long-term outcome improvement 2

Extracorporeal Shock Wave Therapy (ESWT):

• Consider for: Chronic symptoms persisting beyond 3-6 months as a safe, noninvasive option 2

Surgical Referral Indications

Refer for surgical consultation when: radiographic evidence of osteoarthritis with refractory pain despite conservative treatment, specific mechanical pathology identified (unstable osteochondritis dissecans lesion, traumatic meniscal tear causing locking), or persistent symptoms after 6+ weeks of adequate conservative treatment with concerning MRI findings. 1, 3

Critical Pitfalls to Avoid

• Never completely immobilize: This causes muscular atrophy and deconditioning 2
• Joint effusions are red flags: Uncommon with simple tendinopathy and suggest intra-articular pathology requiring imaging 2
• Popping after significant trauma: Requires prompt evaluation to rule out serious injury (ACL tear, meniscal tear) 3, 5
• Rare causes exist: Consider snapping popliteus tendon syndrome if lateral knee popping persists despite standard treatment 6, 7

Reassessment Timeline

Reassess at 6 weeks: If no favorable outcomes observed, revisit assessment findings to ensure interventions align with clinical reasoning and review patient engagement. 4 Consider MRI if not yet obtained and symptoms persist. 4, 1