From the Guidelines
When assessing knee pain following trauma, a comprehensive history is crucial to guide appropriate management, and key points to cover include the mechanism of injury, timing of onset, and presence of an audible "pop". The assessment should be guided by a patient-centred framework, understanding that pain encompasses multiple biological, psychological, and social factors 1. The history should include the patient's needs, preferences, and priorities regarding pain management, as well as their pain characteristics, including severity, type, spread, and quality 1.
Key history points to cover include:
- Mechanism of injury (direct blow, twisting, hyperextension)
- Timing of onset (immediate or delayed)
- Presence of an audible "pop" which may suggest ligamentous injury
- Ability to weight-bear immediately after injury
- Location and character of pain
- Any swelling or hemarthrosis (blood in joint)
- Whether the knee has locked, given way, or felt unstable
- Previous knee injuries or problems
- Functional limitations in daily activities
- Aggravating or relieving factors
- Symptoms suggesting serious pathology such as severe pain disproportionate to injury, neurovascular compromise (numbness, tingling, coldness), or systemic symptoms
The patient's age, occupation, and activity level are important contextual factors that influence management decisions. A comprehensive history helps distinguish between common injuries like ligament tears (ACL, MCL), meniscal injuries, patellar dislocations, and fractures, guiding appropriate physical examination, imaging decisions, and management planning 1. Early accurate assessment is crucial as some knee injuries require prompt specialist referral while others can be managed conservatively. The assessment and treatment process should be guided by a patient-centred framework, taking into account the patient's unique needs and circumstances 1.
From the Research
Key Points in Knee Pain History After Trauma
When evaluating knee pain after trauma, several key points should be covered in the patient's history, as recommended by the Royal Australian College of General Practitioners (RACGP) and Australian Therapeutic Guidelines. These include:
- Age of the patient 2, 3
- Location, onset, duration, and quality of pain 2
- Associated mechanical or systemic symptoms 2
- History of swelling 2
- Description of precipitating trauma 2
- Pertinent medical or surgical history 2
Red Flags for Urgent Referral
Patients requiring urgent referral generally have:
- Severe pain, swelling, and instability or inability to bear weight in association with acute trauma 2
- Signs of joint infection such as fever, swelling, erythema, and limited range of motion 2
Evaluation and Management
The evaluation and management of knee pain after trauma should involve a systematic approach to examination of the knee, including:
- Inspection 2
- Palpation 2
- Evaluation of range of motion and strength 2
- Neurovascular testing 2
- Special (provocative) tests 2 Radiographic imaging should be reserved for chronic knee pain (more than six weeks) or acute traumatic pain in patients who meet specific evidence-based criteria 2, 4. Musculoskeletal ultrasonography and magnetic resonance imaging (MRI) may also be used in certain cases 2, 3.
Clinical Decision Rules
The use of clinical decision rules can help rule out fractures of the knee and reduce the unnecessary cost and radiation exposure associated with plain radiographs 4. If ligamentous or meniscal injury to the knee is suspected, expedited follow-up with the patient's primary care physician or an orthopedic specialist should be arranged for consideration of an MRI and further management 4.
Treatment Options
Treatment options for knee pain after trauma may include non-steroidal anti-inflammatory drugs (NSAIDs) for pain control, as well as exercise therapy, weight loss, education, and self-management programs for conditions such as osteoarthritis (OA) and patellofemoral pain 3, 5. Surgical referral may be considered for patients with end-stage OA or severe traumatic meniscal tears 3, 5.