Discharge Instructions - Knee Pain

As discussed in the Emergency Department prior to discharge, you were diagnosed with knee pain.  Many different conditions can cause knee pain.

Some of the most common causes of knee pain include:

-Bending or using the knee too much – This can cause pain in the front of the knee that worsens with running, climbing steps, or sitting for a long time.

-Arthritis – Arthritis is a general term that means inflammation of the joints.  There are lots of types of arthritis.  The most common type, called osteoarthritis, often comes with age.  It can cause pain, stiffness, and swelling.

-Bursitis – Bursitis happens when fluid-filled sacs around the knee (called "bursae") get irritated or swollen.  Bursitis can cause pain and swelling.

-A collection of fluid in the knee (an effusion) – This can happen after a knee injury.

-A tear in the meniscus – The meniscus is a cushion of rubbery material (cartilage) between the thigh bone and the leg bone.

-A tear in a ligament – Ligaments are bands of tissue that connect one bone to another. There are 4 ligaments in each knee.

-Muscle strain – Different leg muscles move the knee joint, causing the knee to bend and straighten.  If one of these muscles doesn't work well, moving the knee can cause pain.

-Other knee injuries, a knee joint infection, or a condition called gout, which causes crystals to form inside joints.

-Conditions that don't involve the knee – For example, problems in the hip can sometimes cause knee pain.

You may have had x-rays of the affected knee in the Emergency Department and the results have been discussed with you prior to discharge.  Many people are curious about whether they will need more advanced imaging such as an MRI or magnetic resonance imaging.  These studies can only be obtained in the Emergency Department when there is a chance that an emergency surgery needs to be done.  It is possible you will need additional imaging, including an MRI, but this will need to be ordered by your primary care provider.  This is because this study will usually require referral to physical therapy and possibly to Orthopedics for surgery.

There are several ways to reduce swelling in the injured knee and to help the healing process:

-Elevate the injured knee.  This can be done by putting your leg up on a chair when sitting down (watching TV, reading, eating dinner, etc.).

-If the knee is swollen or painful, apply ice wrapped in a towel (or a bag of frozen peas wrapped in a thin towel) on the knee for about 10 minutes at a time.  Then remove the ice pack and allow the skin to return to normal temperature before re-applying the ice pack (to avoid frostbite).  Continue this while the knee is still swollen; do not apply heat while the knee is swollen.

-A tensor bandage can be wrapped around the knee to provide more support over the lengthy healing period.  This bandage can be removed when applying ice to the knee.

-If the sprain was severe, you may have been provided with a splint or immobilizer during your visit to the Emergency Department.  Use the splint as directed by the emergency physician.

You can take Acetaminophen (also known as Tylenol), Ibuprofen (also known as Advil or Motrin), or Naproxen (also known as Aleve) for the pain.

https://orthoinfo.org/en/diseases--conditions/common-knee-injuries/

https://orthoinfo.org/en/diseases--conditions/collateral-ligament-injuries/

https://orthoinfo.org/en/diseases--conditions/combined-knee-ligament-injuries/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

Discharge Instructions - Meniscus Injury

As discussed in the Emergency Department prior to discharge, based on our evaluation you may have a meniscus tear.  A meniscal tear is a condition that causes knee pain and other knee symptoms.  It happens when a part of the knee joint called the "meniscus" tears.  The meniscus is the cushion of rubbery material (cartilage) between the thigh bone and shin bone.

There are different kinds of meniscal tears, depending on the part of the cartilage that tears and how it tears.  A meniscal tear can happen suddenly, such as during a sports injury.  It can also happen slowly over time.  This is more common in older adults.

Symptoms of a meniscal tear can include: knee pain, knee swelling (from a collection of fluid around the knee), the knee locking, not straightening all the way, or feeling like it "catches" on something as it straightens, the knee giving out, feeling unstable, or feeling like it won't support you, an knee stiffness.

You may have had x-rays of the affected knee in the Emergency Department and the results have been discussed with you prior to discharge.  Many people are curious about whether they will need more advanced imaging such as an MRI or magnetic resonance imaging.  These studies can only be obtained in the Emergency Department when there is a chance that an emergency surgery needs to be done.  It is possible you will need additional imaging, including an MRI, but this will need to be ordered by your primary care provider.  This is because this study will usually require referral to physical therapy and possibly to Orthopedics for surgery.

In some cases, the MRI is inconclusive, and patients suspected of having a meniscal tear are referred for a surgical procedure called an arthroscopy.  This lets the doctor look inside your knee at the meniscus.  During arthroscopy, the doctor makes a few small cuts around the knee.  Then he or she inserts long, thin tools into the knee joint.  One tool has a camera on the end that sends pictures to a TV screen that the doctor sees.  If you have a meniscal tear, the doctor can use the other tools to treat it.

There are several ways to reduce swelling in the injured knee and to help the healing process:

-Elevate the injured knee.  This can be done by putting your leg up on a chair when sitting down (watching TV, reading, eating dinner, etc.).

-If the knee is swollen or painful, apply ice wrapped in a towel (or a bag of frozen peas wrapped in a thin towel) on the knee for about 10 minutes at a time.  Then remove the ice pack and allow the skin to return to normal temperature before re-applying the ice pack (to avoid frostbite).  Continue this while the knee is still swollen; do not apply heat while the knee is swollen.

-A tensor bandage can be wrapped around the knee to provide more support over the lengthy healing period.  This bandage can be removed when applying ice to the knee.

-If the sprain was severe, you may have been provided with a splint or immobilizer during your visit to the Emergency Department.  Use the splint as directed by the emergency physician.

You can take Acetaminophen (also known as Tylenol), Ibuprofen (also known as Advil or Motrin), or Naproxen (also known as Aleve) for the pain.

https://orthoinfo.org/en/diseases--conditions/meniscus-tears/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

Discharge Instructions - Patellofemoral Pain Syndrome

As discussed in the Emergency Department prior to discharge, based on our evaluation your pain is most likely due to patellofemoral pain syndrome.  Patellofemoral pain is a condition that causes pain in the front of the knee. It involves the knee cap, which doctors call the "patella."  Many times, patellofemoral pain happens in runners or other people who put a lot of pressure on their knees.  But the condition can also happen when a person's knee cap gets out of line with the knee joint.

Patellofemoral pain causes pain in the front of the knee, or around or behind the knee cap.  The pain can come on slowly or quickly.  The pain is usually worse when people squat, run, or sit for a long time.  Some people might also feel as if their knee is giving out.

Treatment usually involves a few parts.  The first part of treatment helps to reduce your pain. It can include:

-Resting your knee and avoiding activities or movements that make the pain worse.

-Taking nonsteroidal antiinflammatory drugs, also called "NSAIDs."  NSAIDs are a large group of medicines that includes Ibuprofen (sample brand names: Advil, Motrin) and Naproxen (sample brand names: Aleve, Naprosyn).

-Putting ice on your knee when it hurts or after activities that cause pain.  You can put a cold gel pack, bag of ice, or bag of frozen vegetables on the painful area every 1 to 2 hours, for 15 minutes each time.  Put a thin towel between the ice (or other cold object) and your skin.

Another part of treatment involves doing exercises to strengthen the muscles around your knee.  Your doctor or nurse will show you which exercises to do, or he or she will have you work with a physical therapist (exercise expert).

Your doctor might also recommend that you:

  -Wear a knee brace to support your knee.

  -Tape up your knee in a certain way to support your knee.

  -Wear special shoe inserts made to fit your foot (to keep your foot from turning in or out too much).

It is important that you follow up with your primary care provider to arrange for additional treatment options, including referral to physical therapy.

Your symptoms will most likely improve with treatment. But if they don't, your doctor might have you see a knee specialist to discuss treating your condition with surgery.

https://orthoinfo.org/en/diseases--conditions/patellofemoral-pain-syndrome/

https://mydoctor.kaiserpermanente.org/ncal/Images/patellofemoral_tips_exercises_tcm75-823272.pdf

https://thrive.kaiserpermanente.org/care-near-you/northern-california/santarosa/wp-content/uploads/sites/15/2015/09/Patellofemoral-Pain-Syndrome_tcm28-180773.pdf

MDM - Ligamentous Knee Injury

[##]-year-old [male/female] with [right/left] knee pain [and injury] with history and exam consistent with likely [medial/lateral anterior/posterior collateral/cruciate] ligament injury.

Initial consideration in this patient included ligamentous injury to the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and medial and lateral meniscus, knee dislocation, patellar and other knee fractures, patellar and quadriceps tendon injury or rupture, arthritis, pes anserine and prepatellar bursitis, and septic arthritis amongst others.

Patient present with [right/left] knee pain in the setting of [describe injury] concerning for ligamentous injury to the knee.  Patient noted to have tenderness to palpation [over the medial/lateral joint line concerning for MCL injury/LCL injury] on exam.  Specialized testing performed on the [right/left] knee as noted above with [positive valgus (abduction) stress test suggestive of MCL injury/positive varus (adduction) stress test suggestive of LCL injury/positive anterior drawer test/Lachman’s test suggestive of ACL injury/positive posterior drawer test suggestive of PCL injury].  Imaging of the [right/left] knee [felt to not be indicated in a patient meeting all Ottawa Knee Rules/with no evidence suggestive of bony injury on exam/obtained with plain films noted to be unremarkable/ findings].  The patient was noted to have no evidence of associated [collateral/cruciate ligament/any other] injuries.  Patient provided with [compression sleeve/knee immobilizer/crutches] in the ED prior to discharge [and noted to have improved pain after treatment with Toradol/etc.].

Prior to discharge, we discussed return precautions, symptomatic treatment with rest, ice, compression, and exercises as described in the handout provided at time of discharge, and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.  We specifically discussed that while additional imaging, including MRI, may ultimately be a part of the management of this condition, it is not part of the emergent management of this condition.  We recommended close follow up with their primary care provider for further discussion of additional imaging, and the patient demonstrated understanding and agreement.

https://orthoinfo.org/en/diseases--conditions/common-knee-injuries/

https://orthoinfo.org/en/diseases--conditions/collateral-ligament-injuries/

https://orthoinfo.org/en/diseases--conditions/combined-knee-ligament-injuries/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

MDM - Patellofemoral Syndrome

[##]-year-old [male/female] with [right/left] knee pain with history and exam consistent with likely patellofemoral pain syndrome (“runner’s knee”).

Initial consideration in this patient included knee dislocation, patellar and other knee fractures, patellar and quadriceps tendon injury or rupture, meniscus and ligamentous knee injuries, arthritis, Osgood-Schlatter disease, pes anserine and prepatellar bursitis, and septic arthritis amongst others.

Patient presented with report of gradual onset of unilateral, anterior, non-radiating knee pain that is reportedly worsened by prolonged knee flexion (“moviegoer syndrome”) and stair climbing.  Patient noted to have a positive patellar grind test of the [right/left] knee (press patella away from femoral condyles while patient contracts the quadriceps; sudden patellar pain and relaxation of the muscle is a positive test).  Plain films were considered [unnecessary in patient without significant history of trauma, bony tenderness or deformity, or other findings suggestive of dislocation, fracture or other significant injury/and obtained with no evidence of significant abnormality/obtained and notable for a patella that does not line up with the groove of the femur on sunrise view/decreased space posterior to patella/bony erosions].

Prior to discharge, we discussed return precautions, symptomatic treatment with rest, ice, compression, and exercises as described in the handout provided at time of discharge, and follow up with primary care doctor within one week for further evaluation and consideration of referral to physical therapy, and the patient demonstrated understanding and agreement.

https://orthoinfo.org/en/diseases--conditions/patellofemoral-pain-syndrome/

https://mydoctor.kaiserpermanente.org/ncal/Images/patellofemoral_tips_exercises_tcm75-823272.pdf

https://thrive.kaiserpermanente.org/care-near-you/northern-california/santarosa/wp-content/uploads/sites/15/2015/09/Patellofemoral-Pain-Syndrome_tcm28-180773.pdf

MDM - Knee Meniscus Injury

[##]-year-old [male/female] with [right/left] knee pain with history and exam consistent with likely patellofemoral pain syndrome (“runner’s knee”).

Initial consideration in this patient included medial and lateral meniscus injury, ligamentous injury to the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL), knee dislocation, patellar and other knee fractures, patellar and quadriceps tendon injury or rupture, arthritis, pes anserine and prepatellar bursitis, and septic arthritis among others.

Patient present with [right/left] knee pain in the setting of [describe injury] concerning for ligamentous and meniscal injury to the knee.  Patient [reported/denied] episodes of locking and clicking of the [right/left] knee.  Patient noted to have tenderness to palpation [over the medial/lateral joint line concerning for ligamentous injury] on exam.  Specialized testing performed on the [right/left] knee as noted above with [positive McMurray test suggestive of medial meniscus injury].  Imaging of the [right/left] knee [felt to not be indicated in a patient meeting all Ottawa Knee Rules/with no evidence suggestive of bony injury on exam/obtained with plain films noted to be unremarkable/ findings].  The patient was noted to have no evidence of associated [collateral/cruciate ligament/any other] injuries.  Patient provided with [compression sleeve/knee immobilizer/crutches] in the ED prior to discharge [and noted to have improved pain after treatment with Toradol/etc.].

Prior to discharge, we discussed return precautions, symptomatic treatment with rest, ice, compression, and exercises as described in the handout provided at time of discharge, and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.  We specifically discussed that while additional imaging, including MRI, may ultimately be a part of the management of this condition, it is not part of the emergent management of this condition.  We recommended close follow up with their primary care provider for further discussion of additional imaging, and the patient demonstrated understanding and agreement.

https://orthoinfo.org/en/diseases--conditions/meniscus-tears/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

Physical Exam - Orthopedic Knee Exam

[No/Minimal/Moderate] isolated tenderness to palpation over the patella of the [right/left] knee.  [No/Minimal/Moderate] tenderness to palpation at the head of the [right/left] fibula.  [Limited/full] active range of motion of the [right/left] knee to [90/##]°.  [Limited/full] passive range of motion of the [right/left] knee to [90/##]°.  Patient [not able/able] to ambulate 4 steps in the ED [despite pain/due to pain]. 

[No/Mild/Moderate] instability on valgus (medial) stress of the [right/left] knee.  [No/Mild/Moderate] instability on varus (lateral) stress of the [right/left] knee.  [Negative/Positive] Lachman's test (instability with anterior stress on the knee in 15-30° flexion).  [Negative/Positive] anterior drawer test (instability with anterior stress on the knee in 90° flexion).  [Negative/Positive] posterior drawer test (instability with posterior stress on the knee in 90° flexion).  [Negative/Positive] McMurray's test of lateral meniscus (pain when knee is brought from full to 90° flexion while leg is externally rotated with compression over the medial joint line).  [Negative/Positive] McMurray's test of medial meniscus (pain when knee is brought from full to 90° flexion while leg is internally rotated with compression over the lateral joint line). 

[Remainder of extremity exam unremarkable.]

https://www.orthobullets.com/recon/12755/knee-physical-exam--adult