Knee Pain (Anterior)

Diagnosis/Definition

Knee pain localized to the anterior portion of the knee, either retropatellar or peripatellar.  Usually a gradual, non-traumatic onset aggravated with increased activity, running, squatting, stair climbing or prolonged sitting.  Symptoms normally decrease with rest.

Initial Diagnosis and Management

• History and physical examination
• Plain films not required
• NSAIDs
  • Adults - 200 to 400 milligrams (mg) every four to six hours as needed for up to 2 weeks.  Example: Ibuprofen
  • Take tablet or capsule forms of these medicines with a full glass (8 ounces) of water.
  • Do not lie down for about 15 to 30 minutes after taking the medicine. This helps to prevent irritation that may lead to trouble in swallowing.
  • To lessen stomach upset, these medicines should be taken with food or an antacid.
• Avoidance of aggravating activities (profile for active duty soldiers)
• Strengthening exercises for quadriceps, stretching exercises for quads, hamstrings and calf muscle
• Ice PRN after activities
• Compression wrap is contraindicated
• Patient Education
• Please refer to the Clinical standard on knee pain.

Ongoing Management and Objectives

• Resolution or decreasing symptoms in three to four weeks
• If no resolution:
  • Trial of alternate NSAID
  • Trial of neoprene sleeve with patella opening
  • Obtain plain films with sunrise views
  • Do not order an MRI.  Orthopedic clinic will order, or recommend,  if patient meets pre-surgery criteria

Indication a profile is needed

• Any limitations that affect strength, range of movement, and efficiency of feet, legs, lower back and pelvic girdle.
• Slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects that may prevent moderate marching, climbing, timed walking, or prolonged effect.
• Defects or impairments that require significant restriction of use.

Specifications for the profile

• Months 1-3
  • No running, jumping, marching, squatting.
• Months 4-6
  • Gradual transition into own pace and distance

Patient/Soldier Education or Self care Information

• See attached sheet
• Demonstrate deficits that exist
  • Describe/show soldier his/her limitations
• Explain injury and treatment methods
  • Use diagram attached to describe injury, location and treatment.
• Instruct and demonstrate rehab techniques
  • Demonstrate rehab exercises as shown in attached guide
  • Warm up before any sports activity
  • Participate in a conditioning program to build muscle strength
  • Do stretching exercises daily
• Ask the patient to demonstrate newly learned techniques and repeat any other instructions.
• Fine tune patient technique
  • Correct any incorrect ROM/stretching demonstrations or instructions by repeating and demonstrating information or exercise correctly.
• Encourage questions
  • Ask soldier if he or she has any questions
• Give supplements such as handouts
• Schedule follow up visit with Primary Care
  • If pain persists
  • The pain does not improve as expected
  • Patient is having difficulty after three days of injury
  • Increased pain or swelling after the first three days
  • Patient has any questions regarding care

Indications for Specialty Care Referral

• History of joint locking and giving way
• Question of underlying instability
• Prolonged effusion > 10 to 14 days
• R/O fractures, septic joints, rheumatoid arthritis, etc. should be referred to appropriate specialty clinic (Orthopedics or Rheumatology)
• Refer to Physical Therapy if none of the above but progression of atrophy or persistent symptoms despite initial management.
• Completed full course of rehabilitation and have any of the following concerning symptoms:  catching, locking, effusions, instability, warmth or erythema (Orthopedics referral indicated).

Criteria for Return to Primary Care

• Resolution of symptoms
• If persistence of anterior knee pain > 6-12 months, without concerning symptoms as described above, consider permanent profiling with patient specific limitations.
• If meets criteria for P3 profile, referral to MAMC MEB section for MEB is appropriate.  MEB can be initiated by primary care.