Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic left knee pain, exacerbated by weight-bearing activities, following a remote history of significant knee trauma. Reports mechanical symptoms including intermittent locking, catching, and morning stiffness lasting <30 minutes. Pain is localized to the medial/lateral joint line, currently rated at [X]/10. Previous conservative management includes [PT/NSAIDs/Injections] with [partial/minimal] relief.
Clinical Examination Findings
Left knee examination reveals mild joint line tenderness, palpable crepitus with range of motion, and trace effusion. Range of motion is [X] degrees of flexion with [X] degrees extension lag. Ligamentous stability testing (Lachman, Varus/Valgus stress) is negative for acute laxity. Gait analysis demonstrates an antalgic limp favoring the right lower extremity.
Treatment Protocol
Initiate multimodal conservative therapy: 1. Activity modification to low-impact exercises. 2. Prescription of NSAIDs as needed for pain control. 3. Referral to physical therapy for quadriceps strengthening and proprioceptive training. 4. Consider intra-articular [corticosteroid/hyaluronic acid] injection for symptomatic relief. 5. Weight management counseling if BMI > 25.