Textbook of Urgent Care Medicine, Chapter 32 Lower Extremity Pain and Injury

Original authors: Christopher M. Prior, Matthew Speer, and John Shufeldt

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

Introduction

Lower extremity injuries are common in the urgent care setting. Rapid triage, evaluation, and treatment are paramount in order to move a typical urgent care center’s volume of patients. The history of acute trauma resulting in a painful or swollen extremity focuses the evaluation on ruling out a fracture or other injury. Historically remote trauma with persistent pain also may be caused by a stress fracture, bone bruise, or soft-tissue injury.

The initial task is to identify limb-threatening injury and determine which patients may be evaluated safely in urgent care. Loss of distal perfusion, an open fracture, a deformed hip or knee, or rapidly increasing pain and swelling warrants emergency transfer rather than an extended office work-up.

Presentation

Patients present with a painful or swollen pelvis or lower extremity after an injury.

Triage Pearls

• The absence of pulses, movement, or sensation distal to an injury warrants immediate transfer to an emergency department.
• A neurovascular exam should be conducted and documented.
• Do not exclude arterial injury because a pulse is palpable. A knee dislocation may have spontaneously reduced before presentation; deformity, ischemic findings, expanding hematoma, or unexplained neurologic deficits require emergency evaluation.
• Pain out of proportion to the examination, severe pain with passive stretch, tense compartments, or progressive paresthesias are warning signs of acute compartment syndrome. Pulses may be present until late in the course. Arrange immediate EMS transfer without delaying for radiographs or pressure measurements.

History Pearls

• Mechanism of injury is very important and will help to determine if the injury is from a low-energy event (e.g., fall from a couch), which usually causes a more stable fracture pattern, or a high-energy event (e.g., fall from a tree 10 feet above the ground), which can disrupt the periosteum and causes more pain and instability in the fracture pattern.
• If the patient can indicate the location of the pain, the diagnosis can be substantially narrowed down.
• Pain immediately on impact is usually a fracture or ligamentous injury.
• Delayed pain is more commonly seen in soft-tissue injuries and sometimes stress fractures.
• Constant throbbing pain is more common in fractures, whereas pain that occurs only with weight-bearing on the extremity could be related to a bone bruise or stress injury.
• Ask about prior fractures, surgery, anticoagulants, osteoporosis, corticosteroid exposure, diabetes, neuropathy, and inability to walk before the injury. In children, assess whether the history is developmentally plausible and consider nonaccidental trauma when indicated.

Physical Exam Pearls

• Skin: The patient should be assessed for abrasions, lacerations, and puncture wounds. Any open wound could indicate significant soft-tissue injury, and if it is associated with a fracture, further evaluation as an open fracture would be warranted.
• Palpation: Palpation of the entire lower extremity should be completed by all examiners to localize the area of discomfort and to pinpoint which radiographs to order. The joint should be examined above and below the injury.
• Range of motion: Limited motion in a joint may also be indicative of a fracture, strain, or sprain.
• Neurovascular status: Document distal pulses, skin color and temperature, capillary refill, light-touch sensation, and active motor function. Repeat the examination after splinting or any change in alignment.
• The involved extremity may have more than one fracture, or the patient may have other fractures elsewhere in the body.
• After a fall with axial loading, assess both calcanei and the spine; associated injuries may be present even when the patient reports pain in only one location.
• Avoid repeated manipulation or forceful stress testing in a suspected unstable fracture, hip dislocation, knee dislocation, or threatened limb.

Testing Pearls

• A radiograph will often help exclude any possible fractures or tumors.
• Initial radiographs should cover the suspected injury and adjacent joint when clinically appropriate. A normal radiograph does not exclude an occult hip fracture, tibial plateau fracture, stress fracture, or ligamentous injury.
• Computed tomography (CT) is superior to plain radiographs in assessing the posterior arch and the acetabulum and for hemorrhage associated with pelvic injuries.
• Although magnetic resonance imaging (MRI) is not typical of urgent care diagnostics, it can be especially useful for knee injuries.
• For an older adult with traumatic hip pain and persistent inability to bear weight despite normal films, arrange same-day ED or hospital assessment for MRI without contrast or CT without contrast; do not send the patient home for routine delayed imaging.
• For knee trauma, obtain radiographs when there is focal tenderness, effusion, impaired weight-bearing, or a concerning mechanism. MRI is generally a follow-up study for suspected meniscal, ligamentous, osteochondral, or occult bony injury; it should not delay emergency transfer.
• Do not attempt to measure intracompartmental pressure in a typical urgent care clinic as a prerequisite to transfer. Acute compartment syndrome remains a clinical emergency; surgical assessment and pressure measurement, when needed, occur at the receiving facility.

Table 1. Knee radiography decision aids (not independent discharge rules)

Decision aid	Criteria / application
Ottawa Knee Rule	After acute knee trauma, radiographs are indicated with any of: age 55 years or older; isolated patellar tenderness; fibular head tenderness; inability to flex the knee to 90°; or inability to bear weight for four steps immediately after injury and at evaluation.
Pittsburgh Knee Rule	After blunt trauma or a fall, obtain radiographs when the patient is younger than 12 or older than 50 years, or cannot take four weight-bearing steps.
Clinical limitation	Apply only to patients fitting the rule’s validation setting who can be examined reliably. Do not use either rule to dismiss deformity, major trauma, vascular injury, acute dislocation, significant extensor-mechanism injury, or important clinical concern.

Diagnosis Pearls

Pelvic Pain and Injury

• Pelvic fractures (Figure 1) should be suspected whenever there is trauma to the torso or a fall from a height.
• Pain, crepitus, or instability on palpation of the pelvis suggests a fracture.
• Hypotension may be secondary to abdominal or thoracic injuries or blood loss from disrupted pelvic bones or vessels.
• Do not repeatedly compress or “spring” an unstable pelvis. A high-energy mechanism, pelvic deformity, significant pain, hemodynamic instability, or concern for associated genitourinary injury requires immediate EMS/ED trauma evaluation. Imaging and hemorrhage control are hospital-level priorities.

Hip and Femur Pain and Injury

• The affected leg is classically shortened and externally rotated.
• After trauma, the presence of significant hip pain with weight-bearing, even when findings are normal on plain radiographs, suggests the possibility of an occult fracture, especially of the femoral neck or the acetabulum.
• Hip dislocations are most often the result of massive forces during trauma.
• In patients with hip fracture or dislocation, avoid weight-bearing, splint or support in the position found, document neurovascular status, and arrange ED transfer. Hip dislocation requires urgent reduction in a monitored setting; reduction is not a routine urgent care maneuver.
• Trochanteric bursitis is sometimes referred to as “greater trochanteric pain syndrome” because the bursa may not be inflamed.
• The broader term includes tendinitis of the gluteus muscles, iliotibial band (ITB), and tensor fasciae latae.
• It will typically present as tenderness over the greater trochanter, usually after trauma.
• A diagnosis of greater trochanteric pain syndrome is more likely when lateral hip tenderness occurs without a major traumatic mechanism or inability to bear weight. If a fracture remains plausible, imaging and escalation take precedence.
• Lumbar radiculopathy is a chronic pain that occurs in the lower back and legs.
• ITB syndrome is extremely common in runners.
• Sports hernias and nerve entrapments should be considered in the differential diagnosis of unremitting activity-related groin pain, especially in athletes who participate in high-risk sports.
• Groin pain is typically aggravated by strenuous exercise, especially activities involving kicking, sprinting, or rapid directional changes.
• Hip flexor strains commonly present with anterior hip pain brought on by resisted flexion. Osteoarthritis often causes gradual groin pain and restriction of internal rotation. When symptoms are nontraumatic and the patient is stable, outpatient treatment and follow-up are reasonable after dangerous diagnoses have been excluded.

Knee Pain and Injury

• The Ottawa knee rules and the Pittsburgh decision rules provide a rapid means for determining which patients require radiographic evaluation of the knee.
• If a patellar injury is suspected, a sunrise view should be ordered. This is the most useful view for detecting nondisplaced vertical or marginal fractures of the patella.
• Patellar fractures occur from direct trauma or from forceful contraction of the quadriceps tendon.
• The physical exam will reveal tenderness, swelling, effusion, and often a palpable defect of the patella.
• The extensor mechanism of the knee should be evaluated.
• Inability to perform a straight-leg raise or actively extend the knee after injury suggests disruption of the extensor mechanism even if the radiograph is inconclusive; immobilize in extension, avoid weight-bearing, and arrange prompt orthopedic evaluation.
• A first-time traumatic patellar dislocation, including one that has reduced spontaneously, can be associated with a chondral or osteochondral fracture. Obtain radiographs, immobilize or brace as indicated, and arrange timely orthopedic assessment for MRI when appropriate, particularly when hemarthrosis is present.
• Patellofemoral pain syndrome has a multifactorial etiology; patients often report pain behind the patella, aggravated by stairs, squatting, or prolonged sitting.
• A teenager with anterior knee pain localized to the tibial tuberosity may have Osgood-Schlatter disease, especially after a growth spurt.
• Patellar tendinopathy, pes anserine bursitis, and medial plica syndrome remain considerations when the examination localizes symptoms and there is no concern for fracture, infection, or internal derangement.

Ligamentous, Tendinous, and Meniscal Pain and Injury

• Anterior cruciate ligament injuries often result from a deceleration, hyperextension, or internal rotation of the tibia on the femur.
• Patients will often report hearing a “pop” and develop marked swelling minutes to hours after the injury.

• The Lachman test is the most sensitive test for anterior cruciate ligament injuries. Other tests include the anterior drawer test and the lateral pivot shift test.
• The posterior drawer test assists in identifying a posterior cruciate ligament injury; collateral ligament injury may be suggested by valgus or varus stress testing when the examination is safe.
• Symptoms of meniscal injuries include painful locking of the knee, a popping or clicking sensation, and a sensation of the knee giving out.
• Acute isolated meniscal injury is evaluated with a combination of history, joint-line tenderness, and provocative maneuvers when tolerated. MRI is the preferred study when advanced imaging is indicated. A mechanically locked knee or suspected displaced tear requires prompt orthopedic assessment.
• Patellar tendon rupture and quadriceps tendon rupture may cause failure of active extension. These injuries require extension immobilization and urgent orthopedic consultation.
• For a suspected knee dislocation, including one that reduced before arrival, document pulses and nerve function but do not use normal pulses alone to exclude popliteal artery injury. Arrange emergency vascular evaluation and imaging when indicated.

Tibia and Fibula Pain and Injury

• Tibia and fibula shaft fractures are the most common long bone fractures of the lower extremity.
• They occur in falls with a twisting movement to the foot, resulting in oblique or spiral configurations.
• Direct trauma often produces transverse or segmental fractures.
• Patients present with pain at the fracture site and inability to bear weight.
• Radiographs should include AP and lateral radiographs of the tibia and fibula, including the knee and ankle joints.
• A thorough neurovascular exam should be documented, including a check of the dorsalis pedis and posterior tibial pulses as well as active motion of the foot and sensation.
• Tight compartments and severe pain with passive extension of the great toe and paresthesia are indicative of a compartment syndrome, which must be evaluated and treated on an emergency basis.
• Document compartments and repeat the distal examination after immobilization. A normal pulse does not rule out compartment syndrome.

Medial Tibial Stress Syndrome and Stress Fractures

• Medial tibial stress syndrome (shin splints) commonly presents as diffuse activity-related pain along the medial tibia. A tibial stress fracture more often produces localized bony tenderness; symptoms may persist at rest with progression.
• Early radiographs may be normal. When fracture remains suspected, protect weight-bearing and arrange orthopedic or sports medicine evaluation with MRI when appropriate; do not reassure solely on a negative initial film.
• Anterior tibial cortex stress fractures and femoral neck stress fractures are higher-risk injuries and need expedited specialist assessment. Avoid impact activity and weight-bearing pending definitive evaluation.

Toddler’s Pain and Injury

• A toddler with refusal to bear weight after a minor twisting injury may have a nondisplaced tibial spiral fracture despite initially negative radiographs. Immobilize or use a protective boot according to local pediatric practice, reassess the child, and arrange timely pediatric or orthopedic follow-up.
• In a child with fever, systemic illness, joint irritability, or an inconsistent history, do not presume a toddler fracture; consider infection or nonaccidental trauma and escalate evaluation.

Treatment and Disposition Pearls

General

• In general all fractures and significant sprains should be splinted and elevated.
• Great care is important when applying a splint, to prevent ulceration of bony prominences.
• Ice for 20 minutes at a time may be recommended.
• Treat pain with acetaminophen or a short course of an NSAID when appropriate; consider kidney disease, anticoagulation, pregnancy, gastrointestinal bleeding risk, and other contraindications. Opioids are not routinely necessary for uncomplicated soft-tissue injuries.
• For stable sprains and strains, early protected motion and progressive rehabilitation are preferred over prolonged immobilization. Unstable injuries, suspected fractures, or an inability to bear weight generally require immobilization and expedited reassessment.

Pelvic Pain and Injury

• Suspected unstable pelvic injury, hip or femoral dislocation, femoral shaft fracture, or a hemodynamically unstable patient requires EMS transfer. Control external bleeding, minimize manipulation, and follow local trauma protocols. Pelvic binders, transfusion, operative reduction, and definitive fixation belong to appropriately equipped trauma teams.

Hip and Femur Pain and Injury

• After a fall, an older patient with hip pain and inability to bear weight needs ED-level evaluation even when initial radiographs are negative. Do not ask the patient to ambulate to prove stability.
• Suspected displaced hip fracture, hip dislocation, and femoral shaft fracture warrant non-weight-bearing stabilization and emergency orthopedic evaluation.

Knee Pain and Injury

• Nondisplaced patellar fractures with intact extensor mechanisms are treated with knee immobilization, ice, analgesics, elevation, and referral for casting.

• Displaced patellar fracture, loss of active knee extension, associated open wound, or neurovascular compromise requires urgent orthopedic or ED evaluation.
• For uncomplicated collateral ligament sprains and stable meniscal symptoms, a brace, relative rest, and arranged reassessment may be used. A locked knee or major instability merits expedited specialty evaluation.

Tibia and Fibula Pain and Injury

• Most nondisplaced fractures may be treated with a long leg splint with long side slabs from the foot to two-thirds up the thigh. It is helpful to keep the knee bent to about 30° to help prevent weight-bearing on the extremity.
• A prefabricated splint must be padded to prevent pressure on the heel and bony prominences. Redness and pressure ulceration can occur within days when a splint fits poorly.
• In a suspected tibia/fibula fracture, provide a well-padded splint and recheck neurovascular status. Displaced, open, markedly swollen, or high-energy fractures require ED assessment; do not delay transfer for an elaborate immobilization technique.

Compartment Syndrome

• Compartment syndrome occurs when increased tissue pressure within a nondistensible fascial compartment of a limb results in ischemia to the tissues and ultimately muscle death.
• Significantly displaced fractures or crush injuries may lead to compartment syndrome.
• Pain that increases after splinting and pain with passive stretch can be warning signs; assess increasing analgesic need, a firm compartment, sensory change, and motor deficits. The classic absence of pulses is a late or unreliable finding.
• Suspected evolving acute compartment syndrome requires immediate ED transfer for surgical assessment and potential fasciotomy. Remove or loosen constricting external dressings without manipulating the injury, and do not delay transfer for laboratory or imaging tests.

Open Fractures

• Fractures in the lower extremity may be open fractures, meaning there is a soft-tissue opening that communicates with a broken bone.
• These can range from obvious open wounds with exposed bone to minor innocuous-appearing puncture wounds.
• Cover the wound with a sterile dressing, immobilize the limb, document distal neurovascular status, and arrange immediate ED/orthopedic transfer. When available within local protocol, initiate appropriate IV antibiotics promptly without delaying transport; drug selection and expanded coverage depend on injury severity and contamination.
• Assess tetanus vaccination history and wound classification. Tetanus vaccine and, in selected patients with dirty or major wounds and incomplete vaccination or immunodeficiency, tetanus immune globulin may be needed.

Table 2. Urgent care disposition for lower extremity injury

Urgency	Clinical findings	Urgent care action
Immediate EMS/ED	Absent or changing perfusion, suspected knee dislocation/vascular injury, acute compartment syndrome, open fracture, unstable pelvic/hip injury, major crush injury, severe deformity, systemic instability.	Document neurovascular status, support/immobilize, manage external bleeding, avoid delay, transfer.
Same-day ED / urgent specialist	Unable to bear weight with suspected occult hip fracture; displaced fracture; extensor-mechanism failure; true locked knee; suspected femoral neck stress fracture; major effusion following patellar dislocation.	Protect from weight-bearing; arrange prompt advanced evaluation and imaging.
Outpatient with reassessment	Stable soft-tissue injury or stable nondisplaced fracture after appropriate imaging and examination, with reliable follow-up and no red flags.	Functional support or immobilization as indicated; explicit follow-up and escalation instructions documented.

Medicolegal Pearls

• All pelvic and hip fractures or dislocations require further evaluation in an emergency department.
• Femoral condyle fractures and tibial spine fractures in tibial plateau fractures should be evaluated for both popliteal artery and peroneal nerve injuries as well as associated compartment syndrome.
• Document mechanism, weight-bearing ability, skin integrity, pulses, sensation, motor function, and repeat findings after any splint application. Include a brief rationale for obtaining or deferring imaging and for transfer or follow-up.
• Do not treat a painless or well-perfused limb as proof of safety when knee dislocation, compartment syndrome, vascular injury, occult hip fracture, or infection is otherwise suspected.
• Achilles tendon rupture should be considered in patients who report pain after forceful plantarflexion, particularly if they are taking a quinolone antibiotic.
• Documentation of the lack of proximal fibular tenderness (Maisonneuve fracture) should be on every chart for patients reporting an ankle injury.

References

1. American College of Radiology. ACR Appropriateness Criteria: Acute Trauma to the Knee. Revised 2019. Source.

2. Bartolotta RJ, Ha AS, Bateni CP, et al. ACR Appropriateness Criteria Acute Hip Pain: 2024 Update. J Am Coll Radiol. 2025;22(5S):S3-S13. doi:10.1016/j.jacr.2025.02.039. Source.

3. American Academy of Orthopaedic Surgeons. Management of Acute Compartment Syndrome: Evidence-Based Clinical Practice Guideline. Published November 18, 2025. Source.

4. American Academy of Orthopaedic Surgeons. Prevention of Surgical Site Infections After Major Extremity Trauma: Evidence-Based Clinical Practice Guideline. Published March 21, 2022. Source.

5. American Academy of Orthopaedic Surgeons. Acute Isolated Meniscal Pathology: Clinical Practice Guideline. Published June 10, 2024. Source.

6. Blønd L, Askenberger M, Stephen J, et al. Management of first-time patellar dislocation: The ESSKA 2024 formal consensus-Part 1. Knee Surg Sports Traumatol Arthrosc. 2025;33:1925-1932. doi:10.1002/ksa.12620. Source.

7. Centers for Disease Control and Prevention. Clinical Guidance for Wound Management to Prevent Tetanus. Updated September 8, 2026. Source.

8. Noe MC, Jarka DE, Sinclair MK, Grote CW. Toddler’s fracture: an updated guide on evaluation and management. J Pediatr Orthop B. 2025;34(2):193-197. doi:10.1097/BPB.0000000000001210. Source.

9. Balcarek P, Blønd L, Beaufils P, et al. Management of first-time patellar dislocation: The ESSKA 2024 formal consensus-Part 2. Knee Surg Sports Traumatol Arthrosc. 2025;33(12):4197-4206. doi:10.1002/ksa.12637. Source.

10. Tandeter HB, Shvartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician. 1999;60:2599-2608. Source.