Doctor123.org

Knee Pain

- Oral medications: - Acetaminophen: up to 3 g/day. Safe and effective in OA - Nonsteroidal anti-inflammatory drugs (NSAIDs): - Ibuprofen: 200 to 800 mg TID - Naproxen: 250 to 500 mg BID: - Useful for acute sprains, strains - Useful for short-term pain reduction in OA. Long-term use is not recommended due to side effects. - Not recommended for fracture, stress fracture, chronic muscle injury; may be associated with delayed healing; low dose and brief course only if necessary

- Tramadol/opioids: not recommended as first-line treatment; can be used with acute injuries - Celecoxib: 200 mg QD may be effective in OA with less GI side effects than NSAIDs (3)[A].

- Activity modification in overuse conditions - Rehabilitative exercise in OA: - Low-impact exercise: walking, swimming, cycling - Strength, ROM, and proprioception training

para>OA, degenerative meniscal tears, and gout are more common in middle-aged and elderly populations. ‚

Pediatric Considerations

‚

TREATMENT

GENERAL MEASURES

Acute injury: PRICEMM therapy (protection, relative rest, ice, compression, elevation, medications, modalities) ‚

MEDICATION

First Line

  • Oral medications:Acetaminophen: up to 3 g/day. Safe and effective in OANonsteroidal anti-inflammatory drugs (NSAIDs):Ibuprofen: 200 to 800 mg TIDNaproxen: 250 to 500 mg BID:Useful for acute sprains, strainsUseful for short-term pain reduction in OA. Long-term use is not recommended due to side effects.Not recommended for fracture, stress fracture, chronic muscle injury; may be associated with delayed healing; low dose and brief course only if necessaryTramadol/opioids: not recommended as first-line treatment; can be used with acute injuriesCelecoxib: 200 mg QD may be effective in OA with less GI side effects than NSAIDs (3)[A].
  • Topical medications:Topical NSAIDs may provide pain relief in OA and are more tolerable than oral medications.Topical capsaicin may be an adjuvant for pain management in OA.
  • Injections:Intra-articular corticosteroid injection may provide short-term benefit in knee OA (2)[A].Viscosupplementation may reduce pain and improve function in patients with OA (2)[A], particularly those wishing to delay joint replacement.

ISSUES FOR REFERRAL

  • Acute trauma, young athletic patient
  • Joint instability
  • Lack of improvement with conservative measures
  • Salter-Harris physeal fractures (pediatrics)

ADDITIONAL THERAPIES

  • Physical therapy is recommended as initial treatment for patellofemoral pain (4) and tendonopathies (2)[A].
  • Muscle strengthening improves outcome in OA.
  • Foot orthoses, taping, acupuncture
  • May need bracing for stability (4)
  • Plate-rich plasma injection in early OA (5)[B]
  • Botulinum toxin A for patellofemoral pain syndrome (6)[B]

SURGERY/OTHER PROCEDURES

  • Surgery may be indicated for certain injuries (e.g., ACL tear in competitive athletes).
  • Chronic conditions refractory to conservative therapy may require surgical intervention.

COMPLEMENTARY & ALTERNATIVE MEDICINE

May reduce pain and improve function in early OA: ‚

  • Glucosamine sulfate (500 mg TID) (7)
  • Chondroitin (400 mg TID) (7)
  • S-adenosylmethionine (SAMe), ginger extract, methylsulfonylmethane: less reliable improvement with inconsistent supporting evidence (8)
  • Acupuncture

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Activity modification in overuse conditions
  • Rehabilitative exercise in OA:Low-impact exercise: walking, swimming, cyclingStrength, ROM, and proprioception training

Patient Monitoring

  • Rehabilitation after initial treatment of acute injury.
  • In chronic and overuse conditions, assess functional status, rehabilitation adherence, and pain control at follow-up visit.

DIET

Weight reduction for overweight patient with OA ‚

PATIENT EDUCATION

  • Review activity modifications.
  • Encourage active role in the rehabilitation process.
  • Review medication risks and benefits.

PROGNOSIS

Varies with diagnosis, injury severity, chronicity of condition, patient motivation to participate in rehabilitation, and whether surgery is required ‚

COMPLICATIONS

  • Disability
  • Arthritis
  • Chronic joint instability
  • Deconditioning

REFERENCES

11 Hong ‚ E, Kraft ‚ MC. Evaluating anterior knee pain. Med Clin North Am. 2014;98(4):697 " “717.22 Ayhan ‚ E, Kesmezacar ‚ H, Akgun ‚ I. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop. 2014;5(3):351 " “361.33 Bijlsma ‚ JW, Berenbaum ‚ F, Lafeber ‚ FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011;377(9783):2115 " “2126.44 Bolgla ‚ LA, Boling ‚ MC. An update for the conservative management of patellofemoral pain syndrome: a systematic review of the literature from 2000 to 2010. Int J Sports Phys Ther. 2011;6(2):112 " “125.55 Campbell ‚ KA, Saltzman ‚ BM, Mascarenhas ‚ R, et al. Does intra-articular platelet-rich plasma injection provide clinically superior outcomes compared with other therapies in the treatment of knee osteoarthritis? A systematic review of overlapping meta-analyses. Arthroscopy. 2015;31(11):2213 " “2221.66 Chen ‚ JT, Tang ‚ AC, Lin ‚ SC, et al. Anterior knee pain caused by patellofemoral pain syndrome can be relieved by Botulinum toxin type A injection. Clin Neurol Neurosurg. 2015;129(Suppl 1):S27 " “S29.77 Henrotin ‚ Y, Marty ‚ M, Mobasheri ‚ A. What is the current status of chondroitin sulfate and glucosamine for the treatment of knee osteoarthritis? Maturitas. 2014;78(3)184 " “187.88 Debbi ‚ EM, Agar ‚ G, Fichman ‚ G, et al. Efficacy of methylsulfonylmethane supplementation on osteoarthritis of the knee: a randomized controlled study. BMC Complement Altern Med. 2011;11:50.

ADDITIONAL READING

  • Collins ‚ NJ, Bisset ‚ LM, Crossley ‚ KM, et al. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports Med. 2012;42(1):31 " “49.
  • Derry ‚ S, Moore ‚ RA, Rabbie ‚ R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Syst Rev. 2012;(9):CD007400.
  • Lopes ‚ AD, Hespanhol J ƒ ºnior ‚ LC, Yeung ‚ SS, et al. What are the main running-related musculoskeletal injuries? A systematic review. Sports Med. 2012;42(10):891 " “905.
  • Nunes ‚ GS, Stapait ‚ EL, Kirsten ‚ MH, et al. Clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. Phys Ther Sport. 2013;14(1):54 " “59.
  • Ziltener ‚ JL, Leal ‚ S, Fournier ‚ PE. Non-steroidal anti-inflammatory drugs for athletes: an update. Ann Phys Rehabil Med. 2010;53(4):278 " “282.

SEE ALSO

Algorithms: Knee Pain; Popliteal Mass ‚

CODES

ICD10

  • M25.569 Pain in unspecified knee
  • M17.9 Osteoarthritis of knee, unspecified
  • M76.50 Patellar tendinitis, unspecified knee
  • M17.10 Unilateral primary osteoarthritis, unspecified knee
  • M25.461 Effusion, right knee
  • M17.4 Other bilateral secondary osteoarthritis of knee
  • M25.561 Pain in right knee
  • S83.203A Oth tear of unsp meniscus, current injury, right knee, init
  • M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee
  • M70.50 Other bursitis of knee, unspecified knee
  • M76.51 Patellar tendinitis, right knee
  • M25.462 Effusion, left knee
  • M17.32 Unilateral post-traumatic osteoarthritis, left knee
  • S83.204A Oth tear of unsp meniscus, current injury, left knee, init
  • M76.52 Patellar tendinitis, left knee
  • M17.31 Unilateral post-traumatic osteoarthritis, right knee
  • M70.52 Other bursitis of knee, left knee
  • M25.562 Pain in left knee
  • M25.469 Effusion, unspecified knee
  • M17.11 Unilateral primary osteoarthritis, right knee
  • S83.205A Other tear of unspecified meniscus, current injury, unspecified knee, initial encounter
  • M70.51 Other bursitis of knee, right knee
  • M17.12 Unilateral primary osteoarthritis, left knee
  • M17.5 Other unilateral secondary osteoarthritis of knee

ICD9

  • 719.46 Pain in joint, lower leg
  • 715.96 Osteoarthrosis, unspecified whether generalized or localized, lower leg
  • 726.64 Patellar tendinitis
  • 836.2 Other tear of cartilage or meniscus of knee, current
  • 715.16 Osteoarthrosis, localized, primary, lower leg
  • 726.60 Enthesopathy of knee, unspecified
  • 715.36 Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
  • 719.06 Effusion of joint, lower leg
  • 715.26 Osteoarthrosis, localized, secondary, lower leg

SNOMED

  • 30989003 Knee pain (finding)
  • 239873007 Osteoarthritis of knee (disorder)
  • 429360005 tendinitis of knee (disorder)
  • 239720000 tear of meniscus of knee (disorder)
  • 202381003 Knee joint effusion (disorder)
  • 33952002 Localized osteoarthrosis (disorder)
  • 111243002 bursitis of knee (disorder)

CLINICAL PEARLS

  • Consider ligamentous injury, meniscal tear, and fracture for patients presenting with acute knee pain.
  • Consider OA, patellofemoral pain, syndrome, tendinopathy, bursitis, and stress fracture in patients presenting with more chronic symptoms.
  • Consider physeal, apophyseal, or articular cartilage injury in young patients presenting with knee pain.
  • The presence of an effusion in a patient <30 years of age indicates a significant injury.
  • Referred pain from the hip (slipped capital femoral epiphysis, Legg-Calve-Perthes disease) can present as knee pain.