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 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].
- 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, cycling
- Strength, 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.