From the Guidelines
Management of knee instability in urgent care focuses on stabilization, pain control, and appropriate referral, with initial immobilization using a knee immobilizer or hinged brace and implementation of RICE therapy being crucial. The most recent and highest quality study, 1, emphasizes the importance of prompt and accurate diagnosis to facilitate adequate management and prevent potential complications.
Initial Management
- Immobilization with a knee immobilizer or hinged brace to prevent further injury
- RICE therapy (Rest, Ice, Compression, Elevation) to reduce pain and inflammation, with ice applied for 15-20 minutes every 2-3 hours and compression using an elastic bandage
- Pain management typically includes NSAIDs such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily, as recommended by 1
- For more severe pain, acetaminophen 1000mg every 6 hours can be added, or in some cases, a short course of opioids like hydrocodone/acetaminophen 5/325mg every 6 hours for 3-5 days
Physical Examination and Referral
- A thorough physical examination is essential, including assessment for ligamentous instability using tests like the Lachman test, anterior/posterior drawer tests, and varus/valgus stress tests
- Urgent orthopedic referral is necessary for complete ligament tears, especially with associated neurovascular compromise, as highlighted by 1
- Patients should be advised to follow up with orthopedics within 1-2 weeks for definitive management, which may include physical therapy, continued bracing, or surgical intervention depending on the severity and type of instability
Considerations
- Weight-bearing should be limited, with crutches provided for ambulation
- The use of NSAIDs and other pharmacologic agents should be guided by the recommendations of 1, which conditionally recommends the use of oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections for the management of knee OA.
From the Research
Management of Knee Instability
The management of knee instability in urgent care involves a combination of diagnostic techniques and treatment options.
- A thorough history and physical examination, including the application of special tests and clinical decision rules for imaging, are essential for diagnosing knee instability 2.
- The use of biomechanical principles and testing techniques provides essential objective/quantitative information on the function of bone, ligaments, joint capsule, and other contributing soft tissues in response to various loading conditions 3.
- Orthosis management may improve self-reported instability and functional assessment in patients with osteoarthritis, anterior cruciate ligament injury, and posterior cruciate ligament injury 4.
Treatment Options
Treatment options for knee instability include:
- Conservative management, such as exercise therapy, weight loss, education, and self-management programs, which are recommended as first-line treatment for osteoarthritis, patellofemoral pain, and meniscal tears 5.
- Surgical referral for knee joint replacement can be considered for patients with end-stage osteoarthritis after using all appropriate conservative options 5.
- Interventional therapies, such as interventional pain procedures, may be considered for patients with knee pain, although there is a lack of consensus on the order in which these treatments should be offered 6.
Diagnostic Techniques
Diagnostic techniques for knee instability include:
- The McMurray test, which is used to diagnose meniscal tears and has a sensitivity of 61% and specificity of 84% 5.
- Joint line tenderness, which is used to diagnose meniscal tears and has a sensitivity of 83% and specificity of 83% 5.
- Radiographic imaging, which is not recommended for all patients with possible knee osteoarthritis, but may be used to confirm the diagnosis and assess the severity of the condition 5.