What is the next step in treatment for persistent knee pain unresponsive to conservative therapy with a normal knee radiograph (x-ray)?

From the Guidelines

The next step in treatment for knee pain that has persisted for 2 weeks despite conservative therapy and has a normal X-ray would be to obtain an MRI of the knee. An MRI can detect soft tissue injuries that X-rays cannot visualize, such as meniscal tears, ligament injuries, cartilage damage, or early osteoarthritis 1. While waiting for the MRI, the patient should continue with modified conservative management including:

• Rest from aggravating activities
• Ice for 15-20 minutes several times daily
• Compression with an elastic bandage
• Elevation when possible Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen 400-600mg three times daily with food or naproxen 500mg twice daily can be used for pain control if not contraindicated, as recommended by the EULAR guidelines 1. Physical therapy focusing on gentle range of motion exercises and quadriceps strengthening may also be beneficial. If the pain is severe, a short course of protected weight-bearing with crutches might be necessary. The MRI findings will guide further treatment, which could include continued conservative management, corticosteroid injections, specialized physical therapy, or surgical consultation depending on the specific diagnosis. It's worth noting that the American College of Radiology Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations, and an MRI is a suitable next step in this scenario 1.

From the Research

Next Steps in Treatment

For a patient with 2 weeks of knee pain unresponsive to conservative therapy and a normal knee x-ray, the next steps in treatment may include:

• Further evaluation to determine the cause of knee pain, as the normal x-ray does not rule out other potential causes such as meniscal tears, patellofemoral pain, or osteoarthritis 2
• Consideration of advanced imaging such as magnetic resonance imaging (MRI) to evaluate the knee joint and surrounding structures 3
• Referral to an orthopedic surgeon or specialist for further evaluation and treatment, especially if the patient has severe pain, swelling, or instability 4, 5
• Continued conservative management with a focus on exercise, education, and self-management, as this is often the first-line treatment for common causes of knee pain 2, 6

Diagnostic Considerations

The diagnosis of knee pain can be complex and may require a combination of:

• Detailed patient history, including age, location, onset, duration, and quality of pain, as well as associated mechanical or systemic symptoms 5
• Systematic physical examination, including inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and special (provocative) tests 5
• Laboratory tests or imaging studies, such as musculoskeletal ultrasonography or MRI, to confirm or rule out specific diagnoses 3, 5

Treatment Options

Treatment options for knee pain that is unresponsive to conservative therapy may include:

• Intra-articular injections of corticosteroids or hyaluronic acid 6
• Radiofrequency ablation of the genicular nerves 6
• Surgical referral for joint-preserving or joint-replacement options, especially for patients with end-stage osteoarthritis or severe traumatic injuries 2, 6