What is the initial management strategy for a patient presenting with left knee pain without signs of injury?

From the Guidelines

The initial management strategy for a patient presenting with left knee pain without signs of injury should focus on conservative measures, prioritizing self-management programs, strengthening, low-impact aerobic exercise, and neuromuscular education, as recommended by the most recent and highest quality study 1. Begin with rest, ice, compression, and elevation (RICE protocol) for the first 48-72 hours. Recommend over-the-counter analgesics such as acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs like ibuprofen (400-600mg every 6-8 hours with food) for pain relief, as suggested by 1 and 1. Activity modification is essential—advise the patient to avoid activities that exacerbate pain while maintaining gentle range-of-motion exercises. Weight management should be addressed if applicable, as excess weight increases stress on knee joints. Physical therapy focusing on quadriceps and hamstring strengthening can provide long-term benefits, as supported by 1 and 1. Some key points to consider in the management of knee osteoarthritis include:

• The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities, as stated in 1 and 1.
• Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction, as recommended by 1 and 1.
• Paracetamol is the oral analgesic to try first and, if successful, the preferred long term oral analgesic, as suggested by 1 and 1.
• Topical applications (NSAIDs, capsaicin) have clinical efficacy and are safe, as supported by 1 and 1. If pain persists beyond 2-3 weeks despite these measures, or if symptoms worsen, the patient should seek further medical evaluation for possible imaging or specialist referral. This conservative approach works by reducing inflammation, alleviating pain, and allowing natural healing processes to occur while maintaining joint function and preventing muscle atrophy. It is also important to note that opioids, including tramadol, are not recommended for the management of OA pain due to their limited benefit and high risk of adverse effects, as stated in 1. Instead, duloxetine, a selective serotonin and norepinephrine reuptake inhibitor, may be considered for patients with OA, as it has been shown to achieve significant reductions in pain outcomes, as supported by 1.

From the Research

Initial Assessment

The initial management strategy for a patient presenting with left knee pain without signs of injury involves a thorough history and physical examination to determine the underlying cause of the pain.

• The patient's age, location, onset, duration, and quality of pain should be assessed, as well as any associated mechanical or systemic symptoms, history of swelling, and description of precipitating trauma 2.
• A systematic approach to examination of the knee includes inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and special (provocative) tests 2.

Common Causes of Knee Pain

The most common causes of knee pain are osteoarthritis (OA), patellofemoral pain, and meniscal tears 3, 4.

• Knee OA is the most likely diagnosis in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness 3.
• Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25% 3.
• Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma or as a degenerative condition present in patients with knee OA who are aged 40 years or older 3.

Diagnostic Approach

A careful history and a rigorous clinical examination usually enable a diagnosis to be made without the need for further investigations 4.

• The McMurray test and joint line tenderness can assist in the diagnosis of meniscal tears 3.
• Radiographic imaging should be reserved for chronic knee pain or acute traumatic pain in patients who meet specific evidence-based criteria 2.
• Musculoskeletal ultrasonography and magnetic resonance imaging can be used as additional diagnostic tools in certain cases 2.

Management

First-line management of knee pain involves conservative management, with a focus on exercise, education, and self-management 3, 5, 6.

• Exercise therapy, weight loss (if overweight), and education are recommended for patients with OA 3.
• Hip and knee strengthening exercises, in combination with foot orthoses or patellar taping, are recommended for patients with patellofemoral pain 3.
• Conservative management, including exercise therapy, is also appropriate for most meniscal tears 3.