What is the recommended assessment and management for a patient presenting with left knee pain without signs of injury?

From the Guidelines

For a patient presenting with left knee pain without signs of injury, a comprehensive assessment should begin with a detailed history and physical examination, focusing on pain characteristics, duration, aggravating and alleviating factors, and any functional limitations, as recommended by the American College of Rheumatology 1. The assessment should include:

• Evaluation of pain characteristics, such as location, severity, and duration
• Assessment of functional limitations, such as difficulty walking or climbing stairs
• Physical examination to evaluate joint mobility, strength, and tenderness Initial management typically includes:
• Rest, ice, compression, and elevation (RICE protocol) for 48-72 hours
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400-600mg three times daily with food for 7-10 days or naproxen 500mg twice daily for similar duration
• Activity modification to avoid aggravating movements while maintaining gentle range of motion exercises
• Physical therapy focusing on quadriceps and hamstring strengthening, with exercises like straight leg raises, wall slides, and gentle knee extensions Weight management should be addressed if applicable, as excess weight increases knee joint stress, as noted in the AAOS clinical practice guideline 1. If pain persists beyond 2-3 weeks despite conservative measures, further imaging such as X-rays or MRI may be warranted to rule out structural abnormalities like osteoarthritis, meniscal tears, or ligamentous injuries, as recommended by the ACR Appropriateness Criteria 1. This approach targets inflammation reduction while maintaining joint mobility and strength, addressing the most common causes of non-traumatic knee pain including patellofemoral pain syndrome, early osteoarthritis, or overuse injuries.

From the Research

Patient History

• The patient's history should include characteristics of the pain, such as location, onset, duration, and quality, as well as associated mechanical or systemic symptoms 2, 3, 4.
• The history should also include questions about precipitating trauma, history of swelling, and pertinent medical or surgical history 2, 4.
• The patient's age and activity level should also be considered, as certain conditions are more common in certain age groups 5, 6.

Physical Examination

• 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, 4.
• The physical examination should include careful inspection of the knee, palpation for point tenderness, assessment of joint effusion, range-of-motion testing, evaluation of ligaments for injury or laxity, and assessment of the menisci 4.
• Special tests such as the McMurray test can be used to diagnose meniscal tears 5, 6.

Diagnostic Imaging

• Radiographic imaging should be reserved for chronic knee pain (more than six weeks) or acute traumatic pain in patients who meet specific evidence-based criteria 2.
• Musculoskeletal ultrasonography can be used to evaluate effusions, cysts, and superficial structures 2.
• Magnetic resonance imaging is rarely used for patients with emergent cases and should generally be an option only when surgery is considered or when a patient experiences persistent pain despite adequate conservative treatment 2.
• Weight-bearing radiographs can confirm the diagnosis of osteoarthritis (OA) 5.

Laboratory Tests

• Laboratory tests can be used as a confirmatory or diagnostic tool when the initial history and physical examination suggest but do not confirm a specific diagnosis 2.
• Laboratory tests can help evaluate for alternative diagnoses if the diagnosis is still unclear after the initial evaluation 5.

Management

• First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition 6.
• Conservative management, including exercise therapy, is also appropriate for most meniscal tears and patellofemoral pain 6.
• Surgical referral can be considered for patients with end-stage OA or severe traumatic meniscal tears 6.