What is the next step in managing a 38-year-old female (F) with left leg pain and knee swelling after a fall while running, who experienced sharp pain and swelling after continuing to run for 2 days?

From the Guidelines

The next step in managing this 38-year-old female with left leg pain and knee swelling after a fall while running is to immediately discontinue running and perform a comprehensive clinical evaluation, including a detailed physical examination of the knee and imaging studies, as recommended by the American College of Radiology 1. The patient should follow the RICE protocol: Rest the affected leg, apply Ice for 15-20 minutes every 2-3 hours, use Compression with an elastic bandage, and Elevate the leg above heart level when possible. Pain management can include acetaminophen 500-1000mg every 6 hours or ibuprofen 400-600mg every 6-8 hours with food for 5-7 days. Key considerations in her management include:

• Discontinuing running to prevent further injury, as continuing to run after an injury can exacerbate the condition and lead to more significant damage to ligaments, menisci, or cartilage, as suggested by guidelines for returning to running following a tibial bone stress injury 1.
• Obtaining X-rays of the knee to rule out fractures, as recommended by the American College of Radiology for patients with a fall or acute twisting trauma to the knee when at least one of the following is present: focal tenderness, effusion, inability to bear weight 1.
• Considering an MRI if ligamentous or meniscal injury is suspected after radiographs did not show fracture, as recommended for the evaluation of suspected occult knee fractures or internal derangement after a fall or acute twisting trauma to the knee 1.
• Monitoring for the presence of pain during or following activity to guide progressions, as pain suggests that the injury site has been overloaded, and rest is recommended until symptoms have resolved 1. Given the patient's symptoms of sharp pain and swelling after continuing to run for 2 days, it is essential to prioritize a thorough evaluation and management plan to prevent further injury and promote optimal recovery.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Evaluation

The patient, a 38-year-old female, presents with left leg pain and knee swelling after a fall while running. The initial evaluation of acute knee pain should include:

• Plain radiography, which is a quick and cost-effective way to identify a wide range of problems, including fracture, degenerative changes, osteochondral defects, and effusions 2
• Computed tomography (CT) scan may be considered if the history and physical examination point to damage of the cartilage, menisci, and ligaments, or if arthroscopy is contemplated 2

Imaging Tests

The choice of imaging test depends on the clinical presentation and the suspected underlying condition.

• X-ray imaging has a low sensitivity in identifying knee fractures, especially growth plate fractures, and may not be sufficient to determine the type and characteristics of the fracture 3
• CT scan is more accurate than X-ray imaging in identifying fractures and determining their characteristics, and should be performed if the fracture type and characteristics cannot be determined exactly with X-ray imaging 3
• Magnetic resonance imaging (MRI) is useful for evaluating cartilage, menisci, and ligament injuries, and can be used to detect meniscal root tears and associated injury patterns 2, 4

Clinical Decision Rules

The use of clinical decision rules can help improve the efficiency of radiography in acute knee injuries.

• Experienced clinicians can accurately discriminate between fracture and non-fracture cases, and expect most radiographs to be normal 5
• Clinical decision rules can help identify patients who are at low risk of fracture and do not require radiography, reducing unnecessary imaging and costs 5

Pain Management

The patient's pain should be managed appropriately, taking into account the potential risks of opioid use.

• Orthopedic surgeons should tailor their postoperative opioid prescriptions to the individual patient and utilize alternative options for postoperative pain control, such as intraoperative multimodal drug injection and nerve blockade 6
• Patients should be counseled regarding narcotic addiction and dependence, and those who are unable to manage pain postoperatively should be followed closely and receive proper chronic pain management, mental, and social health services referrals 6