What is the recommended treatment for overuse knee injury?

Treatment of Overuse Knee Injury

The optimal management of knee overuse injuries requires a combination of relative rest, cryotherapy, and eccentric strengthening exercises, which together promote healing and reduce pain while improving long-term outcomes.

Understanding Overuse Knee Injuries

Overuse knee injuries result from repetitive stress and microtrauma rather than acute injury. These conditions account for approximately 7% of all injury-related physician office visits 1. Common overuse injuries affecting the knee include:

• Patellar tendinopathy (jumper's knee)
• Iliotibial band friction syndrome (runner's knee)
• Patellofemoral pain syndrome
• Pes anserinus tendinitis/bursitis
• Medial plica syndrome

Treatment Algorithm

First-Line Treatment Approach

1. Relative Rest and Activity Modification

   • Reduce or modify activities that cause pain 1
   • Complete cessation of activity is rarely necessary
   • Gradually reintroduce activity as symptoms improve

2. Cryotherapy (Ice Application)

   • Apply melting ice water through a wet towel for 10-minute periods 1
   • Most effective for acute pain relief
   • Apply after activity and when experiencing pain

3. Eccentric Strengthening Exercises

   • Focus on quadriceps and knee stabilizing muscles 1
   • May reverse degenerative changes in tendons
   • Begin with isometric exercises, progressing to eccentric loading

4. Pain Management

   • Paracetamol (acetaminophen) as first-line analgesic 1
   • Short-term NSAIDs (oral or topical) for pain relief if paracetamol is insufficient 1
   • Note: NSAIDs provide short-term relief but do not affect long-term outcomes 1

Second-Line and Adjunctive Treatments

1. Weight Management

   • Weight reduction recommended for patients with BMI ≥25 kg/m² 1
   • Reduces mechanical stress on knee structures

2. Supportive Devices

   • Consider braces, insoles, or taping based on specific diagnosis 1
   • Evidence is inconclusive but may provide symptomatic relief

3. Corticosteroid Injections

   • Consider for acute exacerbations with effusion 1
   • Provides short-term relief but does not alter long-term outcomes

4. Physical Therapy

   • Focused on proper biomechanics and movement patterns
   • Address contributing factors (muscle imbalances, poor technique)

Special Considerations

Recovery Timeline

Most patients (approximately 80%) with overuse tendinopathies fully recover within three to six months with appropriate conservative management 1. Patience and adherence to the treatment plan are essential.

When to Consider Advanced Interventions

If conservative measures fail after 3-6 months, consider:

• Extracorporeal shock wave therapy 1
• Referral for surgical evaluation 1

Common Pitfalls to Avoid

1. Misdiagnosing as Inflammatory Condition

   • Most chronic tendinopathies are degenerative, not inflammatory 1
   • Using the term "tendinitis" is often incorrect; "tendinopathy" is more accurate

2. Relying Solely on Passive Treatments

   • Active rehabilitation with eccentric strengthening is crucial for recovery 1
   • Passive modalities alone (ultrasound, massage) have limited evidence

3. Returning to Activity Too Soon

   • Gradual progression is essential to prevent recurrence
   • Pain should guide activity modification

4. Overlooking Biomechanical Factors

   • Address underlying movement patterns and technique issues
   • Consider footwear, training surfaces, and training errors

Population-Specific Considerations

Adolescent Athletes

Adolescents may present with growth-related overuse conditions such as Osgood-Schlatter disease or Sinding-Larsen-Johansson disease 2. These typically respond well to activity modification and usually resolve with skeletal maturity.

Older Adults

In older adults, consider the possibility of underlying osteoarthritis contributing to symptoms 1. Treatment approach may need to be modified accordingly, with greater emphasis on joint protection strategies.

By following this structured approach to treating overuse knee injuries, most patients can expect significant improvement in pain and function, allowing return to desired activities while minimizing the risk of recurrence.