What is the best course of treatment for a 44-year-old male patient with a large joint effusion and persistent pain in the medial collateral ligament (MCL) area of the left knee, two months after a basketball injury?

Management of Large Joint Effusion with MCL Pain After Basketball Injury

Intra-articular injection of long-acting corticosteroid is indicated for this patient's acute exacerbation of knee pain with large joint effusion. 1

Assessment of Current Condition

This 44-year-old male patient presents with:

• Large joint effusion confirmed by both X-ray and ultrasound
• Persistent pain in the MCL area despite NSAID therapy
• Failed physical therapy due to pain
• Injury occurred 2 months ago (basketball-related)
• Limping gait and mild inflammation on examination
• Intact ligamentous structures on ultrasound

Treatment Algorithm

Step 1: Immediate Management

• Joint aspiration and corticosteroid injection is the appropriate next step 1
  • The planned knee drainage and steroid injection on 7/18/2025 is appropriate
  • This approach is specifically indicated for acute exacerbations of knee pain with effusion

Step 2: Pharmacological Management

• Continue current NSAID therapy:
  • Ibuprofen 600 mg TID
  • Topical diclofenac
• If pain persists after aspiration/injection, consider:
  • Optimizing NSAID dosage
  • Adding acetaminophen if not already using 1

Step 3: Post-Aspiration Rehabilitation

• Resume physical therapy 1-2 weeks after aspiration/injection when pain decreases
• Focus on:
  • Quadriceps strengthening exercises
  • Knee range of motion exercises
  • Gradual return to weight-bearing activities 1

Evidence-Based Rationale

The EULAR guidelines specifically recommend intra-articular corticosteroid injection for flares of knee pain, especially when accompanied by effusion 1. This patient's presentation aligns perfectly with this indication, showing:

1. Large joint effusion documented on both imaging modalities
2. Persistent pain despite oral NSAIDs
3. Failed physical therapy due to pain
4. Symptoms lasting 2 months with inadequate response to conservative measures

Joint aspiration provides both diagnostic and therapeutic benefits:

• Relieves pressure and pain from the effusion
• Allows analysis of synovial fluid if needed
• Creates space for effective steroid delivery

Monitoring and Follow-up

After aspiration and injection:

1. Schedule follow-up in 2-4 weeks to assess response
2. Monitor for:
   • Resolution of effusion
   • Improvement in pain
   • Ability to resume physical therapy
   • Return to normal gait

Potential Pitfalls and Caveats

• Limited duration of effect: Steroid injections typically provide relief for weeks to months, not permanent resolution 1
• Injection frequency: Limit to 3-4 injections per year to avoid cartilage damage
• Infection risk: Ensure sterile technique during aspiration/injection
• Diabetic patients: Monitor blood glucose levels following injection as transient hyperglycemia may occur
• Post-injection flare: Warn patient about possible temporary increase in pain for 24-48 hours

If symptoms persist despite aspiration, injection, and rehabilitation, consider:

• MRI to evaluate for internal derangement not visible on ultrasound
• Orthopedic consultation for possible arthroscopic evaluation
• Alternative diagnoses such as meniscal pathology or early osteoarthritis

This approach prioritizes addressing the patient's immediate symptoms while creating conditions for successful rehabilitation and return to function.