What is the appropriate management for a patient with a knee strain?

Management of Knee Strain

The optimal management of knee strain requires a combination of non-pharmacological and pharmacological treatment modalities, with exercise therapy being strongly recommended as the cornerstone of treatment. 1

Initial Management (Acute Phase)

PRICE Protocol

• Protection: Avoid activities that exacerbate pain
• Rest: Relative rest (avoid activities that cause pain)
• Ice: Apply ice for 15-20 minutes every 2-3 hours during the first 48-72 hours 2
  • Consider intermittent ice application protocol (10 minutes on, 10 minutes off, 10 minutes on) which may provide better pain relief than continuous application 3
• Compression: Use elastic bandage to reduce swelling
• Elevation: Keep the affected limb elevated when possible

Pharmacological Management

1. First-line medication: Oral acetaminophen (paracetamol) up to 4g/day 1

   • Safe for long-term use when not contraindicated
   • Effective for mild to moderate pain

2. Second-line medication: NSAIDs (if acetaminophen insufficient) 1

   • Oral NSAIDs are strongly recommended when not contraindicated
   • Topical NSAIDs should be considered, especially for patients with gastrointestinal risk factors 1
   • Consider gastroprotective agents with oral NSAIDs in high-risk patients 1

Rehabilitation Phase

Exercise Therapy

• Strong recommendation for exercise therapy to improve pain and function 1
• Focus on:
  • Quadriceps strengthening exercises
  • Range of motion exercises
  • Progressive resistance training
  • Low-impact aerobic conditioning (e.g., stationary cycling, swimming)

Additional Non-Pharmacological Interventions

1. Manual therapy in combination with exercise program 1

   • May improve pain and function (limited strength of recommendation)

2. Neuromuscular training 1

   • Balance, agility, and coordination exercises
   • Moderate recommendation when combined with standard exercise therapy

3. Patient education 1

   • Strong recommendation for self-management education programs
   • Include information about:
     • Nature of the injury
     • Expected recovery timeline
     • Activity modification
     • Home exercise program

4. Weight management 1

   • Moderate recommendation for sustained weight loss in overweight/obese patients
   • Even modest weight loss (5-10% of body weight) can improve symptoms

5. Assistive devices when appropriate 1

   • Cane use (for significant impact on ambulation)
   • Knee bracing if indicated for stability

Special Considerations

Cautions and Pitfalls

• Avoid prolonged immobilization - can lead to muscle atrophy and joint stiffness
• Avoid oral narcotics - not effective for improving pain or function and have significant adverse effects 1
• Gradual return to activity - too rapid progression may lead to reinjury
• Monitor for signs of more serious injury requiring specialist referral:
  • Joint instability
  • Significant effusion
  • Mechanical symptoms (locking, catching)
  • Failure to improve with conservative management

Return to Activity Criteria

• Pain-free or minimal pain with activities of daily living
• Restored range of motion
• Adequate strength (at least 80-90% compared to uninjured side)
• Proper neuromuscular control during functional activities

Algorithm for Management

1. Initial assessment: Determine severity of strain
2. Acute phase (0-72 hours): PRICE protocol + acetaminophen
3. Early rehabilitation (3-14 days): Continue pain management + begin gentle range of motion and isometric exercises
4. Progressive rehabilitation (2-6 weeks): Advance to strengthening exercises, neuromuscular training
5. Functional rehabilitation (6+ weeks): Sport-specific or activity-specific exercises
6. Return to activity: When functional criteria are met

By following this evidence-based approach, most patients with knee strain should experience significant improvement in pain and function, with excellent long-term outcomes and minimal complications 2.