What is the treatment for a 58-year-old male with knee pain, contusions of the medial tibial plateau, a horizontal oblique meniscus tear, and osteoarthritis after a pivot injury?

Treatment for Knee Pain with Medial Tibial Plateau Contusions, Horizontal Oblique Meniscus Tear, and Osteoarthritis

Initial conservative management is strongly recommended for this 58-year-old male with knee pain following a pivot injury, including a combination of self-management strategies, physical therapy, and appropriate medications before considering surgical options. 1

Initial Management (First 1-2 Weeks)

Pain Management

• First-line medication: Acetaminophen for pain relief 1
• Second-line medication: Oral or topical NSAIDs if acetaminophen is insufficient 1
  • Topical NSAIDs should be tried first to minimize systemic side effects
  • Consider gastrointestinal risk factors when prescribing oral NSAIDs

Acute Phase Treatment

• RICE protocol (Rest, Ice, Compression, Elevation) for the first 24-72 hours 2
• Activity modification to avoid aggravating activities 3
• Consider knee bracing for temporary support 3

Comprehensive Treatment Plan (Weeks 2-12)

Exercise Therapy (High Priority)

• Strengthening exercises focusing on quadriceps and hamstrings 1
• Low-impact aerobic activities (swimming, cycling, elliptical) 1
• Neuromuscular education to improve joint stability 1
• Progressive return to activities as tolerated 3

Intra-articular Injections

• Corticosteroid injection can be considered for short-term pain relief (benefits typically last up to 3 months) 1
• Platelet-rich plasma may be beneficial for mild-to-moderate osteoarthritis but shows inconsistent results in severe cases 1
• Hyaluronic acid injections are not routinely recommended based on current evidence 1

Weight Management

• If BMI ≥25 kg/m², weight reduction is strongly recommended to reduce knee load and slow osteoarthritis progression 1, 3

Surgical Considerations

When to Consider Surgical Intervention

• Persistent mechanical symptoms (locking, catching) despite 6-12 weeks of conservative management 1
• Failure to improve with appropriate conservative treatment 1

Surgical Options

• Arthroscopic partial meniscectomy may be appropriate for this patient with both osteoarthritis and a symptomatic meniscal tear that hasn't responded to conservative treatment 1
• The decision for meniscal repair versus partial meniscectomy depends on:
  • Tear location (peripheral tears have better blood supply and healing potential) 4
  • Tear pattern (horizontal oblique tears are often degenerative and less amenable to repair) 5
  • Associated pathology (presence of osteoarthritis affects outcomes) 5

Important Considerations and Pitfalls

Diagnostic Considerations

• MRI findings must be correlated with clinical symptoms, as asymptomatic meniscal tears are common in patients over 50 3
• Bone marrow contusions on MRI after knee trauma are associated with development of focal osteoarthritis within 1 year 1

Treatment Expectations

• Patients should understand that the presence of osteoarthritis may limit outcomes of meniscal procedures 1
• For most patients with knee osteoarthritis, meniscal tears are part of the degenerative process rather than an independent cause of symptoms 1
• A subset of patients with mild-to-moderate knee osteoarthritis and meniscal tears may benefit from arthroscopic partial meniscectomy after failing conservative treatment 1

Follow-up Recommendations

• Re-evaluate in 1-2 weeks if symptoms persist despite initial management 3
• Consider advanced imaging or specialist referral if no improvement after 6-12 weeks of comprehensive conservative treatment

This treatment approach prioritizes conservative management first while recognizing that surgical intervention may be appropriate if the patient fails to respond to non-operative measures, particularly if mechanical symptoms persist.