What treatments are recommended for a patient with sudden onset of knee instability, numbness, and a squeezing sensation in the leg after replacing flooring, who has previously taken steroids for similar symptoms?

Management of Knee Pain with Radicular Symptoms

For a patient with knee instability, numbness, and squeezing sensation down the leg after physical labor, urgent evaluation for possible deep vein thrombosis and nerve compression is necessary, with initial treatment including immobilization, anti-inflammatory medication, and referral for vascular and neurological assessment.

Initial Assessment and Differential Diagnosis

Key Clinical Findings to Evaluate

• Knee instability ("gave out")
• Numbness running down the back of leg and toes
• Sensation of blood pressure "squeezing" from thigh to feet
• Previous steroid use for swelling
• History of flooring work (prolonged kneeling/physical labor)

Priority Conditions to Rule Out

1. Deep Vein Thrombosis (DVT)

   • The squeezing sensation from thigh to feet is concerning for possible DVT 1
   • Previous steroid use and physical labor are risk factors

2. Nerve Compression/Radiculopathy

   • Numbness down the back of leg suggests sciatic nerve involvement
   • Knee "giving out" may indicate neurological weakness

3. Charcot Neuro-osteoarthropathy

   • Though typically seen in diabetic patients, the knee instability after steroid treatment warrants consideration 1

4. Peripheral Arterial Disease

   • The squeezing sensation could represent arterial insufficiency 1

Immediate Management

Step 1: Vascular Assessment

• Perform venous ultrasound of the lower extremity to rule out DVT 1
• Check peripheral pulses and ankle-brachial index (ABI) to assess arterial circulation 1
• If DVT is suspected, prophylactic dose anticoagulation is recommended while awaiting confirmation 1

Step 2: Immobilization and Pain Management

• Immobilize the knee with a knee-high offloading device to prevent further instability 1
• Use assistive devices (crutches, walker) to reduce weight-bearing on the affected limb 1
• For pain management:
  • Acetaminophen (up to 4g daily in divided doses) for mild to moderate pain 1, 2
  • Topical NSAIDs can be applied 3-4 times daily with good safety profile 2
  • If inadequate relief, consider oral NSAIDs at the lowest effective dose with monitoring for side effects 1, 2

Step 3: Anti-inflammatory Treatment

• For acute inflammatory symptoms with effusion, intra-articular corticosteroid injection can provide rapid relief 1, 2
• Short-term oral corticosteroids may be considered if significant inflammation is present, but should be used cautiously given the patient's recent steroid use 3, 4

Further Evaluation and Treatment

Neurological Assessment

• Obtain MRI of the lumbar spine to evaluate for disc herniation or nerve root compression
• Consider electromyography (EMG) and nerve conduction studies to assess nerve function
• If radiculopathy is confirmed, treatment may include:
  • Physical therapy focusing on lumbar stabilization exercises
  • Epidural steroid injection if conservative measures fail 1

Vascular Management

• If DVT is confirmed, therapeutic anticoagulation for at least 3 months is recommended 1
• For arterial insufficiency, referral to vascular surgery may be necessary 1

Physical Therapy Approach

• Once acute symptoms improve, initiate structured exercise program including:
  • Quadriceps strengthening exercises
  • Range of motion exercises
  • Proprioceptive training 2
• Consider aquatic exercises if weight-bearing is painful 2

Follow-up and Monitoring

• Re-evaluate in 7-10 days to assess response to treatment
• Monitor for progression of symptoms, especially worsening numbness or weakness
• If symptoms persist despite conservative management for 4-6 weeks, consider referral to orthopedic specialist and/or neurosurgery

Cautions and Contraindications

• Avoid prolonged steroid use due to risk of osteoporosis, avascular necrosis, and adrenal insufficiency 4, 5
• NSAIDs should be used with caution in patients with renal impairment, cardiovascular disease, or GI risk factors 1
• Do not delay imaging if DVT is suspected, as this is a potentially life-threatening condition 1
• Recognize that the combination of knee instability and neurological symptoms requires multidisciplinary evaluation rather than focusing solely on knee joint pathology