What is the management for knee effusion?

Management of Knee Effusion

Intra-articular corticosteroid injection is the most effective first-line treatment for acute knee effusion, especially when accompanied by pain and inflammatory signs. 1

Initial Assessment and Management

• Evaluate the knee for presence of effusion, pain, and inflammatory signs to guide treatment approach 1
• For mild to moderate effusion with pain, start with oral paracetamol (acetaminophen) up to 4g/day as the initial analgesic 2, 1
• NSAIDs (oral or topical) should be considered for patients unresponsive to paracetamol, particularly when effusion is present 2, 1
• Oral NSAIDs have demonstrated better efficacy than paracetamol but with increased gastrointestinal side effects (effect size median 0.49) 2
• Topical NSAIDs are a useful option for those unwilling or unable to take oral NSAIDs, with positive effect sizes ranging from 0.16 to 1.03 2

Intra-articular Corticosteroid Injection

• Intra-articular corticosteroid injection is indicated for acute exacerbation of knee pain with effusion 2, 1
• Triamcinolone acetonide is commonly used at doses of 5-15 mg for larger joints like the knee 3
• Benefits typically last 1-12 weeks, with significant pain relief over placebo after one and four weeks 2, 1
• One randomized controlled trial showed better outcomes in patients with effusion (effect size 1.27) 2
• Aspiration of excessive synovial fluid prior to injection may aid in pain relief and prevent undue dilution of the steroid 3, 4

Joint Aspiration

• Aspiration alone provides only temporary improvement in clinical parameters, particularly in post-traumatic effusion 4
• Improvement from aspiration typically lasts only for the first week due to early re-accumulation of fluid 4
• Aspiration is beneficial for establishing diagnosis in effusions of unknown origin 4, 5, 6

Non-Pharmacological Management

• Implement non-pharmacological treatments concurrently with pharmacological approaches 1
• Regular patient education about the condition and management is essential 2, 1
• Joint-specific exercises, especially quadriceps strengthening, should be prescribed 1
• Weight reduction is recommended if the patient is overweight 1
• Physical supports such as walking sticks, insoles, or knee bracing may provide additional benefit 1

Management of Refractory Cases

• For persistent effusion and pain despite conservative measures, repeat intra-articular corticosteroid injection may be considered 1
• Hyaluronic acid injections can be considered for patients who don't respond to corticosteroid injections, though they have a slower onset of action 2, 1
• Low-dose spironolactone (25 mg daily for 2 weeks) has shown promising results for OA-related knee effusion with 66% complete improvement compared to 24% with ibuprofen 7
• Joint replacement should be considered for patients with refractory pain, disability, and radiological deterioration 1, 8

Cautions and Considerations

• Avoid overuse of the injected joint for 24 hours following intra-articular therapy 1
• Monitor glucose levels for 1-3 days after corticosteroid injections in diabetic patients due to potential transient hyperglycemia 1
• Avoid both corticosteroid and hyaluronic acid injections within 3 months prior to knee replacement surgery due to increased infection risk 1
• Ensure proper injection technique to avoid injecting the suspension into tissues surrounding the site, which may lead to tissue atrophy 3