What is the best course of treatment for knee pain and swelling?

Management of Knee Pain and Swelling

Begin with standard radiographs (AP, lateral, sunrise/Merchant, and tunnel views) to evaluate structural pathology, then initiate combined non-pharmacological and pharmacological treatment starting with oral NSAIDs or acetaminophen for pain control alongside exercise therapy. 1

Initial Diagnostic Approach

Obtain four-view radiographs immediately for any patient presenting with knee pain and swelling, including anteroposterior, lateral, sunrise/Merchant, and tunnel views to identify structural abnormalities, fractures, or osteoarthritis. 1

• Radiographs serve as the essential first-line imaging study for knee pain with observable signs of inflammation or effusion. 2
• Physical examination should specifically assess for tenderness location, effusion presence, range of motion limitations, and crepitus to guide diagnosis. 1
• Do not order MRI without recent radiographs first—this occurs inappropriately in approximately 20% of cases and wastes resources. 2
• Consider MRI only after initial radiographs if concomitant pathology is suspected (meniscal tears, ligament injury, cartilage damage) or if symptoms persist despite appropriate initial management with normal radiographs. 1, 2

Immediate Treatment Protocol

Pharmacological Management

Start with oral NSAIDs as first-line therapy when not contraindicated, as they provide strong evidence for improving both pain and function. 1

• Oral NSAIDs (such as ibuprofen) are recommended with strong evidence to improve pain and function in knee conditions. 1, 3
• If NSAIDs are contraindicated, use oral acetaminophen as the alternative first-line oral analgesic. 1
• For acute exacerbations with effusion, intra-articular corticosteroid injection is indicated and provides rapid symptom relief. 1

Non-Pharmacological Interventions

Implement PRICE protocol immediately: Protection, Rest, Ice, Compression, and Elevation. 1

• Apply ice/cryotherapy for the first 48-72 hours to reduce pain and swelling—evidence shows benefit for pain medication reduction and decreased swelling in the first 3 postoperative days, though long-term benefits remain uncertain. 4, 5
• Cryotherapy may reduce blood loss (264 mL less) and improve pain scores by 1.6 points on a 0-10 scale at 48 hours, though certainty of evidence is low. 5
• Use compression with semi-rigid supports rather than elastic bandages, as this provides superior outcomes. 1

Ongoing Management Strategy

Exercise and Rehabilitation

Prescribe an individualized exercise program as a core treatment component with strong evidence supporting its use. 1, 2

• Exercise therapy improves pain and function and should be initiated early, even during acute phases as tolerated. 1
• Include neuromuscular training (balance, agility, coordination) combined with strengthening exercises to improve performance-based function and walking speed. 1
• Hip and knee strengthening exercises are particularly important for patellofemoral pain patterns. 2
• Manual therapy may be added to exercise programs for additional benefit in pain and function improvement. 1

Patient Education

Provide structured patient education programs, which have strong evidence for improving pain outcomes. 1

• Education should cover the biopsychosocial aspects including physical status, activities of daily living, participation, mood, and self-management strategies. 2
• Discuss weight loss intervention if the patient is overweight or obese, as sustained weight loss improves both pain and function with moderate-strength evidence. 1

Clinical Pitfalls to Avoid

• Do not immobilize the knee—functional rehabilitation with motion restoration is superior to immobilization for most knee conditions. 1
• Do not rely solely on pharmacological treatment—optimal management requires combining non-pharmacological and pharmacological modalities. 1, 2
• Do not overlook referred pain—if knee radiographs are unremarkable, rule out hip or lumbar spine pathology as the pain source. 2
• Do not continue ineffective treatments—if paracetamol provides inadequate response, escalate to topical NSAIDs/capsaicin, then oral NSAIDs at the lowest effective dose. 1

Monitoring and Follow-up

• Reassess at 3-5 days when pain and swelling have improved, as this timing allows for more accurate diagnosis. 1
• If symptoms persist beyond 3 months despite appropriate conservative management, consider alternative diagnoses or specialist referral. 6
• Monitor for adverse events from NSAIDs, particularly gastrointestinal symptoms, though ibuprofen shows significantly less gastric ulceration than aspirin. 3