What are the treatment options for a dent in the knee in an adult?

Treatment of a Dent in the Knee in Adults

For an adult presenting with a "dent" in the knee—which typically represents either a visible deformity, soft tissue depression, or cartilage defect—initial management should focus on conservative treatment with exercise therapy, weight loss if overweight, and education, avoiding arthroscopic surgery unless there is a true locked knee or acute traumatic injury requiring urgent intervention. 1

Initial Diagnostic Approach

The term "dent in the knee" requires clarification through clinical evaluation:

• Obtain radiographs (AP, lateral, sunrise/Merchant, and tunnel views) if the patient has knee symptoms including pain, swelling, locking, catching, popping, giving way, tenderness, effusion, loss of motion, or crepitus 1
• Consider MRI only if radiographs show a lesion (such as osteochondritis dissecans) or when concomitant pathology is suspected (meniscal tears, ACL injury, articular cartilage injury) 1
• Physical examination should assess for joint line tenderness (83% sensitive and specific for meniscal tears), McMurray test (61% sensitive, 84% specific), and anterior knee pain during squatting (91% sensitive for patellofemoral pain) 2, 3

Common Pitfall

Do not routinely obtain radiographs for all patients with possible knee osteoarthritis—imaging should be reserved for chronic pain (>6 weeks) or acute traumatic pain meeting specific evidence-based criteria 2, 3

Conservative Management (First-Line Treatment)

The evidence strongly supports non-surgical management as the primary treatment approach:

• Exercise therapy is the cornerstone of treatment for degenerative knee disease, meniscal tears, and patellofemoral pain 1, 2
• Weight loss if the patient is overweight 1, 2
• Education and self-management programs to empower patients 2
• Physical therapy for 4-6 weeks, particularly for meniscal tears 2
• Hip and knee strengthening exercises combined with foot orthoses or patellar taping for patellofemoral pain 2

Duration and Expectations

Conservative management should be attempted for at least 3-6 months before considering any surgical intervention 1. Pain tends to improve over time after seeing a physician, and symptoms naturally fluctuate in degenerative knee disease 1

When Surgery is NOT Indicated

Arthroscopic surgery should be avoided in the following scenarios:

• Degenerative knee disease with or without imaging evidence of osteoarthritis 1
• Degenerative meniscal tears, even in the presence of mechanical symptoms like locking or catching 2
• Patients over 35 years old with activity-related knee pain, meniscus tears, or clicking/locking symptoms (unless there is a persistent objective locked knee) 1

The BMJ guideline provides a strong recommendation against arthroscopy based on evidence showing less than 15% probability of small or very small improvement in short-term pain and function that does not persist to one year, while exposing patients to 2-6 weeks recovery time, inability to bear weight for 2-7 days, and rare serious adverse effects 1

When Surgery MAY Be Indicated

Surgical referral should be considered only in these specific circumstances:

• End-stage osteoarthritis (minimal or no joint space with inability to cope with pain) after exhausting all appropriate conservative options—consider knee joint replacement 2
• Severe traumatic tears (e.g., bucket-handle tears) with displaced meniscal tissue 2
• Persistent objective locked knee that cannot be fully extended 1
• Salvageable unstable or displaced osteochondritis dissecans (OCD) lesions in symptomatic patients 1
• Acute traumatic knee dislocation with neurovascular compromise 4, 5

Important Caveat

If arthroscopy is performed, recovery typically requires 2-6 weeks with pain, swelling, and limited function. Patients cannot bear full weight for 2-7 days and may need crutches. Return to work takes 1-2 weeks for sedentary jobs and at least 6 weeks for physical jobs 1

Special Considerations

Suprapatellar synovial plica should be suspected in patients with anterior knee pain where imaging shows no clear intraarticular or periarticular lesions. Initial treatment should be conservative, with arthroscopic excision reserved only for persistent symptoms after failed conservative management 6

Osteochondritis dissecans in skeletally immature patients with symptomatic stable lesions who fail 3+ months of non-surgical treatment may warrant arthroscopic drilling, though evidence is limited 1

Algorithm Summary

1. Clinical evaluation → Determine if "dent" represents deformity, soft tissue depression, or cartilage defect
2. Radiographs if symptomatic (pain, swelling, mechanical symptoms) 1, 3
3. Conservative management for 3-6 months: exercise therapy, weight loss, education 1, 2
4. MRI only if considering surgery or persistent pain despite adequate conservative treatment 2, 3
5. Surgery reserved exclusively for: end-stage OA, severe traumatic tears with displacement, persistent locked knee, or acute neurovascular compromise 1, 2