What treatment options are available for a 30-year-old with right knee pain, swelling, and limited mobility that worsens with stair climbing?

Treatment Approach for Acute Knee Pain with Swelling and Limited Extension

This presentation is most consistent with patellofemoral pain syndrome or possible meniscal pathology, and should be managed with knee-targeted exercise therapy as the primary intervention, combined with education and pain management strategies. 1

Initial Assessment Priorities

The clinical picture of progressive pain over 10 days, swelling with tightness, inability to fully extend the knee, and pain worsening with stairs suggests either patellofemoral pain syndrome or internal derangement (meniscal tear). Key evaluation points include:

• Assess tissue tolerance to load by checking for effusion presence and pain provocation with functional tasks like single-leg squat or decline squat testing 1
• Evaluate quadriceps and hip muscle strength as weakness in these areas commonly drives treatment selection 1
• Observe movement patterns during functional activities to identify biomechanical contributors 1
• Determine symptom severity and irritability as this guides exercise prescription intensity 1

Primary Treatment: Exercise Therapy

Knee-targeted exercise therapy should be the cornerstone of treatment, with the following approach:

• Initiate quadriceps strengthening exercises immediately as they show significant improvements in pain and function 2, 3
• Prescribe exercises relative to symptom severity and irritability - if the patient has poor tolerance to loaded knee flexion, emphasize hip strengthening initially before progressing to more aggressive knee loading 1
• Include range-of-motion exercises to address the limited extension, focusing on gentle stretching of muscles around the knee 2
• Progress to low-impact aerobic exercise (walking, cycling, swimming) which demonstrates effect sizes of 0.52 for pain relief and 0.46 for disability reduction 2, 3
• Aim for at least 3 sessions per week with supervised programs being more effective than self-directed approaches 2

Education as Foundation

Education must underpin all interventions and should address:

• Challenge the belief that pain equals damage, particularly important given the acute presentation and patient's functional limitations 1
• Explain expected recovery timeframes and the concept that symptoms can improve even while exercising with some discomfort 2
• Teach load management principles to help the patient understand how to modify activities during recovery 1
• Build confidence in the diagnosis and promote autonomy in self-management 1

Pharmacological Management

For pain control during the rehabilitation phase:

• Start with acetaminophen (paracetamol) as first-line oral analgesic for mild to moderate pain 1, 3, 4
• Consider NSAIDs (oral or topical) if acetaminophen is insufficient, particularly given the presence of swelling which suggests inflammation 1, 3, 5
• Topical NSAIDs and capsaicin are safe alternatives with clinical efficacy 3

Supporting Interventions

Additional modalities should be considered based on symptom severity:

• Taping may be beneficial if elevated symptom severity and irritability are hindering rehabilitation progress 1
• Prefabricated foot orthoses can be tried if treatment direction tests suggest benefit, particularly for short-term symptom relief 1
• Deep transverse friction massage may reduce pain in patellar tendinopathy presentations 1

Red Flags Requiring Imaging or Referral

Consider imaging if:

• Symptoms fail to improve with conservative management after 4-6 weeks 1
• There is concern for loose bodies, osteochondritis dissecans, or meniscal tear based on examination findings 1
• MRI without contrast is the preferred imaging modality for evaluating soft tissue structures, menisci, and articular cartilage when radiographs are non-diagnostic 1

Critical Pitfalls to Avoid

• Do not delay exercise therapy - waiting for pain to completely resolve before starting strengthening is counterproductive, as exercise itself is therapeutic 1, 2
• Avoid high-impact activities during the acute phase as they may increase joint stress 2
• Do not rely solely on passive modalities - while taping or orthotics may provide short-term relief, exercise therapy is essential for long-term improvement 1
• Pain during exercise should not prevent participation as clinical trials demonstrate improvements even when patients experience some discomfort 2

Implementation Strategy

The optimal approach follows this sequence:

1. Begin knee-targeted strengthening exercises immediately, modified for current irritability level 1
2. Provide concurrent education about pain mechanisms and expected recovery 1
3. Add acetaminophen for pain control 1, 3
4. Consider NSAIDs if swelling persists or pain limits exercise participation 1, 3
5. Progress exercise intensity gradually over several weeks as tolerance improves 2
6. Reassess at 4-6 weeks - if no improvement, consider imaging 1