What are the treatment options for knee pain resulting from roller derby?

Treatment of Knee Pain from Roller Derby

For roller derby-related knee pain, initiate a combined approach of knee-targeted exercise therapy (particularly quadriceps strengthening) as the cornerstone, with acetaminophen (up to 4,000 mg/day) for initial pain control, and consider adding topical NSAIDs if acetaminophen is insufficient. 1

Initial Assessment Priorities

Roller derby athletes most commonly sustain knee injuries (21% of all injuries), with ankle injuries being slightly more prevalent (22.5%). 2 Key examination findings to identify include:

• Anterior knee pain patterns: Pain during squats (91% sensitive for patellofemoral pain), pain with prolonged sitting or stair navigation 1
• Patellar tendon involvement: Pain at inferior pole of patella with resisted leg extension, positive decline squat test 1
• Signs of acute inflammation: Joint effusion, warmth, which may indicate bursitis or acute exacerbation 1, 3
• Mechanical symptoms: Locking or catching suggesting meniscal involvement (though less common in roller derby trauma) 4

First-Line Treatment Protocol

Exercise Therapy (Primary Intervention)

Knee-targeted exercise therapy demonstrates high certainty evidence for short-term pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19). 1

• Progressive quadriceps strengthening using both open and closed kinetic chain exercises 1, 5
• Hip-and-knee combined strengthening provides superior outcomes compared to knee-only exercises 1
• Eccentric exercises specifically for patellar tendinopathy if present 1
• Supervised programs are more effective than home-based programs alone 5

Pharmacological Management

Start with acetaminophen (up to 4,000 mg/day) as first-line analgesia due to favorable safety profile. 1, 3, 5

• Topical NSAIDs are preferred over oral NSAIDs, especially for patients ≥75 years, due to better safety profile 3
• Oral NSAIDs (ibuprofen 1200-3200 mg/day divided tid or qid) if acetaminophen fails, with gastroprotection if gastrointestinal risk factors present 1, 5, 6
• Avoid exceeding 4,000 mg/day acetaminophen to prevent hepatotoxicity 5

Adjunctive Non-Pharmacological Interventions

Prefabricated foot orthoses demonstrate primary efficacy for patellofemoral pain. 1

• McConnell-style patellar taping combined with exercise therapy shows benefit 1
• Deep transverse friction massage for tendon-related pain 1, 5
• Lower quadrant manual therapy demonstrates primary efficacy when combined with exercise 1

Second-Line Interventions

For Acute Exacerbations with Effusion

Intra-articular corticosteroid injection is indicated for acute flare of knee pain, especially if accompanied by effusion. 1, 3

For Refractory Cases

• Perineural dextrose injection combined with knee-targeted exercise therapy shows secondary efficacy 1
• Corticosteroid iontophoresis is effective for patellar tendinosis pain and function 1

Activity Modification

Temporarily reduce training intensity and volume to prevent progression to chronic tendinopathy. 5

• Cross-train with low-impact activities (swimming, aquatic exercise) to maintain fitness 5
• Avoid continuing high-intensity roller derby practice through pain, as this leads to chronic tendinopathy that is more difficult to treat 5

Weight Management (If Applicable)

Weight reduction should be considered for overweight patients to reduce pressure on knee joints. 1, 3

Common Pitfalls to Avoid

• Do not rely solely on pharmacological management without implementing exercise therapy, as this significantly reduces treatment effectiveness 1, 5
• Avoid dry needling as it demonstrates non-efficacy compared to sham needling 1
• Do not recommend hyaluronic acid injections when combined with exercise therapy, as they show non-efficacy compared to sham saline injection 1
• Avoid glucosamine or chondroitin sulfate, as these lack evidence for efficacy in overuse injuries 5
• Do not exceed ibuprofen 3200 mg/day without observing sufficient clinical benefits to offset increased risk 6

When to Consider Multidisciplinary or Surgical Referral

Refer for surgical evaluation only after exhausting conservative options (typically 4-6 weeks of appropriate exercise therapy). 4, 7

• Joint replacement consideration is reserved for end-stage osteoarthritis with minimal joint space and inability to cope with pain after all conservative options 1
• For roller derby athletes, surgery is rarely indicated for patellofemoral pain 1