What is the management for a middle-aged male with acute knee pain and swelling?

Management of Acute Knee Pain and Swelling in a Middle-Aged Male

Start with acetaminophen (paracetamol) up to 4 grams daily as first-line therapy, combined with immediate non-pharmacological interventions including patient education, quadriceps strengthening exercises, and weight reduction if BMI ≥25 kg/m² 1, 2.

Immediate Assessment and Initial Management

Rule Out Acute Inflammatory Arthropathy

• Given the acute onset (yesterday morning) with swelling and no trauma history, assess for joint effusion on examination 1
• If significant effusion is present, strongly consider intra-articular corticosteroid injection (e.g., triamcinolone hexacetonide) for rapid symptom relief 1
• The evidence shows intra-articular steroids are highly effective for acute exacerbations with effusion (effect size 1.27 over 7 days), though benefit may be relatively short-lived 1

First-Line Pharmacologic Therapy

Acetaminophen is the preferred initial oral analgesic because:

• It is as effective as NSAIDs for mild-to-moderate osteoarthritis pain 1
• It has superior safety profile with minimal gastrointestinal, renal, and cardiovascular risks compared to NSAIDs 1
• Maximum dose is 4 grams daily; can be used safely long-term 1, 2

If Acetaminophen Fails After 1-2 Weeks

Second-Line: NSAIDs

If acetaminophen provides inadequate relief, escalate to oral or topical NSAIDs 1:

• Oral NSAIDs (ibuprofen 1200-2400 mg/day or naproxen 500-1000 mg/day) are more effective than acetaminophen but carry increased gastrointestinal and cardiovascular risks 1, 3
• For this 54-year-old patient with no documented cardiovascular disease or GI history, ibuprofen is reasonable 1, 3
• Topical NSAIDs (diclofenac gel) are effective alternatives with lower systemic side effects for those unable to tolerate oral NSAIDs 1

Critical Safety Considerations for NSAIDs:

• Use the lowest effective dose for the shortest duration 1, 3
• NSAIDs increase risk of heart attack, stroke, GI bleeding, and kidney problems 3
• Avoid in patients with recent heart attack or immediately before/after cardiac surgery 3
• Monitor for signs of GI bleeding (black stools, vomiting blood), cardiovascular events (chest pain, shortness of breath), and renal dysfunction 3

Mandatory Non-Pharmacological Interventions (Start Immediately)

All patients must receive combined non-pharmacological therapy regardless of medication choice 1:

Exercise Program (Strongly Recommended)

• Quadriceps strengthening exercises are essential - these directly address the reduced range of motion noted on examination 1
• Low-impact aerobic exercise (walking, swimming, cycling) 1
• Neuromuscular education and proprioceptive training 1
• Regular moderate-level exercise does NOT exacerbate OA or accelerate joint damage 1

Patient Education

• Self-management programs improve outcomes 1
• Explain the chronic nature of likely osteoarthritis given his rugby history 20+ years ago 1

Weight Management

• If BMI ≥25 kg/m², weight reduction is recommended 1
• Weight loss reduces risk and progression of knee OA 1

If Second-Line Therapy Fails

Third-Line Options

For patients unresponsive to acetaminophen and NSAIDs:

• Tramadol 50 mg 1-2 times daily, titrating slowly is conditionally recommended 4, 5
• Duloxetine 30 mg daily, titrating to 60 mg daily, is an alternative 4
• Opioid analgesics may be considered for severe refractory pain with careful monitoring 1, 4

Procedural Interventions

• Intra-articular corticosteroid injection remains an option for acute flares even if used initially 1
• Hyaluronic acid injections are NOT recommended by AAOS due to lack of evidence 1
• Evidence for hyaluronic acid is inconclusive and effect sizes are small 1, 4

What NOT to Use

The following have strong evidence AGAINST their use 1:

• Acupuncture - no clinically significant benefit
• Glucosamine and chondroitin - essentially no evidence of clinically important outcomes vs. placebo
• Lateral wedge insoles - not suggested

Common Pitfalls to Avoid

1. Do not skip acetaminophen and go straight to NSAIDs - this violates guideline recommendations and exposes patients to unnecessary risk 1
2. Do not use NSAIDs chronically at high doses - elderly patients are at particularly high risk for adverse effects 1, 6
3. Do not neglect exercise therapy - pharmacologic therapy alone is insufficient; combination therapy is superior 1
4. Do not reserve intra-articular steroids only for patients with effusion - while better outcomes occur with effusion, clinical predictors of response remain unclear 1
5. Do not exceed acetaminophen 4 grams daily - hepatotoxicity risk increases above this dose 1, 2

Follow-Up and Monitoring

• Reassess pain and function in 1-2 weeks after initiating acetaminophen 1
• If escalating to NSAIDs, monitor for GI symptoms, cardiovascular events, and renal function 3
• Ensure exercise program compliance - this is as important as medication 1
• Consider orthopedic referral for joint replacement if refractory pain with disability and radiographic deterioration develops 1