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

For this 54-year-old male with acute knee pain, swelling, and reduced range of motion, initiate treatment with acetaminophen (paracetamol) up to 4 grams daily as first-line therapy, combined with rest, ice application, and early mobilization exercises. 1

Immediate Management

First-Line Pharmacologic Therapy

• Start with acetaminophen (paracetamol) 1000mg three to four times daily (maximum 4g/day) as it is the preferred initial oral analgesic for knee pain with proven safety and efficacy comparable to NSAIDs in many patients 1, 2
• Acetaminophen can be used safely long-term with minimal contraindications, making it ideal for this patient with no documented comorbidities 1
• Continue for at least 7-10 days before escalating therapy 2

Non-Pharmacologic Interventions (Start Immediately)

• Apply ice through a wet towel for 10-minute periods to reduce acute swelling and pain 1
• Avoid complete immobilization - allow activities that don't worsen pain to prevent muscular atrophy 1
• Initiate gentle range of motion exercises as tolerated to maintain joint function 1

If Inadequate Response After 7-10 Days

Second-Line: NSAIDs

• Add or switch to oral NSAIDs (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) if acetaminophen provides insufficient relief 1, 3
• NSAIDs are more efficacious than acetaminophen but carry increased gastrointestinal, renal, and cardiovascular risks 1, 3
• Use the lowest effective dose for the shortest duration possible 3
• Screen for contraindications: history of GI ulcers/bleeding, cardiovascular disease, renal insufficiency, hypertension 1, 3
• Consider topical NSAIDs (diclofenac gel) as an alternative with lower systemic side effects for patients unable to tolerate oral NSAIDs 1

Intra-articular Corticosteroid Injection

• Strongly consider intra-articular corticosteroid injection (triamcinolone hexacetonide or methylprednisolone) for acute exacerbation with effusion 1
• This is particularly indicated given the patient's visible swelling and acute presentation 1
• Provides effective short-term pain relief (7-14 days) though benefit may be relatively short-lived 1
• Evidence shows better outcomes in patients with effusion, which this patient appears to have 1

Progressive Rehabilitation Program

Phase 1: Pain and Swelling Control (First 2 Weeks)

• Continue ice therapy and protected weight-bearing 1
• Gentle passive and active-assisted range of motion exercises 4
• Focus on restoring normal gait pattern 4

Phase 2: Strengthening (Weeks 2-8)

• Implement strengthening exercises focusing on quadriceps and hip musculature 1
• Low-impact aerobic exercise (swimming, cycling, walking) 1
• Neuromuscular education and postural control exercises 1, 4

Phase 3: Functional Return (Weeks 8-12)

• Progress to functional exercises mimicking work activities 4
• Encourage participation in self-management programs 1

Therapies NOT Recommended

Avoid the following interventions as they lack evidence of efficacy: 1

• Acupuncture
• Glucosamine and chondroitin supplements
• Hyaluronic acid injections (evidence inconclusive per AAOS guidelines)

Red Flags Requiring Urgent Evaluation

Monitor for signs requiring immediate reassessment:

• Worsening pain beyond 10 days despite treatment 2
• Development of fever or systemic symptoms 2
• Inability to bear weight
• Signs of infection (warmth, erythema, fever)
• Locking or giving way suggesting mechanical derangement

Special Considerations for This Patient

• History of rugby-related knee problems 20+ years ago suggests possible underlying degenerative changes or old meniscal injury 5, 6
• Acute onset without trauma raises consideration of crystal arthropathy, though osteoarthritis flare is more likely given age and history 1
• Shift work occupation - ensure adequate rest periods and avoid prolonged standing during acute phase 1
• If symptoms persist beyond 3 months despite conservative management, consider imaging (X-ray initially, MRI if mechanical symptoms present) and orthopedic referral 4

Follow-Up Timeline

• Reassess at 7-10 days to evaluate response to initial therapy 2
• If improved, continue current regimen and advance rehabilitation
• If inadequate response, escalate to NSAIDs or consider intra-articular injection 1
• Re-evaluate at 3 months - persistent symptoms warrant imaging and specialist consultation 4