What is the initial treatment for a 13-year-old male with knee pain, effusion, and minimal tenderness to the medial aspect following a soccer injury?

Initial Treatment for Acute Knee Injury in a 13-Year-Old Soccer Player

For this 13-year-old male with knee effusion and medial tenderness following soccer injury, initiate RICE protocol (rest, ice, compression, elevation) immediately, restrict activities that cause pain, and obtain knee radiographs if Ottawa Knee Rule criteria are met. 1

Immediate First Aid Management

Apply cold therapy (ice and water mixture in a damp cloth) for 20-30 minutes, 3-4 times daily without direct skin contact to reduce pain and swelling. 1

• Cold application provides acute pain relief and reduces swelling in soft tissue injuries, with greatest tissue cooling achieved using ice-water mixture surrounded by damp cloth 1
• Limit cold application duration to prevent cold injury; never place ice directly on skin 1

Consider compression wrap application to promote comfort, ensuring it does not compromise circulation. 1

• Compression wraps may provide acute comfort and pain relief, though evidence for long-term benefit is limited 1
• Avoid overtightening to prevent circulatory compromise 1

Imaging Decision-Making

Obtain anteroposterior and lateral knee radiographs if any Ottawa Knee Rule criteria are present: 1

• Age ≥55 years (not applicable here)
• Isolated tenderness of patella
• Tenderness at head of fibula
• Inability to flex knee to 90 degrees
• Inability to bear weight both immediately and in emergency department (four steps) 1

For this patient with focal medial tenderness and effusion, radiographs are indicated to rule out fracture. 1

• Lateral view should be obtained with knee at 25-30 degrees flexion to evaluate for joint effusion and lipohemarthrosis 1
• Cross-table lateral view with horizontal beam enables visualization of lipohemarthrosis, frequently seen with intra-articular fractures 1

Activity Restriction

The patient must avoid all activities that cause pain, including soccer, until fully evaluated and cleared by a healthcare professional. 1

• Rest and limiting use of injured extremity prevents worsening of injury, particularly important when uncertainty exists about whether injury is sprain, strain, or fracture 1
• Return to contact sports should only occur after full recovery and consultation with healthcare professional 1

Pain Management

If pain persists despite conservative measures, acetaminophen (paracetamol) is the first-line oral analgesic, safe for long-term use in adolescents. 2

• Acetaminophen up to age-appropriate dosing provides effective analgesia with minimal side effects 2

NSAIDs (oral or topical) should be considered if unresponsive to acetaminophen, particularly given the presence of effusion suggesting inflammatory component. 1, 2

• Topical NSAIDs offer clinical efficacy with better safety profile than oral NSAIDs 3
• Oral NSAIDs demonstrate efficacy (effect size median 0.49) but carry increased gastrointestinal side effects compared to acetaminophen 1

Management of Effusion

For acute knee effusion with pain, intra-articular corticosteroid injection is indicated and provides significant pain relief within 1-2 weeks, particularly when effusion is present. 1, 2

• Corticosteroid injection shows better outcomes in patients with effusion (effect size 1.27 at 7 days) 1
• Benefits are relatively short-lived (1-4 weeks of significant benefit), though some studies show effects lasting up to 24 weeks 1

Aspiration may provide temporary symptomatic relief but should be performed with consideration in traumatic effusions. 4

• Aspiration shows only temporary improvement lasting approximately one week due to early re-accumulation 4
• Consider aspiration primarily for diagnostic purposes in effusions of unknown origin or for immediate clinical relief 4

Critical Red Flags Requiring Urgent Evaluation

Activate emergency services if any of the following develop: 1

• Gross deformity suggesting fracture or dislocation
• Neurovascular compromise
• Open wounds or penetrating injury
• Inability to bear any weight suggesting possible fracture

Medial-Specific Injury Considerations

Given medial tenderness, evaluate specifically for medial collateral ligament (MCL) injury through valgus stress testing at full extension and 30 degrees flexion. 5

• Most acute grade III medial knee injuries heal with nonoperative rehabilitation program 5
• Medial knee injuries are the most common knee ligament injuries in young athletes, typically from valgus contact or tibial external rotation forces 5

Common Pitfalls to Avoid

• Do not apply ice directly to skin - always use barrier cloth to prevent cold injury 1
• Do not overlook fracture possibility - effusion with trauma warrants radiographic evaluation per Ottawa rules 1
• Do not allow premature return to sport - risk of reinjury is high without full recovery and professional clearance 1
• Do not assume aspiration provides lasting benefit - it offers only temporary relief in traumatic effusions 4