What is the treatment for superior medial knee pain with swelling and bruising?

Treatment of Superior Medial Knee Pain with Swelling and Bruising

Begin with acetaminophen up to 4,000 mg/day as first-line oral analgesia combined with PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for the first 48-72 hours, followed by early functional rehabilitation with quadriceps strengthening exercises. 1, 2, 3

Immediate Management (First 48-72 Hours)

PRICE Protocol

• Protection: Use functional support devices such as knee bracing or walking aids to reduce load on the affected area 1
• Rest: Limit activities that provoke pain, but avoid complete immobilization beyond 48-72 hours as this leads to suboptimal outcomes 1, 3
• Ice: Apply ice intermittently (15-20 minutes every 2-3 hours) to control pain and swelling 1, 4
• Compression: Use elastic compression bandages or knee sleeves to minimize effusion 1, 4
• Elevation: Keep the knee elevated above heart level when resting to reduce swelling 1, 4

First-Line Pharmacological Management

• Acetaminophen (paracetamol) up to 4,000 mg/day is the preferred initial oral analgesic due to its favorable safety profile and effectiveness for mild-to-moderate pain 1, 2, 5
• Counsel patients to avoid other acetaminophen-containing products to prevent hepatotoxicity from exceeding maximum daily dose 2
• Complete a full dosage trial (at least 2-4 weeks at adequate doses) before considering it ineffective 2

Transition to Active Rehabilitation (After 48-72 Hours)

Exercise Therapy (Critical Component)

• Quadriceps strengthening exercises should begin early (within 3-5 days) as they are the primary treatment for medial knee pathology 1, 2, 3
• Closed kinetic chain exercises (leg press, squats, step-ups) are more effective than open kinetic chain exercises 2
• Progress gradually from lower intensity to higher intensity as tolerated 1, 2
• Both land-based and aquatic exercises are effective; choose based on patient tolerance 1, 2

Weight Management (If Applicable)

• For overweight patients, even modest weight loss significantly improves symptoms and reduces pressure on the knee joint 1, 6
• Implement strategies including regular self-monitoring, structured meal plans, increased physical activity, and reduced fat/sugar intake 1

Second-Line Treatment (If Inadequate Response After 2-4 Weeks)

Topical NSAIDs

• Topical NSAIDs are preferred over oral NSAIDs as they provide effective pain relief with fewer systemic adverse effects 1, 2, 5
• Particularly recommended for patients ≥75 years old due to superior safety profile 2, 5

Oral NSAIDs (If Topical Ineffective)

• Consider oral NSAIDs for patients unresponsive to acetaminophen, especially if signs of inflammation (warmth, effusion) persist 1, 5, 6
• For patients with increased gastrointestinal risk: use COX-2 selective inhibitors OR non-selective NSAIDs with gastroprotective agents 1, 5
• NSAIDs show superior results for reducing pain and swelling compared to acetaminophen in some studies, though adverse event rates are higher 1

Supportive Devices

• Walking stick used on the contralateral side reduces load on the affected knee 1
• Consider medially or laterally wedged insoles depending on compartment involvement 1, 2
• Knee bracing provides functional support and may improve proprioception 1

Advanced Treatment (For Acute Flares with Effusion)

Intra-articular Corticosteroid Injection

• Indicated for acute exacerbations with significant effusion that fail to respond to conservative measures 1, 2, 5, 6
• Provides short-term pain relief (typically 2-4 weeks) 5
• Should not replace ongoing exercise therapy and functional rehabilitation 1

Critical Pitfalls to Avoid

• Do not rely solely on pharmacological management without exercise therapy - this significantly reduces treatment effectiveness and delays recovery 2, 3
• Avoid prolonged immobilization (>10 days) as it leads to worse functional outcomes, increased pain, and delayed recovery 1
• Do not exceed 4,000 mg/day of acetaminophen due to hepatotoxicity risk 2
• Avoid NSAIDs that may delay natural healing by suppressing necessary inflammatory responses, though clinical significance remains debated 1
• Do not prescribe glucosamine or chondroitin sulfate as they lack evidence for efficacy 2

Red Flags Requiring Urgent Evaluation

• Severe pain with inability to bear weight suggests possible fracture or ligamentous rupture 3, 7
• Fever, erythema, and warmth with effusion indicate possible septic arthritis requiring immediate evaluation 7
• Locked knee with inability to extend suggests displaced meniscal tear or loose body 3, 7

Treatment Algorithm Summary

1. Days 0-3: PRICE protocol + acetaminophen up to 4,000 mg/day 1, 2
2. Days 3-7: Begin quadriceps strengthening exercises while continuing acetaminophen 1, 2, 3
3. Weeks 2-4: If inadequate response, add topical NSAIDs and supportive devices 2, 5
4. Week 4+: If persistent symptoms, consider oral NSAIDs with gastroprotection if indicated 1, 5
5. Any time: For acute flares with effusion, use intra-articular corticosteroid injection 1, 5, 6