What is the most appropriate initial management step for a female patient with a 4-day history of left knee pain after a recreational soccer injury, who has moderate edema, tenderness over the medial femoral condyle, and exacerbation of pain with terminal extension, but is able to bear weight with some difficulty?

Initial Management of Acute Knee Injury with Medial Femoral Condyle Tenderness

Referral for physical therapy is the most appropriate initial step in management for this patient with an acute knee injury presenting with moderate edema, medial femoral condyle tenderness, and pain with terminal extension. 1

Clinical Reasoning

This patient's presentation—non-contact injury during soccer, ability to bear weight, medial femoral condyle tenderness, and pain with terminal extension—suggests a soft tissue injury (likely medial collateral ligament strain or meniscal involvement) rather than a fracture or severe structural damage. 2

Why Physical Therapy First?

• Exercise therapy should be started as soon as possible to recover joint functionality in acute knee injuries, as strongly recommended by evidence-based guidelines. 3
• First-line management of knee pain comprises exercise therapy, education, and self-management programs to empower patients to better manage their condition. 1
• The patient's ability to bear weight (even with difficulty) indicates she can safely participate in early therapeutic exercise without risk of further injury. 2

Why Not the Other Options?

Application of Knee Brace

• Immobilization should not be used in the treatment of acute joint injuries, as it delays functional recovery. 3
• Functional support (bracing) is only conditionally recommended for specific conditions like ankle sprains, not as initial management for acute knee injuries without clear ligamentous instability. 3

Intra-articular Corticosteroid Injection

• Intra-articular corticosteroid injections are indicated for acute exacerbation of knee pain, especially if accompanied by effusion, in the context of osteoarthritis—not acute traumatic injuries in young, active patients. 3
• This patient has an acute injury pattern, not an inflammatory arthropathy or osteoarthritis requiring corticosteroid intervention. 4

Narcotic Therapy

• Opioid analgesics are strongly recommended only in patients who have failed medical therapy and are either not willing to undergo or have contraindications for total joint arthroplasty. 3
• For acute knee injuries, NSAIDs may be used to reduce pain and swelling as first-line pharmacologic management, not narcotics. 3
• Acetaminophen or oral NSAIDs are conditionally recommended for initial management of knee pain, with opioids reserved for inadequate response to initial therapy. 3

Orthopedic Surgeon Referral

• Surgical referral is premature without attempting conservative management first. 1
• Conservative management (exercise therapy for 4-6 weeks) is appropriate for most meniscal tears and soft tissue injuries. 1
• Surgery is only indicated for severe traumatic tears with displaced meniscal tissue (bucket-handle tears) or after failed conservative therapy. 1

Recommended Initial Management Algorithm

1. Immediate referral to physical therapy for supervised exercise program focusing on:

   • Quadriceps strengthening exercises 4
   • Range of motion restoration 3
   • Proprioception and functional training 3

2. Adjunctive pharmacologic management:

   • Oral NSAIDs (ibuprofen 400-800 mg three times daily or naproxen 500 mg twice daily) for pain and inflammation control 3, 4
   • Assess gastrointestinal and cardiovascular risk before initiating NSAIDs 4

3. Patient education about expected course and self-management strategies 1

4. Relative rest of the affected joint initially, but not complete immobilization 4

Critical Pitfalls to Avoid

• Do not delay therapeutic exercise waiting for complete pain resolution—early mobilization improves outcomes. 3, 1
• Avoid immobilization with rigid bracing, as this delays functional recovery. 3
• Do not prescribe opioids as first-line therapy for acute musculoskeletal injuries in otherwise healthy patients. 3
• Reassess if no improvement in 1-2 weeks and consider imaging (MRI) or orthopedic referral at that point if symptoms persist. 4, 1

Follow-up Considerations

• If significant effusion persists after 1-2 weeks of conservative management, consider intra-articular corticosteroid injection at that time. 4
• Radiographic imaging is not immediately indicated unless there are specific red flags (inability to bear weight, inability to flex knee to 90 degrees, isolated patellar tenderness, age >55 years). 2