What is the best course of treatment for a patient with moderate degenerative changes of the left knee and varicose veins, presenting with left knee pain after a fall?

Management of Left Knee Pain After Fall with Moderate Degenerative Changes and Varicose Veins

Recommend conservative management with exercise therapy for the knee degenerative changes, avoiding arthroscopic surgery, while addressing the varicose veins separately if they are symptomatic and meet specific treatment criteria.

Knee Pain Management

Primary Recommendation: Conservative Treatment Over Surgery

The BMJ clinical practice guidelines strongly recommend against arthroscopic knee surgery for patients with degenerative knee disease, regardless of imaging findings, mechanical symptoms, or sudden symptom onset 1. This applies directly to your patient with moderate degenerative changes on imaging.

• Arthroscopic surgery provides no clinically meaningful benefit over conservative management for degenerative knee disease 1
• Exercise therapy is equally effective as arthroscopy for pain and function, without surgical risks 1
• The fall may have exacerbated underlying degenerative changes rather than causing acute structural damage requiring surgery 1

Conservative Management Algorithm

First-line treatment should include:

• Exercise therapy as the primary intervention, with structured physical therapy focusing on quadriceps strengthening and range of motion 1
• Pain management with NSAIDs or acetaminophen as needed 1
• Activity modification avoiding high-impact activities while maintaining mobility 1
• Weight management if applicable, to reduce joint loading 1

Important Caveat

The one exception to avoiding arthroscopy is persistent objective locked knee (true mechanical locking where the knee cannot fully extend) 1. If your patient has this specific finding, surgical evaluation may be warranted. However, clicking, catching, or subjective locking sensations do not qualify 1.

Varicose Vein Management

Assessment Requirements

The varicose veins noted on imaging require separate clinical evaluation to determine if treatment is necessary 2, 3, 4:

Before considering any intervention, document:

• Symptom severity: Pain, heaviness, aching, swelling, or skin changes specifically attributable to the varicose veins 2, 3, 4
• Duplex ultrasound findings (if not already done): Reflux duration ≥500 milliseconds at saphenofemoral or saphenopopliteal junction, and vein diameter ≥4.5mm for thermal ablation or ≥2.5mm for sclerotherapy 2, 3, 4
• Conservative management trial: 3-month trial of medical-grade compression stockings (20-30 mmHg) with documented symptom persistence 2, 3, 4

Treatment Algorithm for Symptomatic Varicose Veins

If varicose veins are symptomatic and meet criteria:

1. First-line: Endovenous thermal ablation (radiofrequency or laser) for saphenous trunk reflux with diameter ≥4.5mm, achieving 91-100% occlusion rates at 1 year 2, 3
2. Second-line: Foam sclerotherapy for tributary veins or smaller vessels (2.5-4.5mm diameter), with 72-89% occlusion rates at 1 year 2
3. Adjunctive: Stab phlebectomy for bulging tributary veins when performed with junctional treatment 2, 4

If Varicose Veins Are Asymptomatic

Conservative management with compression stockings only if the patient desires symptom prevention, but intervention is not medically necessary for asymptomatic varicose veins 2, 3.

Addressing the Knee-Vein Connection

While one older study suggested venous insufficiency might worsen knee osteoarthritis 5, and epidemiological data shows an association between osteoarthritis and varicose veins 6, there is no high-quality evidence that treating varicose veins improves knee pain from degenerative disease. These should be managed as separate conditions.

Common Pitfalls to Avoid

• Do not proceed with knee arthroscopy based on imaging findings of degenerative changes or patient report of mechanical symptoms 1
• Do not treat varicose veins without proper ultrasound documentation of reflux duration and vein diameter 2, 4
• Do not skip the 3-month compression therapy trial before interventional vein treatment, as this is required for medical necessity determination 2, 4
• Do not assume the fall caused acute injury requiring surgery without evidence of true locked knee or other acute structural damage 1