What is the best course of treatment for a patient with knee pain and tibia eversion, considering their age, activity level, and past medical history?

Management of Knee Pain with Tibial Eversion

For a patient presenting with knee pain and tibial eversion (external tibial torsion), begin with plain radiographs of the knee as the mandatory first imaging study, followed by MRI without contrast if radiographs are normal or non-diagnostic, and consider infra-tubercle tibial de-rotation osteotomy for severe cases (external tibial torsion >37°) with refractory anterior knee pain after exhausting conservative management. 1, 2

Initial Diagnostic Workup

Mandatory First-Line Imaging

• Obtain anteroposterior and lateral knee radiographs immediately as the initial imaging study for any patient ≥5 years with chronic knee pain, regardless of the suspected etiology 1
• Plain radiographs serve to exclude fracture, assess for degenerative changes, identify loose bodies, and evaluate overall alignment 1

Advanced Imaging When Indicated

• MRI knee without IV contrast is the appropriate next study when initial radiographs are normal or demonstrate only joint effusion, as MRI can assess soft tissue structures, cartilage integrity, and identify internal derangement 1
• For patients with suspected rotational malalignment syndrome, obtain CT scan rotational profile to quantify femoral version, tibial torsion, and tibial tubercle-trochlear groove distance 2

Critical Clinical Assessment

• Evaluate for anterior knee pain during squatting (91% sensitive, 50% specific for patellofemoral pain) 3
• Assess for activity-related joint pain with <30 minutes of morning stiffness in patients ≥45 years (95% sensitive, 69% specific for knee OA) 3
• Perform McMurray test with concurrent knee rotation and extension (61% sensitive, 84% specific) and assess for joint line tenderness (83% sensitive, 83% specific) to evaluate for meniscal pathology 3
• Document the foot progression angle during gait and assess whether the patella and foot are aligned during ambulation 2

Conservative Management Protocol (First-Line for All Patients)

Non-Pharmacological Foundation

• Initiate quadriceps strengthening exercises 2 days per week at moderate-to-vigorous intensity for 8-12 repetitions, which produces effect sizes of 0.57-1.0 for pain reduction 4, 5
• For anterior knee pain specifically, prescribe hip and knee strengthening exercises in combination with foot orthoses or patellar taping 3, 6
• Implement weight loss program if BMI ≥25 kg/m², targeting mean reductions of 4.0 kg, as obesity is a major modifiable risk factor 4, 5
• Enroll patient in structured education and self-management program, which reduces healthcare costs by up to 80% within one year 4, 5, 3
• Exercise therapy should continue for at least 3 months before considering other treatment options 6

Pharmacological Management Algorithm

• Start with acetaminophen up to 4,000 mg/day in divided doses as first-line oral analgesic, particularly for older adults with comorbidities given superior safety profile 4, 5, 7
• Add topical NSAIDs before oral NSAIDs for superior safety, especially in elderly patients 8
• If insufficient relief, prescribe oral NSAIDs (ibuprofen 1,200-3,200 mg daily in divided doses) or COX-2 inhibitors at lowest effective dose with mandatory proton pump inhibitor co-prescription for gastroprotection 5, 9, 7
• Reserve intra-articular corticosteroid injections for acute pain exacerbations with joint effusion, providing significant relief within 1-2 weeks with benefits lasting 1-24 weeks 4, 5, 7

Therapies to Avoid

• Do not prescribe glucosamine, chondroitin, or hyaluronic acid injections, as these have strong recommendations against their use based on lack of effectiveness 4, 8, 5
• Do not refer for arthroscopic lavage or debridement unless there is clear mechanical locking from loose bodies 8

Biomechanical Interventions for Tibial Eversion

Bracing and Orthotic Management

• For patients with varus or valgus malalignment contributing to pain, consider realignment knee bracing as adjunctive treatment, which can reduce the external knee adduction moment by 10-20% and provides pain reduction at 6-12 month follow-up 1
• Prescribe full-length wedged insoles with 6°-8° wedge angle to optimally balance efficacy and patient tolerance 1
• Realignment bracing is particularly effective for patients younger than 60 years with unicompartmental disease and biomechanical knee pain or sense of instability 1

Critical Fitting Considerations for Braces

• Ensure sufficient calf bulk to suspend the brace, as the superior calf strap is most important for maintaining position 1
• Don the brace slightly superior to desired position to account for settling with use 1
• Low-profile braces may be better tolerated by patients concerned about appearance, whereas double-upright designs are more appropriate for patients with ligamentous incompetence 1

Surgical Intervention for Severe Tibial Eversion

Indications for Tibial De-Rotation Osteotomy

• Consider infra-tubercle tibial de-rotation osteotomy for patients with severe external tibial torsion (≥37°) and refractory anterior knee pain after exhausting conservative management for at least 3 months 2, 6
• This procedure is appropriate when CT rotational profile demonstrates significant external tibial torsion (mean 50°, range 37-70°) with femoral anteversion (mean 30°, range 21-54°) in the absence of patellar instability 2
• The surgical technique involves infra-tubercular tibial osteotomy with midshaft fibular osteotomy and application of hexapod circular frame to gradually internally rotate the tibia until foot aligns with patella 2

Expected Outcomes

• Mean VAS pain scores improve from 8 (range 5-9) preoperatively to 1 (range 0-4) postoperatively (p<0.001) 2
• Mean Kujala knee pain scores increase from 53 (range 30-75) to 92 (range 54-100) postoperatively (p<0.001) 2
• All patients report relief of knee pain and satisfaction with alignment, with frames removed at mean 111 days (range 80-168) 2

Alternative Surgical Consideration

• Total knee arthroplasty should be considered only for end-stage disease (grade 3-4 OA with minimal joint space) with refractory pain and significant disability after 6+ months of comprehensive conservative management 5, 3, 7

Critical Pitfalls to Avoid

• Never skip initial radiographs, as they are mandatory first-line imaging for chronic knee pain in patients ≥5 years 1
• Do not withhold exercise therapy based on age or severity, as elderly patients achieve similar gains as younger adults 8
• Avoid prolonged NSAID monotherapy without gastroprotection in elderly patients who have significantly elevated gastrointestinal bleeding risk 4, 9
• Space repeated intra-articular corticosteroid injections appropriately (typically not more frequently than every 3 months) to avoid potential cartilage damage 4
• Do not consider surgery for anterior knee pain or tibial torsion until after at least 3 months of intensive conservative management including exercise, education, weight management, and appropriate pharmacologic therapy 3, 6
• For patients undergoing total knee arthroplasty, patellar eversion rather than subluxation does not provide clinical benefit and may increase risk of patellar tendon damage and lateral tibial component malpositioning 10