What is the initial treatment plan for a patient with a grade 2 sprain of the right knee, presenting with swelling and tenderness after a twisting injury?

Initial Treatment Plan for Grade 2 Knee Sprain

For a grade 2 knee sprain with swelling and tenderness after a twisting injury, immediately implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) combined with NSAIDs for pain control, functional support with a brace, and early supervised exercise therapy starting within 48-72 hours. 1

Immediate Management (First 48-72 Hours)

PRICE Protocol Implementation

• Apply ice (surrounded by damp cloth) for 20-30 minutes, 3-4 times daily to reduce pain and swelling, never placing ice directly on skin to prevent cold injury 1, 2
• Elevate the injured knee above heart level whenever possible to minimize swelling 2
• Apply compression wrap ensuring circulation is not compromised—the wrap should provide comfort without causing numbness or discoloration 1
• Protect the knee from further injury by avoiding activities that cause pain, though complete immobilization should be avoided 1
• Rest from aggravating activities only—prolonged complete rest delays recovery 1

Pharmacological Management

• Start NSAIDs immediately such as naproxen 500 mg twice daily, ibuprofen, or meloxicam 7.5-15 mg daily for 4-6 weeks to reduce pain and swelling 3, 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 1
• Avoid opioids as they cause significantly more side effects without superior pain relief 1

Functional Support

• Apply a lace-up or semi-rigid knee brace within the first 48 hours and continue for 4-6 weeks, as this approach is superior to immobilization and leads to faster return to work and sports 1
• Avoid prolonged immobilization beyond what is needed for initial pain control (maximum 3-5 days), as this delays recovery without improving outcomes 1, 2

Early Rehabilitation Phase (48-72 Hours to 4 Weeks)

Supervised Exercise Therapy

• Begin supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence for effectiveness and is critical for optimal recovery 1
• The exercise program should include:
  • Range of motion exercises to prevent stiffness 1
  • Proprioception training to restore joint position sense 1
  • Strengthening exercises focusing on quadriceps and hamstrings 1
  • Coordination and functional exercises progressing toward sport-specific movements 1
• Supervised exercises are superior to home exercises alone—patients should work with a physical therapist rather than performing unsupervised training 1

Weight-Bearing Progression

• Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 1
• Protected weight-bearing for 4 weeks is appropriate for soft tissue twisting injuries with significant pain 4

Critical Monitoring and Follow-Up

Re-examination Timeline

• Re-examine the patient in 3-5 days when swelling subsides to accurately distinguish between partial tears and complete ligament ruptures, as initial examination cannot make this distinction reliably 1
• This delayed examination is critical and should not be skipped 1

Red Flags Requiring Urgent Evaluation

• High level of pain that is disproportionate to examination findings 3
• Rapid onset of massive swelling suggesting hemarthrosis 3
• Coldness or numbness in the foot 3
• Inability to bear any weight 3
• Mechanism suggesting possible ligament rupture or fracture (apply Ottawa Knee Rules if indicated) 1

Interventions to Avoid

Do not recommend:

• Prolonged immobilization beyond 3-5 days—this leads to decreased range of motion, chronic pain, and joint instability without demonstrated benefits 1, 2
• Ultrasound, laser therapy, or electrotherapy—these have no proven added value 2
• Manual mobilization as a standalone treatment—it has limited added value and should only be used in combination with other modalities 2
• Heat application for acute injuries 1

Expected Recovery Timeline

• Return to sedentary work: 2-3 weeks for grade 2 sprains 1
• Full return to work and sports: 4-6 weeks depending on rehabilitation progress and functional demands 1
• Continue ankle brace during high-risk activities even after recovery to prevent recurrence 1

Prevention of Chronic Problems

• Incorporate ongoing knee exercises into regular training activities after recovery, as inadequate treatment can lead to chronic problems including decreased range of motion, pain, and joint instability 3, 1
• Reassess for signs of incomplete rehabilitation including persistent pain, workload limitations, or difficulty with sports-specific movements, as these increase reinjury risk 1
• Up to 40% of patients may develop chronic instability despite initial treatment if rehabilitation is inadequate 1