What is the appropriate management for a 46-year-old male patient with left knee pain, potential small joint effusion, and a palpable popliteal cyst, currently requesting a Thromboembolic Deterrent (TED) hose and a knee brace, and being considered for ibuprofen (ibuprofen) 400 milligrams twice daily as needed?

From the Guidelines

I strongly recommend providing the 46-year-old male patient with a TED hose, knee brace, and paracetamol 4g/day as needed for 30 days to manage his left knee pain, as paracetamol has been shown to be as effective as ibuprofen in reducing pain in knee osteoarthritis patients 1. The patient has a palpable popliteal cyst in the left knee, which was not clearly identified on x-ray but was detected during physical examination. The x-ray showed a potential small joint effusion without a discernible popliteal cyst. A popliteal cyst (Baker's cyst) is a fluid-filled swelling that forms behind the knee and can cause pain, swelling, and limited range of motion.

• The TED hose will provide compression to help reduce swelling
• The knee brace will offer stability and support to the affected joint
• Paracetamol, will help reduce pain, and has been shown to be a safe and effective option for long-term use in knee osteoarthritis patients 1. The patient should be advised to rest the knee when possible, apply ice for 15-20 minutes several times daily, and elevate the leg when sitting or lying down to further reduce swelling.
• If symptoms persist or worsen after 30 days, further evaluation may be necessary, potentially including an MRI to better visualize the soft tissue structures. Additionally, the use of bracing and/or orthoses is conditionally recommended for patients with knee involvement, as it may improve pain and physical function 2.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals [see WARNINGS] Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.

The patient is being prescribed ibuprofen 400 mg BID PRN for 30 days, which is within the recommended dosage for mild to moderate pain. The dose is also consistent with the principle of using the lowest effective dose for the shortest duration.

From the Research

Patient Assessment and Treatment

• The patient presented with left knee pain and was found to have a potential small joint effusion without a discernible popliteal cyst on x-ray, but a popliteal cyst was palpated on assessment 3.
• The patient was provided with a TED hose and a knee brace, as well as ibuprofen 400 mg BID PRN for 30 days.

Popliteal Cyst Management

• Popliteal cysts, also known as Baker's cysts, are commonly associated with intra-articular knee disorders such as osteoarthritis and meniscus tears 3.
• Management of symptomatic popliteal cysts is typically conservative, with treatment focusing on addressing the underlying intra-articular pathology 3.
• Intermittent vacuum therapy has been shown to be effective in reducing the size of Baker's cysts in patients with knee osteoarthritis 4.

Use of TED Hose

• Knee-length TED hose are more comfortable for patients and encourage higher levels of compliance with treatment compared to thigh-length TED hose 5.
• Patients need ongoing education to resume wearing TED hose after activities of daily living, and knee-length stockings are easier to reapply 5.

Pain Management

• Multimodal pain management is beneficial for pain control and patient recovery from knee surgery 6.
• Ibuprofen 400 mg BID PRN for 30 days was prescribed for the patient's knee pain.