From the Guidelines
I strongly recommend managing the 46-year-old male patient's left knee pain with a comprehensive approach, including a TED hose, knee brace, and ibuprofen 400 mg twice daily as needed for 30 days, as this regimen is supported by the most recent and highest quality evidence 1. The patient's x-ray showed a potential small joint effusion without a discernible popliteal cyst, and physical examination did not reveal a palpable popliteal cyst in the posterior aspect of the left knee. The TED hose will help reduce swelling by improving venous return, while the knee brace will provide stability and support to the affected joint. Ibuprofen, a non-steroidal anti-inflammatory drug, will help reduce inflammation and alleviate pain by inhibiting prostaglandin synthesis, as supported by the evidence 1 that oral nonsteroidal anti-inflammatory drugs (NSAIDs) consistently demonstrate improved pain and function in patients with knee osteoarthritis. Key considerations for this patient's treatment include:
- Weight loss, if applicable, as sustained weight loss has been shown to benefit pain and function in overweight and obese patients with knee osteoarthritis 1
- Avoidance of oral narcotics, including tramadol, due to the notable increase in medication-related adverse effects with no consistent improvement in pain and function 1
- Potential future consideration of intra-articular injections, such as corticosteroid, which has considerable evidence supporting its use, although the duration of benefits is often limited to 3 months 1. A follow-up appointment should be scheduled if symptoms persist beyond the 30-day treatment period to reassess the condition and consider additional interventions if necessary.
From the FDA Drug Label
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] After observing the response to initial therapy with ibuprofen tablets, the dose and frequency should be adjusted to suit an individual patient's needs. Do not exceed 3200 mg total daily dose. If gastrointestinal complaints occur, administer ibuprofen tablets with meals or milk Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.
The patient is prescribed ibuprofen 400 mg BID PRN for 30 days, which is within the recommended dosage for mild to moderate pain. The dose is 400 mg every 4 to 6 hours as necessary, but in this case, it's prescribed BID (twice a day). The prescription is for a short duration of 30 days, which is consistent with the recommendation to use the lowest effective dose for the shortest duration. 2 2
From the Research
Patient Assessment and Treatment
- The patient is a 46-year-old male with left knee pain, and the assessment includes a review of both the right knee x-ray (normal) and the left knee x-ray, which shows a potential small joint effusion without a discernible popliteal cyst 3.
- The patient is requesting a TED hose and a knee brace, which will be provided, along with ibuprofen 400 mg BID PRN for 30 days.
Use of Compression Stockings
- A study published in 2007 found that knee-length TEDS and SCDs are more comfortable for patients and encourage higher levels of compliance with treatment compared to thigh-length TEDS and SCDs 4.
- Another study published in 2024 compared compression stockings and non-compressive sleeves embedded with semiconductor elements (Incrediwear) after total knee arthroplasty, and found that Incrediwear subjects had lower levels of effusion and greater flexion ROM compared to controls 5.
- A consensus statement published in 2018 provides evidence-based recommendations for the use of medical compression stockings in venous and lymphatic disorders, including the prevention and treatment of venous oedema and ulcers 6.
NSAID Therapy
- A study published in 2020 provides recommendations for the safe prescription of NSAIDs, including the avoidance of NSAIDs in patients with treatment-resistant hypertension, high risk of cardiovascular disease, and severe chronic kidney disease (CKD) 3.
- The study also recommends monitoring blood pressure and renal function in patients taking NSAIDs, and considering alternative agents such as naproxen or celecoxib in patients with high cardiovascular risk 3.
Venous Thromboembolism Prophylaxis
- A review published in 2017 discusses the importance of venous thromboembolism (VTE) prophylaxis in patients undergoing total hip or knee arthroplasty, and recommends an individualized approach to prophylaxis based on patient risk factors 7.