From the Guidelines
Evaluation and treatment of knee trauma should begin with a thorough history and physical examination, followed by appropriate imaging, as recommended by the American College of Radiology in 2020 1. The initial assessment is crucial for determining the severity of the injury and guiding further management. Key components of the physical examination include assessing for effusion, point tenderness, range of motion, and stability using specific tests like the anterior drawer, Lachman, valgus/varus stress, and McMurray tests.
- Initial management includes the RICE protocol: Rest the knee, apply Ice for 15-20 minutes every 2-3 hours, use Compression with an elastic bandage, and Elevate the leg above heart level when possible.
- Pain management typically involves NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks.
- For moderate to severe pain, acetaminophen (1000mg every 6 hours) can be added, with short-term opioids reserved for severe cases. Imaging should start with plain radiographs using the Ottawa Knee Rules as guidance, as this approach can help reduce unnecessary radiographic studies and decrease radiation exposure to the patient 1.
- MRI is indicated when internal derangement is suspected, particularly for ligament or meniscal injuries. Treatment varies by specific injury:
- Meniscal tears may require arthroscopic repair for peripheral tears or partial meniscectomy for central tears.
- Ligament injuries like ACL tears often need surgical reconstruction in active patients.
- Patellar dislocations typically receive conservative management initially. Physical therapy is crucial for all knee injuries to restore strength, stability, and range of motion, with programs typically lasting 6-12 weeks, as part of a comprehensive approach to address both structural damage and the surrounding muscular support system 1.
From the Research
Treatment Recommendations for Trauma to the Knee
- For knee osteoarthritis (OA), first-line management comprises exercise therapy, weight loss (if overweight), education, and self-management programs 2
- For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery 2
- For meniscal tears, conservative management (exercise therapy for 4-6 weeks) is appropriate for most cases, while surgery is likely required for severe traumatic tears 2
- For knee ligament injuries, nonoperative treatment is recommended for grade I and II sprains, as well as isolated grade III sprains of the posterior cruciate ligament 3
- For posttraumatic knee injuries, the use of clinical decision rules can help rule out fractures and reduce unnecessary radiation exposure, and patients with suspected ligamentous or meniscal injury should be referred for expedited follow-up with an orthopedic specialist 4
Evaluation Recommendations for Trauma to the Knee
- The McMurray test and joint line tenderness can assist in the diagnosis of meniscal tears 2
- Radiographic imaging is not recommended for all patients with possible knee OA, but may be necessary for patients with suspected fractures or other injuries 2, 4
- Clinical decision rules can help determine the need for imaging studies, such as MRI, in patients with suspected ligamentous or meniscal injury 4
- Patients with posttraumatic arthrofibrosis of the knee may benefit from manipulation under anesthesia (MUA) to improve knee range of motion 5
Rehabilitation and Return to Activity
- Rehabilitation protocols for knee ligament injuries should include immobilization, gradual mobilization, and strengthening exercises, with the goal of rapid and full recovery to work and sports 3
- Patients with knee injuries should be motivated and encouraged to participate in longstanding, intensive rehabilitation work 3
- The decision to return to activity after a knee injury should be based on individual patient factors, including the severity of the injury and the patient's overall health and fitness level 6