What are the evaluation and treatment recommendations for knee trauma?

From the Guidelines

Knee trauma evaluation and treatment should prioritize a thorough history, physical examination, and appropriate imaging, with treatment options depending on the severity of injury and patient factors, including conservative or surgical management, as recommended by the American College of Radiology and the American Academy of Orthopaedic Surgeons 1.

Initial Evaluation and Management

The initial evaluation of knee trauma should include a thorough history and physical examination, followed by imaging studies as needed. For acute injuries, the RICE protocol (Rest, Ice, Compression, Elevation) is recommended for the first 48-72 hours. Mild to moderate pain can be managed with acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-800mg three times daily) for 5-7 days.

• Key considerations in the initial evaluation include:
  • Mechanism of injury
  • Severity of symptoms
  • Presence of any deformity or instability
  • Neurovascular status

Imaging and Diagnostic Considerations

X-rays should be obtained based on Ottawa Knee Rules to rule out fractures, while MRI is indicated when internal derangement such as meniscal or ligamentous injuries are suspected. The choice of imaging modality depends on the clinical presentation and the suspected diagnosis.

• Imaging considerations include:
  • X-rays for fracture evaluation
  • MRI for soft tissue and ligamentous injuries
  • CT scans for complex fractures or suspected osteochondral defects

Treatment of Specific Injuries

Specific injuries require targeted treatments:

• ACL tears often need surgical reconstruction for active patients, with autograft preferred over allograft to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients 1.
• MCL tears typically heal with conservative management including bracing for 4-6 weeks.
• Meniscal tears may require arthroscopic repair depending on location and severity.
• Patellar dislocations need reduction followed by physical therapy.

Rehabilitation and Return to Activity

Physical therapy is crucial for most knee injuries, focusing on strengthening quadriceps and hamstrings, improving range of motion, and proprioceptive training. Weight-bearing status depends on injury severity, with gradual progression as healing occurs. Return to activities should be guided by functional recovery rather than arbitrary timelines, with patients demonstrating full range of motion, adequate strength, and minimal pain before resuming sports or demanding activities.

• Rehabilitation considerations include:
  • Progressive strengthening and range of motion exercises
  • Proprioceptive training and balance exercises
  • Gradual return to weight-bearing and functional activities
  • Patient education on injury prevention and management

From the Research

Evaluation of Knee Trauma

• The evaluation of knee trauma involves a thorough history and physical examination, including the application of special tests and clinical decision rules for imaging 2.
• A study published in the Journal of the American Medical Association (JAMA) found that osteoarthritis, patellofemoral pain, and meniscal tears are among the most common causes of knee pain, and can be diagnosed clinically 3.
• The McMurray test and joint line tenderness can assist in the diagnosis of meniscal tears, with a sensitivity of 61% and 83%, respectively, and a specificity of 84% and 83%, respectively 3.

Treatment Recommendations

• First-line management of osteoarthritis comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition 3.
• For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery 3.
• Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears, while severe traumatic tears may require surgery 3.
• A study published in the Canadian Journal of Surgery found that emergency physicians are more likely to prescribe immobilization for certain acute soft-tissue knee injuries than sports medicine physicians and orthopedic surgeons 4.
• Another study published in the Journal of Clinical Medicine found that immobilization-related changes within the knee can cause impairments of arthrokinematic function, but these changes may be partially reversible with physiotherapy 5.

Pain Management

• A study published in the Journal of Bone and Joint Surgery found that acetaminophen is noninferior to acetaminophen and tramadol for pain relief after operative treatment of an extremity fracture, and should be considered the mainstay for pain relief in these patients 6.
• The use of opioid pain medication is not recommended as a first-line treatment for knee pain, due to the risk of side effects and addiction 6.