Definitions for the Grades of Recommendation (A-C, & I) and Level of Evidence (1-4) are given at the end of the "Major Recommendations" field.
Diagnosis
Excluding Fractures
A The Ottawa Knee Rules should be applied in the evaluation of acute knee injuries to assist clinicians in making decisions about the need for radiography to exclude fractures.
C People with a haemarthrosis should be x-rayed to exclude fractures.
C People with significant fractures should be referred immediately to an orthopaedic surgeon. For people with a minor undisplaced fracture, orthopaedic surgeons need to review the films only.
C The routine use of x-rays is generally not recommended.
Initial Management and Referral
C People with no evidence of ligament laxity or meniscal damage should be treated with R.I.C.E. (rest, ice, compression, elevation) and paracetamol, if required, and advised to resume usual activities when pain and swelling have settled, and return for follow-up if symptoms persist after 7 days.
C Urgent referral to an orthopaedic surgeon is required for people with:
- red flag signs and symptoms (see original guideline document for "Red Flags")
- severe knee injuries
- significant fracture on x-ray
C Early referral to a specialist is recommended for people with:
- injury to the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), or posterolateral complex
- a locked knee due to suspected meniscal entrapment
- equivocal diagnosis
C Subsequent referral to a specialist for people:
- with a suspected meniscal tear if symptoms persist after a trial of rehabilitation for 6 to 8 weeks
- at any stage of the rehabilitation process where symptoms persist and clinical milestones are not being achieved
C Referral for rehabilitation is recommended for people with:
- suspected meniscal tears
- injuries to the medial collateral ligament (MCL)
- other ligament injuries to manage symptoms until seen by a specialist
Imaging
C Magnetic resonance imaging (MRI) may be considered by specialists where further information is required to make a diagnosis and decide appropriate subsequent management.
Clinical Evaluation
Medial Collateral Ligament
C A positive valgus stress test performed in extension and 30 degrees of flexion is reasonably accurate in the diagnosis of an MCL tear.
C Tenderness along the course of the MCL is suggestive of MCL injury.
Medial and Lateral Meniscus
C In the context of an appropriate history the McMurray test, well localised joint line tenderness, and a block to end range extension may have some additional diagnostic significance.
Anterior Cruciate Ligament
A The Lachman test when correctly performed is reasonably accurate in the diagnosis of complete ruptures of the ACL.
B The Lachman test is more accurate when acute pain, swelling, and muscle spasm have subsided at about 10 days.
C The pivot shift test is best performed by experienced practitioners.
C Loss of end range extension should alert the clinician to the possible involvement of the ACL.
Posterior Cruciate Ligament
C The posterior drawer test is the most sensitive test for evaluating the integrity of the PCL.
Posterolateral Complex
C Primary care providers should refer any people with suspected injury of the posterolateral complex to an orthopaedic surgeon for further evaluation.
General Management
R.I.C.E (Rest, Ice, Compression, Elevation)
C There is insufficient evidence in the literature to support the use of R.I.C.E.; however, it is commonly accepted practice for the self-management of a mild soft tissue knee injury in the first 48 to 72 hours. Refer to the original guideline document for R.I.C.E. protocol.
Pharmacology
C Paracetamol is probably the most cost-effective and potentially least harmful choice of analgesic for soft tissue knee injuries.
C Nonsteroidal anti-inflammatory drugs (NSAIDs) may be beneficial for treating a persistent effusion that has not responded to the R.I.C.E. protocol.
A Topical NSAIDs are effective and safe for acute sprains, strains, and sports injuries.
Haemarthrosis
C Aspiration is not generally indicated for diagnosis.
C Aspiration is indicated for a severe and painful suspected haemarthrosis of the knee joint following an acute knee injury.
C For practitioners who are not experienced in the procedure, people should be treated with usual R.I.C.E. and referred to a specialist, local Base Hospital, or another practitioner who has more experience.
Rehabilitation
Physiotherapy
A There is insufficient evidence in the literature to establish the relative effectiveness of the various approaches and methods currently used by physiotherapists in the conservative management of soft tissue knee injuries.
B Proprioceptive training may be beneficial in improving outcomes for people with ACL-deficient knees, and its inclusion in rehabilitation programmes for both the conservative and post-operative management of ACL tears is recommended.
Electrotherapy Modalities
B Ultrasound is of little benefit in the treatment of soft tissue knee injuries.
I At present there is insufficient evidence to support the use of neuromuscular electrical stimulation (NMES), transcutaneous electric nerve stimulation (TENS), or biofeedback in the post-operative rehabilitation following meniscectomy or ACL reconstruction.
Bracing in the Non-operative Management of Knee Injuries
I Bracing is generally not required for the conservative management of soft tissue knee injuries.
C Bracing is appropriate for isolated Grade III and severe Grade II injuries to the MCL for 4 to 6 weeks to stabilise the knee so that rehabilitation can be initiated.
C Bracing may be indicated in selected cases where recurrent instability exists, but concurrent medical conditions or other factors preclude surgery.
C Bracing may be indicated in selected cases where there is a psychological benefit associated with wearing a brace which enhances a person’s ability to undertake tasks in work and sport.
Osteopathy, Chiropractic and Acupuncture
I No recommendations can be made about the use of acupuncture, chiropractic, osteopathy, or other complementary therapies for the treatment of soft tissue knee injuries due to a lack of good quality evidence.
Specific Management
Operative Versus Non-operative
C Non-operative management is recommended for all grades of isolated medial collateral ligament injuries.
Anterior Cruciate Ligament
C In general, ACL reconstruction has the most to offer those people with recurrent instability who must perform multidirectional activity as part of their occupation or sport.
C Age should not be considered a barrier to reconstructive surgery in the older athlete, providing there are appropriate indications.
C An active functional treatment programme supervised by a physiotherapist is recommended following ACL reconstruction.
B Open kinetic chain exercises can be introduced from 4 to 6 weeks between 90 and 45 degrees of knee flexion.
B Bracing in the immediate post-operative period following ACL reconstruction is not recommended.
Medial and Lateral Meniscus
A Physiotherapy is not routinely advocated following meniscectomy.
Posterior Cruciate Ligament
C There is general agreement that Grade I and II isolated PCL tears are best managed nonoperatively.
I There is insufficient evidence to establish the relative benefits of operative versus nonoperative management of isolated Grade III PCL tears.
C Practitioners should follow the post-operative rehabilitation protocol recommended by the orthopaedic surgeon.
Posterolateral Complex
C Practitioners should follow the protocol recommended by the orthopaedic surgeon.
Special Groups
C Health practitioners providing care for Maori and Pacific Island peoples should be sensitive to their particular needs and encourage the use of a support person or advocate.
Definitions
Grades of Recommendations
A
The recommendation is supported by good evidence.
B
The recommendation is supported by fair evidence.
C
The recommendation is supported by expert opinion only, based on level 4 evidence in the text and the expertise within the multidisciplinary team.
I
No recommendation can be made because the evidence is insufficient (i.e., evidence is lacking, of poor quality or conflicting and the balance of benefits and harms cannot be determined).
Level of Evidence
1++
High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+
Well conducted meta-analysis, systematic reviews of RCTs, or RCTs with a low risk of bias
1-
Well conducted meta-analysis, systematic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systematic review or case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal.
2+
Well conducted case-control of cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.
2-
Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3
Non-analytic studies (e.g., case reports, case series)
4
Expert Opinion (e.g., narrative reviews)
