• Work Loss Data Institute. Knee & leg (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 231 p. [231 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Initial Diagnosis

Knee ailments are among the ten most common causes of reported work-related complaints and workers' compensation claims. Initially, the practitioner should make sure that there are no indications of a potentially serious disease or condition (red flags), the presence of which would require that the patient be referred immediately to a specialist. In the absence of such red flags, the occupational provider can safely manage the healing process.

Initial Evaluation

First visit: with Primary Care Physician MD/DO (100%)

• Check for serious underlying conditions often indicated by deformity or bone crepitation (fractures); displaced patella, tibia, or fibula (dislocation); severe pain with motion; infection; additional pain in the back or hip; excessive swelling; nontender mass (possibly indicating tumor); or neurovascular symptoms such as pale, cold skin; painless swelling; and/or paralysis.
• Determine the incident or incidents that caused the complaint, especially torsion, fixed foot "pop," external lateral force, or forward force with abrupt halt in gait.
• Determine whether the problem is acute, subacute, chronic, or of insidious onset.
• Determine the severity and specific anatomic location of the pain.
• Describe location and severity of pain.
• Assess the ability of the patient to lift and carry weight, from no to full lifting ability.
• Assess the ability to climb stairs and hills and walk on uneven ground.
• Determine any present medication.
• Determine any previous medical history, history of systemic disease, or history of previous knee injury, previous knee surgery, discomfort, or related disability.
• Investigate non-industrial reasons that commonly exacerbate knee complaints (i.e., recreational sports or other exercise that aggravates the knee, degenerative disorders, and past acute injury).
• Compare clinical exam findings of injured knee to opposite knee.

Presumptive Diagnosis

• Observe the patient's walk and stance for abnormalities, including swelling, deformity, discoloration, inability to extend, and difficulty walking.
• Examine the knee in an extended position for tenderness and range of motion.
• Check for ligament stability while applying pressure with the joint slightly flexed.
• Pull the tibia forward to examine the knee at 30 degrees (Lachman test). Problems with both flexion and extension at once could indicate the need for surgery.
• Aspiration can be used on initial atraumatic effusions but only if there is no sign of infection.
• Anterior knee pain, popping and clicking, and possible cartilage loss (shown through magnetic resonance imaging [MRI]) are indicators of patellofemoral syndrome.
• Other anterior knee pains, along with tenderness over the patellar tendon, could be signs of patellar tendonitis.
• Swelling over the tibial tubercle could indicate Osgood-Schlatter disease, a congenital condition (common in adolescents – not work related).
• Prepatellar bursitis and contusion/periostitis could be caused by direct force, prepatellar bursitis by repetitive friction force.
• Unexplained knee pain, semi-locking, catching, and swelling could be patellofemoral instability, which is often mistaken for a ligament injury. Patellofemoral instability is successfully treated with physical therapy.
• Neurologic condition should be assessed, especially in regard to evidence of lumbar disk disease with possible radiation to the knee.
• Immediate referral is recommended for patients with neurologic symptoms, infections, tumor, or deformity.

Initial Therapy

The first step is to reduce pain and make the patient feel comfortable, usually with nonprescription analgesics or prescribed pharmaceuticals if necessary. At-home exercises, such as bicycling and straight leg lifting, or other retraining and weight-bearing activities may aid in rehabilitation, although a physical therapist may be necessary depending on patient motivation and degree of pain. Exercise and movement have been shown to be more beneficial than total rest, but care must be taken not to overload the knee during weight bearing exercises.

Imaging

If a fracture is considered, patients should have radiographs if the Ottawa criteria are met. Among the 5 decision rules for deciding when to use plain films in knee fractures, the Ottawa knee rules (injury due to trauma and age >55 years, tenderness at the head of the fibula or the patella, inability to bear weight for 4 steps, or inability to flex the knee to 90 degrees) have the strongest supporting evidence. Diagnostic performance of magnetic resonance imaging is recommended for the menisci and cruciate ligaments of the knee.

Surgery

Immediate emergency surgery is usually unnecessary with knee injuries unless there is a need to drain acute effusions. Otherwise, most knee problems are greatly improved with physical methods alone. Only when exercise programs are unable to increase strength and range of motion in the knee after more than a month should surgery be considered, and even then it may not be necessary. Surgery may be considered in the following cases:

• Anterior Cruciate Ligament (ACL) Tears: The decision on whether or not to surgically repair an ACL tear should take into account the patient's work and life needs. For those whose life does not include active use or load of the knee, surgery may be unnecessary. The rehabilitation process following surgery involves six months of very intense therapy, so non-surgical recovery should be allowed to occur as much as possible before any surgery takes place. Confirmation of a complete tear in the ligament through MRI findings, clear signs of instability confirmed through the Lachman and pivot test, and a history of frequent falls or giving way are consistent with this condition. See ODG Indications for Surgery -- Anterior cruciate ligament (ACL) repair in the original guideline document.

• Collateral Ligament Tears: Surgery is usually unnecessary; healing often occurs with rehabilitative exercises alone.
• Meniscus Tears: Patients with meniscus tears that are not severely limiting or progressive may not need surgical attention. In patients younger than 35, arthroscopic meniscal repair can preserve meniscal function, although the recovery time is longer compared to partial meniscectomy. Arthroscopy and meniscal surgery may not be as beneficial for older patients who are exhibiting signs of degenerative changes, possibly indicating osteoarthritis.

• Osteochondral Defects: Studies are still being done to test the effectiveness of osteochondral autograft transplant system (OATS) procedures for osteochondral defects. Patients under 40 years old with active lifestyles may benefit from OATS, and the procedure may delay the development of osteoarthritis.
• Patellofemoral Syndrome (PFS): While commonly treated with arthroscopic patellar shaving, this procedure is not proven in terms of long-term improvement. In cases of severe patellar degeneration, surgery is usually not helpful. For patients with rheumatoid conditions, patellectomy and patellar replacements are sometimes performed on active patients. Other possible surgeries for PFS are lateral arthroscopic release and surgical realignment of the extensor mechanism.

• Arthritis: Therapeutic exercises are beneficial for knee osteoarthritis. Acetaminophen is an effective agent for relief of knee pain. Although safer, it is less effective than nonsteroidal anti-inflammatory drugs (NSAIDs). For safety reasons acetaminophen should be the first line treatment, with NSAIDs reserved for those who do not respond. Glucosamine may provide effective symptomatic relief for patients with osteoarthritis of the knee. In addition, glucosamine has shown promising results in modifying the progression of arthritis over a 3-year period. Glucosamine has a tolerability profile similar to that of placebo and is better tolerated than ibuprofen or piroxicam. Intra-articular (IA) injection of hyaluronic acid (e.g., Synvisc) can decrease symptoms of osteoarthritis of the knee. The short-term benefit of IA corticosteroids in treatment of knee osteoarthritis is well established, and few side effects have been reported. Longer-term benefits have not been confirmed. Total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function.

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

• Work Loss Data Institute. Knee & leg (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 231 p. [231 references]

Not applicable: The guideline was not adapted from another source.

2003 (revised 2007 Jul 12)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 28, 2005, January 12, 2006, November 10, 2006, March 30, 2007, and August 28, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.