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## Complete Summary

#### GUIDELINE TITLE

Knee pain or swelling: acute or chronic.

#### BIBLIOGRAPHIC SOURCE(S)

University of Michigan Health System. Knee pain or swelling: acute or
chronic. Ann Arbor (MI): University of Michigan Health System; 2005 Apr.
13 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health
System. Knee pain or swelling: acute or chronic. Ann Arbor (MI):
University of Michigan Health System; 2002 Aug \[rev. 2004 Oct\]. 13 p.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [May 2, 2007,
    Colchicine](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Colchicine):
    Immediate drug recall for all strengths, sizes and lots of
    ApothéCure compounded injectable Colchicine sold within the last
    year due to recent deaths associated with the use of the product.

-   [June 15, 2005, Non-Steroidal Anti-Inflammatory Drugs
    (NSAIDs)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID):
    U.S. Food and Drug Administration (FDA) recommended proposed
    labeling for both the prescription and over the counter (OTC) NSAIDs
    and a medication guide for the entire class of prescription
    products.

-   [April 7, 2005, Non-steroidal anti-inflammatory drugs (NSAIDs)
    (prescription and OTC, including ibuprofen and
    naproxen)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra):
    FDA asked manufacturers of prescription and non-prescription (OTC)
    non-steroidal anti-inflammatory drugs (NSAIDs) to revise their
    labeling to include more specific information about potential
    gastrointestinal (GI) and cardiovascular (CV) risks.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Knee pain or swelling (acute or chronic)

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Orthopedic Surgery\
Pediatrics\
Rheumatology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To facilitate a comprehensive, yet efficient evaluation of knee pain

-   To recommend appropriate use of knee X-rays and magnetic resonance
    imaging (MRI)

-   To provide optimal treatment of knee pain

-   To identify indications for consultation

#### TARGET POPULATION

Children, adolescents, and adults with knee pain

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Comprehensive history and physical

2.  Laboratory and ancillary tests

    -   Blood studies (e.g., complete blood count, sedimentation rate,
        fungal, tuberculosis, or bacterial cultures)

    -   Synovial fluid analysis (e.g., cell count, crystals, fungal,
        tuberculosis, or bacterial cultures)

    -   Arthrocentesis/aspiration

    -   X-ray

    -   Magnetic resonance imaging (MRI)

    -   Vascular studies

**Treatment/Management**

1.  Pain/inflammation control

    -   Topical treatment

        -   Ice

        -   Capsaicin

    -   Oral

        -   Acetaminophen

        -   Salicylates

        -   Traditional non-steroidal anti-inflammatory drugs (NSAIDs

        -   Cyclooxygenase-2 (COX-2) inhibitors

        -   Combination preparations such as diclofenac sodium &
            misoprostol

        -   Alternative medicine such as glucosamine and chondroitin

    -   Intraarticular injection

        -   Hyaluronic acid (HA) injections

        -   Anesthetics

        -   Corticosteroids

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2.  Activity modification

    -   Biomechanical assessment

    -   Restriction and/or rest

    -   Knee padding

    -   Extension splints

    -   Crutches

3.  Therapeutic exercise

    -   Quadriceps strengthening

    -   Hamstring and calf stretching

    -   Knee strengthening

    -   Low impact aerobics

4.  Referral to specialist

#### MAJOR OUTCOMES CONSIDERED

-   Utility of diagnostic tests for evaluating knee pain

-   Degree of pain relief

-   Physical functioning

-   Drug interactions and side effects

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The literature search was conducted prospectively using the major
keywords of knee injuries, knee, patellofemoral, patello, anterior
cruciate ligament, meniscus, meniscal tear, osteoarthritis, brace(s),
immobilizer, immobilization, rehabilitation, x-rays, computed
tomography, radiography, magnetic resonance imaging, MRI, diagnosis,
treatment, randomized controlled trial, clinical trials, controlled
clinical trial(s), meta-analysis, multicenter studies, comparative
study(ies). Articles between 1976 and December 1996 were examined. The
search was supplemented with recent clinical trials known to expert
members of the panel. Negative trials were specifically sought.

Literature searches on three new topics were used to update the
guideline: COX-2 inhibitors (cyclooxygenase inhibitors), hyaluronic
acid, and glucosamine/chondroitin sulfates. Publications from July 1996
through available in April 2000 were examined. The following main terms
were included in each of the three searches: knee, knee joint, knee
medical collateral ligament, knee injuries, patella-injuries,
knee-injuries, knee osteoarthritis, osteoarthritis, pain. Searches also
included the following terms to identify the type of information
provided: guidelines, clinical trials, and costs. (Specific Medical
Subject Heading \[MeSH\] search terms are available upon request from
the guideline developer.) The search was a single cycle.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational trials

D.  Opinion of expert panel

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Conclusions were based on prospective randomized clinical trails if
available, to the exclusion of other data. If randomized controlled
trials were not available, observational studies were admitted to
consideration. If no such data were available for a given link in the
problem formulation, expert opinion was used to estimate effect size.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Consideration of benefits, harms, costs, and patient preferences

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

University of Michigan Health System (UMHS) guidelines are reviewed by
leadership and in clinical conferences of departments to which the
content is most relevant. This guideline concerning knee pain was
reviewed by members of the following departments or divisions: Emergency
Medicine Family Medicine, General Medicine, OrothoPedic Surgery, Adult
Rheumatology, and Pediatric Rheumatology, Guidelines are approved by the
Executive Committee for Clinical Affairs.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC)**: The following
key points summarize the content of the guideline. Refer to the full
text of the original guideline document for additional information,
including detailed information on dosing, possible side effects, and
cost of medications; risk factors; and subspecialty referrals.

The levels of evidence (A, B, C, D) are repeated at the end of the Major
Recommendations field.

**Diagnosis**

The majority of knee pain is caused by patellofemoral syndrome and
osteoarthritis *\[evidence: D\]*.

Magnetic resonance imaging (MRI) of the knee has been proven not to be
superior to the clinical exam by an experienced examiner in the
evaluation of acute knee injuries *\[A\]*.

Magnetic resonance imaging may be useful to assess bone pathology
underlying chronic knee pain *\[D\]*.

Differentiating between knee pain without constitutional symptoms, knee
pain with constitutional symptoms, and traumatic knee pain is helpful in
determining a diagnosis (refer to Figures 1, 2, and 3 in the original
guideline document for details).

Patients with knee pain and swelling who have non-bloody aspirates may
also have serious knee pathology (refer to Figure 4 in original
guideline document for details).

**Treatment**

Exercises are important. Many knee conditions will improve with
conservative treatment consisting of low-impact activities and exercises
to improve muscular strength and flexibility. Patellofemoral dysfunction
is best treated with vastus medialis strengthening and hamstring and
calf stretching *\[B\]*.

In most cases a home treatment program should be explained in detail to
the patient, including specific guidelines for activity modification and
exercises. Initially, formal physical therapy is usually not required.

All patients with mild to moderate knee osteoarthritis who do not have
medical contraindications should be offered an exercise program that
includes lower extremity strengthening and stretching exercises combined
with low impact aerobic exercises (e.g., swimming, biking, walking,
cross-country skiing) *\[A\]*.

The initial drugs of choice for the treatment of the pain of knee
osteoarthritis are acetaminophen and/or topical capsaicin *\[A\]*. If a
traditional non-steroidal anti-inflammatory drug (NSAID) is indicated,
the choice should be based on cost (refer to Table 6 in original
guideline document for details). Cyclooxygenase-2 (COX-2) inhibitors are
no more effective than traditional NSAID agents; they may offer a
short-term but probably no long-term advantage in gastrointestinal (GI)
tolerance for some patients. Due to cost and increased heart attack
risk, COX-2 inhibitors should be reserved for carefully selected
patients (refer to Table 7 in the original guideline document for
details).

**Follow-up**

Symptoms should not be allowed to persist for more than 12 weeks before
a reevaluation of the condition, along with possible consultation with
physical therapy or a musculoskeletal specialist (e.g., orthopedic
surgeon, rheumatologist, physiatrist, or sports medicine specialist)
*\[D\]*.

**Definitions**:

**Levels of Evidence**

Levels of evidence for the most significant recommendations

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational trials

D.  Opinion of expert panel

#### CLINICAL ALGORITHM(S)

The original guideline document contains clinical algorithms for:

-   Knee Pain without Constitutional Symptoms

-   Knee Pain with Constitutional Symptoms

-   Traumatic Knee Pain

-   Knee Effusion that is Not Grossly Bloody

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see Major Recommendations).

Conclusions were based on prospective randomized clinical trials if
available, to the exclusion of other data; if randomized controlled
trials were not available, observational studies were admitted to
consideration. If no such data were available for a given link in the
problem formulation, expert opinion was used to estimate effect size.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Comprehensive and efficient evaluation of knee pain

-   Appropriate use of knee x-rays and magnetic resonance imaging (MRI)
    in evaluating knee pain

-   Optimal treatment of knee pain

-   Improved identification of patients in need of specialty
    consultation or referral

#### POTENTIAL HARMS

**Adverse Treatment Effects**

-   *Non-steroidal anti-inflammatory drugs (NSAIDs)* and
    *cyclooxygenase-2 (COX-2) inhibitors*: There is a potential for
    gastrointestinal side effects, including gastrointestinal bleeding,
    with both classes of drugs. Analyses of major trials of COX-2
    inhibitors demonstrate an increase in cardiovascular event rates for
    patients taking COX-2 inhibitors.

-   *COX-2 inhibitors* should be used with caution in patients at high
    risk for atherosclerotic disease until further studies clarify the
    potential risks.

-   Both *glucosamine* and *chondroitin* appear to be quite safe with
    few side effects, particularly in comparison to NSAIDs. The
    chondroitin sulfate molecule is similar in structure to heparin, and
    may interact with anti-coagulation medications.

-   *Intraarticular injection*: Potential side effects include
    introduction of infection, skin necrosis, tendon and cartilage
    weakening, and systemic effects of corticosteroids (especially
    hyperglycemia).

-   *Hyaluronic acid injection*: Adverse effects with intraarticular
    hyaluronic acid injections occur in about 8% of patients and are
    limited usually to a mild, self-limiting local reaction.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Non-steroidal Anti-inflammatory Drugs (NSAIDs)**

Traditional NSAIDs should not be given to patients with documented
intolerance to traditional NSAIDS or risk factors for gastrointestinal
bleeding, such as: (1) a history of upper gastrointestinal bleeding, (2)
receiving chronic, high dose systemic corticosteroids, or (3) presence
of a bleeding disorder.

**Cyclooxygenase-2 (COX-2) Inhibitors**

-   Celecoxib is contraindicated in sulfa-allergic patients.

-   COX-2 inhibitors should usually be avoided in patients with cardiac
    risk factors.

-   Do not prescribe COX-2s to patients with known coronary heart
    disease.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines should not be construed as including all proper methods
of care or excluding other acceptable methods of care reasonably
directed to obtaining the same results. The ultimate judgment regarding
any specific clinical procedure or treatment must be made by the
physician in light of the circumstances presented by the patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Foreign Language Translations\
Patient Resources\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

University of Michigan Health System. Knee pain or swelling: acute or
chronic. Ann Arbor (MI): University of Michigan Health System; 2005 Apr.
13 p.

#### ADAPTATION

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

#### DATE RELEASED

1997 Nov (revised 2005 Apr)

#### GUIDELINE DEVELOPER(S)

University of Michigan Health System - Academic Institution

#### SOURCE(S) OF FUNDING

University of Michigan Health System

#### GUIDELINE COMMITTEE

Knee Pain Guideline Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Team Leader*: Robert Kiningham, MD, Family Medicine

*Team Members*: Jeffrey Desmond, MD, Emergency Medicine; David Fox, MD,
Adult Rheumatology; Hilary Haftel, MD, Pediatric Rheumatology; Mark
McQuillan, MD, General Medicine, Adult Rheumatology; Edward Wojtys, MD,
Orthopedic Surgery

*Guidelines Oversight Team*: Connie Standiford, MD; Lee Green, MD, MPH;
Van Harrison, PhD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The University of Michigan Health System endorses the Guidelines of the
Association of American Medical Colleges and the Standards of the
Accreditation Council for Continuing Medical Education that the
individuals who present educational activities disclose significant
relationships with commercial companies whose products or services are
discussed. Disclosure of a relationship is not intended to suggest bias
in the information presented, but is made to provide readers with
information that might be of potential importance to their evaluation of
the information.

  ------------------------------------------------------------------------
  **Team Member**                     **Company**       **Relationship**
  ----------------------------------- ----------------- ------------------
  Jeffrey Desmond, MD                 (None)             

  David Fox, MD                       Pfizer            Consultant

  Hilary Haftel, MD                   (None)             

  Robert Kiningham, MD                (None)             

  Mark McQuillan, MD                  (None)             

  Edward Wojtys, MD                   (None)             
  ------------------------------------------------------------------------

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health
System. Knee pain or swelling: acute or chronic. Ann Arbor (MI):
University of Michigan Health System; 2002 Aug \[rev. 2004 Oct\]. 13 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[University of Michigan Health System Web
site](http://cme.med.umich.edu/pdf/guideline/knee.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

Continuing Medical Education (CME) information is available from the
[University of Michigan Health System Web
site](http://cme.med.umich.edu/iCME/KneePain/default.asp).

#### PATIENT RESOURCES

The following are available:

-   Patellofemoral pain syndrome rehabilitation exercises. University of
    Michigan Health System; 2002 Aug. Various p. Electronic copies:
    Available from the [University of Michigan Health System Web
    site](http://www.med.umich.edu/1libr/guides/knee/runknee.htm).
    Spanish version also available from the [University of Michigan
    Health System Web
    site](http://www.med.umich.edu/1libr/guides/knee/runknees.htm).

-   Patellofemoral pain syndrome rehabilitation exercises. University of
    Michigan Health System; 2002 Aug. Various p. Electronic copies:
    Available from the [University of Michigan Health System Web
    site](http://www.med.umich.edu/1libr/guides/knee/kneeart.htm).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on March 19, 2003. The
information was verified by the guideline developer on April 23, 2003.

This guideline was updated by the guideline developer in October 2004
following the removal of Vioxx (rofecoxib) from the worldwide markets.
The guideline was updated again by the guideline developer in December
2004 following the release of a public health advisory from the U.S.
Food and Drug Administration (FDA) regarding the use of some
non-steroidal anti-inflammatory drug products (NSAIDs) This summary was
updated on April 14, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs). This summary was most recently updated on September 21,
2005. The updated information was verified by the guideline developer on
November 1, 2005. This summary was updated by ECRI Institute on May 17,
2007 following the U.S. Food and Drug advisory on Colchicine.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the University of Michigan Health System (UMHS).

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008