Saanichton Physical Therapy Blog

Knee Pain Recommendations

Knee Pain Recommendations

Recommendations

Bibliographic Source(s)

Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ, Orthopaedic Section of the American Physical Therapist Association. Knee stability and movement coordination impairments: knee ligament sprain. J Orthop Sports Phys Ther. 2010 Apr;40(4):A1-A37. [175 references] PubMed External Web Site Policy
Major Recommendations

Levels of evidence (I–V) and grades of recommendation (A–F) are defined at the end of the “Major Recommendations” field.

Risk Factors

Clinicians should consider the shoe-surface interaction, increased body mass index, narrow femoral notch width, increased joint laxity, preovulatory phase of the menstrual cycle in females, combined loading pattern, and strong quadriceps activation during eccentric contractions as predisposing factors for the risk of sustaining a noncontact anterior cruciate ligament (ACL) injury. (Grade of Recommendation B)

Diagnosis/Classification

Passive knee instability, joint pain, joint effusion, and movement coordination impairments are useful clinical findings for classifying a patient with knee instability into the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: sprain and strain involving collateral ligament of knee, sprain and strain involving cruciate ligament of knee, injury to multiple structures of knee; and the associated International Classification of Functioning, Disability, and Health (ICF) impairment-based category of knee instability (b7150 Stability of a single joint) and movement coordination impairments (b7601 Control of complex voluntary movements). (Grade of Recommendation A)

Differential Diagnosis

Clinicians should consider diagnostic classifications associated with serious pathological conditions or psychosocial factors when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline or when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function. (Grade of Recommendation B)

Examination

Outcome Measures

Clinicians should use a validated patient-reported outcome measure with a general health questionnaire, along with a validated activity scale for patients with knee stability and movement coordination impairments. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring changes in the patient’s status throughout the course of treatment. (Grade of Recommendation A)

Activity Limitation Measures

Clinicians should utilize easily reproducible physical performance measures, such as single-limb hop tests, to assess activity limitation and participation restrictions associated with their patient’s knee stability and movement coordination impairments, to assess the changes in the patient’s level of function over the episode of care, and to classify and screen knee stability and movement coordination. (Grade of Recommendation C)

Interventions

Continuous Passive Motion

Clinicians can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain. (Grade of Recommendation C)

Early Weight Bearing

Early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function. (Grade of Recommendation C)

Knee Bracing

The use of functional knee bracing appears to be more beneficial than not using a brace in patients with ACL deficiency. (Grade of Recommendation C)

The use of immediate postoperative knee bracing appears to be no more beneficial than not using a brace in patients following ACL reconstruction. (Grade of Recommendation B)

Conflicting evidence exists for the use of functional knee bracing in patients following ACL reconstruction. (Grade of Recommendation D)

Knee bracing can be used for patients with acute posterior cruciate ligament (PCL) injuries, severe medial (tibial) collateral ligament (MCL) injuries, or posterior lateral corner (PLC) injuries. (Grade of Recommendation F)

Immediate Versus Delayed Mobilization

Clinicians should consider the use of immediate mobilization following ACL reconstruction to increase range of motion, reduce pain, and limit adverse changes to soft tissue structures. (Grade of Recommendation B)

Cryotherapy

Clinicians should consider the use of cryotherapy to reduce postoperative knee pain immediately post-ACL reconstruction. (Grade of Recommendation C)

Supervised Rehabilitation

Clinicians should consider the use of exercises as part of the in-clinic program, supplemented by a prescribed home-based program supervised by a physical therapist in patients with knee stability and movement coordination impairments. (Grade of Recommendation B)

Therapeutic Exercises

Clinicians should consider the use of non–weight-bearing (open chain) exercises in conjunction with weight-bearing (closed-chain) exercises in patients with knee stability and movement coordination impairments. (Grade of Recommendation A)

Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation can be used with patients following ACL reconstruction to increase quadriceps muscle strength. (Grade of Recommendation B)

Neuromuscular Reeducation

Clinicians should consider the use of neuromuscular training as a supplementary program to strength training in patients with knee stability and movement coordination impairments. (Grade of Recommendation B)

“Accelerated” Rehabilitation

Rehabilitation that emphasizes early restoration of knee extension and early weight-bearing activity appears safe for patients with ACL reconstruction. No evidence exists to determine the efficacy and/or safety of early return to sports. (Grade of Recommendation B)

Eccentric Strengthening

Clinicians should consider the use of an eccentric exercise ergometer in patients following ACL reconstruction to increase muscle strength and functional performance. Clinicians should consider the use of eccentric squat program in patients with PCL injury to increase muscle strength and functional performance. (Grade of Recommendation B)

Definitions:

Levels of Evidence

Individual clinical research articles were graded according to criteria described by the Centre for Evidence-Based Medicine, Oxford, United Kingdom.

  1. Evidence obtained from high-quality diagnostic studies, prospective studies, or randomized controlled trials
  2. Evidence obtained from lesser-quality diagnostic studies, prospective studies, or randomized controlled trials (e.g., weaker diagnostic criteria and reference standards, improper randomization, no blinding, <80% follow-up)
  3. Case-controlled studies or retrospective studies
  4. Case series
  5. Expert opinion

Grades of Recommendation

The overall strength of the evidence supporting recommendations made in this guideline was graded according to guidelines described by Guyatt et al as modified by MacDermid and adopted by the coordinator and reviewers of this project. In this modified system, the typical A, B, C, and D grades of evidence have been modified to include the role of consensus expert opinion and basic science research to demonstrate biological or biomechanical plausibility.

Grades of Recommendation Strength of Evidence
A Strong evidence A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I study
B Moderate evidence A single high-quality randomized controlled trial or a preponderance of level II studies support the recommendation
C Weak evidence A single level II study or a preponderance of level III and IV studies including statements of consensus by content experts support the recommendation
D Conflicting evidence Higher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies
E Theoretical/foundational evidence A preponderance of evidence from animal or cadaver studies, from conceptual models/principles or from basic sciences/bench research support this conclusion
F Expert opinion Best practice based on the clinical experience of the guidelines development team