Dept. of Industrial Relations logo

Medical Unit - Knee problems

Introduction

Management of knee problems in injured workers includes consideration of environmental and personal factors which may be causing or aggravating the problem, as well as providing treatment that leads to a return to productive work.

Scope of the guideline: This guideline deals with the assessment and treatment of knee problems, including 1) articular surface damage 2) bone damage 3) synovial and capsular damage 4) ligament injuries 5) patellofemoral tracking (chondromalacia) 6) meniscal injuries and 7) loose bodies in the knee. Knee problems can be acute (less than four weeks), subacute (one to three months), or chronic (greater than 3 months).

Initial assessment to rule out serious knee problems is discussed, but definite diagnosis and treatment of serious disorders is beyond the scope of this guideline. This guideline does not deal with issues of legal causation or work-relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of knee injuries. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.

For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.

All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the official medical fee schedule.

A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.

Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.

In all cases, the provider shall document no later than six months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having reached maximum medical improvement (i.e. permanent and stationary status).

1.0 Initial assessment

1.1 Purpose

The purpose of the initial assessment is to define the structural abnormality, in particular knee stability and intra articular abnormalities. Initial evaluation of an acute knee injury focuses on avoiding missed diagnoses. Early diagnoses of repairable abnormalities will speed return to work.

1.2 Appropriate initial assessment methods

1.2.1 History and physical

The history focuses on defining the nature of the injury, the duration of the knee complaint, and the past history of effusion. A history of previous knee injuries or other workplace injuries is important. Pain in the knee may be from the hip, the back, the thigh or the lower leg.

Clinical diagnosis of knee problems can usually be made on history and physical examination with the help of x-rays.

The presence of hemarthrosis suggests a more serious injury. Aspiration of a tense knee effusion may reduce pain and allow a more appropriate evaluation on physical examination. Injection of a local anesthetic may also be indicated.

The usual complaint of individuals with ligament insufficiencies is 'giving away'. Definition of the problem by physical examination is the first step in appropriate care. Appropriate tests should be used to identify ligamentous incompetence, disruption of a meniscus, articular surface irregularity and other soft tissue injury. Many injuries such as meniscus and ligament damage can be established by physical examination and may not require further tests.

1.2.2 X-rays (Mail Survey =4) (Consensus Panel=) [ 4 ]

Appropriate indications for radiography in acute knee injuries include:

Tenderness at the head of fibula

Isolated tenderness of the patella (no other bone tenderness of the knee)

Inability to fully extend the knee

Inability to weight bear both immediately and in the provider's office (four steps regardless of limping)

Tense effusion

Acute direct trauma to the knee

Inability to flex beyond 90 degrees

1.2.3 Diagnostic arthroscopic examination

Arthroscopic examination may be necessary on very rare occasions when clinical evaluation is not diagnostic. (M=4) (C=) [ 2 ]

Arthroscopy allows examination of the under surface of the patella, meniscus tears, cruciate ligament status, synovitis, loose bodies, and the status of the tibial and femoral articular surfaces.

1.2.4 Vascular studies

Vascular studies are indicated if the injury is associated with vascular disruption/damage, a secondary vascular complication, or a dislocation of the knee.(M=4) (C=4) [ 4 ]

1.3 Inappropriate initial assessment methods

1.3.1 MRI/CT

MRI/CT is not usually appropriate at the initial evaluation or within the first month. (M=1) (C=) [ 1 ]

Exceptions include suspected subarticular stress fracture or bone bruise, any evidence of a mass, a tear of the patellar tendon or a locked knee.

1.3.2 Arthrogram

An Arthrogram is not usually appropriate at the initial evaluation or within the first month. (M=1) (C=)[1]

2.0 Initial treatment

2.1 Purpose

The purpose of the initial treatment is to return the worker to their pre-injury status and to facilitate sustained return to work.

2.2 Appropriate initial treatment methods may include:

2.2.1 Aspiration of a tense, painful effusion. (M=4) (C=) [ 4 ]

2.2.2 Ice, compression and elevation of a painful knee. Immobilization of an unstable knee, including functional bracing. (M=4) (C=) [ 4 ]

2.2.3 Initial treatment for primary patellofemoral dislocation includes immobilization. (M=4) (C=4) [ 4 ]

2.2.4 Medications

2.2.4.1 Anti-inflammatory and non-narcotic analgesic medications (M=4) (C=) [ 3 ]

2.2.4.2 Narcotic analgesics are usually not required. (M=1) (C=) [ 2 ]

2.2.5 Physical medicine modalities may enhance early rehabilitation (M=4) (C=) [ 4 ]

2.2.6 Progressive exercise program (M=4) (C=4) [ 4 ]

Progressive exercises should be performed to prevent weakness, stiffness and other forms of deconditioning.

2.2.7 Manual medicine/modalities (M=4) (C=) [ 4 ]

2.2.8 Surgery (M=4) (C=) [ 4 ]

Surgery may be needed to remove loose bodies or to correct major soft tissue or bony disruption.

2.2.9 Ligament injuries

Immediate repair of anterior cruciate ligaments in many situations is not necessary. (M=1) (C=) [ 1 ]

Primary, multiple structural repairs require additional documentation because of a less predictable outcome. (M=1) (C=)[1 ]

Isolated tears of the medial collateral and/or lateral collateral ligament usually do not require surgical repair. (M=1) (C=) [ 1 ]

Although the prognosis is not good, combined repair of cruciate and lateral collateral ligaments may be needed. (M=1) (C=) [ 1 ]

2.3 Inappropriate initial treatments

2.3.1 A TENS unit is inappropriate in the initial phase. (M=1) (C=) [ 1 ]

2.3.2 Psychotropic medications are seldom needed. (M=1) (C=) [1]

2.4 Case management

Management during the first four weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every one to two weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance, and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.

3.0 Secondary assessment

3.1 Purpose

The purpose of reassessment is to determine the reason for delayed recovery in patients who have not functionally improved. It is often difficult initially to assess the severity of the damage and/or instability. Therefore, reassess any individual who remains symptomatic after a trial of rehabilitation.

3.2 Appropriate secondary assessment methods, if clinically indicated, include:

3.2.1 Use of mechanical devices to test strength and stability.

Appropriate tests may be performed with initiation of the rehabilitation process and particularly post operatively and may be necessary to be repeated upon conclusion of rehabilitation. (M=4) (C=) [ 3 ]

Special equipment which isolates the knee and measures strength may be helpful.

3.2.2 Diagnostic imaging testing may be appropriate if the worker remains symptomatic, the diagnosis elusive and/or surgery is planned. (M=4) (C=) [ 4 ]

Testing may include an x-rays, MRI, CT, and arthrogram.

Clinical indications:

Joint instability or obvious ligamentous damage determined by the physical exam that is not responsive to conservative treatment and the decision to do arthroscopy has not yet been made.

Post-traumatic hemarthrosis or persistent effusion (over four weeks).

Acute trauma with unexplained persistent pain of over four weeks that is not responsive to conservative treatment and the decision to do arthroscopy has not yet been made.

Findings suggestive of a defect in the alignment of the patella.

Indications previously mentioned under initial evaluation (suspected subarticular stress fracture or bone bruise, any evidence of a mass, or tear of the patellar tendon).

3.2.3 Functional capacity evaluation may be indicated in situations of ligament reconstruction or other major knee surgery. [ 3 ]

3.3 Inappropriate secondary assessment methods

3.3.1 EMG unless muscle weakness is thought to be secondary to nerve damage. (M=1) (C=) [ 1 ]

3.3.2 Vascular studies are not indicated unless there is associated vascular disruption/damage or a secondary vascular complication. (M=1) (C=) [ 1 ]

3.3.3 Bone scan (M=1) (C=) [ 1 ]

4.0 Secondary treatment

4.1 Purpose

The purpose of secondary treatment is to help the injured worker who is slow to recover.

4.2 Appropriate secondary treatment methods (for the specific clinical indications as noted)

4.2.1 Progressive physical exercise program

4.2.1.1 Individuals without full range of motion and strength can benefit from a progressive exercise program. (M=4) (C=) [ 4 ]

4.2.1.2 Rehabilitation therapy is important following surgery. M=4) (C=) [ 4 ]

4.2.1.3 Functional bracing for unstable knees under non-surgical care. (M=) (C=4) [ 4 ]

4.2.2 Surgery

4.2.2.1 Arthroscopic surgery may be indicated if a clinically significant, surgically correctable abnormality is documented. (M=4) (C=) [ 4 ]

4.2.2.2 Reconstruction of ligaments is best done after appropriate rehabilitation to restore range of motion. (M=) (C=4) [ 4 ]

4.3 Inappropriate secondary treatments

4.3.1 Surgery

4.3.1.1 Total removal of the meniscus(M=1)(C=) [1]

The meniscus is an important component of knee mechanism. Even a mild degenerative meniscus is more useful than an absent meniscus. Excision of the total meniscus leads to a significant amount of problems. The modern approach is to remove as little as possible and try for repair in the younger individual.

4.3.1.2 Multiple ligament repairs performed at the same time as repairs to the meniscus (M=1) [ 1]

Multiple ligament repairs performed at the same time meniscus repairs may lead to a stiff joint.

4.3.1.3 Collateral ligament repair for injuries without instability (M=1) (C=) [ 1 ]

4.3.2 Prolonged immobilization (M=1) (C=) [ 1 ]

4.3.3 Multiple steroid injections into the knee joint (greater than three), or into the ligament or tendon is rarely indicated. Direct steroid injections in the ligament or tendons of the knee is rarely indicated. Steroid injections of the bursae of the knee may be indicated. (M=1) (C=) [ 1 ]

4.3.4 Routine prescription of pain or sedative medication is not recommended and when prescribed for severe pain, should be limited in duration and quantity. (M=1) (C=) [ 1 ]

4.4 Case management

If the injured worker has not resumed near normal work duties after eight weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be rated for permanent disability. If psychosocial issues are judged to contribute delayed recovery heightened disability, it may be appropriate to have a psychiatric evaluation.

5.0 Prevention

5.1 Purpose

The purpose of preventive measures is to avoid reoccurrence of the knee problems.

5.2 Appropriate preventive measures

5.2.1 Exercises which maintain/improve strength, range, and endurance (M=4) (C=) [ 4 ]

5.2.2 Functional bracing for ACL/PCL unstable knees (M=) (C=4) [ 4 ]

5.3 Inappropriate preventive measures

5.3.1 Prolonged total immobilization. (M=4) (C=) [ 1 ]

6.0 Primary references

1. Bonamo JJ et al.: The conservative treatment of the anterior cruciate deficient knee. Am J Sports Med 1990;18:618-23.

2. Casscells SW: Arthroscopy: Diagnostic and Surgical Practice, Ed. by SW Casscells. Lee & Febiger, Philadelphia, 1984;59-63.

3. Daniel DM, Stone ML: KT-1000 Anterior-posterior displacement measurements in Knee Ligaments: Structure, Function, Injury and Repair. Eds. DM Daniel, et al., Raven Press, New York, 1990.

4. Fischer SP, et al.: Accuracy of diagnosis from magnetic resonance imaging of the knee. J Bone Jt Surg 1991;71A:2-10.

5. Griffin LY: The Patellofemoral Joint, Eds. JM Fox, WD Pizzo, McGraw-Hill, New York, 1993;279-290.

6. Indelicato PA, Hermansdorfer J, Huegel M: Non-operative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop 1990;256:174-7.

7. Jones RE, Henley MB, Francis P: Non-operative management of isolated grade III collateral ligament injury in high school football players. Clin Orthop 1986;213:137-40.

8. Kannus P: Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop 1988;226:103-12.

9. Kannus P: Non-operative treatment of grade II and III sprains of the lateral ligament compartment of the knee. Am J Sports Med 1989;17:83-6.

10. Paulos LE, Payne FC, Rosenberg TD: Rehabilitation after ACL surgery in The Anterior Cruciate Deficient Knee. Eds. DW Jackson, D Drez. C.V. Mosby Co., St Louis, 1987;291-313.

11. Polly DW, et al.: The accuracy of selective magnetic resonance imaging compared with the findings of arthroscopy of the knee. J Bone Jt Surg 1988;70A(2):192-8.

12. Schutzer SF, Rasmby GR, Fulkerson JP: The evaluation of patellofemoral pain using computerized tomography. Clin Orthop 1986;204:286-93.

13. Scott WN: Arthroscopic diagnosis and treatment of patellofemoral disorders in Arthroscopy of the Knee. Ed. EH Wickland W.B. Saunders Co., Philadelphia, 1990;163-73.

14. Scuderi G, Cuomo F, Scott WN: Lateral release and proximal realignment for patellar subluxation and dislocation. J Bone Jt Surg 1988;70A(60:856-61.

15. Simpson LA, Barrett JP: Factors associated with poor results following arthroscopic subcutaneous lateral retinacular release. Clin Orthop Rel Res 1984;186:165-71.

16. Wilcox PG, Jackson DW: Factors affecting choices of anterior cruciate ligament surgery in The Anterior Cruciate Deficient Knee. Eds. DW Jackson, D Drez. C.V. Mosby Co., St Louis, 1987;27-141.

17. Wilson WJ, et al.: Combined reconstruction of the anterior cruciate ligament in competitive athletes. J Bone Jt Surg 1990;72A;742-7.

18. Davis JM. Rehabilitation of knee injuries in Techniques in Sports Medicine. Eds. WE Prentice, et al. C.V. Mosby Co., St Louis, 1990;294-315.

Appendix 7.0

Description of IMC appropriateness levels

Level 4

Level 3

Level 2

Level 1


Good research based evidence

Yes

No

No

No


Clinical evidence

Yes

Yes

Some

No


Consensus of the health care community

Yes

Yes

Partial

No

Clinical utility of appropriateness level for common low back problems
Appropriate and recommended
Acceptable or appropriate in most cases
Appropriate in uncommon individual cases. Document the case-specific clinical factors or circumstances which make this procedure reasonable and necessary for this injured worker.
Inappropriate