Musculoskeletal Disorders: Knee

Appendix C: State-of-the-Art Care for Knee Disorders

While knee injuries and disorders are common in both athletic and general populations, there is a lack of high-quality data on functional outcomes, rehabilitation, or best practice for returning to prior levels of activity. The ACOEM Occupational Medicine Practice Guidelines only identified antibodies to confirm specific rheumatologic disorders as the single diagnostic test for knee disorders that had a strong evidence base. ACOEM’s recommendations for managing common knee disorders are summarized below (and are limited only to those interventions that have – at a minimum – a limited evidence base.38

Strength-of-Evidence Ratings:
A = Strong evidence-based: Two or more high-quality studies.
B = Moderate evidence-base: At least one high-quality study or multiple moderate-quality studies relevant to the topic and the working population.
C = Limited evidence-base: At least one study of moderate quality.

Acute, Subacute, or Chronic Knee Pain

Strongly Recommended (A)
NSAIDs for chronic knee pain.

Concomitant prescriptions for cytoprotective medications for persons at substantial increased risk for GI bleeding (PPI or misoprostol) getting NSAIDs for acute knee pain.

Acetaminophen or aspirin should be considered as first-line therapy for patients with cardiovascular disease risk factors.

Moderately Recommended (B)
Concomitant prescriptions for cytoprotective medications for persons at substantial increased risk for GI bleeding (sucralfate) getting NSAIDs for acute knee pain.

Recommended (C)
NSAIDS for acute flairs of knee pain.

Acetaminophen for knee pain (including those contraindicated for NSAIDs).

Acetaminophen particularly for those with contraindications for NSAIDs.

Concomitant prescriptions for cytoprotective medications for persons at substantial increased risk for GI bleeding (H2 blockers) getting NSAIDs for acute knee pain.

Selective serotonin reuptake inhibitors (SSNRIs), SSRIs, and/or tricyclic anti-depressants for patients with chronic knee pain with co-morbid depression.

Manipulation or mobilization for subacute or chronic knee pain.

Knee Osteoarthrosis

Strongly Recommended (A)
Aerobic exercise.

Knee arthroplasty for severe arthritides.

Moderately Recommended (B)
Strengthening exercises.

Acupuncture for select use for chronic osteoarthrosis of the knee as an adjunct to more efficacious treatments.

Recommended (C)
Off-loader braces for select patients with medial joint osteoarthrosis.

Knee braces (e.g., unloader braces) for moderate to severe chronic knee pain due to osteoarthrosis that is largely or totally unicompartmental.

Percutaneous electric therapy.
Intra-articular glucocorticosteroid injections for knee osteoarthrosis especially for short-term control of symptoms.

Unicompartmental arthroplasty for largely unicompartmental disease.
Simultaneous bilateral knee replacement for carefully selected patients with bilateral disease.

Anterior/Posterior Cruciate Ligament Tears

Recommended
Rehabilitation after ACL injury with or without surgical reconstruction.

Home-based physical therapy for post-ACL operative repair patients.

Meniscal Tears

Recommended
Rehabilitation for select patients after meniscal tears without surgical repair.

Iliotibial Band Syndrome

Recommended
Glucocorticosteroid injections in a subset of patients with insufficient results from other treatments.

Quadriceps’s, Gastrocnemius and Soleus Strains

Recommended
Progressive agility, trunk stabilization, and icing

Patellar Tendinosis, Patellar Tendinopathy (“jumpers knee), and anterior knee pain

Moderately Recommended
Exercise for patellofemoral joint pain.

Glucocorticosteroid injections for select patients with chronic patellar tendinopathy.

Aprotinin injections for select patients with chronic patellar tendinopathy.

Further complicating the evaluation of an acute or chronic knee disorder, is the lack of consistent treatment guidelines from surgeons often tasked with treatment and repair of acute and chronic knee injuries. At the time of this writing, the American Academy of Orthopedic Surgeons has completed guidelines for treatment of osteoarthritis of the knee.39

The AAOS recommendations are summarized below (treatment recommendations only, recommendation against treatment are not included). Of note, guidelines only consider alternatives to knee replacement. It is also important to note that the AAOS and ACOEM guidance differs in several areas, including the use of off-loader bracing and the use of viscosupplementation injections.

Strongly Recommended
Patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, neuromuscular education, and engage in physical activity consistent with national guidelines.

NSAIDs (oral or topical) or Tramadol for patients with symptomatic osteoarthritis of the knee.

Moderately Recommended
Weight loss for patients with symptomatic osteoarthritis of the knee and BMI >25

Limited
Valgus producing proximal tibial osteotomy in patients with symptomatic medial compartment osteoarthritis of the knee

In summary, there are almost no objective or treatment standards that inform the police physician that the LEO’s knee disorder is being optimally managed by his/her provider – this in contrast to other medical conditions with well-defined best practice guidelines. ACOEM, along with the Reed Group, has also looked at work modifications for knee disorders and time out of work if modified duty is not offered. Disability duration ranges from 0 to 42 days for knee and ligament strains and up to indefinite days for knee arthritis in the setting of heavy and very heavy occupations. ACOEM has no recommendation for or against specific vocational and recreational activities for post-operative TKA patients and does not address post-ACL repair/injury work modifications beyond the initial acute injury.