Guideline:
Knee complaints
Bibliographic Source(s)
- Knee complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 31 p. [87 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Harris J ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms MA: OEM Press; 1997.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)
- To provide information and guidance on generally accepted elements of quality care in occupational and environmental medicine
- To improve the efficiency with which the diagnostic process is conducted the specificity of each diagnostic test performed and the effectiveness of each treatment in relieving symptoms and achieving cure
- To present recommendations on assessing and treating adults with potentially work-related knee complaints
Target Population
Adults with potentially work-related knee complaints seen in primary care settings
Interventions and Practices Considered
Note from the National Guideline Clearinghouse (NGC): The following general clinical measures were considered. Refer to the original guideline document for information regarding which specific interventions and practices under these general headings are recommended optional or not recommended by the American College of Occupational and Environmental Medicine.
- History
- Physical exam
- Patient education
- Medication
- Physical treatment methods
- Aspirations and injections
- Rest and immobilization
- Activity and exercise
- Detection of neurologic abnormalities
- Radiography
- Imaging
- Surgical considerations
Major Outcomes Considered
Missed work days
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Note from the National Guideline Clearinghouse (NGC): The American College of Occupational and Environmental Medicine contracted the Work Loss Data Institute to provide medical library research services.
Disability-Duration Data
This edition includes disability-duration data that have been extracted from National Health Interview Survey data. Only data from interviews with individuals without workers' compensation claims has been included.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
A = Strong research-based evidence (multiple relevant high-quality scientific studies).
B = Moderate research-based evidence (one relevant high-quality scientific study or multiple adequate scientific studies).
C = Limited research-based evidence (at least one adequate scientific study of patients with knee complaints).
D = Panel interpretation of information not meeting inclusion criteria for research-based evidence.
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Contributors reviewed at least one chapter each and reviewed the relevant medical literature that had been published since the creation of the original Guidelines in 1997.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
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
Internal Peer Review
Description of Method of Guideline Validation
Following the chapter and literature review participants provided written or verbal comments to the American College of Occupational and Environmental Medicine's Practice Guidelines Committee.
Verbal comments were in the form of participation in multi-specialty conference calls during which the issues raised in each chapter were extensively discussed. Draft chapters were prepared and distributed by the American College of Occupational and Environmental Medicine to all chapter reviewers. Follow-up multi-specialty teleconferences were then held as appropriate during which time the draft was again reviewed.
Major Recommendations
Recommendations are followed by evidence classification (A-D) identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.
Summary of Recommendations for Evaluating and Managing Knee Complaints (refer to the original guideline document for more detailed information)
| Clinical Measure | Recommended | Optional | Not Recommended |
|---|---|---|---|
| History | Basic history with careful search for mechanism of injury (C D) | ||
| Physical exam | Focused physical exam including ligament testing and careful search for any swelling (C D) | ||
| Patient education | Patient education Full disclosure of diagnostic accuracy prognosis and expectations of treatment (D) | ||
| Medication (See Chapter 3 in the original guideline document) | Acetaminophen Aspirin (C D) | Opioids for severe pain Non-steroidal anti-inflammatory drugs (NSAIDs) (C D) | Use of opioids for more than 2 weeks (C D) |
| Physical treatment methods | Nonoperative rehabilitation for medial collateral ligament injuries (C D) Short postoperative rehabilitation for anterior cruciate ligament (ACL) repair prior to home exercise program (D) Conservative treatment for selected ruptures of the ACL (D) Exercises for cases of anterior knee pain or ligament strain(D) | Passive modalities without exercise program (D) Manipulation (D) | |
| Aspirations and injections | Aspiration of tense acute effusions (D) Aspiration of tense prepatellar bursa (D) | Repeated aspirations or corticosteroid injections (D) | Aspiration through infected area (D) |
| Rest and immobilization | Short period of immobilization after an acute injury to relieve symptoms (C) | Functional bracing as part of a rehabilitation program (D) | Prophylactic braces (D) Prolonged bracing for ACL deficient knee (D) |
| Activity and exercise | Stretching Aerobic exercise Maximal activity of other parts while recovering from knee injury (D) | Excessive rest (may lead to generalized debilitation) (D) | |
| Detection of neurologic abnormalities | Electrical studies (contraindicated for nearly all knee injury diagnoses) (D) | ||
| Radiography | Plain-film radiographs for suspected red flags (C) | Plain-film radiographs for tense hemarthroses (C) | Routine radiographic film for most knee complaints or injuries (C) |
| Imaging | Magnetic resonance imaging (MRI) study to determine extent of ACL tear preoperatively (C) | MRI for ligament collateral tears (C) | |
| Surgical considerations | Arthroscopic meniscectomy or repair for severe mechanical symptoms and signs or serious activity limitations if MRI findings are consistent for meniscal tear (C D) ACL repair for symptomatic instability (i.e. serious activity limitation) if results of Lachman and pivot-shift tests and MRI are positive (C D) | ACL reconstruction before rehabilitation has been attempted (C D) | Surgical repair of isolated medial collateral ligament (MCL) ruptures (D) Immediate surgical reconstruction of all ACL tears on basis of MRI findings without physical findings confirming diagnosis or worker life demands requiring high knee performance (D) |
Definitions:
Levels of Evidence
A = Strong research-based evidence (multiple relevant high-quality scientific studies).
B = Moderate research-based evidence (one relevant high-quality scientific study or multiple adequate scientific studies).
C = Limited research-based evidence (at least one adequate scientific study of patients with knee complaints).
D = Panel interpretation of information not meeting inclusion criteria for research-based evidence.
Clinical Algorithm(s)
The following clinical algorithms are provided in the original guideline document:
- American College of Occupational and Environmental Medicine Guidelines for care of acute and subacute occupational knee complaints
- Initial evaluation of occupational knee complaints
- Initial and follow-up management of occupational knee complaints
- Evaluation of slow-to-recover patients with occupational knee complaints (symptoms >4 weeks)
- Surgical considerations for patients with anatomic evidence of torn meniscus or ligament and persistent knee symptoms
- Further management of occupational knee complaints
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
- Improved efficiency of the diagnostic process
- Effective treatment resulting in symptom alleviation and cure
Potential Harms
- False-positive or false-negative diagnostic tests
- Risks and complications of surgical procedures and imaging studies (e.g. infection radiation)
Contraindications
Electrical studies are contraindicated for nearly all knee injury diagnoses
Qualifying Statements
- The American College of Occupational and Environmental Medicine (ACEOM) provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly the ACOEM disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.
- The guidelines for modification of work activities and disability duration (see original guideline document) are general guidelines based on consensus or population sources and are never meant to be applied to an individual case without consideration of workplace factors concurrent disease or other social or medical factors that can affect recovery. The parameters for disability duration are "consensus optimal" targets as determined by a panel of ACOEM members in 1996 and reaffirmed by a panel of ACOEM members in 2002. In most cases persons with one non-severe extremity injury can return to modified duty immediately. Restrictions should take into consideration the opposite extremity also to prevent strain injuries to the uninjured extremity.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- Knee complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 31 p. [87 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American College of Occupational and Environmental Medicine
Guideline Committee
American College of Occupational and Environmental Medicine Practice Guidelines Committee
Composition of Group that Authored the Guideline
Chapter Lead: Lee S. Glass MD
Committee Members: Jennifer H. Christian MD MPH FACPM; Philip I. Harber MD MPH FACOEM FCCP; John P. Holland MD MPH FACOEM; Kathryn L. Mueller MD MPH FACEP FACOEM; Douglas J. Patron MD MSPH; Bernyce M. Peplowski DO MS; and Jack Richman MD CCFP DOHS FACOEM
Timothy J. Key MD MPH FACOEM as Responsible Officer and ACOEM President Elect and Edward A. Emmett MD MS FACOEM Chair of the ACOEM Council on Occupational and Environmental Medical Practice contributed to the development of the guidelines as well.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Harris J ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms MA: OEM Press; 1997.
Guideline Availability
Print copies are available from ACOEM 25 Northwest Point Boulevard Suite 700 Elk Grove Village IL 60007; Phone: 847-818-1800 x399. To order a subscription to the online version call 800-441-9674 or visit http://www.acoempracguides.org/.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on May 31 2006. The information was verified by the guideline developer on November 3 2006.
COPYRIGHT STATEMENT
The American College of Occupational and Environmental Medicine the signator of this license represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.
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