What is the next step in managing mild bilateral knee degenerative (osteoarthritic) changes?

From the Guidelines

For mild bilateral knee degenerative changes, I strongly recommend starting with conservative management, prioritizing education, structured exercise, and weight loss as core treatments, as supported by the most recent and highest quality study 1.

Key Recommendations

• Education and self-management: Emphasize the importance of self-management strategies, including exercise, weight loss, and proper footwear, as recommended by 1 and 1.
• Exercise: Begin low-impact exercises like swimming, cycling, or walking to strengthen muscles supporting the knees, aiming for 30 minutes of exercise at least 5 days per week, as suggested by 1 and 1.
• Weight loss: Encourage weight loss in patients with knee OA who are overweight or obese, as strongly recommended by 1 and 1.
• Pain relief: Use topical NSAIDs as first-line treatment for pain relief, and consider oral NSAIDs and intra-articular injections for persistent pain, as recommended by 1 and 1.
• Supportive devices: Consider using supportive devices like knee braces or cushioned insoles to distribute weight more evenly, as suggested by 1 and 1.

Additional Considerations

• Apply ice for 15-20 minutes several times daily to reduce inflammation, especially after activity, as recommended by the example answer.
• Consider physical therapy for personalized strengthening exercises and proper movement techniques, as suggested by the example answer.
• Maintain a healthy weight to reduce stress on knee joints, as recommended by 1 and 1.
• If these measures don't provide adequate relief after 4-6 weeks, consult your doctor about next steps, which might include corticosteroid injections, hyaluronic acid injections, or referral to an orthopedic specialist, as suggested by the example answer.

From the FDA Drug Label

In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease

Treatment Options:

• Naproxen may be considered for the treatment of mild bilateral knee degenerative changes, as it has been shown to reduce joint pain and improve mobility in patients with osteoarthritis.
• The use of naproxen should be weighed against potential gastrointestinal and other adverse effects, and the lowest effective dose should be used for the shortest duration necessary 2.

From the Research

Diagnosis and Treatment of Mild Bilateral Knee Degenerative Changes

• The patient's condition is likely related to osteoarthritis (OA), patellofemoral pain, or meniscal tears, which are common causes of knee pain 3.
• Knee OA is the most likely diagnosis in patients aged 45 years or older with activity-related knee joint pain and no or less than 30 minutes of morning stiffness 3.
• The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain 3.
• Meniscal tears can be diagnosed using the McMurray test and joint line tenderness, with a sensitivity of 61% and 83%, respectively, and a specificity of 84% and 83%, respectively 3.

Conservative Management

• First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition 3, 4.
• Conservative management is also appropriate for most meniscal tears, with exercise therapy being the first-line treatment 5.
• Weight loss can decrease pain and improve function in overweight patients with degenerative meniscus tears 5.
• Injections, including viscosupplementation and the use of orthobiologics, can be considered in the presence of osteoarthritis 5.

Pharmacological Management

• Non-steroidal anti-inflammatory drugs (NSAIDs) are widely recommended and prescribed to treat pain in osteoarthritis, but have been associated with adverse events affecting the gastrointestinal, cardiovascular, and renal systems 6.
• The use of NSAIDs should be carefully considered, taking into account the patient's individual risk factors and comorbid conditions 6.

Surgical Referral

• Surgical referral for knee joint replacement can be considered for patients with end-stage OA after using all appropriate conservative options 3.
• Arthroscopic partial meniscectomy is the most commonly performed treatment for most degenerative tears, but repair may be considered for appropriately selected tears 5.