From the Guidelines
For severe bilateral knee pain unresponsive to current treatments, a multimodal approach is recommended, prioritizing non-surgical interventions and considering the patient's overall health and well-being, as supported by the most recent and highest quality study 1.
Key Recommendations:
- Begin with optimizing non-surgical interventions including prescription-strength NSAIDs (such as naproxen 500mg twice daily or celecoxib 200mg daily), combined with physical therapy focusing on quadriceps strengthening and low-impact exercises 2-3 times weekly for at least 6-8 weeks.
- Consider intra-articular corticosteroid injections (such as methylprednisolone 40-80mg or triamcinolone 40mg) which can provide temporary relief for 1-3 months, as recommended by the 2022 AAOS clinical practice guideline summary 1.
- Hyaluronic acid injections may not be consistently supported by evidence, but may benefit some patients with a series of 3-5 weekly injections, as noted in the 2022 AAOS clinical practice guideline summary 1.
- For persistent pain, referral to orthopedic surgery for evaluation for knee arthroplasty is appropriate, particularly if imaging shows advanced osteoarthritis with significant joint space narrowing, as recommended by the 2022 AAOS clinical practice guideline summary 1.
- Total knee replacement offers the most definitive solution for end-stage arthritis, with over 90% of patients experiencing significant pain relief, as supported by the 2022 AAOS clinical practice guideline summary 1.
- Weight management is crucial, as each pound lost reduces knee joint forces by 3-4 pounds, and assistive devices like knee braces, canes, or walkers can help redistribute weight and improve mobility while awaiting definitive treatment, as recommended by the 2022 AAOS clinical practice guideline summary 1.
Rationale:
The recommended approach is based on the most recent and highest quality study, which prioritizes non-surgical interventions and considers the patient's overall health and well-being 1. The use of prescription-strength NSAIDs and physical therapy is supported by evidence from previous studies, including the EULAR recommendations for the management of knee osteoarthritis 1. The consideration of intra-articular corticosteroid injections and hyaluronic acid injections is also supported by evidence, although the evidence for hyaluronic acid injections is not as strong 1. The recommendation for referral to orthopedic surgery for evaluation for knee arthroplasty is based on the 2022 AAOS clinical practice guideline summary, which notes that total knee replacement offers the most definitive solution for end-stage arthritis 1.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals. The recommended dose is 2 pump actuations on each painful knee, 2 times a day.
For relief of the pain of osteoarthritis (OA) of the knee(s), the recommended dose is 40 mg of diclofenac sodium (2 pump actuations) on each painful knee, 2 times a day.
Considering the patient's severe bilateral knee pain unresponsive to current treatments, diclofenac sodium topical solution may be a viable option. The recommended dose is 40 mg (2 pump actuations) on each painful knee, 2 times a day. It is essential to follow the administration instructions carefully, including applying the solution to clean, dry skin, and avoiding skin-to-skin contact with others until the treated area is dry. However, it is crucial to weigh the benefits and risks, especially since the patient is already using Alleve (an oral NSAID), and combination therapy with diclofenac sodium topical solution and an oral NSAID should only be used if the benefit outweighs the risk, with periodic laboratory evaluations 2.
From the Research
Management Options for Severe Bilateral Knee Pain
The patient's complaint of 10 out of 10 bilateral knee pain, unresponsive to meloxicam and currently being managed with Alleve, requires a comprehensive approach to management. Considering the patient's history of Baker's cyst in the right knee and minimal arthritis, the following options can be explored:
- Intraarticular Injections: Intraarticular injections of corticosteroids, hyaluronic acid, or platelet-rich plasma can be considered as a non-operative modality for managing knee osteoarthritis, as suggested by 3. These injections can provide short-term pain relief and improve knee function.
- Conservative Management: First-line management of osteoarthritis comprises exercise therapy, weight loss (if overweight), education, and self-management programs, as recommended by 4. This approach can help empower patients to better manage their condition and alleviate symptoms.
- Interventional Therapies: Interventional therapies, such as radiofrequency ablation of the genicular nerves, can be effective in managing chronic knee pain, as stated by 5. However, these options should be considered after conservative management has failed.
- Surgical Referral: Surgical referral for knee joint replacement can be considered for patients with end-stage osteoarthritis, as suggested by 4. However, this option should be explored after all conservative and interventional therapies have been exhausted.
Diagnostic Considerations
When evaluating the patient's knee pain, it is essential to consider the following:
- Differential Diagnosis: The differential diagnosis should exclude other causes of knee pain, including bone and joint disorders, rheumatoid arthritis, spondylo- and other arthropathies, and infections, as mentioned by 5.
- Imaging Studies: Radiographic imaging should be reserved for chronic knee pain or acute traumatic pain in patients who meet specific evidence-based criteria, as recommended by 6. Musculoskeletal ultrasonography and magnetic resonance imaging can be useful in evaluating effusions, cysts, and superficial structures.
- Laboratory Tests: Laboratory tests can be used as a confirmatory or diagnostic tool when the initial history and physical examination suggest but do not confirm a specific diagnosis, as stated by 6.
Treatment Guidelines
The American Society of Pain and Neuroscience has published consensus guidelines on interventional therapies for knee pain, as presented by 7. These guidelines provide a comprehensive approach to managing knee pain, ranging from physical therapy and pharmacologic agents to interventional pain procedures and surgical options. By following these guidelines, practitioners can develop an individualized treatment plan for patients with severe bilateral knee pain.