What is the best course of treatment for a 56-year-old male patient with chronic right knee pain and a history of lateral meniscus repair, who has previously undergone intra-articular (IA) injection and is now presenting with persistent symptoms?

From the Guidelines

For a 56-year-old male with chronic right knee pain and history of lateral meniscus repair, I strongly recommend a multimodal approach prioritizing oral NSAIDs, physical therapy, and weight management, as these interventions have been consistently supported by recent high-quality evidence to improve pain and function in patients with knee osteoarthritis. The patient's history of previous intra-articular injection therapy and ongoing symptoms suggests the need for a comprehensive treatment plan. According to the most recent guidelines 1, oral NSAIDs such as naproxen 500mg twice daily or celecoxib 200mg daily are recommended for 2-4 weeks to address inflammation and pain.

Additionally, physical therapy focusing on quadriceps and hamstring strengthening (2-3 sessions weekly for 6-8 weeks) is crucial for improving function and reducing pain, as emphasized in the guidelines 1. Weight management should also be a key component of the treatment plan, as sustained weight loss has been shown to benefit pain and function in overweight and obese patients with knee osteoarthritis 1.

While intra-articular corticosteroid injections have considerable evidence supporting their use, with 19 high-quality and six moderate-quality studies demonstrating benefits, albeit often only for 3 months 1, their use should be considered on a case-by-case basis, taking into account the patient's response to previous injections and current symptoms. Hyaluronic acid injections, although commonly used, have inconsistent evidence supporting their effectiveness and are not recommended for routine use in patients with knee osteoarthritis 1.

For breakthrough pain, acetaminophen 1000mg three times daily can be used, but it is essential to monitor for potential adverse effects and adjust the treatment plan as needed. If these conservative measures fail after 3-6 months, orthopedic consultation for possible arthroscopic debridement or, depending on the degree of degenerative changes, partial or total knee replacement should be considered. This approach is supported by the guidelines 1 and prioritizes the patient's quality of life, morbidity, and mortality.

Key components of the treatment plan include:

• Oral NSAIDs for pain and inflammation management
• Physical therapy for strengthening and improving function
• Weight management through diet and exercise
• Consideration of intra-articular corticosteroid injections on a case-by-case basis
• Monitoring for potential adverse effects and adjusting the treatment plan as needed
• Orthopedic consultation for surgical options if conservative measures fail.

From the Research

Treatment Options for Chronic Right Knee Pain

The patient's history of chronic right knee pain and previous lateral meniscus repair suggests that a comprehensive treatment plan is necessary. Considering the patient's previous intra-articular (IA) injection and ongoing symptoms, the following treatment options can be explored:

• Prescribing an x-ray of the right knee to compare with previous images and assess the current state of the knee joint 2
• Starting Ibuprofen 400 mg for pain management, as combination therapy with paracetamol and ibuprofen has been shown to reduce morphine requirement after total knee arthroplasty 3
• Scheduling an IA injection to provide temporary pain relief and reduce inflammation
• Prescribing physical therapy (PT) to improve mobility and strength, as same-day PT following total knee arthroplasty has been shown to lead to improved inpatient physical therapy performance and decreased inpatient opioid consumption 4

Diagnostic Imaging

Diagnostic imaging plays a crucial role in evaluating knee osteoarthritis. The current evidence suggests that:

• Radiography is the most commonly used imaging modality, but it has limitations in detecting early stages of osteoarthritis 2
• MRI is a preferred option for whole-joint evaluation in osteoarthritis research, as it provides more detailed images of the joint and surrounding tissues 2
• X-ray imaging has a low sensitivity in identifying knee fractures, and CT scanning should be performed in patients whose fracture type and fracture characteristics are not able to be determined exactly with X-ray imaging 5
• An X-ray-based diagnosis and explanation of knee osteoarthritis may have potentially undesirable effects on people's beliefs about management, highlighting the importance of careful communication and patient education 6

Rehabilitation and Follow-up

Rehabilitation and follow-up are essential components of the treatment plan. The patient should be:

• Prescribed a bottom bunk to reduce strain on the knee joint
• Scheduled for a follow-up appointment in two months to evaluate the progress of care (POC) and adjust the treatment plan as needed
• Encouraged to participate in physical therapy and other rehabilitation activities to improve mobility and strength, and reduce the risk of further complications 4