What should be recommended, in addition to physical therapy, for a 37-year-old patient with knee pain, bilateral overpronation, and a normal range of motion, who is training for a 10k race and currently taking ibuprofen (ibuprofen) for pain relief?

From the Guidelines

For this patient with knee pain and bilateral overpronation, I strongly recommend prefabricated foot orthoses, as they have been shown to be beneficial in the short term, especially for those who respond favourably to treatment direction tests, as evidenced by the expert opinion in the 2024 study published in the British Journal of Sports Medicine 1. In addition to physical therapy, the use of foot orthotics can help change function and reduce pain, as supported by the expert opinion that they can help change function and that a test can be done to see if it makes a difference when squatting with or without them 1. The patient's bilateral overpronation is likely contributing to the knee pain, and correcting this with foot orthotics can help alleviate the pain. Other interventions such as education, hip and knee strengthening exercises, and movement retraining can also be considered, but prefabricated foot orthoses are a key recommendation for this patient, as they can provide immediate relief and help improve function. It is also important to note that the patient's current use of ibuprofen can be continued for short-term pain management, but foot orthotics should be the primary recommendation for addressing the underlying cause of the pain, which is the bilateral overpronation. The expert opinion in the study suggests that education should underpin any intervention, and the patient should be educated on the benefits of foot orthotics and how they can help manage their knee pain 1. Overall, prefabricated foot orthoses are a crucial recommendation for this patient, and they should be used in conjunction with physical therapy and other interventions to manage the knee pain and improve function.

From the Research

Recommendations for a 37-year-old patient with knee pain

• In addition to physical therapy, the following options can be considered:
  • Foot orthotics: A study published in the Journal of Science and Medicine in Sport in 2018 found that foot exercises and foot orthoses are more effective than knee-focused exercises in individuals with patellofemoral pain 2.
  • X-ray of the knee: Although not directly mentioned in the provided studies, an X-ray may be necessary to rule out any underlying conditions that could be causing the knee pain.
• Ibuprofen for a traditional week: The patient is already taking ibuprofen, and there is no clear indication to continue or discontinue its use based on the provided studies.
• Intra-articular corticosteroid injection: Studies have shown that intra-articular corticosteroid injections may be associated with a dose-dependent risk of total knee arthroplasty at 5 years 3, and may increase the risk of requiring knee arthroplasty 4. Another study found that intra-articular corticosteroids appeared to be more beneficial in pain reduction than control interventions, but the benefits decrease over time 5.

Considerations for bilateral overpronation

• Foot orthotics may be beneficial in addressing bilateral overpronation, as they can help to redistribute pressure and reduce stress on the knee joint.
• Foot exercises, as mentioned in the study published in the Journal of Science and Medicine in Sport in 2018, may also be helpful in addressing patellofemoral pain associated with overpronation 2.

Additional considerations

• The patient's training for a 10k race should be taken into account when developing a treatment plan, as excessive running can exacerbate knee pain.
• A comprehensive treatment plan should include a combination of physical therapy, orthotics, and potentially other interventions to address the patient's knee pain and bilateral overpronation.