What are the next steps in managing a 44-year-old male patient with bilateral knee pain, particularly with a sensation of bone-to-bone pain in the left knee, who is currently prescribed ibuprofen (ibuprofen) 400 mg three times a day as needed and is using a knee sleeve?

From the Guidelines

For this 44-year-old male with bilateral knee pain and bone-to-bone sensation in the left knee, I recommend a comprehensive management approach beyond the current ibuprofen regimen and knee sleeve, prioritizing sustained weight loss, exercise, and potentially intra-articular corticosteroid injections as supported by the most recent and highest quality evidence from the 2022 AAOS clinical practice guideline summary 1.

Initial Assessment and Management

The patient's current ibuprofen dose can be optimized to 600-800 mg three times daily (not exceeding 3200 mg/day) if tolerated and no contraindications exist, as oral nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to consistently demonstrate improved pain and function in patients with knee osteoarthritis 1. Adding acetaminophen 1000 mg three times daily (maximum 3000 mg/day) could provide additional pain relief through a different mechanism.

Weight Management and Exercise

Sustained weight loss has been shown to benefit pain and, to a lesser extent, function in overweight and obese patients with knee osteoarthritis, with no risk or downside to sustained weight loss and obvious other health benefits 1. Exercise, particularly strengthening the quadriceps and hamstrings, improving range of motion, and enhancing joint stability, is also crucial. While the evidence does not support one form of exercise over another, supervised exercise programs are more effective, and patient preferences and access should guide the choice of exercise 1.

Intra-articular Injections

For the more symptomatic left knee with bone-to-bone sensation, consideration should be given to intra-articular corticosteroid injection (such as methylprednisolone 40-80 mg), which has considerable evidence supporting its use, although the duration of benefits was often only 3 months 1. Hyaluronic acid injections may also be considered, though the current evidence does not consistently support their routine use in patients with knee osteoarthritis 1.

Activity Modification

Activity modification to reduce high-impact exercises while maintaining movement through swimming or cycling will help preserve function while minimizing pain. These interventions target both pain management and functional improvement while addressing the likely underlying osteoarthritis that causes the bone-to-bone sensation through cartilage loss.

Imaging and Further Evaluation

Imaging studies, particularly weight-bearing X-rays of both knees, should be conducted to assess for osteoarthritis severity and rule out other pathologies. This comprehensive approach, guided by the most recent evidence, aims to improve the patient's quality of life by addressing pain, function, and the underlying causes of his symptoms.

From the FDA Drug Label

Patients and physicians should remain alert for signs and symptoms of GI ulcerations and bleeding during NSAID therapy and promptly initiate additional evaluation and treatment if a serious GI event is suspected. The patient is currently prescribed ibuprofen 400 mg three times a day as needed, and the next steps in managing the patient's bilateral knee pain, particularly with a sensation of bone-to-bone pain in the left knee, should include:

• Monitoring for signs and symptoms of GI ulcerations and bleeding during ibuprofen therapy
• Continuing to use the knee sleeve for support
• Following up on the x-ray results of the left knee to determine the cause of the bone-to-bone pain
• Advising the patient to continue with low-impact exercises and gradually increase the exercise load as tolerated 2

From the Research

Management of Bilateral Knee Pain

The patient's complaint of bilateral knee pain, particularly with a sensation of bone-to-bone pain in the left knee, suggests a possible diagnosis of osteoarthritis or degenerative meniscus tears.

• The prescribed treatment of ibuprofen 400 mg three times a day as needed and the use of a knee sleeve may help alleviate pain and inflammation, as supported by studies such as 3 and 4.
• Low-impact exercises, as advised, can also help improve joint mobility and reduce pain, although the evidence does not directly address the specific exercise regimen.
• The ordered x-ray of the left knee will help confirm the diagnosis and rule out other potential causes of knee pain.

Treatment Options

Considering the patient's symptoms and age, the following treatment options may be considered:

• Conservative management with physical therapy, NSAIDs, and supervised exercise, as recommended in 5.
• Injections, including viscosupplementation and orthobiologics, may be considered in the presence of osteoarthritis, as mentioned in 5.
• Surgical options, such as arthroscopic partial meniscectomy or meniscus repair, may be considered if conservative management fails and the patient experiences mechanical symptoms or persistent pain, as discussed in 5.

Pain Management

The use of ibuprofen 400 mg three times a day as needed may provide adequate pain relief, as shown in studies such as 6 and 7.

• However, the evidence suggests that the severity of knee pain does not predict a better response to ibuprofen than to analgesic therapy, as found in 7.
• The combination of ibuprofen and oxycodone may provide better pain relief than either drug alone, as demonstrated in 6, but this may not be necessary for the patient's current level of pain.