What are the initial treatment steps for knee osteoarthritis?

Initial Treatment Steps for Knee Osteoarthritis

The initial treatment for knee osteoarthritis should focus on non-pharmacological approaches including exercise therapy, weight loss for overweight patients, and self-management education programs, followed by pharmacological options like acetaminophen or NSAIDs if needed. 1

Core Non-Pharmacological Treatments

Exercise Therapy (Strong Recommendation)

• Land-based exercise:
  • Strengthening exercises for quadriceps and hamstrings
  • Low-impact aerobic activities (walking, cycling, swimming)
  • Neuromuscular education 1
• Aquatic exercise for patients who are deconditioned or have difficulty with weight-bearing exercises 1
• Exercise frequency: At least 3 times weekly for 30-60 minutes per session

Weight Management (Strong Recommendation)

• Weight loss counseling for all patients with BMI ≥25 kg/m² 1
• Target: 5-10% reduction in body weight
• Combination of dietary modification and increased physical activity 2

Self-Management Education

• Patient education about the condition and treatment options
• Strategies to manage pain and maintain function
• Setting realistic goals and expectations 1

Adjunct Non-Pharmacological Approaches

• Thermal agents: Local heat or cold applications 1
• Assistive devices: Walking aids as needed 1
• Appropriate footwear with shock-absorbing properties 1
• Activity pacing: Avoiding peaks and troughs of activities 1

Initial Pharmacological Management

If non-pharmacological approaches provide insufficient relief:

1. First-line: Acetaminophen (paracetamol) up to 3,000 mg/day

   • Regular dosing may be needed for optimal effect
   • Monitor for hepatotoxicity, especially with alcohol use or liver disease 1

2. Second-line: If acetaminophen is ineffective:

   • Topical NSAIDs (particularly for patients ≥75 years) 1
   • Oral NSAIDs at lowest effective dose for shortest duration 1, 3
     • Ibuprofen: Start with 400mg 3-4 times daily, can increase to 600mg 3-4 times daily if needed 3
     • Use with proton pump inhibitor in high-risk patients
     • Consider cardiovascular, gastrointestinal, and renal risks

3. Alternative options:

   • Intra-articular corticosteroid injections for moderate to severe pain 1
   • Tramadol for patients who cannot use NSAIDs or have insufficient relief 1

Treatments Not Recommended

• Glucosamine and chondroitin supplements 1
• Acupuncture (except in specific circumstances) 1
• Lateral wedge insoles (not supported by evidence) 1
• Arthroscopy with lavage or debridement for primary knee OA 1

Common Pitfalls to Avoid

1. Overreliance on medications: Non-pharmacological approaches should remain the foundation of treatment even when medications are added
2. Inadequate exercise instruction: Patients need specific guidance on appropriate exercises and proper form
3. Expecting immediate results: Therapeutic response to exercise and weight loss may take 2-6 weeks to become apparent
4. Using high-dose NSAIDs for extended periods: This increases risk of adverse effects; use lowest effective dose for shortest time 3
5. Neglecting to reassess: Regular follow-up is needed to evaluate treatment response and adjust the management plan

Treatment Algorithm

1. Start with core treatments (exercise, weight management, education)
2. If inadequate response after 4-6 weeks, add acetaminophen
3. If still inadequate response after 2-4 weeks, consider topical NSAIDs (especially in elderly) or oral NSAIDs (in younger patients without contraindications)
4. For persistent moderate-severe pain, consider intra-articular corticosteroid injection
5. Continue to emphasize and reinforce non-pharmacological approaches throughout treatment

The evidence strongly supports that a comprehensive approach beginning with non-pharmacological interventions provides the best outcomes for reducing pain and improving function in knee osteoarthritis 4.