What is the best treatment for osteoarthritis (OA) of the knee?

Best Treatment for Osteoarthritis of the Knee

The optimal management of knee osteoarthritis requires a combination of non-pharmacological and pharmacological interventions, with exercise therapy, weight loss (if overweight), and oral NSAIDs forming the cornerstone of treatment for improving pain, function, and quality of life. 1

First-Line Interventions

Exercise Therapy

• Strong recommendation for regular exercise programs 1
  • Quadriceps strengthening exercises (improve muscle strength around knee joint)
  • Low-impact aerobic exercises (walking, cycling, swimming)
  • Range-of-motion/flexibility exercises
  • Neuromuscular training (balance, agility, coordination) 1

Exercise has consistently shown significant improvements in pain (effect size 0.52-1.0) and function (effect size 0.46-0.67) 1. Both home-based and supervised programs are effective.

Weight Management

• Moderate recommendation for sustained weight loss in overweight/obese patients 1
  • Target minimum 5% reduction in body weight 1
  • Each pound lost reduces four pounds of pressure on knee joints
  • Produces clinically important functional improvement (WOMAC function score effect size 0.69) 1

Patient Education and Self-Management

• Strong recommendation for education programs 1
  • Individualized education packages
  • Group education sessions
  • Patient coping skills training
  • Understanding activity modification and flare management

Pharmacological Management

Oral Medications

• Strong recommendation for oral NSAIDs when not contraindicated 1

  • Effective for improving pain and function
  • Monitor for gastrointestinal, cardiovascular, and renal adverse effects
  • Naproxen has shown effectiveness in osteoarthritis with less gastrointestinal effects than aspirin or indomethacin 2

• Strong recommendation for oral acetaminophen (paracetamol) 1

  • First-line oral analgesic due to favorable safety profile
  • Dosage up to 4g daily divided every 8 hours 3
  • Less effective than NSAIDs but better safety profile

Topical Treatments

• Strong recommendation for topical NSAIDs 1
  • Apply 3-4 times daily to affected knee
  • Provides local anti-inflammatory effect with minimal systemic absorption 3
  • Particularly useful for patients who cannot tolerate oral NSAIDs

Intra-articular Injections

• Limited recommendation for intra-articular corticosteroid injections 1
  • Specifically indicated for knee pain with effusion
  • Provides rapid relief of inflammatory symptoms
  • Effects typically last up to 3 months

Adjunctive Therapies

Physical Modalities (Limited Evidence)

• Manual therapy in addition to exercise 1
• Massage therapy 1
• FDA-approved laser treatment 1
• Transcutaneous electrical nerve stimulation (TENS) 1

Mechanical Interventions

• Knee bracing or insoles to improve biomechanics
• Walking aids (cane or walking stick) used in hand opposite to affected knee

Advanced Interventions

For patients with refractory pain, disability, and radiological deterioration who have failed conservative management:

• Consider referral for joint replacement surgery 1
• In specific cases with mechanical symptoms and mild-to-moderate OA, arthroscopic partial meniscectomy may be considered after failing non-surgical treatments 1

Common Pitfalls and Caveats

1. Overreliance on medications alone: The most effective approach combines non-pharmacological and pharmacological interventions.

2. Inadequate exercise prescription: Many patients receive vague exercise advice rather than specific, structured programs targeting quadriceps strengthening and aerobic fitness.

3. Failure to address weight: Even modest weight loss significantly improves outcomes but is often not emphasized enough.

4. Inappropriate use of opioids: These should not be routinely used for knee OA due to poor risk-benefit ratio 4.

5. Expecting immediate results: Some interventions (particularly exercise and weight loss) require consistent adherence over time before benefits are realized.

6. Overlooking psychological aspects: Pain coping strategies and addressing psychological factors are important components of successful management.

7. Continuing ineffective treatments: Regular reassessment of treatment response is essential to modify the approach as needed.