What are the best ways to manage knee pain?

Management of Knee Pain

For knee pain management, start with paracetamol (acetaminophen) as first-line oral analgesic, along with exercise therapy and education, followed by topical NSAIDs if needed, and consider intra-articular corticosteroid injections for pain with effusion. 1

Non-Pharmacological Approaches

Exercise Therapy

• Land-based aerobic exercise is strongly recommended for all patients with knee pain 1
• Quadriceps strengthening exercises improve muscle strength around the knee joint and reduce pain 1
• Range of motion exercises should be performed regularly to maintain joint mobility 1
• Aquatic exercise is recommended for deconditioned patients 1

Physical Interventions

• Apply ice for 10-minute periods through a wet towel to reduce pain and inflammation 1
• Use compression with an elastic bandage to control swelling 1
• Rest and elevate the affected limb during acute flare-ups 1
• Consider knee bracing or insoles to improve biomechanics 1
• Walking aids (cane or walking stick) may be used in the hand opposite to the affected knee 1

Lifestyle Modifications

• Weight loss is strongly recommended for overweight patients (each pound lost reduces four pounds of pressure on the knee joint) 1
• Activity modification to avoid aggravating movements 1, 2
• Open-backed shoes or accommodative footwear for posterior knee bursitis 1

Pharmacological Treatment Algorithm

First-Line

• Paracetamol (acetaminophen) up to 4g daily divided every 8 hours 3, 1
  • Safe for long-term use with minimal drug interactions
  • Comparable efficacy to ibuprofen in short-term management 3, 4, 5

Second-Line

• Topical NSAIDs (e.g., diclofenac) applied 3-4 times daily 3, 1
  • Provides local anti-inflammatory effect with minimal systemic absorption
  • Good safety profile compared to oral NSAIDs 1

Third-Line

• Intra-articular corticosteroid injection for acute exacerbation of knee pain, especially with effusion 3, 1
  • Provides rapid relief of inflammatory symptoms
  • Effects may be relatively short-lived (1-7 weeks) 3

Fourth-Line

• Oral NSAIDs (e.g., ibuprofen) 3, 6
  • Use the lowest effective dose for the shortest duration (400-800mg 3-4 times daily) 6
  • Monitor for gastrointestinal, cardiovascular, and renal side effects
  • Not recommended for anticoagulated patients 1

Special Considerations

Osteoarthritis-Specific Management

• First-line management includes exercise therapy, weight loss, education, and self-management programs 2
• Surgical referral for knee joint replacement only after exhausting all appropriate conservative options 2

Patellofemoral Pain

• Hip and knee strengthening exercises in combination with foot orthoses or patellar taping 2
• No indication for surgery in most cases 2

Meniscal Tears

• Conservative management with exercise therapy for 4-6 weeks for most tears 2
• Surgery only indicated for severe traumatic tears (e.g., bucket-handle) with displaced meniscal tissue 2
• For degenerative meniscal tears, exercise therapy is first-line; surgery is not indicated even with mechanical symptoms 2

Monitoring and Follow-up

• Regular evaluation of renal and hepatic function with prolonged NSAID use 1
• Use NSAIDs cautiously in elderly patients or those with comorbidities 1
• Reassess pain, function, and quality of life regularly 1
• Consider referral to an orthopedic specialist for cases not responding to conservative treatment after 6-8 weeks 1

Patient Education

• Provide education about the condition and realistic expectations about treatment outcomes 1
• Teach self-management strategies including activity modification 1
• Emphasize the importance of adherence to exercise programs and weight management 1, 2