What is the next best step in managing a 27-year-old male patient with chronic right knee pain unresponsive to ibuprofen and recently started on Naproxen 500 mg BID?

Management of Chronic Knee Pain in a Young Adult

For a 27-year-old male with chronic right knee pain unresponsive to ibuprofen, physical therapy along with naproxen 500 mg BID is the most appropriate treatment approach, with emphasis on exercise therapy as the cornerstone of management.

Assessment of Current Treatment Plan

The current management plan includes:

• Naproxen 500 mg BID (recently started)
• Voltaren cream (topical NSAID)
• Knee sleeve for support
• Physical therapy referral
• X-ray of the right knee

This approach aligns with current evidence-based guidelines for chronic knee pain management.

Efficacy of Current Treatment

NSAID Therapy

• Naproxen 500 mg BID is an appropriate dose for knee osteoarthritis or musculoskeletal pain 1
• Naproxen has demonstrated superior efficacy in reducing knee pain compared to hip pain in osteoarthritis 2
• The switch from ibuprofen to naproxen is justified as:
  • Different NSAIDs have varying efficacy in individual patients
  • Naproxen 500 mg BID has shown similar or superior efficacy to other NSAIDs in knee pain 3, 4

Physical Therapy and Exercise

• Exercise therapy has similar effects on pain and function as oral NSAIDs 5
• Physical therapy should be emphasized as a core treatment, not just an adjunct 6
• Exercise programs that include strengthening, aerobic fitness training, and proprioceptive exercises are essential components 5, 6

Next Best Steps in Management

1. Continue and emphasize physical therapy

   • Ensure PT focuses on strengthening exercises, proprioception, and functional training
   • Patient should be educated that exercise therapy has comparable efficacy to NSAIDs with better safety profile 5

2. Optimize NSAID therapy

   • Continue naproxen 500 mg BID for 2-4 weeks to assess efficacy 5
   • Use the lowest effective dose for the shortest duration to minimize adverse effects 6
   • Consider adding a proton pump inhibitor if GI symptoms develop, especially with prolonged use 6

3. Incorporate additional non-pharmacological approaches

   • Continue using the knee sleeve if providing benefit 6
   • Consider local heat or cold applications as adjuncts 5
   • Assess footwear for shock-absorbing properties 5

4. Follow-up evaluation

   • Schedule follow-up in 2 weeks to assess response to naproxen and PT 6
   • Review X-ray results to guide further management
   • If no improvement after 4-6 weeks of combined therapy, consider:
     • Intra-articular corticosteroid injection for moderate to severe pain 5
     • MRI if mechanical symptoms suggest internal derangement

Cautions and Monitoring

• Monitor for GI side effects with naproxen (abdominal pain, heartburn, nausea)
• Assess renal function if prolonged NSAID use is anticipated
• Avoid long-term high-dose NSAID use due to increased risk of GI bleeding, cardiovascular events, and renal impairment 6
• The combination of oral and topical NSAIDs (naproxen + Voltaren) may increase risk of adverse effects - consider using one or the other based on response

Key Points for Patient Education

• Exercise is not just supplementary but a core treatment with efficacy comparable to medications 5
• Consistency with PT exercises is crucial for long-term benefit
• NSAIDs work best when combined with non-pharmacological approaches
• Weight management is important if the patient is overweight
• Pacing activities to avoid "peaks and troughs" can help manage pain 5