What are the treatment options for a veteran experiencing knee pain due to a grinding position?

Treatment Options for Veterans with Knee Pain from Grinding Position

For veterans experiencing knee pain due to a grinding position, a comprehensive management plan should include physical therapy, topical NSAIDs, and self-management strategies including exercise and possibly bracing as first-line treatments. 1

Initial Assessment and Non-Pharmacological Interventions

Self-Management Program

• Exercise therapy: Implement low-impact aerobic exercises, muscle strengthening exercises, and aquatic exercises
  • Effect size for pain relief: 0.52 (95% CI, 0.34,0.70)
  • Effect size for disability reduction: 0.46 (95% CI, 0.25,0.67) 2
• Weight loss: For veterans with BMI >25 kg/m², target 5-10% weight reduction
  • Provides clinically important functional improvement measured by WOMAC function subscale (0.69; 95% CI, 0.24,1.14) 2
• Bracing: Consider soft braces or valgus/varus knee braces to improve pain and physical function
  • Caution: Ensure appropriate exercise is maintained to prevent atrophy 1

Physical Therapy

• Physical therapy is strongly recommended as part of comprehensive management 1
• Benefits include:
  • Proper exercise instruction
  • Manual therapy techniques (manipulation and stretching)
  • Self-efficacy training
  • Alternative delivery models available (group visits, internet-based, telephone-based) 1

Pharmacological Management

Topical Treatments (First-Line)

• Topical NSAIDs: STRONGLY RECOMMENDED for knee osteoarthritis pain

  • Diclofenac is the only commercially manufactured topical NSAID available in the US
  • Superior to placebo and equivalent to oral NSAIDs for knee pain
  • Significantly fewer gastrointestinal adverse events than oral NSAIDs 1

• Topical capsaicin: Recommended for knee osteoarthritis pain

  • Works by depleting substance P in a reversible fashion
  • May need 2-4 weeks of continuous use before therapeutic effect
  • Common side effects: local burning or stinging at application site 1

Oral Medications (Second-Line)

• Acetaminophen and/or oral NSAIDs: Recommended for persistent pain

  • Use lowest effective dose for shortest possible time
  • Consider gastrointestinal, liver, and cardiorenal toxicity 1, 2

• Duloxetine: Consider as alternative or adjunctive therapy when:

  • Inadequate response to acetaminophen or NSAIDs
  • Contraindications to acetaminophen or NSAIDs exist 1

• Opioids (including tramadol): NOT RECOMMENDED for initiation in osteoarthritis pain

  • For veterans already on long-term opioid therapy, refer to VA/DoD Clinical Practice Guideline for Opioid Therapy 1

Interventional Options (For Refractory Cases)

• Intra-articular corticosteroid injections: Consider for persistent knee pain inadequately relieved by other interventions 1, 3

• Radiofrequency ablation: May provide longer-lasting analgesic effects (>6 months) for those not eligible for surgery or with persistent post-surgical pain 3, 4

Treatment Algorithm

1. First-Line Treatment:

   • Physical therapy referral
   • Self-management program (exercise, weight loss if applicable)
   • Topical NSAIDs (diclofenac)
   • Consider bracing for knee osteoarthritis

2. If Inadequate Response After 4-6 Weeks:

   • Add or switch to topical capsaicin
   • Consider oral acetaminophen and/or NSAIDs (with appropriate precautions)

3. For Persistent Pain Despite Above Measures:

   • Consider duloxetine as adjunctive therapy
   • Consider intra-articular corticosteroid injection

4. For Refractory Cases:

   • Consider radiofrequency ablation of genicular nerves
   • Evaluate for surgical candidacy if conservative measures fail

Important Considerations for Veterans

• Veterans have a higher prevalence and complexity of chronic pain than the general public due to multiple deployments and battlefield exposures 5

• The VA/DoD has developed a stepped pain management approach specifically for veterans 5

• Regular monitoring of treatment response is essential, with reassessment after 1-2 weeks of initial treatment and evaluation of response after 4-6 weeks 2

• Avoid MRI for diagnosis of osteoarthritis unless suspecting other pathology 1, 6

• For end-stage osteoarthritis with inability to cope with pain despite conservative management, consider surgical referral 6