What are the best ways to manage knee pain?

Management of Knee Pain

The optimal management of knee pain requires a combination of non-pharmacological interventions (particularly exercise therapy and weight loss if overweight) and appropriate pharmacological treatments, with paracetamol (acetaminophen) as first-line medication for most patients. 1

Non-Pharmacological Interventions (First-Line)

Exercise Therapy

• Strongly recommended for all patients with knee pain 1, 2
• Include:
  • Land-based aerobic exercise
  • Quadriceps strengthening exercises
  • Range of motion exercises
• Should be performed regularly and consistently for optimal benefit

Weight Management

• Essential for overweight patients 1
• Each pound lost reduces four pounds of pressure on the knee joint
• Should be combined with exercise for maximum benefit

Activity Modification

• Avoid movements that aggravate pain 1
• Use open-backed shoes or accommodative footwear for posterior knee bursitis
• Consider assistive devices:
  • Knee bracing or insoles to improve biomechanics
  • Walking aids (cane or walking stick) used in the hand opposite to the affected knee

Patient Education

• Regular education about the condition 1
• Self-management strategies:
  • Understanding activity modification
  • Recognizing and managing flares
  • Setting realistic expectations about treatment outcomes

Pharmacological Interventions

First-Line

• Paracetamol (acetaminophen) 1
  • Dosage: Up to 4g daily divided every 8 hours
  • Safe for long-term use with minimal drug interactions
  • Suitable for mild to moderate osteoarthritis

Second-Line

• Topical NSAIDs 1

  • Apply 3-4 times daily
  • Provides local anti-inflammatory effect with minimal systemic absorption
  • Better safety profile than oral NSAIDs

• Oral NSAIDs (e.g., ibuprofen) 1, 3

  • Use lowest effective dose for shortest duration
  • Ibuprofen: 400-800mg 3-4 times daily (not to exceed 3200mg total daily dose)
  • Take with meals or milk if gastrointestinal complaints occur
  • Monitor for gastrointestinal, cardiovascular, and renal side effects
  • Caution: Not recommended for anticoagulated patients due to high risk of interaction

Advanced Options

• Intra-articular corticosteroid injections 1, 4, 5
  • Provides rapid relief of inflammatory symptoms
  • Particularly effective when effusion is present
  • Effects may be relatively short-lived (1-7 weeks)

Surgical Considerations

• Surgical referral for knee joint replacement should only be considered after exhausting all appropriate conservative options 1, 2
• Surgery is indicated only for severe traumatic tears (e.g., bucket-handle) with displaced meniscal tissue 1
• For degenerative meniscal tears, exercise therapy remains first-line treatment 1, 2

Monitoring and Follow-up

• Regular assessment of pain, function, and quality of life 1
• Regular evaluation of renal and hepatic function with prolonged NSAID use
• Consider referral to an orthopedic specialist if not responding to conservative treatment after 6-8 weeks

Common Pitfalls to Avoid

1. Overreliance on medications: Non-pharmacological interventions should be the foundation of treatment
2. Premature imaging: Radiographic imaging of all patients with possible knee OA is not recommended 2
3. Inappropriate surgical referral: Conservative management should be exhausted first
4. Inadequate pain assessment: Pain severity does not necessarily predict which medication will be more effective 6
5. Prolonged NSAID use without monitoring: Regular evaluation of renal and hepatic function is necessary

Treatment Algorithm

1. Start with non-pharmacological interventions (exercise, weight loss if applicable)
2. Add paracetamol (acetaminophen) up to 4g daily
3. If inadequate response, consider topical NSAIDs
4. For persistent pain, consider oral NSAIDs at lowest effective dose
5. For inflammatory flares with effusion, consider intra-articular corticosteroid injection
6. Reassess regularly and consider orthopedic referral if no improvement after 6-8 weeks of comprehensive management