What are the best treatments for knee pain due to osteoarthritis?

Best Treatments for Knee Pain Osteoarthritis

Exercise therapy, oral NSAIDs, and topical NSAIDs are strongly recommended as first-line treatments for knee osteoarthritis pain, with patient education and weight loss as essential complementary interventions. 1, 2

First-Line Treatments

Non-Pharmacological Interventions

1. Exercise Therapy (Strong recommendation)

   • Land-based aerobic exercise and quadriceps strengthening exercises 2
   • Neuromuscular training (balance, agility, coordination) in combination with exercise (Moderate recommendation) 1
   • Benefits: Improves pain, function, and walking speed
   • Pitfall: Patient compliance may be limited by pain, transportation issues, or time commitment 3

2. Patient Education Programs (Strong recommendation)

   • Self-management strategies 1, 2
   • Understanding activity modification and managing flares 2
   • Benefits: Improves pain and function, cost-effective intervention 1

3. Weight Loss (Moderate recommendation)

   • For overweight and obese patients 1
   • Each pound lost reduces four pounds of pressure on the knee joint 2
   • Benefits: Improves pain, function, and reduces disease progression 3
   • Pitfall: Can be challenging for patients with limited mobility 3

Pharmacological Interventions

1. Oral NSAIDs (Strong recommendation)

   • Recommended when not contraindicated 1
   • Use at lowest effective dose for shortest duration (e.g., ibuprofen 400-800mg 3-4 times daily) 2
   • Benefits: Effective for moderate-severe pain 4
   • Caution: Monitor for GI, cardiovascular, and renal side effects 2, 5

2. Topical NSAIDs (Strong recommendation)

   • Apply 3-4 times daily 2
   • Benefits: Local anti-inflammatory effect with minimal systemic absorption 2
   • Safer profile compared to oral NSAIDs 2

3. Oral Acetaminophen (Strong recommendation)

   • First-line oral analgesic for mild to moderate pain 1, 2
   • Dosage: Up to 4g daily divided every 8 hours 2
   • Benefits: Safe for long-term use with minimal drug interactions 2
   • Pitfall: Less effective than NSAIDs for moderate-severe pain 4

Second-Line Treatments

1. Intra-articular Corticosteroid Injections

   • Indicated for flares of knee pain, especially with effusion 1, 2
   • Benefits: Rapid relief of inflammatory symptoms 2
   • Limitation: Effects may be short-lived (1-7 weeks) 2

2. Manual Therapy (Limited recommendation)

   • In addition to exercise program 1
   • Benefits: May improve pain and function

3. Massage (Limited recommendation)

   • In addition to usual care 1
   • Benefits: May improve pain and function

4. Assistive Devices

   • Knee bracing or insoles to improve biomechanics 2
   • Walking aids (cane or walking stick) used in hand opposite to affected knee 2
   • Benefits: Improves stability, reduces pain during activities 2, 6

5. Transcutaneous Electrical Nerve Stimulation (TENS) (Limited recommendation)

   • May improve pain 1, 4

Treatment Algorithm

1. Initial Assessment

   • Evaluate pain intensity, functional limitation, presence of inflammation/effusion
   • Assess comorbidities that may affect treatment choices

2. First-Line Approach

   • Start exercise therapy program
   • Initiate acetaminophen for mild pain OR topical NSAIDs
   • Provide patient education on self-management
   • Recommend weight loss if overweight/obese

3. If Inadequate Response After 2-4 Weeks

   • Switch to or add oral NSAIDs if no contraindications
   • Consider assistive devices (braces, insoles)
   • Add manual therapy to exercise program

4. For Acute Flares with Effusion

   • Consider intra-articular corticosteroid injection

5. For Persistent Symptoms Despite Above Measures

   • Consider TENS or other modalities (massage, laser treatment)
   • Reassess after 6-8 weeks and consider referral to specialist if no improvement

Common Pitfalls and Considerations

• NSAID Use: Avoid in patients with renal impairment, heart failure, or history of GI bleeding; use with caution in elderly 2, 5
• Exercise Adherence: Address barriers to compliance such as pain during activities and transportation issues 3
• Weight Loss: Provide realistic goals and support systems to improve adherence 3
• Acetaminophen: Monitor for hepatotoxicity with long-term use or in patients with liver disease 2
• Treatment Expectations: Set realistic expectations about treatment outcomes; OA is a chronic condition requiring periodic review and adjustment of therapy 4

By following this evidence-based approach, most patients with knee osteoarthritis can achieve significant improvements in pain, function, and quality of life.