What are the treatment options for knee arthritis?

Treatment Options for Knee Arthritis

The optimal management of knee osteoarthritis requires a combination of non-pharmacological and pharmacological treatment modalities, with exercise therapy, weight loss, and self-management education forming the cornerstone of treatment. 1

First-Line Non-Pharmacological Interventions

Exercise Therapy

• Strongly recommended for all patients with knee osteoarthritis 1, 2
• Types of beneficial exercises:
  • Low-impact aerobic exercises (walking, cycling) 1
  • Quadriceps strengthening exercises 1
  • Range-of-motion/flexibility exercises 1
  • Core and hip muscle strengthening 2
  • Both land-based and aquatic exercises 2

Weight Loss

• Strongly recommended for patients with BMI >25 kg/m² 1, 2
• Target: Minimum 5% of body weight loss 1
• Should be combined with appropriate dietary modification and exercise 1

Self-Management Education

• Participation in self-management educational programs 1
• Activity modifications (e.g., walking instead of running) 1
• Regular contact to promote self-care 1

Pharmacological Treatment Options

First-Line Medications

• Acetaminophen/paracetamol - oral analgesic to try first 1, 2
• Topical NSAIDs - recommended as first-line therapy, especially for patients with diabetes 2

Second-Line Medications

• Oral NSAIDs (like naproxen) - for patients unresponsive to acetaminophen 1, 3
  • Shown to reduce joint pain and tenderness in osteoarthritis 3
  • Consider gastrointestinal risk; use gastroprotective agents if needed 1
  • Lower frequency and severity of GI side effects compared to aspirin 3

Additional Pharmacological Options

• Tramadol - an alternative when NSAIDs are contraindicated 1
• Intra-articular corticosteroid injections - indicated for flares of knee pain, especially with effusion 1, 4

Treatments Not Recommended

• Acupuncture - not recommended 1
• Glucosamine and chondroitin - not recommended 1
• Lateral wedge insoles - not suggested 1

Advanced Treatment Options

• Total knee arthroplasty - should be considered when conservative symptomatic management is ineffective 4, 5
• Joint-preserving procedures - may be considered for younger adults 2

Treatment Algorithm

1. Initial approach: Start with non-pharmacological interventions

   • Exercise therapy (daily)
   • Weight loss program (if BMI >25)
   • Self-management education

2. If pain persists: Add pharmacological therapy

   • Start with acetaminophen/paracetamol
   • If inadequate response, add topical NSAIDs
   • If still inadequate, consider oral NSAIDs with appropriate gastroprotection

3. For acute flares or persistent pain:

   • Consider intra-articular corticosteroid injections
   • Adjust activity and exercise regimen temporarily

4. For end-stage disease with significant disability:

   • Consider surgical referral for total knee arthroplasty

Common Pitfalls to Avoid

• Relying solely on medications without implementing exercise and weight loss
• Underutilizing first-line non-pharmacological treatments
• Overuse of opioids for chronic pain management
• Premature referral for surgery without adequate trial of conservative measures
• Using treatments without evidence of benefit (glucosamine, chondroitin, acupuncture)

Monitoring and Assessment

• Regular assessment of pain control and functional status
• Monitoring for medication side effects, particularly with NSAIDs
• Periodic reassessment of treatment efficacy and need for treatment adjustments

By following this comprehensive approach to knee osteoarthritis management, focusing on non-pharmacological interventions first and adding medications as needed, patients can experience significant improvements in pain, function, and quality of life.