What are the recommended treatment options for managing chronic knee pain?

Management of Chronic Knee Pain

The most effective approach to managing chronic knee pain is a structured exercise program combined with patient education, appropriate pain medication, and lifestyle modifications, particularly weight management for overweight patients.

First-Line Treatment Options

Exercise Therapy

• Land-based aerobic exercises, quadriceps strengthening, hip muscle strengthening, and range of motion exercises have shown consistent positive effects on pain reduction (effect sizes 0.57-1.0) 1
• Exercise regimens improve both pain and function with long-term benefits (6-18 months) 2
• For patients with mobility limitations, aquatic exercises are beneficial 1

Patient Education

• Education should cover:
  • Nature of the condition and prognosis
  • Self-management strategies
  • Activity modification techniques
  • Managing pain flares
  • Expected recovery timeframes 1
• Educational interventions have shown uniform positive effects on pain in osteoarthritis 2

Weight Management

• Weight reduction is strongly recommended for overweight and obese patients 1
• Each pound lost reduces four pounds of pressure on the knee joint 1
• Weight loss reduces both pain and improves function 2, 1

Pharmacological Management

First-Line Medications

• Acetaminophen (Paracetamol): Start with up to 4g daily in divided doses due to good safety profile 1
• Topical NSAIDs: Apply 3-4 times daily for localized knee pain; provides good efficacy with minimal systemic absorption 1

Second-Line Medications

• Oral NSAIDs: Consider when acetaminophen or topical NSAIDs provide inadequate relief
  • Use lowest effective dose for shortest duration
  • Monitor for GI, cardiovascular, and renal side effects
  • Avoid in patients on anticoagulants 1, 3
  • Regular monitoring of renal and hepatic function is necessary with prolonged use 1

Intra-articular Injections

• Corticosteroid injections: Effective for short-term pain relief (1-3 weeks), particularly for pain with effusion 1, 4
  • Dosage: 5-15mg for larger joints like the knee 4
  • Caution: Avoid repeated injections as they may accelerate cartilage loss
• Hyaluronic acid: Evidence supports efficacy for both pain reduction and functional improvement 2
  • Slower onset of action than steroids but longer duration of effect (several months)
  • Requires 3-5 weekly injections 2

Adjunctive Therapies

Orthotics and Assistive Devices

• Knee orthoses (especially sleeves, elastic bandages) show small but consistent positive effects on pain 2
• Walking aids should be considered if mobility is significantly affected 1
• Appropriate footwear and insoles are important for patients with knee pain 1

Physical Modalities

• Thermal interventions (locally applied heat or cold) provide short-duration benefits 1
• Acupuncture is conditionally recommended with positive trials and large effect sizes 1
• Radiofrequency ablation of genicular nerves can be effective for pain relief 1, 5

Psychological Interventions

• Cognitive behavioral therapy (CBT) shows uniform positive effects on pain in osteoarthritis 2
• Psychosocial and coping interventions are beneficial 2
• Internet-delivered pain-coping skills training combined with exercise has shown clinically meaningful improvements in pain and function sustained for at least 6 months 6

Treatment Algorithm

1. Initial approach: Exercise + education + weight management (if overweight) + acetaminophen or topical NSAIDs
2. If inadequate response: Add oral NSAIDs (if not contraindicated)
3. For acute flares with effusion: Consider intra-articular corticosteroid injection
4. For persistent pain: Consider hyaluronic acid injections, physical modalities, psychological interventions
5. Last resort: Tramadol can be considered when other options fail (50mg every 4-6 hours, not exceeding 400mg/day) 1

Monitoring and Referral

• Reassess regularly for pain, function, and quality of life
• Consider referral to an orthopedic specialist if not responding to conservative treatment after 6-8 weeks 1
• Surgical options should only be considered after exhausting all appropriate conservative options 1

Common Pitfalls to Avoid

• Relying solely on medications without implementing exercise and education
• Overuse of opioids for chronic knee pain
• Neglecting weight management in overweight patients
• Repeated corticosteroid injections without adequate time intervals
• Premature referral for surgical intervention before optimizing conservative management