What are the treatment options for medial knee pain?

Management of Medial Knee Pain

The optimal management of medial knee pain requires a combination of non-pharmacological and pharmacological interventions tailored to the specific underlying cause, with quadriceps strengthening exercises being the cornerstone of treatment for most cases. 1, 2

Causes of Medial Knee Pain

Medial knee pain can result from various conditions including:

• Medial compartment osteoarthritis (most common cause)
• Medial meniscus injury
• Medial collateral ligament (MCL) injury
• Pes anserine bursitis/tendinopathy
• Medial plica syndrome
• Medial tibial crest friction syndrome
• Medial meniscal extrusion

Initial Assessment

Key findings to identify on examination:

• Location of pain (joint line, above/below joint)
• Presence of effusion
• Joint stability
• Mechanical symptoms (locking, catching)
• Alignment issues (varus deformity)
• Muscle weakness, particularly quadriceps

Treatment Algorithm

First-Line Treatment (0-8 weeks)

1. Exercise therapy 1, 2

   • Quadriceps strengthening exercises (daily)
   • Closed kinetic chain exercises (semi-squats) are superior to open kinetic chain exercises
   • Proximal hip girdle muscle strengthening
   • Aerobic activity (walking program)
   • Range of motion/stretching exercises

2. Weight management 1, 2

   • For overweight patients, implement structured weight loss program
   • Regular self-monitoring with monthly weight recording
   • Structured meal planning starting with breakfast
   • Reduced fat, sugar, and salt intake
   • Increased fruit and vegetable consumption
   • Limited portion sizes

3. Pain control 1, 2

   • Paracetamol (acetaminophen) up to 4g/day as first-line oral analgesic
   • Topical NSAIDs for localized pain with fewer systemic effects

4. Biomechanical interventions 1, 2

   • Appropriate and comfortable shoes
   • Consider medial patellar taping for patellofemoral involvement
   • Walking aids if needed (walking stick on contralateral side)

Second-Line Treatment (if inadequate response after 8 weeks)

1. Pharmacological options 1, 2

   • Oral NSAIDs for patients unresponsive to paracetamol
   • Consider gastroprotective agents in high-risk patients
   • Intra-articular corticosteroid injection for acute flares with effusion

2. Advanced biomechanical interventions 1, 2

   • Knee bracing:
     • For medial compartment OA: Unloader brace with valgus-directing force
     • For patellofemoral involvement: Patellofemoral brace
   • Insoles (though lateral-wedged insoles are NOT recommended for medial knee pain)

3. Physical therapy intensification 2

   • Supervised exercise program
   • Aquatic exercises for deconditioned patients
   • Neuromuscular training

Third-Line Treatment (if persistent symptoms after 3-6 months)

1. Re-evaluation 2

   • Confirm diagnosis
   • Assess treatment adherence
   • Consider advanced imaging (MRI) if not previously done

2. Specialist referral 2

   • Orthopedic evaluation for surgical options
   • Consider joint replacement for refractory pain with disability and radiological deterioration

Condition-Specific Approaches

For Medial Compartment Osteoarthritis

• Focus on quadriceps strengthening and weight management 1
• Consider unloader bracing 1
• Intra-articular corticosteroid for flares with effusion 1

For Medial Plica Syndrome

• Physical therapy focusing on quadriceps strengthening 3
• Consider corticosteroid injection if not responding 3
• Surgical intervention (arthroscopic resection) if conservative measures fail 3

For Medial Meniscal Extrusion

• Stretching of the semimembranosus tendon 4
• Passive range of motion exercises 4
• Focus on improving knee extension ROM 4

Common Pitfalls to Avoid

• Neglecting quadriceps strengthening exercises, which are essential for most medial knee conditions 2
• Using lateral-wedged insoles for medial compartment OA (not recommended) 1
• Rushing to surgical intervention before adequate trial of conservative management (minimum 3-6 months) 2
• Failing to address weight management in overweight patients 1
• Overlooking medial plica syndrome, which is commonly missed 3

By following this structured approach to managing medial knee pain, clinicians can effectively address most cases through conservative measures before considering surgical intervention.