What is the initial approach to managing knee pain with observable signs?

Initial Approach to Managing Knee Pain with Observable Signs

The optimal management of knee pain requires a combination of non-pharmacological and pharmacological treatment modalities tailored according to knee risk factors, general risk factors, pain intensity, signs of inflammation, and degree of structural damage. 1

Initial Assessment

• Perform a biopsychosocial assessment including physical status, activities of daily living, participation, mood, and health education needs 1
• Evaluate knee-specific factors including:
  • Pain characteristics (location, severity, duration, aggravating/relieving factors) 2
  • Observable signs of inflammation (effusion, warmth, redness) 1
  • Mechanical symptoms (locking, catching, instability) 3
  • Functional limitations and impact on quality of life 2
• Obtain radiographs as the initial imaging study for chronic knee pain, including:
  • At least one frontal projection (anteroposterior, Rosenberg, or tunnel view)
  • Tangential patellar view
  • Lateral view of the affected knee 1

Management Based on Clinical Presentation

For Osteoarthritis (most common cause in patients ≥45 years)

1. First-line non-pharmacological interventions:

   • Regular education about the condition and self-management 1
   • Individualized exercise regimen focusing on strengthening and range of motion 1, 3
   • Weight reduction if overweight or obese 1
   • Appropriate footwear and assistive devices if needed 1

2. Pharmacological management:

   • Start with paracetamol (acetaminophen) as first-line oral analgesic 1
   • If inadequate response, consider topical NSAIDs or capsaicin 1
   • For patients unresponsive to paracetamol, consider oral NSAIDs (e.g., naproxen) at the lowest effective dose 1, 4
   • For acute flares with effusion, consider intra-articular corticosteroid injection 1

For Patellofemoral Pain (common in younger, active individuals)

• Hip and knee strengthening exercises combined with:
  • Patellar taping for symptom relief during activity 1, 3
  • Foot orthoses when biomechanical factors contribute 1, 3
• Education on activity modification and load management 1, 3

For Meniscal Tears

• Conservative management with exercise therapy for 4-6 weeks for most tears, especially degenerative tears in patients >40 years 3
• Surgical referral only for severe traumatic tears with mechanical symptoms that don't respond to conservative care 3

Special Considerations

• Rule out referred pain from hip or lumbar spine if knee radiographs are unremarkable 1
• Consider additional imaging (MRI) only when initial radiographs are normal or show joint effusion and symptoms persist despite appropriate initial management 1
• Be aware that dangerous outcomes (fracture, thrombosis) are rare; knee pain in general practice is mainly associated with chronic problems 5
• Age-related patterns can help guide diagnosis:
  • Teenage girls/young women: more likely to have patellar tracking problems
  • Teenage boys/young men: more likely to have extensor mechanism problems
  • Older adults: more likely to have osteoarthritis 6

Common Pitfalls to Avoid

• Ordering MRI without recent radiographs (occurs in approximately 20% of chronic knee pain cases) 1
• Recommending surgical intervention for degenerative meniscal tears before adequate trial of conservative management 3, 7
• Failing to consider weight management as a core component of treatment for patients with knee osteoarthritis 1
• Underutilizing non-pharmacological approaches, which should be the foundation of management for most knee pain conditions 1, 3