What treatment options are available for severe left knee pain?

Treatment Options for Severe Left Knee Pain

For severe left knee pain, I recommend starting with a self-management program including exercise, weight loss if overweight, and knee bracing, combined with topical NSAIDs as first-line pharmacological treatment. 1

Initial Assessment and Non-Pharmacological Approaches

• A comprehensive self-management program should be the foundation of treatment for knee osteoarthritis (OA), which is the most likely cause of severe knee pain 1
• Regular exercise focusing on quadriceps strengthening and preserving knee mobility is strongly recommended as it reduces pain and improves function 1
• Weight loss is essential for patients who are overweight as it directly correlates with knee pain severity 1, 2
• Knee bracing provides stability and helps decrease weight burden on the affected joint 1
• Physical therapy should be offered as part of the comprehensive management plan, with early referral recommended based on pain severity and functional limitations 1

Pharmacological Treatment Options

First-Line Options:

• Topical NSAIDs (such as diclofenac) are strongly recommended for knee pain with excellent efficacy and better safety profile than oral medications 1
• Topical capsaicin can be offered as an alternative topical treatment for knee pain 1
• Acetaminophen (up to 4,000 mg/day) should be considered as an initial oral analgesic, though patients must be counseled to avoid other acetaminophen-containing products 1

Second-Line Options:

• Oral NSAIDs (like ibuprofen 400-800 mg three to four times daily) can be considered if topical treatments and acetaminophen are ineffective 3, 1
  • The lowest effective dose should be used for the shortest duration to minimize risks 3
  • Patients with gastrointestinal risk factors should take NSAIDs with meals or milk 3
• Duloxetine can be offered as an alternative or adjunctive therapy when there's inadequate response to acetaminophen or NSAIDs 1
  • Should be taken daily (not as needed) and tapered when discontinuing 1

Interventional Options:

• Intra-articular corticosteroid injections are recommended for acute flares of knee pain, especially when accompanied by effusion 1
• Joint replacement should be considered for refractory pain associated with disability and radiological deterioration 1

Important Considerations and Pitfalls

• Opioids (including tramadol) are not recommended for initial management of knee OA pain due to unfavorable risk-benefit ratio 1
• Nutritional supplements like glucosamine and chondroitin sulfate are not recommended due to insufficient evidence of efficacy 1
• Many patients with severe knee pain don't seek medical attention, incorrectly believing that knee pain is a normal part of aging 4
• The Ottawa Knee Rule can help determine when imaging is necessary for suspected fractures, but routine radiographic imaging is not recommended for all patients with knee pain 1, 5
• For patients with persistent pain despite conservative management, a multidisciplinary approach including procedural options such as radiofrequency ablation may be considered 6

By following this treatment algorithm, starting with non-pharmacological approaches and topical treatments before progressing to oral medications and interventional procedures, most patients with severe knee pain can achieve significant improvement in symptoms and function.