What is the recommended treatment for knee pain without an apparent injury?

Treatment for Knee Pain Without an Injury

The optimal management of knee pain without apparent injury should begin with non-pharmacological approaches including regular exercise therapy, weight loss (if overweight), education, and self-management programs before considering pharmacological options. 1, 2

First-Line Non-Pharmacological Approaches

• Regular individualized exercise regimen should include:

  • Strengthening exercises for both legs, particularly quadriceps and hip girdle muscles
  • Aerobic activity
  • Range of motion/stretching exercises 1, 3

• Weight reduction strategies for overweight patients:

  • Regular self-monitoring with monthly weight recording
  • Structured meal plans
  • Increased physical activity
  • Reduced fat intake 1, 4

• Appropriate footwear and assistive devices:

  • Comfortable, appropriate shoes
  • Walking aids (sticks used on the contralateral side, frames)
  • Assistive technology at home/work (chair height adjustments, hand-rails) 1, 4

Pharmacological Management

• Paracetamol (acetaminophen) should be tried first as the initial oral analgesic and, if effective, used as the preferred long-term oral analgesic 1, 3, 5

• If paracetamol is ineffective, consider:

  • Topical NSAIDs which have demonstrated clinical efficacy with better safety profile than oral NSAIDs 1, 4, 5
  • Oral NSAIDs (like ibuprofen) for patients unresponsive to paracetamol, with caution regarding gastrointestinal, cardiovascular, and renal side effects 1, 6

Interventional Options for Persistent Pain

• Intra-articular corticosteroid injections should be considered for acute flares of knee pain, especially if accompanied by effusion 1, 5

• Arthroscopic surgery is strongly NOT recommended for degenerative knee disease as evidence shows it provides no benefit over conservative management 1

Special Considerations

• Monitor patients on NSAIDs for:

  • Gastrointestinal side effects (ulcers, bleeding)
  • Cardiovascular thrombotic events
  • Hepatic effects (elevated liver enzymes)
  • Hematological effects (anemia, prolonged bleeding time) 6

• Patients with pre-existing asthma should use NSAIDs with caution due to potential cross-reactivity with aspirin 6

• For patients with work-related concerns, consider vocational rehabilitation including workplace modifications and altered work behaviors 1

Treatment Algorithm

1. Start with non-pharmacological approaches (exercise, weight loss if applicable)
2. If pain persists, add paracetamol (up to 4,000 mg/day)
3. If inadequate relief, consider topical NSAIDs (preferred) or oral NSAIDs
4. For flares with effusion, consider intra-articular corticosteroid injection
5. Continue conservative management for at least 4-6 weeks before considering other interventions 2, 7

Remember that even with unexplained knee pain, a conservative approach is often successful, with studies showing improvement without intervention in more than half of patients over time 8.