What is the initial treatment for knee pain?

Initial Treatment for Knee Pain

The initial treatment for knee pain should include a combination of non-pharmacological approaches (regular education, exercise, appliances, weight reduction) and pharmacological treatment with acetaminophen (paracetamol) as the first-line oral analgesic due to its favorable safety profile. 1, 2

Non-Pharmacological Treatment

• Regular education about knee pain management and self-care strategies should be provided to all patients with knee pain 1
• Exercise therapy should be prescribed, with focus on strengthening the quadriceps and preserving normal knee mobility 1, 3
  • Specific exercises include quad sets, short-arc quad sets, long-arc quad sets, and gluteal squeezes 1
  • Exercises should be performed 5-7 times, 3-5 times daily 1
• Weight reduction for overweight patients is strongly recommended as it reduces the risk of knee osteoarthritis progression 1, 2
• Appropriate appliances such as walking sticks, insoles, and knee bracing should be considered to reduce joint loading 1
• Aquatic exercises in warm water (86°F) may provide additional pain relief through buoyancy and reduced joint loading 1

First-Line Pharmacological Treatment

• Acetaminophen (paracetamol) should be tried first at a full dosage of up to 4,000 mg/day (1,000 mg four times daily) 1, 2
• A full therapeutic trial of acetaminophen should be completed before considering it ineffective 2
• Patients should be counseled to avoid other products containing acetaminophen to prevent exceeding the maximum daily dose 2
• Acetaminophen has fewer gastrointestinal side effects compared to NSAIDs, making it safer for long-term use 1, 2

Alternative First-Line Options

• Topical NSAIDs (such as diclofenac) are a good alternative, especially for patients ≥75 years old 1, 2, 4
  • Apply to clean, dry skin around the knee, spreading evenly 4
  • Wait until the area is completely dry before covering with clothing 4
• Intra-articular corticosteroid injections may be considered for acute exacerbations with effusion 1, 2, 5

Second-Line Treatment Options

• If acetaminophen is ineffective, NSAIDs (oral or topical) should be considered 1, 2
• For patients with increased gastrointestinal risk, use either:
  • Non-selective NSAIDs with gastroprotective agents 1, 2
  • Selective COX-2 inhibitors 1, 2
• Opioid analgesics (with or without acetaminophen) are useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1, 2

Important Considerations and Caveats

• While some studies question acetaminophen's efficacy compared to NSAIDs 6, others show comparable effectiveness between acetaminophen and ibuprofen, even for severe knee pain 7, 8
• The lowest effective dosage of medication should be used for the shortest duration consistent with treatment goals 4
• High-impact aerobic training should be avoided as it may increase joint pain 1
• For patients with persistent pain despite conservative treatment, consider referral for interventional procedures such as radiofrequency ablation of genicular nerves 5
• Surgical options should only be considered after failure of appropriate conservative management 1, 3