What are the treatment options for osteoarthritis of the knees?

Treatment Options for Osteoarthritis of the Knees

The most effective treatment approach for knee osteoarthritis includes a combination of exercise programs, weight loss for overweight patients, topical and oral NSAIDs, and patient education programs to improve pain, function and quality of life. 1, 2, 3

First-Line Non-Pharmacological Interventions

• Exercise Programs: Strong recommendation for both strengthening and low-impact aerobic exercise to reduce pain and improve function 1, 2

  • Land-based exercises focusing on quadriceps strengthening should be prescribed early in treatment 3
  • Aquatic exercises are beneficial alternatives, particularly for patients with mobility limitations 3
  • Neuromuscular training (balance, agility, coordination) combined with exercise shows moderate evidence for improving function and walking speed 1, 3

• Weight Loss: Moderate strength recommendation for sustained weight loss in overweight or obese patients (BMI ≥25 kg/m²) to improve pain and function 1, 3

  • Even modest weight reduction can significantly reduce symptoms and slow disease progression 2, 4

• Patient Education: Strong recommendation for self-management programs to improve pain management 1, 3

  • Education about disease process, coping skills, and self-management strategies is essential 2, 3

• Manual Therapy: Limited evidence supports manual therapy in addition to exercise programs to improve pain and function 1, 3

Pharmacological Interventions

• Topical NSAIDs: Strong recommendation for improving function and quality of life when not contraindicated 1, 2

  • Should be considered early in the treatment plan due to favorable safety profile compared to oral NSAIDs 2

• Oral NSAIDs: Strong recommendation for improving pain and function when not contraindicated 1

  • For patients with increased gastrointestinal risk, either non-selective NSAIDs with gastroprotective agents or selective COX-2 inhibitors should be used 2

• Tramadol: Recommended for patients who have not responded to other pharmacological treatments 1, 2

• Paracetamol (Acetaminophen): Recommended as first-line oral analgesic for mild to moderate pain due to its favorable safety profile 2

Adjunctive Therapies

• Assistive Devices: Walking aids (canes) and knee braces can decrease weight burden, provide stability, and reduce pain 2, 5

• Transcutaneous Electrical Nerve Stimulation (TENS): Limited evidence supports its use for pain relief 1, 3

• FDA-approved Laser Treatment: Limited evidence supports its use to improve pain and function 1

• Massage: Limited evidence supports massage in addition to usual care to improve pain and function 1

Interventions Not Recommended

• Acupuncture: Not recommended due to lack of statistically significant evidence 1

• Glucosamine and Chondroitin: Not recommended despite limited evidence 1

• Vitamin D: Limited evidence supports its use 1

• Hyaluronic Acid Injections: Not recommended according to recent guidelines 1

Common Pitfalls to Avoid

• Delaying Physical Therapy: Early exercise intervention is crucial for maintaining function 3

• Over-reliance on Opioids: Can increase adverse events without effectively improving pain or function 2, 3

• Neglecting Weight Management: Failing to address weight in overweight patients negatively impacts outcomes 3, 4

• Inadequate Patient Education: Patient education has strong evidence for improving outcomes and should not be overlooked 3

Treatment Algorithm

1. Initial Management:

   • Start with patient education and self-management programs 1, 3
   • Prescribe appropriate exercise regimen (strengthening, aerobic, neuromuscular) 1, 2
   • Recommend weight loss for overweight/obese patients 1, 2

2. First-line Pharmacological Treatment:

   • Topical NSAIDs (when not contraindicated) 1, 2
   • Paracetamol for mild to moderate pain 2

3. Second-line Pharmacological Treatment:

   • Oral NSAIDs (with appropriate gastroprotection if needed) 1, 2
   • Consider tramadol for patients unresponsive to other treatments 1, 2

4. Adjunctive Therapies:

   • Assistive devices (canes, braces) 2, 5
   • TENS, massage, or FDA-approved laser treatment 1, 3

5. Advanced Disease Management:

   • Refer for surgical evaluation when conservative measures fail to provide adequate pain relief and functional improvement 2