What is the best nonsteroidal anti-inflammatory drug (NSAID) for a knee injury?

Best NSAID for Knee Injury

For knee injuries, ibuprofen is the recommended first-line NSAID due to its favorable efficacy and safety profile, with topical NSAIDs like diclofenac being an excellent alternative for those who cannot tolerate oral NSAIDs. 1

Treatment Algorithm

First-Line Treatment:

• Start with paracetamol (acetaminophen) 4g/day as the initial oral analgesic for mild knee pain 1
• If paracetamol is ineffective or the injury shows signs of inflammation, proceed to NSAIDs 1

NSAID Selection:

1. Oral Ibuprofen

   • Recommended dosage: 1200-2400 mg/day 1, 2
   • Provides approximately 50-60% improvement over placebo in knee pain 2
   • Effective for both analgesic and anti-inflammatory effects 3

2. Topical NSAIDs

   • Excellent alternative for those unable to tolerate oral NSAIDs 1
   • Topical diclofenac shows high efficacy (effect size 0.91 compared with placebo) 1
   • Fewer systemic side effects than oral NSAIDs 4

3. Other Oral NSAIDs

   • Naproxen (750 mg/day) may provide greater pain reduction than paracetamol but with increased risk of gastrointestinal side effects 1, 5

Evidence Comparison

Efficacy:

• Randomized controlled trials have shown that ibuprofen at both analgesic (1200 mg/day) and anti-inflammatory doses (2400 mg/day) provides significant pain relief for knee conditions 3
• Naproxen has demonstrated greater pain reduction than paracetamol (effect size 0.32 after 42 days and 0.45 after 730 days) 1
• Topical diclofenac has shown impressive efficacy with an effect size of 0.91 compared to placebo 1

Safety Considerations:

• Oral NSAIDs carry risks of gastrointestinal, cardiovascular, and renal adverse effects 6
• Ibuprofen has a more favorable safety profile compared to other NSAIDs, particularly at lower doses 2
• In a year-long trial comparing ibuprofen to aspirin, only 7% of ibuprofen users discontinued due to adverse effects compared to 16% of aspirin users 7
• Topical NSAIDs show equivalent efficacy to oral preparations with fewer systemic side effects 4

Special Considerations

• Inflammatory Component: NSAIDs are particularly beneficial for knee injuries with signs of inflammation or effusion 1
• Duration of Treatment: Short-term use (days to weeks) minimizes risk of adverse effects 6
• Patient Factors: Consider:
  • Age (older patients have higher risk of adverse effects) 1
  • Comorbidities (especially gastrointestinal, cardiovascular, or renal conditions) 6
  • Concomitant medications 1

Common Pitfalls to Avoid

• Overreliance on NSAIDs: NSAIDs should be part of a comprehensive approach including rest, ice, compression, and elevation for acute injuries 1
• Prolonged Use: Extended use increases risk of adverse effects; use for shortest duration necessary 6
• Inadequate Dosing: Subtherapeutic doses may not provide sufficient anti-inflammatory effect 2
• Ignoring Contraindications: Assess for history of GI bleeding, cardiovascular disease, renal impairment before prescribing 6

Conclusion for Clinical Practice

For knee injuries, a stepwise approach is recommended:

1. Try paracetamol first for mild pain
2. If ineffective or if inflammation is present, use ibuprofen at 1200-2400 mg/day
3. Consider topical NSAIDs (particularly diclofenac) if oral NSAIDs are contraindicated or poorly tolerated
4. For severe cases with significant inflammation, consider short-term higher-dose therapy followed by the lowest effective dose 1