What is the approach to assess and manage knee pain?

Assessment and Management of Knee Pain

Initial Assessment

A biopsychosocial approach is essential for the initial assessment of knee pain, including evaluation of physical status, activities of daily living, participation, mood, and health education needs. 1

The assessment should include:

• Physical examination components:

  • Pain characteristics (location, onset, duration, quality) 2
  • Observable signs of inflammation (effusion, erythema) 2
  • Joint status assessment (mobility, strength, alignment) 1
  • Palpation for point tenderness 3
  • Range of motion and strength testing 1
  • Neurovascular testing 4
  • Special provocative tests for specific conditions 4

• Risk factor evaluation:

  • Knee-specific factors (obesity, adverse mechanical factors, physical activity) 1
  • General factors (age, comorbidity, polypharmacy) 1
  • Pain intensity and disability level 1
  • Signs of inflammation (effusion) 1
  • Location and degree of structural damage 1

• Imaging considerations:

  • Obtain radiographs for chronic knee pain (>6 weeks) or in patients with:
    • Isolated patellar tenderness or tenderness at fibular head 3
    • Inability to bear weight or flex knee to 90 degrees 3
    • Age greater than 55 years 3
  • Include frontal projection, tangential patellar view, and lateral view 2
  • Avoid ordering MRI without recent radiographs 2

Management Based on Clinical Presentation

For Osteoarthritis

Non-pharmacological interventions should be the first-line treatment for knee osteoarthritis, including education, individualized exercise, weight reduction if needed, and appropriate assistive devices. 1, 2

• Education and exercise:

  • Provide individualized education packages 1
  • Prescribe joint-specific exercises to reduce pain and improve function 1
  • Consider both strength/range of motion exercises and aerobic conditioning 1
  • Exercise can be supervised (land or water) or home-based 1

• Weight management:

  • Recommend weight reduction for overweight/obese patients 1, 2
  • Weight loss has been shown to reduce risk of knee OA 1

• Assistive devices:

  • Consider appropriate footwear, walking sticks, insoles, and knee bracing 1, 2

• Pharmacological management:

  • Start with paracetamol as first-line oral analgesic 1, 2
  • If inadequate response, consider topical NSAIDs or capsaicin 1, 2
  • For patients unresponsive to paracetamol, consider oral NSAIDs at lowest effective dose 2, 5
    • Naproxen has shown effectiveness for osteoarthritis with reduction in joint pain and improved mobility 5
    • Celecoxib 100mg twice daily or 200mg once daily has demonstrated significant reduction in pain within 24-48 hours 6
  • Consider intra-articular corticosteroid injection for flares with effusion 1

For Patellofemoral Pain

Hip and knee strengthening exercises combined with patellar taping should be the primary treatment for patellofemoral pain. 1, 2

• Exercise therapy:

  • Prescribe individualized knee-targeted exercise therapy 1
  • Consider hip exercises for patients with poor tolerance to loaded knee flexion 1

• Supporting interventions:

  • Use prefabricated foot orthoses when biomechanical factors contribute 1, 2
  • Apply taping when rehabilitation is hindered by symptom severity 1
  • Consider movement/running retraining for task-specific biomechanical issues 1

Special Considerations

• Rule out referred pain from hip or lumbar spine if knee radiographs are unremarkable 2

• Consider additional imaging only when initial radiographs are normal or show joint effusion and symptoms persist despite appropriate management 2

• For persistent pain despite conservative treatment, consider:

  • Intra-articular injections 7
  • Radiofrequency treatment of genicular nerves 7
  • Multidisciplinary approach including psychological therapy and integrative treatments 7
  • Surgical consultation for refractory cases 1

• Common pitfalls to avoid:

  • Ordering MRI without recent radiographs (occurs in ~20% of chronic knee pain cases) 2
  • Failing to assess for systemic conditions that may present with knee pain 4
  • Neglecting to evaluate the impact of knee pain on function and quality of life 1
  • Inadequate trial of conservative management before considering invasive interventions 7