What are the non-surgical management options for knee osteoarthritis?

Non-Surgical Management of Knee Osteoarthritis

The most effective non-surgical management of knee osteoarthritis includes education, structured exercise, weight loss as core treatments, with topical NSAIDs as first-line pharmacological therapy, followed by oral NSAIDs and intra-articular injections for persistent pain. 1

Core Treatments

• Education about the condition and its management is a fundamental component of knee OA treatment, helping patients understand their condition and participate actively in their care 1
• Structured exercise programs, including both land-based and aquatic exercises, are strongly recommended to improve pain and function 1
• Weight loss is strongly recommended for overweight and obese patients with knee OA, as it reduces joint loading and improves pain, physical function, and mobility 1, 2
• Self-management programs that incorporate exercise and weight loss strategies should be offered to all patients with knee OA 1
• Physical therapy should be included as part of a comprehensive management plan, focusing on strengthening exercises and improving range of motion 1, 2

First-Line Pharmacological Treatment

• Topical NSAIDs are recommended as the first-line pharmacological treatment for knee OA due to their effectiveness and lower risk of systemic side effects 1, 3
• Topical capsaicin may be offered as an alternative topical agent for pain management in knee OA 1, 3

Second-Line Pharmacological Options

• Oral NSAIDs (both non-selective and COX-2 selective) are recommended when topical treatments provide inadequate relief, but should be used at the lowest effective dose for the shortest duration possible due to potential gastrointestinal, cardiovascular, and renal risks 1, 4
• Acetaminophen may be offered, though there is disagreement between guidelines about its effectiveness - ESCEO recommends low-dose, short-term use while OARSI recommends against it 1
• Duloxetine can be considered as an alternative or adjunctive therapy for patients with inadequate response to acetaminophen or NSAIDs 1, 3

Intra-articular Treatments

• Intra-articular corticosteroid injections are recommended for patients with persistent pain inadequately relieved by other interventions 1, 5
• There is disagreement regarding viscosupplementation (hyaluronic acid injections) - some guidelines support their use while others find evidence inconclusive 2

Controversial Treatments

• Pharmaceutical-grade glucosamine and chondroitin sulfate are recommended by ESCEO but strongly discouraged by OARSI 1, 6
• Opioids, including tramadol, should be avoided as initial therapy for knee OA pain management due to limited efficacy and significant risk of adverse effects 1, 3

Adjunctive Treatments

• Bracing (including soft braces, valgus or varus knee braces) may improve pain and self-reported physical function 1, 2
• Appropriate footwear and assistive devices (canes, walkers) can help reduce pain and improve function 2

Treatment Algorithm

1. Start with core treatments for all patients: education, structured exercise, and weight loss if overweight 1
2. Add topical NSAIDs as first-line pharmacological treatment 1
3. If inadequate response, consider oral NSAIDs at lowest effective dose for shortest duration 1, 4
4. For patients with contraindications to NSAIDs, consider duloxetine 1, 3
5. For persistent pain despite above measures, consider intra-articular corticosteroid injections 1, 5
6. Consider bracing and assistive devices as adjunctive treatments 1, 2

Common Pitfalls and Caveats

• Lack of adherence to exercise and weight loss programs is common; regular follow-up and encouragement can improve compliance 7
• Only 19% of patients use all guideline-consistent treatments, highlighting the need for better education and implementation 7
• NSAIDs should be used cautiously in patients with cardiovascular, gastrointestinal, or renal comorbidities 4
• Intra-articular corticosteroid injections should be limited in frequency (typically no more than 3-4 per year) to avoid potential cartilage damage 5
• Opioids should be avoided due to their limited efficacy and significant risk of adverse effects 1, 3
• Arthroscopic procedures have not shown benefit over sham procedures or optimized physical and medical therapy for knee OA 6