What are the conservative management options for knee osteoarthritis?

Conservative Management of Knee Osteoarthritis

Initial Non-Pharmacological Interventions (First-Line Treatment)

Begin with exercise therapy and weight management as the foundation of treatment, as these interventions have the strongest evidence for reducing pain and improving function in knee osteoarthritis. 1, 2, 3

Exercise Programs

• Strongly recommend both land-based and aquatic exercise programs that include aerobic conditioning, quadriceps strengthening, and neuromuscular training—no single type is superior to another. 1, 2, 3
• Supervised exercise programs produce better outcomes than unsupervised programs, particularly for patients with multiple comorbidities where safety monitoring is essential. 2, 3
• Refer to physical therapy for structured programming and proper instruction, as this provides significant benefits beyond general exercise advice. 3
• Walking, resistance training, and aquatic exercise are all effective modalities that can be selected based on patient preference and functional capacity. 1, 2

Weight Management

• Strongly recommend weight loss for all overweight or obese patients (BMI >28 kg/m²), as even modest weight reduction significantly improves pain and function. 2, 3, 4
• A combined diet and exercise approach is most effective for sustained weight reduction compared to either intervention alone. 2, 3

Patient Education

• Provide education about the diagnosis, disease course, and appropriate activities to enhance self-management and set realistic expectations. 3, 5
• Self-management education programs reduce pain and increase coping skills. 5

Pharmacological Management (Stepwise Approach)

First-Line Pharmacological Options

• Start with topical NSAIDs as initial pharmacological therapy due to lower systemic exposure and favorable safety profile, particularly important for patients with cardiovascular or gastrointestinal comorbidities. 1, 2, 3
• Acetaminophen (up to 3,000-4,000 mg/day) can be used for mild to moderate pain, though efficacy is modest; ensure patients are not taking other acetaminophen-containing medications. 2, 3

Second-Line Pharmacological Options

• Prescribe oral NSAIDs (ibuprofen, diclofenac, naproxen) if topical NSAIDs and acetaminophen provide inadequate relief, using the lowest effective dose for the shortest duration. 1, 2, 3, 6, 4
• Consider COX-2 selective NSAIDs with gastroprotection for patients at higher gastrointestinal risk. 2
• Monitor blood pressure closely in hypertensive patients taking NSAIDs, as these medications can worsen blood pressure control and increase cardiovascular risk. 3
• In patients with diabetes, monitor glycemic control as NSAIDs may affect insulin sensitivity. 2

Intra-Articular Injections

• Administer intra-articular corticosteroid injections for acute pain flares, especially when joint effusion is present, with benefits typically lasting up to 3 months. 1, 2, 3, 4
• Limit frequency to 3-4 injections per year to minimize potential cartilage damage. 2
• Monitor glucose levels in diabetic patients following corticosteroid injections. 2
• Intra-articular hyaluronic acid has mixed evidence but may be considered in select patients. 4, 7

Assistive Devices and Bracing

• Strongly recommend tibiofemoral braces for tibiofemoral compartment osteoarthritis to reduce pain and improve function. 1
• Conditionally recommend patellofemoral braces specifically for patellofemoral osteoarthritis. 1
• Braces and heel wedges decrease pain and improve function in appropriate patients. 7

Advanced Conservative Interventions

For Refractory Cases

• Consider genicular nerve blocks for patients who have failed exercise programs, weight loss, oral analgesics, and intra-articular corticosteroid injections. 2
• Radiofrequency ablation may be an option for chronic pain unresponsive to other conservative measures. 1

Treatment Algorithm

Follow this stepwise approach:

1. Initiate immediately: Exercise program (supervised if possible) + weight loss (if BMI >28) + patient education 1, 2, 3
2. Add if inadequate response: Topical NSAIDs 1, 2, 3
3. Escalate if needed: Oral NSAIDs (with appropriate monitoring) 1, 2, 3
4. For acute flares: Intra-articular corticosteroid injections 1, 2, 3
5. Consider assistive devices: Bracing for appropriate compartment involvement 1
6. Refractory cases: Genicular nerve blocks or radiofrequency ablation 1, 2
7. Surgical referral: Total knee arthroplasty when conservative management fails 2, 3

Critical Pitfalls to Avoid

• Do not advise "general exercise" without providing a structured program or physiotherapy referral—this represents a significant evidence-performance gap where patients receive inadequate guidance. 8
• Do not combine NSAIDs with aspirin, as aspirin increases naproxen excretion and the combination increases adverse events without additional benefit. 6
• Do not perform arthroscopic surgery for knee osteoarthritis, as it has been shown to have no benefit. 7
• Do not overlook cardiovascular risk when prescribing NSAIDs—these medications increase risk of cardiovascular adverse effects, particularly in patients with hypertension. 3
• Do not fail to address mechanical factors such as alignment abnormalities and muscle weakness, which significantly impact outcomes. 5

Monitoring Requirements

• Assess pain levels, functional capacity, and medication side effects at regular intervals. 2, 3
• Adjust treatment based on response and tolerance rather than following a rigid protocol. 2, 3
• Monitor blood pressure in patients on NSAIDs, particularly those with pre-existing hypertension. 3
• Check glucose control in diabetic patients receiving corticosteroid injections. 2