What are the recommended management strategies for usual joint pains?

Management of Usual Joint Pains

Start with exercise as the cornerstone of treatment—it is strongly recommended for all joint pain patients and should be combined with weight management if overweight, followed by oral NSAIDs or acetaminophen for additional symptom control when needed. 1

Initial Non-Pharmacologic Management (First-Line)

Exercise Therapy (Strongly Recommended)

• Exercise is the single most important intervention for joint pain and should be initiated immediately. 1
• Begin with low-intensity range-of-motion exercises as a 5-10 minute warm-up phase. 1
• Progress to strengthening exercises targeting muscles around affected joints—perform 5-7 repetitions, 3-5 times daily (before getting out of bed, before climbing stairs, before sleep). 1
• For knee/hip pain: quadriceps sets, gluteal squeezes, and short-arc knee extensions holding each contraction for 6-7 seconds with 2-3 seconds rest between repetitions. 1
• Avoid high-impact aerobic training as rapid joint loading causes more damage than the magnitude of load itself. 1
• Pool exercises in warm water (86°F) are particularly beneficial as buoyancy reduces joint loading while providing resistance for strengthening. 1

Weight Management

• If the patient is overweight or obese, weight reduction interventions must be provided as they directly reduce joint loading and pain. 1

Self-Management Programs

• Offer structured self-management education programs that incorporate self-efficacy training. 1
• Physical and occupational therapy referral is helpful for proper exercise instruction, fitting of splints/braces, and thermal therapy guidance. 1

Pharmacologic Management (Adjunctive to Exercise)

First-Line Pharmacologic Options

• Acetaminophen is the preferred first-line medication for mild to moderate joint pain, dosed up to 4 grams daily (not exceeding this maximum). 1, 2
• Acetaminophen provides pain relief comparable to NSAIDs without gastrointestinal risks. 1

Second-Line Pharmacologic Options

• If acetaminophen is insufficient, trial oral NSAIDs (ibuprofen 400mg every 4-6 hours as needed, maximum 3200mg daily). 1, 3
• For osteoarthritis specifically: 1200-3200mg ibuprofen daily divided into 3-4 doses with meals or milk to reduce GI complaints. 3
• Critical caveat: NSAIDs carry significant risks in elderly patients including GI bleeding, platelet dysfunction, and nephrotoxicity—avoid high doses for prolonged periods. 1
• Take detailed medication histories including over-the-counter use to identify drug-drug and drug-disease interactions (heart failure, hypertension, renal/hepatic disease). 1

For Patients with GI Risk Factors

• If history of gastroduodenal ulcers, GI bleeding, or development of GI symptoms, consider COX-2 selective inhibitors (celecoxib, rofecoxib) which provide equivalent pain relief with lower GI toxicity. 1

What NOT to Do

Avoid These Interventions

• Do not use glucosamine or chondroitin—they do not modify disease. 1
• Do not offer paracetamol (acetaminophen) as monotherapy for chronic low back pain specifically. 1
• Do not prescribe opioids for chronic joint pain—they carry significant risks without clear benefit. 1
• Do not perform knee arthroscopic lavage/debridement unless mechanical locking is present. 1
• Never combine NSAIDs with opioids—this increases risk without additional benefit. 4, 5

Treatment Algorithm Structure

1. Immediate initiation: Exercise program + weight management (if applicable)
2. Add if needed: Acetaminophen up to 4g daily
3. Escalate if insufficient: Oral NSAIDs at lowest effective dose for shortest duration
4. Modify if GI risk: Switch to COX-2 selective inhibitors
5. Reassess regularly: If no improvement after 2 weeks of comprehensive treatment, reconsider diagnosis and evaluate for inflammatory arthritis or structural damage requiring specialist referral 1

Common Pitfalls to Avoid

• Do not skip exercise and go straight to medications—non-pharmacologic therapy must be the foundation, with drugs as adjuncts only. 1
• Do not use NSAIDs long-term without reassessing risk-benefit, especially in elderly patients with cardiovascular, renal, or GI comorbidities. 1
• Do not assume all joint pain is osteoarthritis—evaluate for inflammatory conditions, infection, or structural damage requiring different management. 6
• Do not prescribe irreversible treatments (permanent dental alterations, discectomy) before exhausting conservative options. 4, 5