What is the recommended initial management for a 69-year-old male patient with bilateral knee pain, primarily affecting the medial aspect of both knees?

Initial Management of Bilateral Medial Knee Pain in a 69-Year-Old Male

The cornerstone of initial management should be a structured exercise program combining quadriceps strengthening, low-impact aerobic activity, and range-of-motion exercises, performed at least 3 times weekly, ideally with supervised sessions initially. 1, 2

First-Line Non-Pharmacological Interventions

Exercise Therapy (Highest Priority)

• Initiate quadriceps strengthening exercises (sustained isometric) for both legs, regardless of which knee hurts more 1
• Add low-impact aerobic exercises such as walking, cycling, or swimming for 30-60 minutes most days of the week 2
• Include range-of-motion/stretching exercises as adjunctive therapy 1
• Aim for at least 12 supervised sessions initially, as supervised programs demonstrate superior outcomes compared to self-directed programs 2
• Exercise should be performed at least 3 times per week, with gradual intensity increases over several months 1, 2
• Pain during exercise should not prevent participation—clinical trials show improvements even when patients experience pain during activity 2

Weight Management (If Applicable)

• If the patient is overweight, strongly recommend weight loss with a minimum 5% reduction in body weight 1, 2
• Combine dietary modification with exercise: reduce saturated fat and sugar intake, limit salt, increase fruit and vegetables (at least 5 portions daily), limit portion sizes 1
• Implement regular self-monitoring with monthly weight recording and support meetings 1

Assistive Devices and Footwear

• Recommend appropriate and comfortable shoes 1
• Do NOT prescribe lateral wedge insoles for medial compartment knee pain—evidence shows limited effectiveness and potential for increased symptoms 1
• Consider a walking stick used on the contralateral side if pain significantly impacts ambulation 1
• Consider increasing height of chairs and toilet seats to reduce knee stress 1

Pharmacological Management

Oral Medications

• Start with acetaminophen (paracetamol) as the first-line oral analgesic—it is the preferred long-term option if successful 1
• If acetaminophen is insufficient, consider oral NSAIDs for patients unresponsive to acetaminophen 1

Topical Therapy

• Topical NSAIDs (such as diclofenac sodium topical solution 2%) can be applied to clean, dry skin: 2 pump actuations (40 mg) on each painful knee, twice daily 3
• Apply evenly around front, back, and sides of the knee without massaging 3
• Avoid showering/bathing for at least 30 minutes after application 3
• Wait until the treated area is completely dry before covering with clothing 3

Adjunctive Therapies

• Patellar taping may provide short-term relief of pain and improvement in function (effects most notable immediately and within 4 days of application) 1
• Kinesiotaping is conditionally recommended for knee OA 1

Injection Therapy (If Conservative Measures Fail)

• Intra-articular corticosteroid injection is indicated for acute exacerbation of knee pain, especially if accompanied by effusion 1
• For persistent medial knee pain unresponsive to standard superolateral approach injections, consider ultrasound-guided anteromedial joint line (AMJL) approach targeting the medial compartment 4
• The AMJL approach shows 92.3% positive response rates at 11-week follow-up in patients with medial knee pain 4

Patient Education and Self-Management

• Enroll in self-management education programs to help with goal-setting, problem-solving, and coping strategies 2
• Teach the patient to link exercise regimens to daily activities (e.g., before morning shower or meals) so they become part of lifestyle 1
• Emphasize "small amounts often" (pacing) as an important principle 1
• Consider cognitive behavioral therapy (CBT) to address pain, mood, and coping 1

Important Caveats

• Avoid high-impact exercises as they may increase joint damage 2
• Do not combine topical NSAIDs with oral NSAIDs unless benefit outweighs risk, and conduct periodic laboratory evaluations if combination therapy is necessary 3
• Evidence for valgus-directing braces in medial compartment OA is inconclusive, though tibiofemoral knee braces are strongly recommended if disease causes sufficient impact on ambulation or joint stability 1
• The bilateral nature of this patient's symptoms (with both knees showing medial pain) suggests high risk for progressive bilateral medial OA—90% of patients with medial knee OA either have concurrent or develop contralateral medial OA within 10 years 5