What are the best ways to manage pain in my right knee?

Managing Right Knee Pain

Start with targeted exercise therapy combined with education as your primary intervention, regardless of the underlying cause, as this approach reduces pain and improves function across all major knee conditions including osteoarthritis, patellofemoral pain, and meniscal pathology. 1, 2

Initial Clinical Assessment

Determine the specific diagnosis through focused evaluation:

• Age and activity level guide your differential: patients under 40 with anterior knee pain during squatting likely have patellofemoral pain (91% sensitive), while those over 45 with activity-related pain and less than 30 minutes of morning stiffness likely have osteoarthritis (95% sensitive, 69% specific) 3

• Check for urgent referral criteria: severe pain with inability to bear weight after acute trauma, joint instability, or signs of infection (fever, erythema, swelling with limited range of motion) require immediate specialist evaluation 4

• Perform McMurray test (knee rotation with extension) if meniscal tear suspected—61% sensitive and 84% specific—though conservative management is still first-line even if positive 3

• Obtain plain radiographs only for chronic pain (>6 weeks) or acute traumatic pain meeting evidence-based criteria; do not order MRI without recent radiographs first 2, 5

Core Treatment Algorithm

First-Line Non-Pharmacological Management (All Patients)

Prescribe knee-targeted strengthening exercises as your primary intervention:

• Quadriceps strengthening reduces pain with effect size of 1.05 and improves function in osteoarthritis 1
• Hip and knee strengthening combined improves patellofemoral pain outcomes 1
• Exercise should be performed 5-7 times, 3-5 times daily (before getting out of bed, before stairs, before sleep) 1
• Modify intensity based on symptom irritability—use more hip-focused exercises if loaded knee flexion is poorly tolerated 1

Provide patient education as the foundation underlying all interventions:

• Explain that pain does not equal tissue damage, particularly for chronic symptoms 1
• Set realistic goals for recovery timeframes and expected outcomes 1
• Teach load management principles to build tissue tolerance 1

Recommend weight reduction if overweight or obese, as this reduces knee osteoarthritis risk and improves pain outcomes 1

Pharmacological Management

Start with acetaminophen (paracetamol) up to 4 grams daily as first-line oral analgesic:

• Provides pain relief comparable to NSAIDs without gastrointestinal risks 1, 2
• Preferred for long-term use in mild to moderate pain 1, 2

Progress to topical NSAIDs if acetaminophen inadequate:

• Topical applications have clinical efficacy with superior safety profile compared to oral NSAIDs 1

Consider oral NSAIDs (ibuprofen 400mg every 4-6 hours, maximum 3200mg daily) only if unresponsive to acetaminophen:

• Use lowest effective dose for shortest duration 6
• Ibuprofen 400mg provides equivalent analgesia to higher doses for acute pain 6
• In patients with gastrointestinal risk, add gastroprotective agents or use COX-2 selective inhibitors 1

Supporting Interventions Based on Clinical Findings

Add prefabricated foot orthoses for patellofemoral pain when biomechanical factors contribute:

• Test response with squat assessment (with/without orthoses) before prescribing 1
• Most beneficial short-term; customize for comfort by modifying density and geometry 1

Apply patellar taping when elevated symptom severity and irritability hinder rehabilitation:

• Provides symptom relief during activity for patellofemoral pain 1
• Reassess if no favorable outcomes after realistic trial period 1

Consider knee orthoses (sleeves, elastic bandages) for osteoarthritis:

• Small but consistent positive effects on pain 1

Recommend assistive devices (walking stick, insoles) for osteoarthritis with gait impairment:

• Controlled studies show improvement over control groups 1

Common Pitfalls to Avoid

• Do not order MRI routinely—approximately 20% of chronic knee pain cases inappropriately receive MRI without recent radiographs 2

• Do not perform surgery for degenerative meniscal tears—exercise therapy is first-line even with mechanical symptoms (locking, catching); surgery not indicated 3

• Do not rely solely on pharmacological management—drug therapy is most effective when used adjunctively with coordinated non-pharmacological strategies 1

• Do not prescribe high-impact aerobic exercise—rapid joint loading may worsen symptoms; use low-impact activities (walking, swimming, cycling, aquatic exercise) instead 1

When to Refer for Surgery

Consider joint replacement only for end-stage osteoarthritis with:

• Radiographic evidence of no or minimal joint space 1, 2
• Refractory pain and disability despite exhausting all appropriate conservative options 1, 2

Refer for arthroscopic surgery only for severe traumatic meniscal tears with displaced tissue (bucket-handle tears) 3