What is the initial management for a patient with a swollen knee due to osteoarthritis?

Initial Management of Swollen Knee from Osteoarthritis

For a patient presenting with a swollen knee due to osteoarthritis, begin with intra-articular corticosteroid injection for the acute effusion, combined with oral NSAIDs or acetaminophen for pain control, while simultaneously initiating a comprehensive non-pharmacological program including patient education, exercise therapy, and weight loss if overweight. 1, 2

Immediate Assessment Priorities

When examining a swollen knee from OA, your initial assessment must evaluate: 2

• Physical status: Specifically assess pain severity, presence and size of effusion, joint alignment, range of motion, quadriceps strength, and proprioception 2
• Functional impact: Walking ability, stair climbing capacity, and activities of daily living limitations 2
• Comorbidities: Weight/BMI, cardiovascular status, and contraindications to NSAIDs 2
• Psychosocial factors: Mood, health beliefs, and motivation to self-manage 2

Pharmacological Management Algorithm

First-Line for Acute Swelling

Intra-articular corticosteroid injection is indicated specifically for acute flares with effusion and serves as either monotherapy or adjunct to systemic therapy. 1, 3 This directly addresses the inflammatory component causing the swelling.

Concurrent Oral Analgesics

Choose based on patient factors: 2, 1

• Acetaminophen up to 4,000 mg/day (strong recommendation): Favorable safety profile with only 1.5% adverse events, making it appropriate as initial oral analgesic 2, 1
• Oral NSAIDs (strong recommendation): Recommended to improve pain and function when not contraindicated 2
• Topical NSAIDs (strong recommendation): Strongly preferred over oral NSAIDs for patients ≥75 years 2, 1

Critical pitfall: Avoid oral narcotics including tramadol—they result in notable increase of adverse events and are not effective at improving pain or function. 2

Non-Pharmacological Core Interventions (Initiate Immediately)

All patients must receive an individualized management plan including these five core elements: 2

1. Patient Education (Strong Recommendation)

Patient education programs are strongly recommended to improve pain. 2, 1 Education must specifically address: 2

• The nature of OA as a repair process triggered by various insults 2
• Individual causes and prognosis 2
• Activity pacing techniques 2
• Reinforcement at subsequent encounters with written/DVD/website materials 2

2. Exercise Therapy (Strong Recommendation)

Manual therapy combined with an exercise program is strongly recommended to improve pain and function. 2, 1 The exercise regimen should include: 2, 1

• Quadriceps and proximal hip girdle strengthening exercises 2
• Aerobic activity 2
• Range of motion and stretching exercises 2
• Neuromuscular training (balance, agility, coordination) to improve performance-based function and walking speed (moderate recommendation) 2

High-quality evidence shows sustained pain reduction and functional improvement for 2-6 months. 1

3. Weight Loss (Moderate Recommendation)

Sustained weight loss is recommended to improve pain and function in overweight and obese patients. 2, 1 Implement structured programs including: 2

• Regular self-monitoring of weight 2
• Increased physical activity 2
• Structured meal planning and portion control 2

4. Mechanical Factor Reduction

Address adverse mechanical factors: 2

• Appropriate footwear to reduce stress 2
• Walking aids (cane on opposite side) if needed 2
• Assistive technology as appropriate 2

5. Ongoing Monitoring

Provide individually tailored program with: 2

• Long-term and short-term goals 2
• Intervention/action plans 2
• Regular evaluation and follow-up with program adjustments 2

What NOT to Do

Do not routinely use (based on guideline recommendations): 2

• Hyaluronic acid intra-articular injections: Not recommended for routine use (moderate recommendation) 2
• Glucosamine and chondroitin: Limited recommendation with insufficient evidence 2
• Oral narcotics/tramadol: Strong recommendation against due to notable adverse events without efficacy 2

When Conservative Management Fails

If the patient remains unresponsive to comprehensive conservative therapy after adequate trial: 3

• Consider orthopedic consultation for evaluation 3
• Joint replacement is considered for end-stage OA (minimal/no joint space) with refractory pain and disability after exhausting conservative options 1

Key Clinical Pitfall

The most common error is relying solely on medications without implementing the core non-pharmacological interventions. 2 The evidence strongly supports that exercise, education, and weight management (when appropriate) form the foundation of treatment, with pharmacological options serving as adjuncts rather than primary therapy. 2, 1