What are the treatment options for limited range of motion of the knee with pain?

Treatment of Limited Knee Range of Motion with Pain

Begin with a structured exercise program focused on range-of-motion exercises for extension first, followed by flexion exercises, before progressing to strengthening—this approach has prevented 76% of patients from requiring knee replacement surgery. 1

Initial Assessment and Diagnosis

Obtain radiographs including AP, lateral, sunrise/Merchant, and tunnel views to evaluate for underlying pathology such as osteoarthritis, osteochondritis dissecans, or intra-articular disorders. 2, 3 Consider MRI only if radiographs show joint effusion with persistent symptoms, or when concomitant pathology (meniscal tears, ligament injury) is suspected. 2, 3

Non-Pharmacological Treatment (First-Line)

Exercise Therapy - The Foundation

Implement a systematic ROM-based rehabilitation program in this specific sequence: 1

• Start with knee extension exercises to address extension deficits first 1
• Progress to flexion exercises once extension improves 1
• Add swelling reduction techniques before strengthening 1
• Finally incorporate strengthening exercises (particularly quadriceps strengthening) 4, 5

This sequential approach produced significant improvements in both extension and flexion ROM, with extension deficits decreasing from 13.6° to 3° and flexion increasing from 91.6° to 117.8°. 1

Mobilization Techniques

Mobilization with movement (MWM) provides Grade A evidence for reducing knee pain and increasing ROM, either alone or combined with conventional therapy. 6 This manual therapy technique demonstrates superior results compared to standard care alone. 6

Additional Exercise Components

• Low-impact aerobic exercise (walking, cycling, swimming) for 30-60 minutes most days of the week, with effect sizes of 0.52 for pain relief and 0.46 for disability reduction 4, 5
• Supervised exercise programs are more effective than self-directed programs, with at least 12 supervised sessions recommended 5
• Aquatic exercises in warm water provide additional pain relief through reduced joint loading 5

Weight Management

Achieve at least 5% body weight reduction if BMI ≥25 kg/m², combining dietary modification with exercise for optimal functional improvement. 4, 5

Assistive Devices and Bracing

• Tibiofemoral knee braces are strongly recommended when disease causes significant impact on ambulation, joint stability, or pain 2
• Cane use is strongly recommended for patients with substantial functional impairment 2
• Kinesiotaping is conditionally recommended as it permits ROM while providing support 2

Pharmacological Treatment (Adjunctive)

Oral Medications

Start with acetaminophen for mild-to-moderate pain, then escalate as needed: 4, 7

• Topical NSAIDs (strongly recommended for knee OA) before oral NSAIDs to minimize systemic exposure 2, 4
• Oral NSAIDs at lowest effective dose (such as naproxen 375-750 mg twice daily) for patients unresponsive to acetaminophen, using gastroprotective agents or COX-2 inhibitors for those at increased GI risk 2, 4, 8
• Tramadol for moderate-to-severe pain unresponsive to NSAIDs 4

Topical Agents

• Topical capsaicin has demonstrated clinical efficacy and safety 2, 4

Intra-articular Injections

Corticosteroid injections are indicated for pain flares, especially with effusion, providing targeted relief for acute exacerbations. 4, 7

Advanced Interventions

Arthroscopic Arthrolysis

Consider arthroscopic arthrolysis for intra-articular scar tissue causing ROM limitation (flexion deficit ≤40°, extension deficit ≤20°), particularly after previous surgery or trauma. 9 This minimally invasive approach releases adhesions, removes fibrotic tissue, and preserves cruciate ligaments. 9

Surgical Referral

Refer for joint replacement evaluation when radiographic OA is present with refractory pain and disability despite 3-6 months of comprehensive conservative management. 4, 7

Complementary Approaches

• Cognitive behavioral therapy (CBT) is conditionally recommended to address pain, mood, and coping strategies 2
• Acupuncture is conditionally recommended though evidence remains controversial 2
• Self-management education programs help with goal-setting and problem-solving 4, 5

Critical Pitfalls to Avoid

Do not use lateral or medial wedged insoles—they are conditionally recommended against due to lack of clear efficacy. 2 Avoid massage therapy as it lacks evidence for OA-specific outcomes despite patient preference. 2 Do not order MRI without recent radiographs first, as this occurs inappropriately in 20% of cases. 3 Avoid high-impact exercises that may accelerate joint damage. 5

Treatment Algorithm Summary

1. Obtain radiographs (4 views) 2, 3
2. Initiate ROM exercises (extension → flexion → swelling reduction → strengthening) 1
3. Add MWM therapy for enhanced ROM gains 6
4. Implement weight loss if BMI ≥25 4, 5
5. Start topical NSAIDs for pain control 2, 4
6. Progress to oral NSAIDs if inadequate response 4, 8
7. Consider bracing/assistive devices for functional support 2
8. Use intra-articular steroids for acute flares with effusion 4, 7
9. Refer for arthroscopic arthrolysis if intra-articular adhesions persist 9
10. Refer for arthroplasty if conservative measures fail after 3-6 months 4, 7