What are the treatment options for hip and knee pain?

Treatment Options for Hip and Knee Pain

Begin with a structured self-management program combining exercise therapy, weight loss if overweight, and patient education, supplemented by topical NSAIDs for knee pain or oral NSAIDs/acetaminophen for both hip and knee pain. 1

Initial Treatment Approach

Non-Pharmacological Core Interventions

Exercise therapy is the cornerstone of management and must be implemented first. 1

• Physical therapy referral should be considered early based on pain severity and functional limitations, with a minimum of 12 supervised sessions showing superior outcomes compared to fewer sessions 1
• Exercise programs should include hip and knee strengthening, with progressive loading in both open and closed chain movements 1, 2
• Treatment duration must be at least 3 months to demonstrate effectiveness; if no improvement occurs after 6 weeks, reassess rather than continuing the same approach 3

Weight loss programs are recommended for overweight/obese patients with structured goals of 4-7 kg reduction, delivered through weekly supervised sessions 1

Bracing is strongly recommended for knee osteoarthritis when disease causes sufficient impact on ambulation, joint stability, or pain 1

• Tibiofemoral knee braces for general knee OA 1
• Patellofemoral braces for patellofemoral knee OA 1
• Must be combined with appropriate exercise to prevent atrophy 1

Assistive devices including canes should be prescribed when disease impacts ambulation 1

Mind-Body Interventions

Tai chi is strongly recommended for knee and hip OA, combining meditation with gentle movements, breathing exercises, and relaxation 1

Yoga is conditionally recommended for knee OA only (insufficient evidence for hip) 1

Cognitive behavioral therapy may reduce pain and improve coping in chronic knee, hip, or hand OA 1

Pharmacological Management

First-Line Pharmacotherapy

For knee pain:

• Topical NSAIDs (diclofenac) are strongly recommended as first-line with superior efficacy to placebo, equivalent pain relief to oral NSAIDs, but markedly fewer gastrointestinal adverse events 1
• Topical capsaicin is conditionally recommended for knee OA 1

For hip and knee pain:

• Acetaminophen and/or oral NSAIDs are suggested for initial treatment 1
• Oral NSAIDs demonstrate superiority to acetaminophen in moderate-to-severe OA pain 1

Second-Line and Combination Therapy

Duloxetine (60 mg daily) is recommended as alternative or adjunctive therapy when acetaminophen/NSAIDs are inadequate or contraindicated 1

• Start at 30 mg/day, increase to goal of 60 mg/day 1
• Must be taken daily (not as needed) and tapered over 2-4 weeks when discontinuing after >3 weeks of therapy 1
• Demonstrates significant reductions in pain and improvements in physical function 1

Intra-articular corticosteroid injections are suggested for persistent knee or hip pain inadequately relieved by other interventions 1

• Hip injections must be image-guided due to joint depth and proximity to neurovascular structures 1
• Knee injections do not require image guidance 1
• Avoid within 3 months preceding joint replacement surgery 1
• Effects are time-limited without long-term improvement at 2-year follow-up 1
• Repeat injections may cause negative effects on bone health, joint structure, and meniscal thickness 1

Medications to Avoid

Opioids (including tramadol) are recommended against for hip and knee OA pain 1

• Limited benefit with high risk of adverse effects (relative risk 1.28-1.69) 1
• Significantly worse withdrawal symptoms, study withdrawal due to adverse events, and serious adverse events compared to placebo 1

Surgical Referral Criteria

Consider surgical consultation when: 1

• End-stage OA with minimal/no joint space on weight-bearing radiographs 1
• Inability to cope with pain after exhausting all appropriate conservative options 1, 4
• Obtain weight-bearing plain radiographs before surgical referral 1

Common Pitfalls

Avoid these errors:

• Ordering MRI for diagnosis of hip/knee OA (not recommended) 1
• Continuing same treatment beyond 6 weeks without reassessment if no improvement 3
• Prescribing opioids for OA pain management 1
• Performing hip corticosteroid injections without image guidance 1
• Administering corticosteroid injections within 3 months of planned joint replacement 1

For patellofemoral pain specifically (typically age <40 years, anterior knee pain with squatting): hip and knee strengthening exercises combined with foot orthoses or patellar taping are recommended, with no indication for surgery 1, 2

For meniscal tears: conservative management with exercise therapy for 4-6 weeks is first-line treatment; surgery is not indicated for degenerative tears even with mechanical symptoms 2