What are the options for non-surgical management of osteoarthritis (OA) of the knee?

Non-Surgical Management of Knee Osteoarthritis

All patients with knee osteoarthritis should begin with the triad of patient education, structured exercise programs, and weight loss (if overweight), as these core interventions improve pain, function, and quality of life regardless of disease severity. 1

Core Non-Pharmacological Treatments (Universal for All Patients)

Patient Education and Self-Management

• Provide structured education about the disease process, prognosis, and treatment expectations to improve self-efficacy and adherence 1
• Implement formal self-management programs that teach patients how to monitor symptoms and adjust activities 1

Exercise Programs

• Prescribe structured exercise as the foundation of treatment, including land-based strengthening, aerobic exercise, and aquatic therapy 1
• Exercise reduces pain and improves function with substantial evidence supporting its effectiveness 1, 2
• Ensure patients understand that exercise should be continued long-term, not just during acute flares 3

Weight Loss

• For overweight or obese patients (BMI ≥25), weight reduction is mandatory as it improves pain, physical function, mobility, and quality of life by reducing cumulative joint loading 1
• Weight loss is particularly effective for knee OA compared to hip OA 1

Physical Therapy

• Offer formal physical therapy as part of comprehensive management, focusing on strengthening exercises and range of motion 1, 2
• Physical therapy provides significant improvements in pain and function but requires addressing barriers to compliance (cost, transportation, time commitment) 3

Pharmacological Management Algorithm

First-Line: Topical Agents

• Start with topical NSAIDs for knee OA as they provide effective pain relief with lower systemic side effects compared to oral medications 1, 4
• Topical capsaicin can be offered as an alternative topical agent for pain management 1, 4

Second-Line: Oral Medications

• If topical agents are insufficient, add acetaminophen and/or oral NSAIDs for pain control 1, 4
• Oral NSAIDs are more effective than acetaminophen for moderate-to-severe pain but carry gastrointestinal and cardiovascular risks 2, 5
• Use NSAIDs continuously rather than intermittently for optimal effect 3
• Consider duloxetine as alternative or adjunctive therapy for patients with inadequate response or contraindications to acetaminophen/NSAIDs 1

Controversial Agents (Guideline Disagreement)

• ESCEO recommends pharmaceutical-grade glucosamine and chondroitin sulfate for symptom relief 1
• OARSI strongly recommends against all glucosamine and chondroitin formulations due to lack of convincing efficacy 1
• Given this major disagreement between high-quality guidelines, avoid these agents as primary therapy and reserve them only for patients who have failed standard treatments and request them specifically 1

Opioids: Avoid

• Do not initiate opioids (including tramadol) for knee OA pain due to poor risk-benefit ratio 1, 4
• The VA/DoD and OARSI guidelines recommend against opioid use without exceptions 4
• If patients are already on long-term opioids, refer to opioid management guidelines for tapering 1

Intra-Articular Injections for Persistent Pain

Corticosteroid Injections

• Offer intra-articular corticosteroid injections for persistent pain inadequately relieved by oral medications and physical therapy 1, 4
• These provide effective short-term pain relief (weeks to months) 2, 3

Hyaluronic Acid Injections (Controversial)

• Evidence for hyaluronic acid is mixed across guidelines 4, 3
• ACR/AF recommends against hyaluronic acid, while OARSI and VA/DoD conditionally support its use 4
• Given conflicting evidence, reserve hyaluronic acid for patients who have failed corticosteroid injections and are not surgical candidates 4

Mechanical Interventions

Bracing

• Offer knee bracing (soft braces, valgus, or varus braces) for patients with mechanical malalignment or instability 1, 3
• Bracing improves pain and self-reported physical function and may delay time to surgery 3
• Critical caveat: Bracing must be combined with appropriate exercise programs to prevent muscle atrophy and functional loss 1

Treatment Sequencing Strategy

1. Initiate immediately: Education + structured exercise + weight loss (if applicable)
2. Add topical NSAIDs for symptomatic relief
3. If inadequate response after 2-4 weeks: Add oral NSAIDs or acetaminophen
4. If still inadequate after 4-6 weeks: Consider duloxetine or intra-articular corticosteroid injection
5. For mechanical symptoms: Add bracing with continued exercise
6. If all conservative measures fail: Refer for surgical evaluation (total knee arthroplasty)

Common Pitfalls to Avoid

• Do not skip core treatments (education, exercise, weight loss) and jump directly to medications—this undermines long-term outcomes 1
• Do not prescribe bracing without concurrent exercise programs, as this leads to muscle atrophy 1
• Do not use NSAIDs intermittently—continuous use is more effective 3
• Do not obtain MRI for diagnosis of knee OA—plain radiographs are sufficient and MRI adds unnecessary cost without changing management 1
• Avoid arthroscopic surgery for knee OA—it has been shown to have no benefit 2

Monitoring and Reassessment

• Reassess pain and function every 4-6 weeks during initial treatment phase 1
• If no improvement after 3 months of comprehensive non-surgical management, consider surgical consultation 2
• Continue core treatments (exercise, weight management) indefinitely, even if symptoms improve 1