What is the best course of treatment for a 55-year-old patient with right knee pain, particularly when walking up and down stairs, with no history of injury or trauma, and negative X-ray results?

Management of Atraumatic Knee Pain in a 55-Year-Old with Negative X-ray

This presentation is most consistent with either early knee osteoarthritis or patellofemoral pain syndrome, and should be managed with a structured exercise therapy program targeting hip and knee strengthening, combined with weight reduction if overweight, topical NSAIDs for pain control, and patient education—avoiding any consideration of arthroscopic surgery. 1

Clinical Diagnosis

The clinical presentation strongly suggests one of two diagnoses:

• Knee osteoarthritis (OA) is the most likely diagnosis given the patient's age (>45 years), activity-related knee pain with stair climbing, and absence of trauma—this combination has 95% sensitivity and 69% specificity for knee OA 2
• Patellofemoral pain syndrome remains in the differential, particularly given the anterior/posterior knee swelling and pain with stairs, though this typically affects patients under 40 years 2

The negative X-ray does not exclude early OA, as radiographic imaging is not recommended for all patients with possible knee OA 2. The swelling suggests an inflammatory component that requires attention 3.

First-Line Treatment Algorithm

1. Exercise Therapy (Cornerstone of Treatment)

Implement a structured exercise program immediately focusing on both hip and knee strengthening exercises. 1, 3

• Joint-specific strengthening exercises and range of motion exercises reduce pain and improve function in knee OA 1
• Hip and knee strengthening exercises are evidence-based for both patellofemoral pain and early OA 1
• Exercise can be supervised or home-based; both approaches demonstrate efficacy 1
• Aerobic conditioning should be added to the strengthening program 1

Critical implementation detail: If the patient has poor tolerance to loaded knee flexion (likely given stair pain), emphasize hip exercises initially and gradually progress to knee-focused exercises as tolerance improves 1

2. Weight Management (If Applicable)

If the patient is overweight or obese, sustained weight loss through combined diet and exercise is essential and provides significant symptom improvement. 1, 3, 4

• Even modest weight reduction significantly improves symptoms and function 4
• Weight loss reduces the risk of knee OA progression 1
• This intervention has no downside and provides obvious additional health benefits 1

3. Pain Management

Start with topical NSAIDs as first-line pharmacological therapy for localized knee pain. 3, 4

• Topical NSAIDs provide localized pain relief with fewer systemic side effects 4
• Paracetamol (acetaminophen) is an alternative oral analgesic option if topical NSAIDs are insufficient 1, 3
• Oral NSAIDs should be used at the lowest effective dose for the shortest possible period if topical agents fail 3

For persistent swelling: If effusion persists after 3 months of conservative management, consider intra-articular corticosteroid injection for short-term relief (typically 2-3 months) 1, 5, 4

4. Patient Education

Education must underpin all interventions and address specific misconceptions. 1, 4

• Explain that pain does not correlate with structural damage, particularly important if symptoms persist 1
• Discuss the nature of degenerative knee disease and realistic expectations from conservative management 4
• Emphasize that exercise is therapeutic, not harmful, to reduce fear of movement 1
• Provide insight into recovery timeframes and the importance of load management 1

5. Activity Modification and Assistive Devices

Modify activities that exacerbate symptoms while maintaining overall activity levels. 3, 5

• Consider prefabricated foot orthoses if the patient responds favorably to treatment direction tests (e.g., improved squat mechanics with orthoses) 1
• A cane used in the hand opposite to the affected knee can reduce medial compartment loading 4
• Patellar taping may be considered if rehabilitation is hindered by elevated symptom severity 1

Critical Pitfalls to Avoid

Do NOT refer for arthroscopic surgery or MRI at this stage. 5, 4, 2

• High-quality evidence demonstrates that arthroscopic surgery provides no clinically meaningful benefit over conservative treatment for degenerative knee conditions 5, 4
• Even if mechanical symptoms (clicking, catching, locking sensations) develop, these respond equally well to conservative treatment and do not indicate need for surgery 5
• MRI is not routinely indicated for acute knee evaluation and should not be obtained without first attempting conservative management 1

Do not assume the negative X-ray means "nothing is wrong." 2

• Early OA may not show radiographic changes 2
• Clinical diagnosis is sufficient to initiate appropriate treatment 2

Follow-Up and Reassessment

Reassess symptoms and function at 4-6 weeks, adjusting the treatment plan based on response. 3

• Regular monitoring is essential for effective management 3
• If symptoms worsen despite 3-6 months of appropriate conservative management, consider specialist referral 3, 4
• Specialist referral is indicated if conservative measures fail to provide adequate symptom relief or if there is significant functional limitation despite appropriate management 3

Expected Timeline

Most patients respond to this conservative approach within 4-6 weeks, with continued improvement over 3-6 months 3, 5, 2. The combination of exercise therapy, weight management (if applicable), appropriate pain control, and education provides the best outcomes for both morbidity and quality of life in this clinical scenario 1, 2.