What are the treatment options for knee stiffness?

Treatment Options for Knee Stiffness

For knee stiffness, begin with a structured non-pharmacological approach combining daily quadriceps strengthening exercises, low-impact aerobic activity, and range-of-motion exercises, supplemented with acetaminophen for pain control as first-line therapy. 1, 2

Non-Pharmacological Treatments (First-Line)

Exercise Therapy - The Foundation

• Quadriceps strengthening exercises are essential and should be performed daily, targeting both legs regardless of whether one or both knees are affected 1, 2
• Start with sustained isometric exercises within the patient's capability, then progressively increase intensity over several months 1
• Low-impact aerobic exercises (walking, cycling, aquatic exercise) reduce pain (effect size 0.52) and disability (effect size 0.46), with benefits sustained for 2-6 months 1, 2
• Aim for 30-60 minutes of moderate-intensity aerobic activity most days of the week 2
• Range-of-motion and flexibility exercises specifically address joint stiffness, though evidence is limited to expert opinion 1

Key Exercise Principles

• Practice "small amounts often" (pacing) rather than intensive single sessions 1
• Link exercise regimens to daily activities (before shower or meals) to ensure adherence 1
• Supervised programs are more effective than self-directed approaches 3

Weight Loss (If Applicable)

• Strongly recommended for patients with BMI ≥25 kg/m², with minimum 5% body weight reduction significantly improving function 2
• Combine dietary modification with exercise for optimal results 2
• Implement regular self-monitoring with monthly weight recording 1

Education and Self-Management

• Patients should participate in self-management programs including individualized education packages, phone calls, group education, and coping skills training 1, 2
• Education reduces primary care visits and associated costs within one year 1

Assistive Devices

• Walking aids (stick on contralateral side), knee bracing, and patellar taping may provide symptomatic relief 1, 2
• Medial patellar taping shows statistically significant and possibly clinically important pain reduction immediately and 4 days after application 1
• Lateral wedge insoles are NOT recommended 2

Pharmacological Treatments (Adjunctive)

First-Line Analgesics

• Acetaminophen is the oral analgesic to try first for mild to moderate pain 1, 2
• If successful, acetaminophen is the preferred long-term oral analgesic 1

Second-Line Options

• NSAIDs (oral or topical) should be considered in patients unresponsive to acetaminophen 1, 2
• For patients with increased gastrointestinal risk, use non-selective NSAIDs with gastroprotective agents or selective COX-2 inhibitors 1, 2
• Topical NSAIDs and capsaicin have clinical efficacy and are safe alternatives 1, 2
• Tramadol is recommended for moderate to severe pain 2

Intra-Articular Injections

• Corticosteroid injections are indicated for acute flares of knee pain, especially if accompanied by effusion 1, 2
• Hyaluronic acid injections may have symptomatic effects, though evidence for clinical importance is limited 1, 2

Surgical Interventions (When Conservative Treatment Fails)

Timing and Indications

• Joint replacement should be considered in patients with radiographic evidence of knee osteoarthritis who have refractory pain and disability despite conservative management 1, 2
• For post-surgical stiffness, manipulation under anesthesia is most effective when performed less than 8 weeks after prosthetic insertion (ideally within 6 weeks) 4
• Arthroscopic release should be performed between 8 weeks and 6 months post-implantation 4
• Open surgical release is reserved for stiffness persisting beyond 6 months 4

Critical Pitfalls to Avoid

• Do not proceed with surgery if arthrogenic muscle inhibition (AMI) is present - this reflex motor inhibition mechanism must be resolved first to reduce postoperative stiffness risk 5
• Screen for AMI by assessing active knee extension deficit and Vastus Medialis Obliquus contraction 5
• In cases of hemarthrosis, perform joint aspiration for immediate pain relief and reduction of motor inhibition 5
• Classical electrostimulation and "cushion crush" exercises are ineffective for persistent AMI 5
• Preoperative range of motion is the most important risk factor for postoperative stiffness 6