What is the best approach for managing pain in a patient with a bone on bone knee injury?

Management of Bone-on-Bone Knee Pain

For a patient with bone-on-bone knee osteoarthritis, initiate a structured exercise program focused on quadriceps strengthening combined with topical NSAIDs and oral acetaminophen, while strongly avoiding oral narcotics including tramadol due to their ineffectiveness and significant adverse event profile. 1

First-Line Treatment: Exercise Therapy

Exercise is the cornerstone of treatment and provides pain relief equivalent to oral NSAIDs with superior safety. 2, 3

• Quadriceps strengthening exercises demonstrate the strongest evidence with an effect size of 1.05 for pain reduction—matching oral analgesics without adverse effects 1, 3
• Begin with isometric exercises if pain permits, progressing to concentric and eccentric exercises 2
• Aerobic fitness training (walking, cycling) is equally efficacious to strengthening over 18 months 1, 3
• Neuromuscular training (balance, agility, coordination) combined with exercise improves performance-based function and walking speed 1, 2
• Manual therapy in addition to exercise may improve pain and function 1
• Do not prescribe complete rest—exercise even in the presence of pain improves outcomes 2, 3

Pharmacological Management Algorithm

Step 1: Topical NSAIDs (Strongest Recommendation)

• Topical NSAIDs should be used to improve function and quality of life when not contraindicated 1
• Provides localized pain relief with minimal systemic absorption 2

Step 2: Oral Acetaminophen

• Oral acetaminophen up to 4g/day is recommended to improve pain and function 1
• Safest oral analgesic option 2, 4

Step 3: Oral NSAIDs (If Steps 1-2 Inadequate)

• Oral NSAIDs are recommended to improve pain and function when not contraindicated 1
• Reserve for patients unresponsive to acetaminophen and topical agents 2

What NOT to Use:

• Oral narcotics including tramadol result in notable increase of adverse events and are NOT effective at improving pain or function 1
• Hyaluronic acid intra-articular injections are not recommended for routine use 1

Weight Loss (If Applicable)

• Sustained weight loss is recommended to improve pain and function in overweight/obese patients 1
• Weight reduction significantly improves knee pain and reduces disease progression 2

Patient Education and Self-Management

• Patient education programs are strongly recommended to improve pain 1
• Provide specific, individualized advice rather than generic encouragement 3
• Neglecting patient education reduces treatment effectiveness 2, 3

Adjunctive Modalities (Limited Evidence)

• Transcutaneous electrical nerve stimulation (TENS) may improve pain 1
• FDA-approved laser treatment may improve pain and function 1
• Massage may be used in addition to usual care 1
• Corticosteroid injections provide short-term (4-8 weeks) relief for acute flare-ups 4, 5

Supplements (Inconsistent Evidence)

The following may be helpful for mild-to-moderate knee OA, but evidence is inconsistent 1:

• Turmeric
• Ginger extract
• Glucosamine and chondroitin in combination 1, 5
• Vitamin D

Surgical Referral Considerations

• Consider total joint replacement for refractory pain with disability despite maximal conservative therapy 1, 6
• Arthroscopic surgery has no benefit in knee osteoarthritis 4
• Surgery should only be considered after appropriate conservative options have been exhausted 6

Critical Pitfalls to Avoid

• Delaying physical therapy referral—early supervised exercise intervention is crucial for optimal outcomes 2, 3
• Underestimating exercise efficacy and over-relying on medications, which have inferior long-term outcomes 2, 3
• Prescribing oral narcotics—these are strongly contraindicated due to lack of efficacy and significant adverse events 1
• Prescribing complete rest—this leads to deconditioning and prolonged recovery 2
• Overaggressive exercise progression that exacerbates symptoms rather than gradually building tolerance 2

Monitoring Strategy

• Reassess at 2-4 weeks to evaluate response to exercise therapy 2
• Track functional improvements using patient-reported outcome measures 2
• Some discomfort during exercise is acceptable, but sharp pain or pain lasting >24 hours indicates excessive load 2