What are the treatment options for knee pain?

Treatment Options for Knee Pain

For knee pain, start with a combination of exercise therapy, weight loss if overweight, and education as first-line treatment, then add topical NSAIDs for persistent pain, followed by oral acetaminophen or NSAIDs if needed, reserving intra-articular corticosteroid injections for acute flares with effusion. 1

Initial Non-Pharmacological Management (Start Here)

All patients with knee pain should begin with non-pharmacological interventions before or alongside medications. 1

• Exercise therapy is essential and should include 30-60 minutes of moderate-intensity aerobic activity most days plus quadriceps strengthening exercises, showing a pain reduction effect size of 0.52 2
• Weight reduction of at least 5% body weight for patients with BMI ≥25 kg/m², combining dietary modification with exercise for optimal results 2
• Physical therapy should be offered as part of comprehensive management, with alternative delivery models (group visits, internet-based, telephone-based) equally effective as traditional in-person appointments 1
• Self-management programs including education about the condition empower patients to better manage their symptoms 1, 3
• Assistive devices such as walking sticks, knee bracing, and appropriate insoles may provide additional benefit 1

Common pitfall: Neglecting weight reduction counseling in overweight patients is a frequent mistake; avoid prescribing lateral wedge insoles as they are not recommended 2

Pharmacological Treatment Algorithm

Step 1: Topical Agents (Preferred Initial Pharmacotherapy)

Topical NSAIDs are strongly recommended as first-line pharmacological treatment for knee pain. 1

• Topical diclofenac is superior to placebo and equivalent to oral diclofenac for pain reduction, with markedly fewer gastrointestinal adverse events but more local skin reactions 1
• Safety profile at 1 year is consistent with 12-week data 1

Topical capsaicin can be offered as an alternative, though it requires continuous use for 2-4 weeks before therapeutic effect and causes initial burning/stinging at application site 1

Step 2: Oral Analgesics

If topical agents are insufficient, acetaminophen should be tried first as the preferred long-term oral analgesic. 1

• Acetaminophen up to 4g/day is as effective as ibuprofen 2400mg/day for knee pain, with good safety profile (1.5% adverse events) 1
• Can be used safely for up to 2 years with efficacy similar to naproxen 750mg/day 1

Oral NSAIDs should be considered if acetaminophen is ineffective 1

• For patients with increased gastrointestinal risk, use non-selective NSAIDs with gastroprotective agents (proton pump inhibitors) or selective COX-2 inhibitors 1
• Assess renal function before prescribing; avoid NSAIDs in patients with eGFR <30 mL/min per 1.73 m² 1
• Monitor cardiovascular risk factors as NSAIDs may increase cardiovascular events 1

Step 3: Alternative Oral Agents

Duloxetine can be offered as alternative or adjunctive therapy for patients with inadequate response or contraindications to acetaminophen or NSAIDs 1

Opioids (including tramadol) should NOT be initiated for knee pain; for patients already on long-term opioid therapy, refer to opioid management guidelines 1

Injection-Based Therapies

Corticosteroid Injections

Intra-articular corticosteroid injections should be offered for acute exacerbations of knee pain, especially when accompanied by effusion, or for persistent pain inadequately relieved by other interventions 1

• Provides short-term pain relief (most marked in first month) 1
• Can be combined with joint lavage for additional benefit 1

Viscosupplementation (Hyaluronic Acid)

Intra-articular hyaluronic acid injections may be offered for persistent knee pain when other treatments fail 1

• Provides longer-term pain relief (6,9, and 12 months) compared to corticosteroid injections, though corticosteroids provide better short-term relief 1
• Not recommended for hip pain 1

Platelet-Rich Plasma

There is insufficient evidence to recommend for or against PRP for knee pain; studies show mixed results with some showing small benefits and others showing no benefit 1

Symptomatic Slow-Acting Drugs (SYSADOA)

Glucosamine sulphate, chondroitin sulphate, and hyaluronic acid have symptomatic effects and may possess structure-modifying properties, though the effect size is relatively small 1

Complementary and Integrative Therapies

There is insufficient evidence to recommend for or against acupuncture, massage, tai chi, yoga, transcutaneous electrical nerve stimulation, or dietary supplements/nutraceuticals for knee pain 1

When to Consider Surgical Referral

Joint replacement should be considered for patients with end-stage radiographic evidence of knee osteoarthritis who have refractory pain and disability after exhausting all appropriate conservative options 1, 3

Treatment Tailoring

Treatment must be individualized based on: 1

• Knee-specific risk factors (obesity, mechanical factors, physical activity level)
• Patient age and comorbidities
• Pain intensity and disability level
• Presence of inflammation or effusion
• Degree of structural damage on imaging

Critical safety considerations: 1

• Assess gastrointestinal risk before prescribing NSAIDs; use gastroprotection in high-risk patients
• Evaluate cardiovascular disease risk with NSAID use
• Check renal function and avoid NSAIDs if eGFR <30 mL/min per 1.73 m²
• Avoid initiating opioids for knee pain management