What are the treatment options for knee pain?

Treatment of Knee Pain

Start with acetaminophen (up to 4,000 mg/day) combined with exercise therapy focused on quadriceps strengthening—this is the preferred first-line approach for knee pain, particularly when osteoarthritis is suspected. 1, 2

First-Line Treatment Algorithm

Non-Pharmacological Interventions (Initiate Immediately)

• Exercise therapy targeting quadriceps strengthening and preserving normal knee mobility is strongly recommended and should be started at the first visit. 3, 1, 4
• Weight reduction is essential for overweight patients to reduce joint pressure—this intervention alone can significantly improve outcomes. 3, 1, 4
• Patient education and self-management programs should be provided to empower patients in managing their condition. 4
• Appliances such as walking sticks or insoles can reduce pressure on the affected knee and should be considered early. 3, 1

Pharmacological Interventions

• Acetaminophen (up to 4,000 mg/day) is the oral analgesic to try first and remains the preferred long-term option if effective. 3, 2
• If acetaminophen provides inadequate relief after 2-4 weeks, add or switch to topical NSAIDs, particularly in patients ≥75 years old due to superior safety profile. 1, 2

Second-Line Treatment (If Inadequate Response After 2-4 Weeks)

Oral NSAIDs

• Consider oral NSAIDs in patients unresponsive to acetaminophen, especially those with effusion suggesting inflammation. 3, 2
• For patients with increased gastrointestinal risk, combine NSAIDs with gastroprotective agents. 2

Intra-Articular Corticosteroid Injections

• Indicated specifically for acute exacerbations of knee pain, especially when accompanied by effusion—this provides effective short-term pain relief. 3, 2, 5
• The combination of joint lavage plus intra-articular steroid shows additional benefit over either treatment alone, with most marked improvement in the first month. 3

Advanced Treatment Options

Interventional Procedures (When Conservative Measures Fail)

• Radiofrequency ablation (conventional and cooled) of genicular nerves has demonstrated effectiveness when conservative treatment fails. 5
• Hyaluronic acid injections are conditionally recommended, though evidence is mixed and the effect size is relatively small. 3, 6

Surgical Referral

• Joint replacement should be considered for refractory pain associated with disability and radiological deterioration after exhausting appropriate conservative options. 3, 4
• Arthroscopic surgery has no benefit in knee osteoarthritis and should not be performed. 6

Critical Pitfalls to Avoid

• Do not initiate second-line pharmacological treatments or surgical referral before trying core treatments (exercise, weight loss, education, acetaminophen). 7
• Avoid early reliance on opioids—tramadol has a poor risk-benefit trade-off and is not routinely recommended. 6
• Do not perform routine radiographic imaging for all patients with suspected knee osteoarthritis—clinical diagnosis is sufficient in most cases. 4
• Treatment must be tailored based on age, comorbidity, presence of inflammation, and structural damage severity. 3, 2

Treatment Combination Strategy

• Optimal management requires combining pharmacological and non-pharmacological modalities rather than relying on a single intervention. 3
• Home exercise programs, physiotherapy, and education offer additional benefit even when patients are already receiving analgesics. 3
• The combination of wedged insoles with oral NSAIDs shows significantly better pain reduction compared to NSAIDs alone. 3