What is the best course of treatment for a 60-year-old female with left knee pain, likely due to osteoarthritis?

Treatment of Left Knee Pain in a 60-Year-Old Female with Suspected Osteoarthritis

Begin with a structured exercise program, weight loss if BMI ≥25 kg/m², and topical NSAIDs or acetaminophen (up to 4g/day) for pain control. 1, 2

Initial Non-Pharmacological Management (First-Line)

Exercise therapy is the cornerstone of treatment and should be initiated immediately:

• Implement strengthening exercises targeting the quadriceps muscle 1
• Add low-impact aerobic activities (walking, swimming, cycling) 1
• Include neuromuscular education and self-management programs 1
• These interventions reduce pain and improve function without accelerating joint degeneration 1

Weight management is critical if BMI ≥25 kg/m²:

• Even modest weight loss significantly improves symptoms 1, 2
• The patient in the surgical case reduced BMI from 33 to 28 with structured weight loss, which delayed surgical intervention 1

Pharmacological Management

For initial pain control, follow this hierarchy:

First-Line Analgesics:

• Topical NSAIDs are recommended as first-line for localized knee pain 2
• Acetaminophen up to 4g/day is an alternative, though evidence for clinical benefit is limited 1
• Oral NSAIDs (at lowest effective dose for shortest duration) if topical agents insufficient 1

Special Considerations for GI Risk:

If the patient is ≥60 years, has history of peptic ulcer disease, GI bleeding, or uses corticosteroids/anticoagulants:

• Use topical NSAIDs, acetaminophen, oral NSAIDs plus gastroprotective agent, or COX-2 inhibitors 1
• COX-2 inhibitors have similar efficacy to traditional NSAIDs with better GI safety profile 1
• Caution: Rofecoxib may cause fluid retention and carries cardiovascular risk without aspirin 1

What NOT to Use:

• Do not prescribe glucosamine or chondroitin - evidence shows no clinically important benefit over placebo 1
• Do not recommend acupuncture - lacks statistical and clinical significance 1
• Hyaluronic acid injections are not recommended 1

Procedural Interventions

Intra-articular corticosteroid injections:

• Use for short-term pain relief (1-2 weeks duration) 1
• Particularly effective when joint effusion is present 1
• Provides clinically important pain reduction at 1 week post-injection 1
• Limited evidence for longer-term benefits beyond 2-3 weeks 1

When to Consider Surgical Referral

Refer to orthopedic surgery if:

• Conservative measures fail after 4-6 weeks 2
• Significant functional limitation persists despite appropriate conservative management 2
• Radiographs show moderate to severe tricompartmental degenerative changes with progressive symptoms 1

Total knee arthroplasty is indicated when:

• Patient has exhausted non-pharmacological and pharmacological options 1
• Pain significantly limits activities of daily living despite optimal medical management 1, 3
• The case example showed excellent outcomes (pain-free at 3 months, 0-120° range of motion) 1

Common Pitfalls to Avoid

• Do not use NSAIDs at high doses for prolonged periods - elderly patients are at high risk for GI, renal, and platelet toxicity 1
• Do not prescribe opioids routinely - evidence is inconclusive and risks often outweigh benefits 1
• Do not recommend arthroscopic surgery - shown to have no benefit in knee osteoarthritis 3
• Do not rely on acetaminophen alone - clinical importance of pain relief cannot be determined from available evidence 1
• Do not exceed 4g/day of acetaminophen due to hepatotoxicity risk 1

Monitoring and Adjustment

• Reassess symptoms and function regularly 2
• Adjust treatment plan based on response within 4-6 weeks 2
• Continue physical therapy and exercise as long-term maintenance even if pain improves 1