Treatment of Sore Knees and Hamstring Cramps
Begin with acetaminophen up to 4,000 mg/day combined with quadriceps strengthening exercises for the knee pain, while addressing hamstring cramps through stretching, hydration assessment, and electrolyte evaluation. 1, 2
Initial Management for Knee Pain
First-Line Pharmacologic Treatment
- Acetaminophen (up to 4,000 mg/day) is the preferred initial oral analgesic due to its favorable safety profile and should be used at full dosage for 2-4 weeks before considering it ineffective 3, 1, 2
- Topical NSAIDs are an excellent alternative to acetaminophen, particularly if the patient is ≥75 years old, as they provide comparable efficacy with superior safety compared to oral NSAIDs 1, 2
- Avoid other acetaminophen-containing products to prevent exceeding the maximum daily dose of 4,000 mg/day due to hepatotoxicity risk 2, 4
First-Line Non-Pharmacologic Treatment
- Structured exercise programs focusing on quadriceps strengthening are strongly recommended, as they reduce pain and improve function without accelerating joint degeneration 3, 2
- Weight reduction should be strongly recommended if the patient is overweight (BMI ≥25 kg/m²), as even modest weight loss significantly improves knee symptoms 3, 2
- Walking aids (sticks) or insoles may help reduce pressure on the affected knee 3, 5
Second-Line Management for Knee Pain (If Acetaminophen Fails)
- Switch to or add oral NSAIDs (such as ibuprofen), as they provide superior pain relief compared to acetaminophen, though with increased gastrointestinal risk 3, 1, 6
- Use the lowest effective dose for the shortest duration to minimize cardiovascular and gastrointestinal risks 2, 6
- For patients with GI risk factors, use COX-2 selective inhibitors or nonselective NSAIDs plus proton-pump inhibitor 3, 2
- Monitor blood pressure closely during NSAID treatment, as NSAIDs can cause new-onset hypertension or worsen preexisting hypertension 6
Third-Line Management for Acute Knee Exacerbations
- Intra-articular corticosteroid injections are indicated for acute exacerbations of knee pain, especially when accompanied by effusion, providing effective short-term pain relief (1-2 weeks duration) 3, 1, 2
Management of Hamstring Cramps
- Hamstring cramps in the context of knee pain may represent referred pain from tight hamstring insertions at the ischial tuberosity, particularly if pain is triggered by sitting, stretching the posterior thigh, or running 7
- Implement regular hamstring stretching exercises to address muscle tightness 7
- Assess hydration status and electrolyte balance, as these are common contributors to muscle cramping 8
- Consider physical therapy with manual therapy techniques combined with exercise 3
When to Consider Imaging
- Radiographs are not recommended initially unless pain persists beyond 6 weeks or there is history of significant trauma 3, 8
- MRI should be reserved for persistent pain despite adequate conservative treatment for 4-6 weeks, or when surgery is being considered 3, 2
- Approximately 20% of patients with chronic knee pain have had unnecessary MRI performed without recent radiographs 3
Critical Pitfalls to Avoid
- Do not prescribe glucosamine or chondroitin sulfate, as high-quality evidence demonstrates no clinical benefit 1
- Avoid routine prescription of opioids, as evidence is inconclusive and risks often outweigh benefits 2
- Do not use NSAIDs in patients with chronic kidney disease stage IV or V (estimated glomerular filtration rate below 30 cc/minute) 3
- Avoid concomitant use of ibuprofen with low-dose aspirin for cardioprotection, as ibuprofen may render aspirin less effective 3
- NSAIDs are contraindicated in the setting of recent coronary artery bypass graft (CABG) surgery 6