What is the likely diagnosis and management for a patient with hip and knee pain, exacerbated by activities such as walking up steps, and could it be related to arthritis?

Hip and Knee Pain with Stair Climbing: Osteoarthritis Diagnosis and Management

Yes, this presentation is highly consistent with osteoarthritis (OA) of the hip and knee, and you should initiate a comprehensive non-pharmacological treatment program centered on exercise, weight management if applicable, and patient education, supplemented with topical or oral NSAIDs for pain control. 1

Clinical Diagnosis

The symptom pattern of hip and knee pain exacerbated by weight-bearing activities like stair climbing is characteristic of OA. 2, 3

Key diagnostic physical examination findings to confirm:

• For hip OA: Pain with passive internal rotation of the hip, groin pain on passive abduction or adduction (sensitivity 33%, specificity 94%, LR 5.7), decreased passive hip adduction (sensitivity 80%, specificity 81%, LR 4.2), and abductor weakness (sensitivity 44%, specificity 90%, LR 4.5) 4
• For knee OA: Bony enlargement, joint line tenderness, and pain with weight-bearing activities 2, 5
• Plain radiographs showing marginal osteophytes and joint space narrowing confirm the diagnosis 2, 4

Common pitfall: Normal passive hip adduction makes OA unlikely (negative LR 0.25), so don't assume OA without proper examination. 4

First-Line Management: Exercise (Strongly Recommended)

Exercise is the cornerstone of treatment and must be prescribed to all patients with hip and knee OA. 1

Specific exercise prescription:

• Quadriceps strengthening is mandatory for all patients, using sustained isometric exercises for both legs 1, 6
• Proximal hip girdle muscle strengthening provides critical knee stability 6
• Aerobic conditioning (walking, stationary cycling, aquatic exercise) and range of motion/stretching exercises 1
• Supervised sessions are superior: 12 or more directly supervised sessions show significantly better outcomes (pain effect size 0.46 vs 0.28, p=0.03; function effect size 0.45 vs 0.23, p=0.02) compared to fewer sessions 1

Implementation strategy:

• Follow the "small amounts often" principle, linking exercises to daily activities to promote adherence 1, 7
• Start within the patient's capability and build intensity over several months 1, 7
• Refer to physical therapy for supervised initiation and maintenance 1
• Continue exercise long-term at 1-3 times per week, as benefits deteriorate when stopped 8

Address patient concerns: Patients in pain may hesitate to exercise, but clinical trials demonstrate improvements in pain and function even in symptomatic patients, so pain is not a contraindication to starting exercise. 1

Weight Management (If Overweight)

For overweight patients, weight loss education must be incorporated as it reduces OA risk and improves outcomes. 1, 7

• Weight-loss programs delivered as weekly supervised sessions for 8 weeks to 2 years show significant effects on pain (effect size 0.20), physical function (effect size 0.23), and mean weight loss of 6.1 kg 1
• Include regular self-monitoring with monthly weight recording, increased physical activity with structured meal plans, and reduced saturated fat and sugar intake 7

Pharmacological Management

Acetaminophen (paracetamol) up to 4,000 mg/day is the first-line oral analgesic. 7, 6

Algorithmic approach to pain control:

1. Start with topical NSAIDs: These have clinical efficacy with superior safety profiles and should be tried before oral NSAIDs 7, 6
2. Oral NSAIDs only if unresponsive to acetaminophen, using the lowest effective dose for the shortest duration 7, 6
3. Intra-articular corticosteroid injections provide relief up to 3 months for acute pain flares, especially with effusion 6, 5
4. Topical capsaicin provides additional pain relief options 6
5. Duloxetine has demonstrated efficacy as an adjunctive medication 2
6. Avoid opiates 2

Evidence note: Naproxen has been shown comparable to aspirin and indomethacin for controlling OA symptoms but with fewer gastrointestinal and nervous system adverse effects. 9

Assistive Devices and Adaptations

Walking aids, assistive technology, and home/work adaptations should be considered systematically and recurrently for all patients. 1

• Most people with severe hip (63%) or knee pain (90%) use walking aids 1
• Use a walking stick on the contralateral side for unilateral knee pain 7
• Satisfaction rates exceed 87% for all categories of assistive devices 1
• For knee OA, shock-absorbing insoles for 1 month reduced pain and improved physical function 1

Important caveat: Lateral wedged insoles should be avoided as they lack evidence and may worsen symptoms. 7

Additional Modalities

• Patellar taping provides short-term pain relief and functional improvement for patellofemoral dysfunction 7
• Patellofemoral braces provide symptomatic relief for lateral patellar subluxation or maltracking 7
• Tai chi and yoga show growing evidence for pain reduction (effect sizes 0.28 to 1.67) 1

When to Consider Surgical Referral

Patients with advanced symptoms and structural damage unresponsive to conservative management are candidates for total joint replacement. 2, 5

• Orthopedic consultation for evaluation of osteotomy or total joint arthroplasty is appropriate for severe symptomatic OA 5
• Total joint replacement effectively relieves pain in advanced disease 2