What is the best course of treatment for an adult, possibly over 40, with knee pain that worsens with walking down stairs and kneeling, potentially indicating osteoarthritis or patellofemoral pain syndrome?

Treatment of Knee Pain with Stair Descent and Kneeling

Start with a structured exercise program targeting hip and knee strengthening combined with education, as this is the cornerstone of treatment for both osteoarthritis and patellofemoral pain syndrome—the two most likely diagnoses given your symptom pattern. 1

Initial Diagnostic Considerations

Your symptom pattern—pain with stairs (especially descending) and kneeling—suggests either:

• Patellofemoral pain syndrome (PFPS) if you're under 40 years old, physically active, with anterior knee pain during squatting (91% sensitive) 2, 3
• Knee osteoarthritis (OA) if you're over 45 years old with activity-related joint pain and less than 30 minutes of morning stiffness (95% sensitive) 2

Pain with stair descent and kneeling is characteristic of both conditions because these activities load the patellofemoral joint maximally during knee flexion. 3, 4

Core Treatment: Exercise Therapy (Start Immediately)

Begin with quadriceps strengthening, hip strengthening, and low-impact aerobic exercise—this has the strongest evidence base with effect sizes of 0.52 for pain and 0.46 for disability. 1, 5

Specific Exercise Protocol:

• Quadriceps isometric exercises: Squeeze thigh muscles and hold 6-7 seconds, performed multiple times daily (before meals, before stairs, before bed) 1
• Hip strengthening: Target hip abductors and external rotators, as hip weakness contributes significantly to patellofemoral pain 1
• Straight leg raises: Lift leg until straight, hold 6-7 seconds 1
• Low-impact aerobic activity: Walking, cycling, or pool exercises in warm water (86°F) to reduce joint loading while maintaining fitness 1

Avoid high-impact activities and rapid loading—the rate of joint loading matters more than the magnitude. 1

Weight Management (If Applicable)

If your BMI is ≥25 kg/m², aim for at least 5% body weight reduction, as this significantly improves function and pain. 1, 5

• Combining diet and exercise provides optimal results 5

Pain Management: Stepwise Pharmacological Approach

First-Line: Acetaminophen

Start with acetaminophen (paracetamol) up to 4000 mg daily in divided doses—this is the preferred first-line medication for mild-to-moderate OA pain. 1, 5

Second-Line: Topical NSAIDs

If acetaminophen is insufficient, add topical NSAIDs (like diclofenac gel) applied directly to the knee—these provide clinical efficacy with minimal systemic absorption and lower risk. 1, 5, 6

Third-Line: Oral NSAIDs

If topical treatments fail, use oral NSAIDs (ibuprofen, naproxen) or COX-2 inhibitors at the lowest effective dose for the shortest duration, always with a proton pump inhibitor for gastroprotection. 1, 6

• Critical warning: Never use NSAIDs if you have active peptic ulcer disease—this is an absolute contraindication 7
• Consider cardiovascular, renal, and gastrointestinal risk factors before prescribing 1

Adjunctive Non-Pharmacological Treatments

Supportive Measures:

• Shock-absorbing footwear or insoles: Particularly helpful for biomechanical pain 1
• Patellar taping: May provide short-term pain relief for PFPS, though evidence is limited 1, 3
• Knee braces or supports: Consider for biomechanical instability, though primarily useful for tibiofemoral OA rather than patellofemoral pain 1
• Local heat or cold applications: Simple adjuncts for symptom relief 1

Physical Therapy Referral:

Refer to physical therapy for supervised exercise progression, movement retraining, and manual therapy (manipulation and stretching). 1

What NOT to Do (Common Pitfalls)

Do not recommend glucosamine, chondroitin, acupuncture, or other supplements—these have strong evidence against their use. 1, 5

• The American Academy of Orthopaedic Surgeons and American College of Rheumatology both strongly recommend against these due to lack of efficacy 1, 5
• Vitamin D, fish oil, turmeric, and ginger extract are also not recommended 5

Avoid opioids as initial treatment—these should only be considered after all safer therapies have failed due to risks of falls, cognitive impairment, and respiratory depression. 7, 6

When to Consider Injection Therapy

If you have moderate-to-severe pain with joint effusion (swelling), consider intra-articular corticosteroid injection for acute symptom relief. 1, 5

• Do not use hyaluronic acid injections—these are not recommended by AAOS guidelines. 1

When to Refer for Surgical Consultation

Refer to orthopedics only after 6-8 weeks of optimized conservative treatment (exercise, physical therapy, appropriate medications) has failed and you have documented structural damage on standing knee X-rays. 6, 2

Before Referral, Ensure You've Tried:

• Structured exercise program for at least 6-8 weeks 6
• Weight loss if applicable 5
• Appropriate analgesics (acetaminophen, topical NSAIDs, oral NSAIDs) 6
• Physical therapy 6
• Intra-articular corticosteroid injection if indicated 6

Surgery is rarely indicated for patellofemoral pain syndrome and should be considered a last resort. 3, 4

Expected Timeline

Inform patients that symptom resolution typically takes several months with conservative treatment—this is normal and expected. 4

• Consistency with exercise is more important than any single intervention 1
• Avoid "peaks and troughs" of activity—pace yourself 1