What is the initial management approach for a patient presenting with knee osteoarthritis?

Initial Management of Knee Osteoarthritis

All patients with knee osteoarthritis must begin with an individualized exercise program combined with patient education as the foundation of treatment, implemented before or alongside any pharmacological therapy. 1, 2, 3

Initial Assessment Components

Your clerking should systematically evaluate the following domains using a biopsychosocial approach 1:

Physical Status Assessment

• Pain characteristics: intensity, duration, pattern, aggravating/relieving factors 1
• Joint examination: effusion presence, alignment (varus/valgus deformity), range of motion, crepitus, tenderness 1
• Functional mobility: gait pattern, walking distance, stair climbing ability 1
• Muscle strength: quadriceps and hip girdle strength bilaterally 2
• Weight and BMI: critical for risk stratification 1, 3
• Comorbidities: cardiovascular disease, renal function, gastrointestinal history, other joint involvement 1, 3

Functional Impact Assessment

• Activities of daily living: dressing, bathing, toileting, household tasks 1
• Work/leisure participation: occupational demands, recreational activities 1
• Social roles: impact on family responsibilities, social engagement 1

Psychosocial Factors

• Mood assessment: depression, anxiety screening 1, 3
• Health beliefs: patient's understanding of OA, expectations for treatment 1
• Motivation to self-manage: readiness for lifestyle changes 1

Core Non-Pharmacological Management (Mandatory for All Patients)

Exercise Prescription (First-Line Treatment)

Prescribe a daily individualized strengthening program focusing on quadriceps and hip girdle muscles for both legs, regardless of which knee is affected. 2, 3

Specific exercises to prescribe 2:

• Quad sets: 5-7 repetitions, 3-5 times daily, 6-7 second holds, 2-3 second rest
• Short-arc quad sets: same frequency and duration
• Long-arc quad sets: same frequency and duration
• Gluteal squeezes: same frequency and duration
• Closed-chain knee extensions: same frequency and duration

Additional exercise components 1, 2:

• Aerobic activity: land-based cardiovascular exercise (walking, cycling) or aquatic exercise in warm water 1, 2
• Range of motion/stretching exercises 2
• Avoid high-impact aerobic training as it increases pain and potential damage 2

Patient Education (Essential Component)

Provide structured education addressing 1, 2:

• Nature of OA: explain it as a repair process triggered by various insults, not simply "wear and tear" 1
• Specific causes: particularly those relevant to the individual patient (obesity, mechanical factors, previous injury) 1
• Prognosis: realistic expectations about disease course 1
• Activity pacing: teach linking exercise to daily activities, "small amounts often" principle 2, 3
• Self-management strategies: reinforce at subsequent visits 1

Weight Management (If BMI ≥25)

Strongly recommend weight loss for all overweight patients with knee OA. 1, 2, 3

Implement structured program including 2, 3:

• Monthly self-monitoring and weight recording 2
• Regular support meetings 2
• Increased physical activity 2
• Structured meal plans with reduced fat/sugar intake 3

Mechanical Interventions

• Appropriate footwear: comfortable, supportive shoes 2, 3
• Walking aids: cane used on contralateral side to reduce joint loading 1, 2, 3
• Assistive devices: hand-rails for stairs, raised toilet seats, elevated chairs/beds 2, 3
• Medially directed patellar taping: for symptom relief 1, 2
• Avoid laterally wedged insoles for medial compartment OA 2

Pharmacological Management Algorithm

Step 1: Initial Pharmacological Treatment (If Pain Limits Function)

Start with acetaminophen up to 4,000 mg/day as the preferred initial oral analgesic. 1, 2, 3

• Favorable safety profile with efficacy comparable to NSAIDs without gastrointestinal risks 2, 3
• Counsel patient to avoid all other acetaminophen-containing products including OTC cold remedies 1
• Continue for adequate trial period before escalating 1, 3

Step 2: If Inadequate Response to Acetaminophen

Choose from the following options based on patient risk factors 1, 3:

Topical NSAIDs (preferred for patients with GI/renal/cardiac comorbidities) 1, 2, 3:

• Provides local anti-inflammatory effects with fewer systemic side effects 2
• Particularly appropriate for elderly patients 3

Oral NSAIDs (use lowest effective dose for shortest duration) 1, 3:

• Ibuprofen or naproxen at standard doses 4
• Contraindications: heart failure (fluid retention risk), renal impairment, history of GI bleeding 3
• Provide gastroprotection in high-risk patients 1, 3
• Monitor for gastrointestinal bleeding, platelet dysfunction, nephrotoxicity 2

Intra-articular corticosteroid injections 1, 3:

• Particularly indicated for acute flares with effusion 1, 3
• Provides short-term pain relief 3

Tramadol 1, 2, 3:

• Alternative for patients with contraindications to NSAIDs 1, 3
• Consider when other options ineffective or poorly tolerated 1

Step 3: Treatments to Avoid

Do NOT recommend the following 1, 2:

• Chondroitin sulfate 1, 2
• Glucosamine 1, 2
• Topical capsaicin (conditionally recommended against) 1
• Long-term opioid use 2

Critical Implementation Pitfalls

Never prescribe medications alone without exercise therapy - this violates guideline recommendations and reduces long-term effectiveness 2, 3. Exercise must be the foundation, with pharmacotherapy as adjunctive treatment 1.

Do not order routine radiographs for all patients - diagnosis is primarily clinical 2. Imaging is reserved for atypical presentations or surgical planning 3.

Instruct patients to never hold their breath during exercises to avoid Valsalva maneuver 2.

Avoid combining NSAIDs with aspirin as aspirin increases naproxen excretion and the combination increases adverse event frequency 4.

Follow-Up and Monitoring

Establish individualized program with 1:

• Short-term and long-term goals 1
• Specific intervention/action plans 1
• Regular evaluation and follow-up with program adjustment possibilities 1
• Reassessment of pain, function, and medication side effects 2

Surgical Referral Threshold

Consider total knee arthroplasty referral only when 1, 2, 3:

• Radiographic evidence of end-stage OA with minimal joint space 2
• Refractory pain and disability despite optimal conservative management 1, 3
• Significant impact on quality of life 3
• Patient has exhausted all appropriate conservative options 2