What is the recommended treatment approach for an adult patient with knee varus?

Treatment of Knee Varus in Adults

For adult patients with knee varus deformity, treatment should begin with conservative non-pharmacological interventions including strengthening exercises, low-impact aerobic activity, neuromuscular education, and weight loss if BMI ≥25 kg/m², with surgical correction reserved for severe deformity causing instability or refractory symptoms despite optimal medical management. 1, 2

Initial Conservative Management

Non-Pharmacological Interventions (First-Line)

• Participate in strengthening exercises, low-impact aerobic exercise, and neuromuscular education programs as these form the cornerstone of varus knee management 1, 2
• Low-impact aerobic exercises demonstrate significant effects with effect sizes of 0.52 for pain relief and 0.46 for disability reduction 2
• Quadriceps strengthening is specifically critical for varus deformity as it helps stabilize the knee joint 2
• Aim for 30-60 minutes of moderate-intensity aerobic activity most days of the week 2

Weight Management

• Achieve at least 5% body weight reduction if BMI ≥25 kg/m² as this significantly improves function and reduces medial compartment loading 1, 2
• Combine dietary modification with exercise for optimal results 2

Orthotic Support

• Consider varus-reducing hindfoot shoe insoles with lateral hindfoot wedges as these can reduce pain and improve function in varus knee deformity 3
• A prospective study showed significant pain reduction (VAS from 5.4 to 0.6) when lateral wedge insoles were combined with other conservative measures 3
• Note: Standard lateral wedge insoles alone are not recommended by AAOS guidelines, but specialized varus-reducing hindfoot insoles show promise in combination therapy 1
• Walking sticks may provide additional symptomatic relief 2

Patient Education

• Enroll in self-management educational programs to learn coping skills and activity modifications 2
• Education should cover diagnosis, suitable activities, and realistic expectations 4, 5

Pharmacological Management

Analgesics

• Start with acetaminophen (up to 4,000 mg/day) for mild to moderate pain as the preferred first-line oral analgesic 1, 2
• Progress to NSAIDs (oral or topical) if acetaminophen is insufficient 1, 2
• Use topical NSAIDs preferentially in patients ≥75 years due to better safety profile 6
• Tramadol is recommended for moderate to severe pain unresponsive to other measures 1, 2

Intra-articular Injections

• Administer intra-articular corticosteroid injections for acute exacerbations, especially with effusion 1, 2
• Hyaluronic acid injections may provide symptomatic relief, though AAOS does not recommend them; EULAR suggests they may be effective with small effect sizes 1, 2

Combination Conservative Therapy

• A "trio-therapy" approach combining lateral wedge insoles, oral viscosupplementation, and physiotherapy showed significant improvements in varus knee OA, with 7 of 9 patients achieving complete pain relief at 6 months 3
• Optimal management requires combining pharmacological and non-pharmacological modalities rather than relying on single interventions 1

Surgical Considerations

Indications for Surgery

• Consider surgical intervention for severe varus deformity causing knee instability even before skeletal maturity in rare cases 1
• Joint replacement should be considered when there is radiographic evidence of OA with refractory pain and disability despite conservative management 2
• In severe varus deformity, postero-stabilized or mid-level constrained implants may be necessary 7

Timing of Surgery

• For residual deformity without instability, delaying surgical treatment until skeletal maturity is prudent due to high complication rates (57%) and recurrence rates (29%) in younger patients 1
• Guided growth techniques should commence early (after 12 months) if deformity persists despite maximized medical therapy 1

Common Pitfalls to Avoid

• Do not recommend acupuncture, glucosamine, or chondroitin as these lack evidence for clinically important outcomes 1
• Avoid excessive medial collateral ligament releases during surgical correction 7
• Do not use standard lateral wedge insoles as monotherapy, as AAOS provides moderate recommendation against them 1
• Recognize that varus deformity often indicates medial compartment OA, requiring assessment for associated pathology 3, 7

Treatment Algorithm

1. Begin with conservative trio: Exercise (strengthening + aerobic) + weight loss (if BMI ≥25) + patient education 1, 2, 3
2. Add orthotic support: Varus-reducing hindfoot insoles with lateral wedge 3
3. Initiate pharmacological therapy: Acetaminophen → NSAIDs → Tramadol as needed 1, 2
4. Use injections for flares: Intra-articular corticosteroids for acute exacerbations 1, 2
5. Reassess at 6 months: If refractory symptoms with radiographic OA, consider surgical referral 2, 7