What are the next steps for a 67-year-old female patient with chronic right knee pain, no previous imaging, and currently prescribed toradol (ketorolac) injection and naproxen 250 mg three times a day (TID)?

Management of Chronic Right Knee Pain in a 67-Year-Old Female

Your current plan is appropriate as a starting point, but you need to add structured physical therapy and consider intra-articular corticosteroid injection once imaging results are available, while being aware that ketorolac should not exceed 5 days of use. 1

Immediate Medication Adjustments Needed

Ketorolac Duration Limitation

• Ketorolac (Toradol) injection must be limited to a maximum of 5 days total duration due to increased risk of serious gastrointestinal bleeding and renal complications, particularly in patients ≥65 years of age 1
• For patients ≥65 years, the recommended dose is 15 mg IM every 6 hours with a maximum daily dose of 60 mg 1
• The analgesic effect begins in approximately 30 minutes with maximum effect in 1-2 hours, lasting 4-6 hours 1

Naproxen Dosing Concern

• Your prescribed dose of naproxen 250 mg TID (three times daily) is appropriate for chronic knee pain management 2
• Naproxen has demonstrated greater efficacy for knee osteoarthritis compared to hip osteoarthritis, with effect sizes around 0.8 for knee pain 2

Essential Non-Pharmacologic Interventions to Add Now

Structured Physical Therapy Program

• Initiate a structured physical therapy program focusing on quadriceps strengthening exercises immediately 3
• This is a core component of osteoarthritis management and should not be delayed until imaging results return 3

Weight Management

• If the patient has elevated BMI, enrollment in a weight loss program is strongly recommended as it directly impacts morbidity and quality of life 3
• The guideline case example showed successful BMI reduction from 33 to 28 prior to surgical consideration 3

Assistive Devices

• Consider prescribing a cane for use in the contralateral hand (left hand for right knee pain) for longer walking distances 3

Next Steps After X-Ray Results

If Radiographs Show Osteoarthritis

• Consider intra-articular corticosteroid injection, which typically provides 2 months of pain relief 3
• Ultrasound guidance is not required for knee joint injections (unlike hip joints where it is strongly recommended) 3
• Intra-articular glucocorticoid injection is conditionally recommended over hyaluronic acid preparations based on higher quality evidence 3

If Radiographs Are Normal or Show Only Effusion

• Order MRI of the knee without IV contrast to evaluate for meniscal pathology, cartilage lesions, bone marrow edema, and subchondral insufficiency fractures 3
• MRI is particularly important in this age group as it can detect bone marrow lesions (BMLs) that correlate with knee pain severity 3
• Subchondral insufficiency fractures commonly involve the medial femoral condyle in middle-aged to elderly females and may not be visible on initial radiographs 3

Additional Pharmacologic Options to Consider

Acetaminophen

• Add acetaminophen up to 3 grams daily in divided doses as adjunctive therapy, though evidence shows very small effect sizes 3
• Regular monitoring for hepatotoxicity is required if used on a regular basis 3

Duloxetine

• Consider duloxetine as a centrally acting agent if NSAIDs provide inadequate relief, as it has demonstrated efficacy alone or in combination with NSAIDs 3
• This is particularly useful for patients with contraindications to NSAIDs or those requiring multimodal pain management 3

Tramadol

• Reserve tramadol for circumstances when the patient has contraindications to NSAIDs, finds other therapies ineffective, or has no available surgical options 3
• If considering opioids, tramadol is conditionally recommended over other non-tramadol opioids 3

Critical Pitfalls to Avoid

Duration of Ketorolac

• Do not continue ketorolac beyond 5 days - the risk of serious gastrointestinal or operative site bleeding increases markedly with high dosages used for more than 5 days, especially in elderly patients 1, 4
• Acute renal failure may occur after ketorolac treatment but is usually reversible on discontinuation 4

Premature MRI

• Do not order MRI before obtaining and reviewing plain radiographs, as approximately 20% of patients with chronic knee pain have had unnecessary MRI without recent radiographs 3

Meniscal Tear Overinterpretation

• Be aware that meniscal tears are often incidental findings in older patients - the majority of people over 70 years have asymptomatic meniscal tears 3
• The likelihood of a meniscal tear being present is not significantly different between painful and asymptomatic knees in patients 45-55 years of age 3

Referred Pain

• Consider referred pain from the hip or lumbar spine if knee radiographs are unremarkable and symptoms persist 3

Transition Plan After 5 Days

• Switch from ketorolac to continued naproxen monotherapy or add acetaminophen after the 5-day ketorolac limit 3, 1
• Reassess pain control at this point and consider intra-articular corticosteroid injection if radiographs confirm osteoarthritis 3
• If pain remains inadequately controlled despite these measures, consider adding duloxetine or referring to orthopedics for surgical evaluation 3