What are the next steps for managing persistent knee pain unresponsive to corticosteroid (cortisone) injection?

From the Guidelines

For knee pain that hasn't responded to cortisone injections, a multi-faceted approach should be considered, prioritizing oral NSAIDs, physical therapy, weight management, and potentially hyaluronic acid or platelet-rich plasma (PRP) therapy, as recommended by the most recent and highest quality study 1.

Key Considerations

• The management of knee osteoarthritis (OA) should be tailored to the individual patient, taking into account factors such as age, comorbidity, and the presence of inflammation 1.
• A combination of non-pharmacological and pharmacological treatment modalities is recommended for optimal management of knee OA 1.
• Oral NSAIDs and acetaminophen are widely adopted in the treatment of knee OA, with evidence supporting their use for improved pain and function 1.
• Physical therapy focusing on quadriceps and hamstring strengthening exercises is strongly recommended, with sessions 2-3 times weekly for 6-8 weeks 1.
• Weight management is crucial if the patient is overweight, as sustained weight loss has been shown to benefit pain and function in overweight and obese patients with knee OA 1.

Treatment Options

• Oral NSAIDs: ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks, combined with acetaminophen (1000mg three times daily) for additional pain relief.
• Physical Therapy: focusing on quadriceps and hamstring strengthening exercises, with sessions 2-3 times weekly for 6-8 weeks.
• Weight Management: crucial if the patient is overweight, with a goal of sustained weight loss.
• Hyaluronic Acid or PRP Therapy: may be considered for persistent pain, although the evidence for hyaluronic acid is inconsistent and PRP therapy has concerns regarding cost and safety profile 1.
• Topical NSAIDs: like diclofenac gel (apply to affected area 4 times daily) can provide localized relief with fewer systemic side effects.
• Activity Modification: reducing high-impact exercises while maintaining movement is important to manage knee OA.

Further Evaluation

If pain persists despite these interventions, further evaluation for possible surgical options may be warranted, including joint replacement for refractory pain associated with disability and radiological deterioration 1.

From the FDA Drug Label

Naproxen has been studied in patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease

• Knee pain refractory to cortisone injection may be treated with naproxen, as it has been shown to reduce joint pain or tenderness and increase range of motion in knee joints in patients with osteoarthritis 2
• The use of naproxen in combination with corticosteroids may not cause greater improvement over that seen with corticosteroids alone, but it may be used safely in combination with them 2
• Naproxen cannot be expected to substitute for corticosteroids or to treat corticosteroid insufficiency, and abrupt discontinuation of corticosteroids may lead to disease exacerbation 2

From the Research

Treatment Options for Knee Pain Refractory to Cortisone Injection

• Intraarticular injections of hyaluronic acid, platelet-rich plasma (PRP), stem cells, and prolotherapy can provide relief for knee pain refractory to conservative therapies, including cortisone injections 3.
• Geniculate knee injections, radiofrequency, and peripheral nerve stimulation are also considered for patients with knee pain refractory to conservative therapies 3.
• The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis, osteoarthritis, and juvenile idiopathic arthritis, with pain relief and functional improvement lasting for months up to 1 year after the injection 4.
• Intraarticular injection of hyaluronate may provide longer pain relief than steroid injection in osteoarthritis, and is also effective for rheumatoid arthritis knee pain 4.

Comparative Efficacy of Treatments

• A network meta-analysis of randomized controlled trials found that combined treatments of intra-articular injections (IAI) and physical therapy (PT) afford more benefits than their corresponding monotherapies in patients with knee osteoarthritis, with dextrose prolotherapy plus PT being the most optimal treatment for pain reduction and global function restoration 5.
• Physical therapy has been shown to be more effective than glucocorticoid injection in relieving pain and improving physical function in patients with osteoarthritis of the knee, with a mean between-group difference of 18.8 points in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 1 year 6.

Clinical Practices and Perceptions

• A survey of the American Association of Hip and Knee Surgeons membership found that nearly all respondents use intra-articular corticosteroid injections in their practice, with most using a three-month minimum interval between injections, and a great variability in the number of injections allowed 7.
• The survey also found that nearly all responders use a local anesthetic mixture with the cortisone injection, but there was great variation in corticosteroid type, with methylprednisolone, triamcinolone, betamethasone, and dexamethasone being the most commonly used 7.