What are the treatment options for knee pain (arthralgia)?

From the Guidelines

Knee pain can be effectively managed through a combination of self-management programs, strengthening, low-impact aerobic exercise, and pharmacologic therapies, prioritizing oral or topical nonsteroidal anti-inflammatory drugs or acetaminophen, as recommended by the most recent and highest quality study 1.

Key Recommendations

• Participate in self-management programs, including regular education, exercise, and weight reduction, as these are crucial for managing knee osteoarthritis 1.
• Use oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for pain management, as they have been shown to be effective in reducing pain and improving function in patients with knee osteoarthritis 1.
• Consider physical therapy as part of a comprehensive management plan, including exercises such as straight leg raises, hamstring stretches, and wall sits to stabilize the joint 1.
• Weight management is essential, as each pound lost reduces knee pressure by four pounds, and a comprehensive lifestyle intervention for weight reduction should be discussed 1.
• Bracing, including the use of knee braces, may improve pain and self-reported physical function in the knee, and should be considered as part of a self-management program 1.

Medication

• Acetaminophen (Tylenol) at 325-650mg every 4-6 hours (not exceeding 3000mg daily) or NSAIDs such as ibuprofen (Advil, Motrin) at 200-400mg every 4-6 hours with food (maximum 1200mg daily) or naproxen sodium (Aleve) at 220mg every 8-12 hours (maximum 660mg daily) can be used for immediate relief 1.
• Duloxetine may be considered as an alternative or adjunctive therapy for patients with an inadequate response or contraindications to acetaminophen or NSAIDs 1.

Important Considerations

• Opioids, including tramadol, should not be used for the management of knee osteoarthritis due to the notable increase in medication-related adverse effects with no consistent improvement in pain and function 1.
• Intra-articular injections, such as corticosteroid or hyaluronic acid, may be considered for patients with persistent pain, but the evidence for their effectiveness is limited, and they should not be used as a routine treatment 1.
• Meniscus tears in patients with knee osteoarthritis should be treated conservatively, with surgery considered only for patients with mechanical symptoms or those who have failed nonsurgical treatment 1.

From the FDA Drug Label

PRECAUTIONS General Ibuprofen tablets cannot be expected to substitute for corticosteroids or to treat corticosteroid insufficiency. The pharmacological activity of ibuprofen tablets in reducing fever and inflammation may diminish the utility of these diagnostic signs in detecting complications of presumed noninfectious, painful conditions.

The FDA drug label does not answer the question about knee pain treatment.

From the Research

Causes of Knee Pain

• Osteoarthritis (OA) is the most common cause of knee pain in patients aged 45 years or older, affecting an estimated 654 million people worldwide 2
• Patellofemoral pain typically affects people younger than 40 years who are physically active, with a lifetime prevalence of approximately 25% 2
• Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma or as a degenerative condition in patients with knee OA 2

Diagnosis of Knee Pain

• Knee OA can be diagnosed clinically, with a focus on activity-related knee joint pain and morning stiffness lasting less than 30 minutes 2
• Patellofemoral pain can be diagnosed with anterior knee pain during a squat, which is approximately 91% sensitive and 50% specific 2
• Meniscal tears can be diagnosed with the McMurray test and joint line tenderness, which have a sensitivity of 61% and 83%, respectively, and a specificity of 84% and 83%, respectively 2

Treatment of Knee Pain

• First-line management of OA comprises exercise therapy, weight loss, education, and self-management programs 2, 3, 4
• Conservative management, including exercise therapy and weight loss, is also recommended for patellofemoral pain and meniscal tears 2, 5
• Pharmacological treatment options, such as topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs), can be used to manage OA-related pain, but should be used with caution due to potential side effects 6
• Intra-articular injections with glucocorticoids or hyaluronic acid can be used to achieve short-term pain relief in patients with severe OA-related pain, but the evidence for their effectiveness is uncertain 6