What are the appropriate treatment steps for a patient with left knee pain?

Management of Left Knee Pain

Start with acetaminophen up to 4,000 mg/day as first-line pharmacologic therapy combined with immediate initiation of land-based exercise and weight loss counseling if overweight. 1

Immediate First-Line Treatment (Start All Simultaneously)

Non-Pharmacologic Interventions (Equally Important as Medications)

• Prescribe cardiovascular and/or resistance land-based exercise immediately - this is as critical as medication and should never be delayed 2, 1
• For aerobically deconditioned patients, aquatic exercise programs can be started with transition to land-based programs later 2, 1
• Counsel all overweight patients regarding sustained weight loss to reduce joint pressure and improve pain/function 2, 1
• Enroll patient in self-management education programs to improve pain outcomes 2, 1

First-Line Pharmacologic Options

• Acetaminophen (paracetamol) 500-1000 mg every 6-8 hours, maximum 4,000 mg/day - safest long-term oral analgesic with 1.5% adverse event rate 2, 1
• Topical NSAIDs (particularly diclofenac) - equivalent efficacy to oral NSAIDs with significantly fewer gastrointestinal adverse events, preferred in patients ≥75 years old 1
• Oral NSAIDs at lowest effective dose - use only after screening for contraindications including GI ulcers, cardiovascular disease, renal impairment (avoid if GFR <30 mL/min), and concurrent anticoagulation 2, 1

Second-Line Treatment for Inadequate Response to Acetaminophen

Escalation to NSAIDs

• Oral NSAIDs (naproxen 500 mg twice daily or equivalent) if acetaminophen insufficient 2, 1, 3
• For patients with increased GI risk, use non-selective NSAIDs with gastroprotective agents or COX-2 selective inhibitors 2
• Critical contraindication: Do not use COX-2 inhibitors in patients taking low-dose aspirin for cardioprotection due to pharmacodynamic interaction 2

Intra-Articular Corticosteroid Injection

• Strongly indicated for acute pain flares, especially when knee effusion is present - provides significant relief within 1-2 weeks lasting 1-12 weeks 2, 1, 4
• Patients with baseline effusion respond better than those without 4
• Monitor diabetic patients for glucose levels 1-3 days post-injection due to transient hyperglycemia risk 1, 4
• Avoid within 3 months prior to knee replacement surgery due to increased infection risk 1, 4

Adjunctive Therapies (Add to Core Treatment)

Physical Therapy Modalities

• Manual therapy combined with supervised exercise to improve pain and function 2, 1
• Neuromuscular training (balance, agility, coordination) programs combined with exercise to improve performance-based function 2
• Medially directed patellar taping as adjunctive measure 1

Assistive Devices

• Walking aids (canes, crutches) to reduce joint pressure 2, 1
• Knee bracing for mechanical support 2
• Shoe insoles for biomechanical correction 2

Alternative Modalities (Limited Evidence)

• Tai chi programs for chronic pain 1
• Traditional Chinese acupuncture only for chronic moderate-to-severe pain in surgical candidates who cannot/will not undergo surgery 2, 1
• FDA-approved laser treatment may improve pain/function 2
• Transcutaneous electrical nerve stimulation for pain 2, 1

Third-Line Treatment for Refractory Cases

For Patients Unresponsive to Above Measures

• Opioid analgesics only for patients with contraindications to NSAIDs or who have failed all other options - follow American Pain Society guidelines for chronic non-cancer pain management 2
• Duloxetine conditionally recommended for patients unwilling/unable to undergo arthroplasty 2

Surgical Consideration

• Total knee arthroplasty for patients with radiographic evidence of OA, refractory pain and disability despite conservative measures 2, 4

What NOT to Use (Evidence-Based Recommendations Against)

• Do not initiate glucosamine - conditionally recommended against 1
• Do not initiate chondroitin sulfate - conditionally recommended against 1
• Do not use topical capsaicin - conditionally recommended against 1
• Do not start new opioid prescriptions including tramadol due to poor risk-benefit ratio 1

Critical Pitfalls to Avoid

• Never delay exercise therapy - it is as important as pharmacologic management and must begin immediately, not after medication trials 1
• Never prescribe oral NSAIDs without screening for GI history, cardiovascular disease, renal function (avoid if CrCl <30 mL/min), and medication interactions 2, 1
• Never use both corticosteroid and hyaluronic acid injections within 3 months of planned knee replacement due to infection risk 1, 4
• Never assume exercise alone is sufficient - optimal management requires combination of non-pharmacological and pharmacological modalities 2, 1
• Never use ibuprofen in patients taking low-dose aspirin for cardioprotection - renders aspirin less effective 2