What is the appropriate treatment for knee pain in a 62-year-old woman?

Treatment of Knee Pain in a 62-Year-Old Woman

Begin with a structured non-pharmacological and pharmacological approach centered on exercise, weight management if overweight, patient education, and paracetamol or topical NSAIDs as first-line analgesics, reserving oral NSAIDs and advanced interventions for inadequate response. 1

Initial Diagnostic Approach

• Obtain weight-bearing anteroposterior and lateral knee radiographs to confirm osteoarthritis (the most likely diagnosis in this age group) and assess severity, typically revealing medial joint space narrowing if OA is present 2, 3
• Perform focused physical examination including palpation of the medial joint line (tenderness suggests medial compartment OA or meniscal pathology), assessment for joint effusion via ballottement, and range of motion testing 4, 3
• Consider hip radiographs only if knee radiographs are unremarkable and clinical concern exists for referred pain from hip pathology 1
• Do not routinely order MRI for typical knee osteoarthritis presentation; reserve MRI for persistent pain despite adequate conservative therapy or unexpectedly rapid progression 2

Core Non-Pharmacological Treatment (Foundation for All Patients)

Patient Education and Self-Management

• Enroll in a structured self-management program incorporating disease education, goal-setting, problem-solving, and joint protection strategies, delivered by health educators, nurses, physical therapists, or peers, 2-6 times weekly 5
• Provide education on the nature of osteoarthritis, emphasizing that it can be effectively managed and is not inevitably progressive, using resources from arthritis organizations 1
• Structured education can offset up to 80% of healthcare costs within one year by reducing primary care visits 2

Exercise Therapy (Mandatory Component)

• Refer for supervised physical therapy with minimum 12 directly supervised sessions to achieve optimal outcomes (effect size 0.46 versus 0.28 for fewer sessions) 1, 2, 5
• Prescribe quadriceps strengthening exercises as critical for knee OA management, since muscle weakness is both cause and consequence of the disease 1, 2
• Include progressive strength training of major muscle groups 2 days per week at 60-80% of one repetition maximum for 8-12 repetitions 2, 5
• Add low-impact aerobic activity for 30-60 minutes daily at moderate intensity, which has equivalent long-term efficacy to strengthening exercises 1, 2
• Supervised programs are significantly more effective than home exercise alone for pain reduction 5

Weight Management (If Overweight or Obese)

• Initiate structured weight loss program aiming for ≥5% body weight reduction within 3-6 months, with further benefits observed up to 20% loss 5
• Use low-calorie meal replacement bars or powders combined with balanced meal plan to ensure adequate nutrition 5
• Schedule weekly to bi-weekly follow-up visits during initial phase for goal reassessment and plan adjustment 5
• For severe obesity (BMI >40 kg/m²), refer for bariatric surgery evaluation as part of comprehensive weight management 5

Assistive Devices and Footwear

• Recommend walking stick for patients with medial compartment OA to improve stability and reduce joint load 1, 2
• Advise shock-absorbing insoles and appropriate footwear, which can reduce knee pain and improve function within one month 5
• Consider simple neoprene knee sleeve for symptom improvement, which has demonstrated superiority to oral analgesics at 6 months in early-stage disease 2

Adjunctive Mind-Body Therapies

• Strongly recommend tai chi as adjunct therapy to enhance strength, balance, mood, and self-efficacy 5
• Conditionally recommend yoga as alternative mind-body practice 5

Pharmacological Treatment Algorithm

First-Line Analgesics

• For knee osteoarthritis, start with topical NSAIDs (e.g., diclofenac gel 40 mg/2 pump actuations to each painful knee twice daily) as first-line for localized pain, showing effect size of 0.91 versus placebo with excellent safety profile 1, 2, 6
• Apply to clean, dry skin; wait 30 minutes before showering/bathing; wash hands after application 6
• Alternatively, prescribe paracetamol up to 4 g/day on scheduled dosing as preferred long-term oral analgesic 1, 2

Second-Line: Oral NSAIDs (If Topical Agents Insufficient)

• Add oral NSAID (e.g., naproxen 375-500 mg twice daily) at lowest effective dose for shortest duration if topical NSAIDs and paracetamol provide inadequate relief 1, 5
• Prescribe COX-2 inhibitor (other than etoricoxib 60 mg) or standard NSAID alongside proton pump inhibitor (choose PPI with lowest acquisition cost) 1
• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but vary in gastrointestinal, liver, and cardiorenal toxicity 1
• Consider individual risk factors including age when selecting agent and dose, with appropriate monitoring 1
• Avoid prolonged high-dose NSAIDs in elderly due to GI, renal, and platelet toxicity risk 2

Third-Line: Duloxetine (For Moderate-to-Severe Refractory Pain)

• Add duloxetine 30 mg daily, titrating to 60 mg after one week when pain remains moderate-to-severe after 4-6 weeks of optimized therapy 2, 5
• Discontinue with 2-4 week taper if used >3 weeks 5

Intra-Articular Corticosteroid Injection

• Administer intra-articular corticosteroid injection only when knee effusion is present, providing short-term relief with effect size of 1.27 over 7 days 1, 2

Opioids (Generally Avoid)

• Do not prescribe opioids including tramadol beyond short-term co-codamol, as they offer limited benefit with relative risk of adverse events 1.28-1.69 2, 5

Treatments to Avoid (Strong Evidence Against)

• Do not prescribe glucosamine or chondroitin supplements 1, 2
• Do not use intra-articular hyaluronic acid injections as they do not provide clinically meaningful pain relief 2
• Do not prescribe lateral heel wedges for medial compartment OA 2
• Do not refer for arthroscopic lavage or debridement as it does not alter disease progression or provide sustained benefit 2
• Do not use electroacupuncture 1

Structured Treatment Timeline

Weeks 1-2 (Immediate Initiation)

• Start topical NSAID to affected knee twice daily 2, 6
• Optimize paracetamol to 4 g/day scheduled dosing if additional analgesia needed 2
• If effusion detected on examination, administer intra-articular corticosteroid injection 2
• Refer for supervised physical therapy (minimum 12 sessions) 5
• Initiate patient education and self-management program 2

Weeks 2-6 (Short-Term Escalation)

• Continue supervised quadriceps strengthening and aerobic exercise 1
• If pain remains severe despite topical NSAID and paracetamol, add oral NSAID with PPI 1
• If pain still moderate-to-severe after 4-6 weeks, introduce duloxetine 30 mg daily, titrating to 60 mg 5
• Reinforce home exercise program and self-management strategies 2

Month 2 Onward (Long-Term Maintenance)

• Maintain home exercise regimen (quadriceps strengthening plus low-impact aerobic activity) 1
• Continue paracetamol and/or topical NSAID as needed for symptom control 2
• Integrate exercise into daily life after initial supervised sessions 2
• Schedule annual or as-needed reassessment of symptoms and functional status 2

Surgical Referral Criteria

Refer for orthopedic evaluation for total knee arthroplasty when: 2

1. Non-operative measures optimally applied for ≥3-6 months
2. Radiographs show advanced structural damage (minimal or no joint space)
3. Functional impairment significantly limits valued activities despite conservative treatment
4. Patient has refractory pain associated with disability

• For tricompartmental disease, total knee arthroplasty is preferred over unicompartmental replacement 2
• Advise substantial weight loss before TKA if obese, as obesity increases technical difficulty and complication risk 2

Critical Pitfalls to Avoid

• Do not delay referral to physical therapy; early supervised exercise is essential for optimal outcomes 2
• Do not rely on unsupervised home exercise alone; supervised therapy yields larger functional benefits (effect size 0.45 versus 0.23) 5
• Do not order MRI prematurely in routine OA; meniscal tears seen on MRI are often incidental in patients >65 years and majority are asymptomatic 2
• Do not use meniscal tear findings on MRI as sole indication for arthroscopy 4
• Do not underestimate synergistic effect of combining exercise, weight loss, and self-management programs; together they produce superior outcomes compared with exercise alone 5
• Do not prescribe rigid valgus-directing realignment braces routinely; evidence base is limited to small cohort studies 2
• Do not use immobilizer or "rest" braces for chronic knee OA, as they weaken surrounding musculature 2