What are the recommended conservative and joint‑preserving treatment options for an adult with early knee osteoarthritis?

Knee Preservation in Adults with Early Osteoarthritis

For adults with early knee osteoarthritis, initiate a comprehensive joint-preserving strategy combining mandatory exercise therapy (strengthening and low-impact aerobics), weight loss if BMI ≥25 kg/m², and topical NSAIDs, escalating to oral NSAIDs or acetaminophen only when needed for pain control. 1

First-Line Non-Pharmacological Interventions (Mandatory Foundation)

Exercise Therapy

• Prescribe regular strengthening exercises, low-impact aerobic activity, and neuromuscular education as the absolute foundation of treatment. 2, 1
• Target 30-60 minutes of moderate-intensity aerobic activity most days of the week, as low-impact aerobic exercises demonstrate substantial effects with effect sizes of 0.52 for pain relief and 0.46 for disability reduction. 2, 1
• Emphasize quadriceps strengthening exercises specifically, which show significant improvements in both pain and function. 2
• Both aquatic and land-based exercise programs are effective; recommend 8-12 weeks of training, 3-5 sessions per week, with each session lasting approximately 1 hour. 3

Weight Management

• Mandate weight loss for any patient with BMI ≥25 kg/m², targeting a minimum 5% reduction in body weight. 2, 1
• Combine dietary modification with exercise for optimal results in both weight loss and improved function. 2, 1

Self-Management and Education

• Enroll patients in self-management educational programs to learn coping skills and activity modifications, utilizing individualized education packages, phone calls, group education, patient coping skills training, and spouse-assisted coping skills training. 2

Assistive Devices

• Consider walking sticks, appropriate footwear with shock-absorbing properties, and knee bracing for symptomatic relief or biomechanical instability. 2, 4
• Do not prescribe lateral wedge insoles, as they are not recommended. 5, 2

Pharmacological Treatment Algorithm

Initial Pharmacological Approach

• Start with topical NSAIDs for the knee combined with oral acetaminophen for mild-to-moderate pain. 1, 4
• Topical NSAIDs and capsaicin have demonstrated clinical efficacy and safety. 2

Escalation for Persistent Pain

• If pain persists despite acetaminophen and topical NSAIDs, escalate to oral NSAIDs (non-selective with gastroprotective agents) or selective COX-2 inhibitors. 2, 1
• Use the lowest effective dose for the shortest possible period. 4
• Always add a proton pump inhibitor for gastroprotection when prescribing oral NSAIDs, especially in patients over 50 or those with cardiovascular, gastrointestinal, or renal risk factors. 4

Additional Options for Inadequate Response

• For patients with inadequate response to NSAIDs, add duloxetine, which achieves significant reductions in pain and statistically significant improvements in physical function. 1
• Consider combination pharmacotherapy using multiple agents from different classes if pain or functional limitation has not improved after initial treatment. 1

Intra-Articular Injections (For Specific Indications)

• Use intra-articular corticosteroid injections specifically for acute flares of knee pain, especially when accompanied by effusion. 2, 4
• Corticosteroid injections provide short-term relief lasting 4-8 weeks. 1
• The evidence for hyaluronic acid injections is mixed; while they may have symptomatic effects, the American Academy of Orthopaedic Surgeons does not recommend them. 5, 2

Treatments to Avoid

Strong Recommendations Against

• Do not prescribe acupuncture, glucosamine, or chondroitin, as they lack evidence of clinically important outcomes compared to placebo. 5, 4
• Avoid opioids, including tramadol, for osteoarthritis pain management, as current evidence does not support their use and they carry significant adverse event risks. 1

Surgical Interventions to Avoid

• Arthroscopic lavage and débridement should not be performed, as it does not alter disease progression or provide benefit in knee osteoarthritis. 6, 7

Joint-Preserving Surgical Options (When Conservative Management Fails)

Indications for Surgical Referral

• Obtain weight-bearing plain radiographs before surgical referral. 1
• Refer for surgical consultation when patients have radiographic evidence of knee osteoarthritis with refractory pain and disability despite maximal conservative management. 1, 7

Specific Joint-Preserving Procedures

• If OA is limited to one compartment in young and active patients, consider unicompartmental knee arthroplasty or unloading osteotomy as joint-preserving alternatives to total knee replacement. 6
• These procedures are recommended in younger, active patients given the risks and limited durability of total knee replacement. 6

Critical Monitoring and Reassessment

• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs, particularly in patients over 50. 4
• Regular monitoring of treatment effectiveness is essential as disease course and patient needs change over time. 4
• Refer for additional physical therapy if initial interventions are insufficient. 1

Common Pitfalls to Avoid

• Do not passively await disease progression; OA develops slowly over 10-15 years and is amenable to prevention and treatment at early stages. 8
• Do not view pain and disability as inevitable consequences of aging; implement active prevention and comprehensive care models. 8
• Do not proceed directly to surgical intervention without exhausting conservative measures, as pharmacologic and nonpharmacologic interventions are generally effective at alleviating pain and improving physical function. 9