Knee Osteoarthritis Management

Aka: Knee Osteoarthritis Management

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II. Management: General Measures

  1. Weight loss (for those with BMI >25 kg/m2)
    1. Improves pain and function (as well as overall general health)
    2. Brosseau (2011) Phys Ther 91(6):843-61 +PMID:21493746 [PubMed]
  2. Lower Extremity Strengthening Exercises
    1. Educate patient regarding importance of Exercise
    2. Exercise knees 20-30 minutes per day
    3. Physical Therapy to teach low extremity strength
      1. Quadriceps strengthening
      2. Gait training
      3. Active range of motion of hip, knee, and ankle
      4. Instruction in use of cane
      5. Graded elastic band use
    4. Pool Therapy
    5. Thai Chi
    6. Re-Evaluate after 4-6 weeks
    7. Modestly effective in reducing Knee Pain and improving function
      1. Exercises tailored to the patient performed for 20-30 min (and better results with 70-90 min) three times weekly
      2. Thomas (2002) BMJ 325:752-5 [PubMed]
      3. Torstensen (2023) Ann Intern Med 176(2): 154-65 [PubMed]
  3. Unloader Knee Brace (valgus) for medial Knee DJD
    1. Kirkley (1999) J Bone Joint Surg Am 81:539-48 [PubMed]
  4. Knee taping (pattelar taping)
    1. Upper tape for medial/AP tilt and medial glide
    2. Lower tape to protect pes anserine bursa
    3. Hinman (2003) BMJ 327:135-8 [PubMed]
  5. Progressive Walking Program
    1. Reevaluate monthly over 3-6 months
  6. Adjust prior activities
    1. Avoid high knee impact activities
      1. Running
      2. Stair Climbing
    2. Avoid prolonged standing, kneeling, or squatting
    3. Consider Biking, Swimming
  7. Avoid ineffective methods
    1. Lateral 5 degree heel wedge for medial knee Arthritis was not found effective
      1. Parkes (2013) JAMA 310(7): 722-30 [PubMed]

III. Management: Analgesics

  1. Local Cold Therapy
  2. Acetaminophen
    1. Dosing: 1000 mg orally two to four times daily prn (<2-4 grams/day)
    2. As effective as Ibuprofen (at any dose)
    3. Bradley (1991) N Engl J Med 325(2): 87-91 [PubMed]
    4. Verkleij (2011) Osteoarthritis Cartilage 19(8): 921-9 [PubMed]
  3. NSAIDS (use only with caution in older adults)
    1. Avoid in elderly
      1. See Nephrotoxicity due to NSAIDs
      2. See NSAID Gastrointestinal Adverse Effects
    2. COX2 Inhibitors offer no benefit over standard NSAIDs, and increased Cardiac Risk
    3. Consider Topical NSAIDs (e.g. Diclofenac)
      1. Effective and well tolerated
      2. Derry (2012) Cochrane Database Syst Rev (9):CD007400 +PMID:22972108 [PubMed]
  4. Sodium hyaluronate or Hyaluronic acid or Viscosupplementation (Synvisc)
    1. Variable study results
    2. Study supporting use
      1. Intra-articular viscosupplementation
      2. Effectively decreases pain and increases function
      3. Petrella (2002) Arch Intern Med 162:292-8 [PubMed]
    3. Studies suggesting minimal to no benefit
      1. Lo GH (2003) JAMA 290:3115-21 [PubMed]
      2. Arrich (2005) CMAJ 172:1039-43 [PubMed]
      3. Rutjes (2012) Intern Med 157(3): 180-91 [PubMed]
      4. Jevsevar (2015) J Bone Joint Surg Am 97(24): 2047-60 [PubMed]
  5. Platelet-Rich Plasma Injections
    1. No benefit over Hyaluronic acid (Synvisc) or Placebo (saline) injections
    2. Filardo (2015) Am J Sports Med 43(7): 1575-82 [PubMed]
    3. Lewis (2022) Bone Joint J 104-B(6): 663-71 [PubMed]
  6. Intra-articular Corticosteroid
    1. See Knee Joint Injection
    2. Offers short-term relief, but does not improve quality of life,and may result in greater cartlage loss
      1. Reserve for special occasion (e.g. pre-vacation)
      2. May consider for persistent pain not relieved with other measures, to temporize before replacement
      3. Mcalindon (2017) JAMA 317(19):1967-75 [PubMed]
    3. Depot Glucocorticoid (Triamcinolone hexacetonide)
    4. Avoid more than 3 times per year
  7. Intramuscular Corticosteroid Injection (experimental)
    1. One study evaluated gluteal IM Injection Triamcinolone Acetonide 40 mg
      1. Compared with intraarticular injection at 8 and 24 weeks, IM Injection showed equivalent efficacy
      2. However, intraarticular injection was superior at 4 weeks
      3. Wang (2022) JAMA Netw Open 5(4):e224852 +PMID: 35380645 [PubMed]
  8. Glucosamine Sulfate (controversial)
    1. Dosing: Glucosamine 500 mg three times daily
    2. Glucosamine and Chondroitin are NOT recommended by AAOS
    3. Mixed study results, although Cochrane review did not show compelling benefit
      1. Towheed (2005) Cochrane Database Sysy Rev (2):CD002946 +PMID:15846645 [PubMed]

IV. Management: Chronic Unrelenting Pain

  1. Topical Capsaicin Creams
  2. Transcutaneous electrical nerve stimulation
  3. Local massage
  4. Systemic Opioid Analgesics
    1. Tramadol (Ultram)
    2. Opioids
  5. Acupuncture
    1. Decreases pain scores by 40% and improves function
    2. Berman (2004) Ann Intern Med 141:901-10 [PubMed]
  6. Amitriptyline (Elavil)
  7. Pain management counseling and support groups

V. Management: Assistive Devices

  1. Physical Therapy
    1. Unloader Knee Brace (valgus) for medial Knee DJD
    2. Knee sleeve
    3. Cane
    4. Walker
  2. Occupational Therapy home visit
    1. Bath benches
    2. Raised toilet seat
    3. Grab bars
    4. Object reachers

VI. Management: Surgery

  1. Arthroscopy Indications
    1. May be indicated for loose bodies or locking, catching or giving way
    2. Not indicated in most cases of Knee Osteoarthritis (no longterm benefit, PT is preferred)
      1. Thorlund (2015) BMJ 350:h2747 [PubMed]
      2. Khan (2014) CMAJ 186(14):1057-64 [PubMed]
  2. Total Knee Replacement
    1. Indicated if moderate to severe persistent pain refractory to conservative measures

VII. References

  1. (1997) Postgrad Med 102(5): 167-79 [PubMed]
  2. Ebell (2018) Am Fam Physician 97(8): 523-6 [PubMed]
  3. Jones (2015) Am Fam Physician 92(10): 875-83 [PubMed]
  4. Ringdahl (2011) Am Fam Physician 83(11): 1287-92 [PubMed]

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