Nonsurgical Management of Knee Pain in Adults

 

Am Fam Physician. 2015 Nov 15;92(10):875-883.

  Patient information: See related handout on knee pain, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

The role of the family physician in managing knee pain is expanding as recent literature supports nonsurgical management for many patients. Effective treatment depends on the etiology of knee pain. Oral analgesics—most commonly nonsteroidal anti-inflammatory drugs and acetaminophen—are used initially in combination with physical therapy to manage the most typical causes of chronic knee pain. The American Academy of Orthopaedic Surgeons recommends against glucosamine/chondroitin supplementation for osteoarthritis. In patients who are not candidates for surgery, opioid analgesics should be used only if conservative pharmacotherapy is ineffective. Exercise-based therapy is the foundation for treating knee osteoarthritis and patellofemoral pain syndrome. Weight loss should be encouraged for all patients with osteoarthritis and a body mass index greater than 25 kg per m2. Aside from stabilizing traumatic knee ligament and tendon tears, the effectiveness of knee braces for chronic knee pain is uncertain, and the use of braces should not replace physical therapy. Foot orthoses can be helpful for anterior knee pain. Corticosteroid injections are effective for short-term pain relief in patients with osteoarthritis. The benefit of hyaluronic acid injections is controversial, and recommendations vary; recent systematic reviews do not support a clinically significant benefit. Small studies suggest that regenerative injections can improve pain and function in patients with chronic knee tendinopathies and osteoarthritis.

Knee pain affects approximately 25% of adults, limiting function, mobility, and quality of life.1 The prevalence of knee pain has increased 65% over the past 20 years,1 with an estimated 4 million primary care visits per year attributed to knee pain.2 Knee symptoms are the 10th most common reason for outpatient visits.3 Recent studies support nonsurgical management for common knee diseases, such as osteoarthritis and meniscal disease.46  Although there are many causes of and treatments for knee pain, this article focuses on the evidence supporting nonsurgical interventions for typical causes of knee pain in adults: osteoarthritis (Table 1722); patellofemoral pain syndrome (Table 212,2327); and meniscal, tendon, and ligament injuries (Table 32835).

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Exercise-based therapy is the first-line treatment for knee osteoarthritis and patellofemoral pain syndrome, in addition to weight loss, if necessary, for those with osteoarthritis.

C

7, 23

Nonsteroidal anti-inflammatory drugs are effective for short-term treatment of knee osteoarthritis and patellofemoral pain syndrome.

B

7, 8, 25

Glucosamine/chondroitin supplementation has limited effectiveness in the treatment of osteoarthritis.

B

7, 15, 17, 48, 49

Active rehabilitation is as effective as arthroscopy at reducing pain and improving function in patients with nontraumatic degenerative medial meniscal tears without mechanical symptoms.

A

28, 29

Braces are a reasonable option for treatment of common knee overuse conditions, but should not replace treatments such as active rehabilitation.

C

21, 22, 26, 27, 33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Exercise-based therapy is the first-line treatment for knee osteoarthritis and patellofemoral pain syndrome, in addition to weight loss, if necessary, for those with osteoarthritis.

C

7, 23

Nonsteroidal anti-inflammatory drugs are effective for short-term treatment of knee osteoarthritis and patellofemoral pain syndrome.

B

7, 8, 25

Glucosamine/chondroitin supplementation has limited effectiveness in the treatment of osteoarthritis.

B

7, 15, 17, 48, 49

Active rehabilitation is as effective as arthroscopy at reducing pain and improving function in patients with nontraumatic degenerative medial meniscal tears without mechanical symptoms.

A

28, 29

Braces are a reasonable option for treatment of common knee overuse conditions, but should not replace treatments such as active rehabilitation.

C

21, 22, 26, 27, 33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

BEST PRACTICES IN ORTHOPEDICS: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.

American Academy of Orthopaedic Surgeons

Do not use lateral wedge insoles

The Authors

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BRANDON Q. JONES, MD, is a family physician at Menlo Medical Clinic in Menlo Park, Calif. At the time the article was written, he was an assistant professor at Nellis Family Medicine Residency at Mike O'Callaghan Federal Medical Center, Nellis Air Force Base, Nev....

CARLTON J. COVEY, MD, is a fellow at the National Capital Consortium's Military Primary Care Sports Medicine Fellowship, Bethesda, Md. At the time the article was written, he was an assistant professor at Nellis Family Medicine Residency at Mike O'Callaghan Federal Medical Center, Nellis Air Force Base.

MARVIN H. SINEATH, JR., MD, is an assistant professor and sports medicine physician at Nellis Family Medicine Residency at Mike O'Callaghan Federal Medical Center, Nellis Air Force Base.

Address correspondence to Brandon Q. Jones, MD, Menlo Medical Clinic, 321 Middlefield Rd, Ste. 260, Menlo Park, CA 94025 (e-mail: bqjones@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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