Simple and Sage Advice for a Common Problem: Osteoarthritis of the Knee

What is the best approach to knee osteoarthritis in everyday office practice?

Complaints of knee pain are very common in primary care practice. Osteoarthritis is the cause in many instances, especially in an aging, obese population. A recent “Top Paper” offers practical advice for the diagnosis and management of this problem.¹ The message will be summarized in 10 valuable pearls for everyday practice.

KNEE OSTEOARTHRITIS: 10 CLINICAL PEARLS

1. Weight is a risk factor: In the words of the authors, “Public health strategies targeted toward weight reduction and prevention of knee injuries could prevent large numbers of people from developing (osteoarthritis).”¹ A meta-analysis referenced in the “Top Paper” demonstrated that a reduction in body weight of 5% reduced pain and improved disability.

2. Diagnosis is primarily based on history and physical examination: Adding plain radiography provides a sensitivity and specificity of 91% and 86%, respectively. Symptoms include persistent knee pain, limited stiffness (less than 30 minutes), and reduced function. Signs are crepitus, restricted movement, and bony enlargement.

3. MRI should not be performed.

4. Exercise is essential! It provides pain relief similar to that of medications. Water exercises may be better.

5. Acetaminophen (less than 4 g/d) is the best initial treatment. NSAIDs may be better in some patients, but these drugs lead to more side effects. For those older than 75 years, topical NSAIDs are safer.

6. Duloxetine may benefit patients with osteoarthritis who are depressed, affording greater pain relief.

7. Joint injections at best offer only 1 to 2 weeks of improvement. A Cochrane Database Review cited in the paper demonstrated their inadequacy.

8. Viscosupplementation with hyaluronic acid provides only a “small and a clinically irrelevant reduction in pain” with a risk of adverse events. A recent systematic review and meta-analysis strengthen this recommendation.²

9. There is no reason to use glucosamine or topical capsaicin.

10. Surgery in the form of arthroplasty is reserved for patients with severe disease only.