Management of moderate to severe knee osteoarthritis
- Leticia Alle Deveza, MD
Leticia Alle Deveza, MD
- Rheumatology Fellow
- Department of Rheumatology, Royal North Shore Hospital
- Institute of Bone and Joint Research, Sydney Medical School
- Kolling Institute of Medical Research, University of Sydney
- Kim Bennell, PhD
Kim Bennell, PhD
- Professor, Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy
- University of Melbourne, Australia
All patients with knee osteoarthritis (OA) should have appropriate interventions that include a combination of nonpharmacologic and pharmacologic treatment modalities. In contrast to patients with mild knee OA, patients with moderate to severe knee OA generally require additional interventions given the degree of functional impairment and impact on quality of life.
The management of moderate to severe knee OA is reviewed here. Separate topic reviews on OA as well as knee pain include the following:
●(See "Pathogenesis of osteoarthritis".)
- Wallis JA, Taylor NF. Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis. Osteoarthritis Cartilage 2011; 19:1381.
- Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev 2016; 3:CD005523.
- Moyer RF, Birmingham TB, Bryant DM, et al. Valgus bracing for knee osteoarthritis: a meta-analysis of randomized trials. Arthritis Care Res (Hoboken) 2015; 67:493.
- Hunter D, Gross KD, McCree P, et al. Realignment treatment for medial tibiofemoral osteoarthritis: randomised trial. Ann Rheum Dis 2012; 71:1658.
- Hinman RS, Crossley KM, McConnell J, Bennell KL. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ 2003; 327:135.
- Cushnaghan J, McCarthy C, Dieppe P. Taping the patella medially: a new treatment for osteoarthritis of the knee joint? BMJ 1994; 308:753.
- Hunter DJ, Harvey W, Gross KD, et al. A randomized trial of patellofemoral bracing for treatment of patellofemoral osteoarthritis. Osteoarthritis Cartilage 2011; 19:792.
- Callaghan MJ, Parkes MJ, Hutchinson CE, et al. A randomised trial of a brace for patellofemoral osteoarthritis targeting knee pain and bone marrow lesions. Ann Rheum Dis 2015; 74:1164.
- Jones A, Silva PG, Silva AC, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis 2012; 71:172.
- Dekker J, Bossen D, Holla J. Psychological strategies in osteoarthritis of the knee or hip. In: Oxford Textbook of Osteoarthritis and Crystal Arthropathy, Third Edition, Doherty M, Hunter DJ, Bijlsma H, Arden N, Dalbeth N (Eds), Oxford University Press, 2016.
- Keefe FJ, Porter L, Somers T, et al. Psychosocial interventions for managing pain in older adults: outcomes and clinical implications. Br J Anaesth 2013; 111:89.
- Wluka AE, Lombard CB, Cicuttini FM. Tackling obesity in knee osteoarthritis. Nat Rev Rheumatol 2013; 9:225.
- Bennell KL, Ahamed Y, Jull G, et al. Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2016; 68:590.
- Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 2012; 64:465.
- Bennell KL, Nelligan R, Dobson F, et al. Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med 2017; 166:453.
- van Walsem A, Pandhi S, Nixon RM, et al. Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or rheumatoid arthritis: a network meta-analysis. Arthritis Res Ther 2015; 17:66.
- da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet 2017; 390:e21.
- Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev 2006; :CD004257.
- Bannuru RR, Schmid CH, Kent DM, et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015; 162:46.
- Bjordal JM, Ljunggren AE, Klovning A, Slørdal L. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. BMJ 2004; 329:1317.
- Bjordal JM, Klovning A, Ljunggren AE, Slørdal L. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials. Eur J Pain 2007; 11:125.
- Zhang W, Jones A, Doherty M. Does paracetamol (acetaminophen) reduce the pain of osteoarthritis? A meta-analysis of randomised controlled trials. Ann Rheum Dis 2004; 63:901.
- Brown JP, Boulay LJ. Clinical experience with duloxetine in the management of chronic musculoskeletal pain. A focus on osteoarthritis of the knee. Ther Adv Musculoskelet Dis 2013; 5:291.
- Wang ZY, Shi SY, Li SJ, et al. Efficacy and Safety of Duloxetine on Osteoarthritis Knee Pain: A Meta-Analysis of Randomized Controlled Trials. Pain Med 2015; 16:1373.
- Wohlreich M, Frakes E, Risser RC, Ahl J. Duloxetine dose escalation in patients with osteoarthritis knee pain, who were taking optimized NSAIDs. Curr Med Res Opin 2013; 29:879.
- McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA 2017; 317:1967.
- Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev 2015; :CD005328.
- Bellamy N, Campbell J, Robinson V, et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2005; :CD005328.
- Maricar N, Callaghan MJ, Felson DT, O'Neill TW. Predictors of response to intra-articular steroid injections in knee osteoarthritis--a systematic review. Rheumatology (Oxford) 2013; 52:1022.
- Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015; 350:h2747.
- Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369:2515.
- OVERALL APPROACH
- Nonpharmacologic measures
- - Exercise
- - Knee braces
- - Walking aids
- - Psychological interventions
- Pharmacologic measures
- - Oral NSAIDs
- Choice and use of oral NSAID
- Efficacy of oral NSAIDs
- Adverse effects of oral NSAIDs
- - Inadequate response to oral NSAIDs or NSAIDs contraindicated
- Intraarticular glucocorticoid injection
- Refractory symptoms
- - Surgery
- THERAPIES LACKING EFFICACY OR OF UNCERTAIN BENEFIT
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS