Management of Hip and Knee Pain

Initial Treatment Approach

The American College of Physicians recommends beginning with a structured self-management program combining exercise therapy, weight loss if overweight, and patient education, supplemented by topical NSAIDs for knee pain or oral NSAIDs/acetaminophen for both hip and knee pain 1, 2
Exercise therapy is the cornerstone of management and must be implemented first, with a minimum of 12 supervised sessions showing superior outcomes compared to fewer sessions 1, 2, 3, 4
Weight loss programs are recommended for overweight/obese patients with structured goals of 4-7 kg reduction, delivered through weekly supervised sessions 2, 4
Bracing is strongly recommended for knee osteoarthritis when disease causes sufficient impact on ambulation, joint stability, or pain, including tibiofemoral knee braces for general knee OA and patellofemoral braces for patellofemoral knee OA 1, 5
Assistive devices, including canes, should be prescribed when disease impacts ambulation 4, 5

Topical NSAIDs, such as diclofenac, are strongly recommended as first-line treatment for knee pain, with superior efficacy to placebo and fewer gastrointestinal adverse events 6, 3
Acetaminophen and/or oral NSAIDs are suggested for initial treatment of hip and knee pain, with oral NSAIDs demonstrating superiority to acetaminophen in moderate-to-severe OA pain 1, 7, 6
Duloxetine, 60 mg daily, is recommended as alternative or adjunctive therapy when acetaminophen/NSAIDs are inadequate or contraindicated, with significant reductions in pain and improvements in physical function 1, 7, 6
Intra-articular corticosteroid injections are suggested for persistent knee or hip pain inadequately relieved by other interventions, with hip injections requiring image guidance and avoiding injections within 3 months preceding joint replacement surgery 1, 7, 6, 3

Surgical consultation should be considered when there is end-stage OA with minimal/no joint space on weight-bearing radiographs, or inability to cope with pain after exhausting all appropriate conservative options, with weight-bearing plain radiographs obtained before surgical referral 1

Tai chi is strongly recommended for knee and hip OA, combining meditation with gentle movements, breathing exercises, and relaxation 5
Yoga is conditionally recommended for knee OA only, with insufficient evidence for hip OA 5
Cognitive behavioral therapy may reduce pain and improve coping in chronic knee, hip, or hand OA 5