Knee Osteoarthritis Treatment Guidelines

Introduction to Treatment Options

• The American Academy of Orthopaedic Surgeons (AAOS) recommends against the routine use of hyaluronic acid injections for treating symptomatic knee osteoarthritis, with a moderate strength recommendation 1, 2
• The American College of Rheumatology/Arthritis Foundation conditionally recommends against intra-articular hyaluronic acid injections due to limited evidence of benefit 3

First-Line Treatments

• Non-pharmacologic interventions including weight loss, physical therapy, regular exercise, and knee bracing are recommended as first-line treatments 5, 3
• Oral acetaminophen is strongly recommended for pain management 1, 2
• Oral NSAIDs are strongly recommended when not contraindicated 2

Second-Line Treatments

• Intra-articular corticosteroid injections are recommended for short-term pain relief, with evidence showing benefit for up to 3 months 4, 5
• These injections have considerable evidence with 19 high-quality and six moderate-quality studies supporting their use 4

Treatments Not Recommended or Not Covered

• Oral narcotics, including tramadol, are not recommended due to notable increase in adverse events without consistent improvement in pain or function, with a strong recommendation 1, 2
• Hyaluronic acid injections are not recommended for routine use, with a moderate recommendation 1, 2

Potential Alternative Treatments with Limited Evidence

• Platelet-rich plasma may reduce pain and improve function, but has inconsistent results, especially in severe knee osteoarthritis, with a limited recommendation 2, 4
• Transcutaneous electrical nerve stimulation for pain is recommended with a limited recommendation 1
• Percutaneous electrical nerve stimulation for pain and function is recommended with a limited recommendation 1
• Extracorporeal shockwave therapy may improve pain and function, with a limited recommendation 1

Common Pitfalls in Treatment Selection

• Assuming all injectable treatments are equally effective or covered by Medicare is a common pitfall, with evidence from 19 high-quality and six moderate-quality studies 4, 3
• Proceeding to more invasive or experimental treatments before exhausting evidence-based conservative options is a common pitfall 3
• Continuing treatments without documented improvement in pain and functional capacity is a common pitfall 3
• Failing to consider the risk-benefit ratio when evidence for efficacy is limited is a common pitfall 3