Managing the pain of osteoarthritis of the knee

by David A. Provenzano, MD, and Eric Schwenk, MD

Osteoarthritis of the knee requires comprehensive pain management, from the early stages of pain, through surgery, and for as long as pain persists.

One of the most common types of pain is osteoarthritis of the knee, which often involves pain and inflammation resulting from wear and tear. It affects more than 30 million Americans and a quarter of a million people worldwide. About 45% of people develop osteoarthritis of the knee over their lifetime. This condition highlights the importance of seeking a pain specialist to develop a comprehensive pain management approach.

In patients with knee osteoarthritis, pain typically worsens over time. During the early stages, patients can often reduce pain by modifying activities with continued lower impact aerobic and strengthening exercises. Mind-body (e.g. meditative practices) are also helpful. Doctors often prescribe non-opioid medications such as acetaminophen and non-steroidal anti-inflammatory drugs, such as ibuprofen.  Physical therapy, muscle strengthening, and weight loss can also slow progression and improve symptoms. Another approach for short-term pain relief is the use of periodic corticosteroid injections. 

When patients are not responsive to initial treatments, radiofrequency ablation is an option. This treatment involves applying heat to nerves surrounding the knee. There are some other treatments, such as platelet-rich plasma, that can be tried; however, its effectiveness is not yet proven.

Opioids are not considered a first-line treatment for knee osteoarthritis and are often not the best pain relievers for many patients. However, they may be used in some cases with limited quantities. Be sure to follow your physician’s instructions carefully and properly dispose of any unused opioids

When knee osteoarthritis pain has progressed to interfering with everyday activities, total knee replacement may be considered. For pain management during and after surgery, the surgeon and anesthesiologist will create an individually tailored plan. In general, a multimodal approach to pain management is most effective. This means combining medication types and techniques to control pain rather than relying on one single type. For example, patients may be given oral medications like acetaminophen (Tylenol), non-steroidal anti-inflammatory drugs, medications for nerve pain, low-dose opioids for a short time, and techniques such as nerve blocks or injections directly into the knee. Many of these can be continued beyond the hospital stay. Future advancements continue to be investigated for effective postoperative pain control including electrical stimulation and cryoneurolysis (temporary freezing) of nerves controlling pain signals from the knee.

Although a majority of patients experience good outcomes with knee replacement surgery, about 20% of patients develop chronic pain, which is pain lasting for three months or more. If pain persists outside of the normal healing window, it is important to seek the assistance of a board-certified pain specialist early on, before the pain becomes severe and difficult to manage.

Dr. Provenzano is the treasurer of ASRA and president of Pain Diagnostics and Interventional Care in Pittsburgh, PA. Dr. Schwenk is an associate professor and the director of Orthopedic Anesthesia at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, PA.