Core management for all patients
- Structured exercise program
- Low-impact aerobics: cycling, walking, swimming.
- Quadriceps & hip strengthening (3–4×/week).
- Refer to physiotherapy as early as possible.
- Weight reduction
- Even 5–10% weight loss significantly reduces pain.
- Refer to health coach or obesity clinic if needed.
- Lifestyle & aids
- Cane on opposite side; knee brace or sleeve for support.
- Avoid prolonged sitting, deep squatting, stairs, heavy loads.
Stepwise pain management
| Step | Recommendation |
|---|---|
| First-line (mild) | Topical NSAIDs — Diclofenac 1% gel, 2–4 g QID to knee (max 16 g/day/joint). |
| Moderate/severe | Short-term oral NSAIDs: Diclofenac 50 mg BID/TID (preferred), Naproxen 250–500 mg BID (safer CV profile for longer use), or Meloxicam 7.5–15 mg OD (once-daily, GI tolerability). |
Before prescribing NSAIDs
- Always assess renal function, GI risk, cardiovascular risk.
- If ≥65y or GI risk → co-prescribe PPI (omeprazole 20 mg daily).
- Avoid long-term use; use lowest effective dose for shortest duration.
Note: Paracetamol is no longer first-line for OA due to limited efficacy. It may be adjunctive or for patients who cannot tolerate NSAIDs, but benefit is modest and inferior to NSAIDs.
Indications for referral to Orthopedics
- Persistent moderate-severe symptoms despite 6 months of PHC management.
- Confirmed advanced knee OA (Level 3–4).
- Symptoms affecting QoL and/or sleep.
- Significant impact on daily activity and functional capacity.
- Patient is medically fit and accepting surgical treatment.