A majority of patients I see for knee osteoarthritis (OA) want a quick fix. Many would like to skip conservative treatment–activity modification, weight loss, physical therapy (PT), anti-inflammatory medication, and intra-articular steroid injections–and go straight to surgical management. Regarding nonoperative management of knee OA, the most recent AAOS Clinical Practice Guidelines “strongly” recommend that patients participate in PT and “inconclusively” recommend intra-articular steroid injections.1 Yet, in my clinical practice, I confess to typically offering a knee injection first, before PT.
I may change that practice in light of the randomized controlled trial (RCT) by Deyle et al. in the April 9, 2020 issue of The New England Journal of Medicine. The trial compared PT to glucocorticoid knee injections among 156 primary-care knee OA patients within a military health system. The primary outcome measure was the WOMAC score at 1 year. Secondary outcomes included the Alternate Step Test and the Timed Up and Go test.
Seventy-eight patients randomly assigned to each group were included in the analysis. The PT intervention included detailed home-exercise instructions and 8 sessions with a therapist over the initial 4- to 6-week period. Patients could also attend 1 to 3 PT sessions at the 4-month and 9-month reassessments. Knee-injection patients received 1 ml of triamcinolone acetonide (40 mg per milliliter) and 7 ml of 1% lidocaine up to three times in one year.
The mean baseline WOMAC scores were similar between the groups. However, at 1 year, the authors found a mean between-group difference of 18.8 points in WOMAC scores, favoring PT over injections. Secondary outcomes also favored PT over knee injections.
Regardless of this RCTs limitations, such as the lack of reporting on knee-injection techniques, the findings serve as a reminder to orthopaedists to recommend PT as an effective nonoperative treatment option for knee OA. Additionally, our primary care colleagues can use this data to help convince patients with knee OA that they do not need to rush in to see a surgeon.
Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.
Reference
- AAOS Clinical Practice Guidelines, Treatment of Osteoarthritis of the Knee, 2nd Edition (2013), http://www.orthoguidelines.org/topic?id=1005, accessed 4/14/2020.