What are the current NICE guidelines for the management of knee pain in adults, including pharmacological and non-pharmacological treatments?

Non-pharmacological management:

• Offer therapeutic exercise tailored to individual needs, including local muscle strengthening and general aerobic fitness, for all people with knee osteoarthritis. Supervised exercise sessions should be considered. Explain that initial joint pain may increase but regular exercise improves pain, function, and quality of life long-term.
• Advise weight loss for people who are overweight or obese, supporting them to set goals. Any weight loss is beneficial, but losing 10% of body weight is likely better than 5%.
• Consider manual therapy (manipulation, mobilisation, soft tissue techniques) only alongside therapeutic exercise and only for hip or knee osteoarthritis.
• Do not offer acupuncture or dry needling.
• Consider walking aids such as sticks if needed. Do not routinely offer insoles, braces, tape, splints, or supports unless there is joint instability or abnormal biomechanical loading and exercise alone is ineffective.

Pharmacological management:

• If drug treatment is needed, use it alongside non-pharmacological treatments and to support exercise, at the lowest effective dose for the shortest time.
• Offer topical NSAIDs as a first-line pharmacological option for knee osteoarthritis, as they are effective and have minimal adverse effects.
• If topical NSAIDs are ineffective or unsuitable, consider oral NSAIDs, taking into account gastrointestinal, renal, liver, and cardiovascular risks, and offer gastroprotection (e.g., proton pump inhibitors) during NSAID use.
• Paracetamol is not routinely recommended due to lack of strong evidence of benefit but may be used infrequently for short-term pain relief if other treatments are contraindicated or not tolerated.
• Do not offer glucosamine or strong opioids. Weak opioids like codeine may be considered only infrequently and short-term if other options fail.
• Consider intra-articular corticosteroid injections when other pharmacological treatments are ineffective or unsuitable, or to support exercise; explain these provide only short-term relief (2 to 10 weeks). Do not offer intra-articular hyaluronan injections.

Additional advice:

• Provide tailored information and support, including sources for further information and peer support.
• Arrange follow-up based on clinical need, with patient-initiated follow-up encouraged.
• Offer psychosocial support if needed, including for stress, anxiety, or depression.

These recommendations reflect the current NICE guideline NG226 on osteoarthritis in over 16s: diagnosis and management, supported by CKS and other expert consensus ¹,³.