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Knee and hip osteoarthritis pain management

Musculoskeletal pain · C4 · Reviewed by a board-certified pain physician on October 31, 2026

Bottom line

Osteoarthritis care rests on exercise, weight loss when overweight, and the least systemic drugs that work. Know the ACR/AF 2019 grades: what is strongly recommended, conditionally recommended, and recommended against.

Key points

  1. Diagnose clinically, and know the mimics. Hip osteoarthritis classification centers on hip pain with painful or limited internal rotation 1. Lateral pain with focal trochanteric tenderness worse side-lying suggests gluteal tendinopathy instead 2.
  2. Exercise and weight loss are foundational. ACR/AF strongly recommends exercise for knee, hip and hand osteoarthritis, and weight loss for overweight patients with knee or hip disease; tai chi is strongly recommended for knee and hip 3. Aquatic exercise gives small short-term benefits 4.
  3. Prefer the least systemic drug. Topical NSAIDs are strongly recommended for knee osteoarthritis and should be considered before oral NSAIDs; tramadol is only conditionally recommended 3.
  4. Injections: steroid yes, PRP no. Intra-articular glucocorticoid is strongly recommended for knee and hip, and conditionally for hand. Hyaluronic acid is conditionally against for the knee; PRP is strongly against for knee and hip 3. RESTORE found PRP no better than saline for pain or cartilage 5.
  5. Genicular nerve ablation for refractory knee pain. The classic targets are the superomedial, superolateral and inferomedial genicular nerves; the inferolateral quadrant is usually avoided because of the nearby common fibular nerve 67.
  6. Gluteal tendinopathy responds to loading education. In LEAP, education plus exercise beat corticosteroid injection for global improvement at 52 weeks 2.

Watch for

Recommendations are joint-specific: chondroitin is strongly against for knee and hip but conditionally recommended for hand osteoarthritis, and TENS is strongly against for knee and hip 3.

High-yield for the exam

  • ACR/AF strongly recommends against glucosamine for knee, hip and hand osteoarthritis 3.
  • Acupuncture is conditionally recommended for knee, hip and hand osteoarthritis; massage is conditionally against 3.
  • Lateral and medial wedged insoles are conditionally recommended against 3.
  • Intra-articular glucocorticoid is preferred over other intra-articular agents because its evidence is stronger 3.
  • RESTORE: PRP versus saline showed no difference in pain or medial tibial cartilage volume at 12 months 5.
  • Tramadol is only conditionally recommended for knee and hip osteoarthritis, while other opioids are conditionally recommended against 3.
  • Topical diclofenac has a more favorable renal profile than oral, but kidney function still needs monitoring in at-risk patients 8.

Numbers to know

Item Value
RESTORE trial size 288 patients 5
Cartilage volume change, PRP vs saline −1.4% vs −1.2% at 12 months 5
Hip OA criteria (one pathway) internal rotation ≥15° painful, stiffness ≤60 min, age >50 1
Standard genicular targets 3 nerves 7
LEAP follow-up favoring education plus exercise 52 weeks 2
Topical NSAIDs for knee osteoarthritis strongly recommended, before oral NSAIDs 3

Common traps

  • Assuming hyaluronic acid or PRP is endorsed because some patients report relief 3.
  • Applying knee or hip recommendations to the hand, or vice versa 3.
  • Calling trochanteric pain "bursitis" and defaulting to repeat steroid injections when loading education and exercise give better 1-year results 2.
  • Reaching for oral NSAIDs first in older adults when a topical NSAID is the guideline-preferred starting point 3.

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Sources

  1. Altman R, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum, 1991. pubmed.ncbi.nlm.nih.gov/2025304/
  2. Mellor R, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ, 2018. pmc.ncbi.nlm.nih.gov/articles/PMC5930290/
  3. Kolasinski SL, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol, 2020. pmc.ncbi.nlm.nih.gov/articles/PMC10518852/
  4. Bartels EM, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev, 2016. pubmed.ncbi.nlm.nih.gov/27007113/
  5. Bennell KL, et al. Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial. JAMA, 2021. pubmed.ncbi.nlm.nih.gov/34812863/
  6. Shi W, et al. The safety and efficacy of genicular nerve radiofrequency ablation for pain in inferolateral quadrant of the knee. Interv Pain Med, 2023. pmc.ncbi.nlm.nih.gov/articles/PMC11373012/
  7. Spalkit S, et al. Genicular nerves: ultrasound anatomy, scanning techniques, and clinical implications. J Ultrason, 2026. pmc.ncbi.nlm.nih.gov/articles/PMC13474172/
  8. Coșovanu EO, et al. Renal safety of topical diclofenac in adults with increased renal risk: a systematic review. Medicina (Kaunas), 2026. pmc.ncbi.nlm.nih.gov/articles/PMC13515200/

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Independent study material for the ABA Pain Medicine exam, written and reviewed by a board-certified pain physician. Not medical advice; not affiliated with the American Board of Anesthesiology.