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Knee Pain Without Trauma: Why Treatment Order Matters

The amount of people with knee pain continues to rise, especially as we age. Typically, if knee pain becomes a big enough problem, you may go see a physician. As long as there is no trauma associated with the knee pain, placing one at a higher risk for bone and ligament injuries, a decision needs to be made about how to treat the problem. Should the doctor prescribe medications, physical therapy, injections, or surgery? Which, and in what order? Although there may be good reason for variance from case to case, some surprising findings have been shown when looking back at some of the data from insurance claims. People who received physical rehabilitation within 15 days of the physician visit were much less likely to use narcotics, nonsurgical invasive procedures such as injections, and surgery.

What did physicians prescribe?

  • 17% were prescribed physical therapy.
  • 85% were given a prescription. Prescriptions included NSAIDs and up to 57% filled narcotic analgesics. The problem with narcotic pain killers is that users are at an elevated risk for dependency, falls, fractures, and death. If someone had early rehabilitation, they were 33% less likely to have a narcotic prescription filled.
  • 40% were prescribed injections. Guidelines recommend injections only after simple pharmacologic and non-pharmacologic interventions no longer can manage pain and disability. Injections were given much sooner on average than outpatient rehabilitation by approximately 24 days. This could problematic sequencing because if someone had early rehabilitation, they were 50% less likely to have an injection.
  • 8% underwent surgical interventions. Surgery rates are on the rise and up to 1/3 of these surgeries have been shown to be inconsistent with clinical guideline recommendations. Many times the surgery procedure is not the best match to the problem or in other cases conservative rehabilitation measures have not been exhausted prior to the surgical intervention. If patients were exposed to early rehabilitation, they were 42% less likely to have surgery within that next year.

Physical therapy has been shown to be one of the most effective treatments for knee pain and is strongly supported by the research. The American Academy of Orthopedic Surgeons recommend physical therapy as more effective than injections or even knee scopes. It is unfortunate that over 83% of the individuals seen in the clinic did not receive what is considered the best treatment. In addition, those who did not receive physical therapy in the first 15 days were more likely to have narcotic prescriptions filled, injections, and surgeries within that year.

What can you do?

  1. Spread the word. Physical therapy should be one of the first line interventions according to the research. Quality information can help get people better in faster and safer ways.
  2. Get physical therapy 1st. It could mean much less cost and risk of invasive procedures down the road.
  3. Get physical therapy soon. This study showed there may be some big consequences for waiting. The likelihood of having need for medications, injections, and surgeries were increased if people did not get physical therapy early in the process.
  4. Talk to your physician if physical therapy would be a good option for you. Some insurance companies allow you to go directly to a physical therapist for them to evaluate if physical therapy would be a good option for you.

Although this study has some very interesting findings, it was an observational study describing what happened rather than demonstrating cause and effect. There is no guarantee that physical therapy will fix everything, but it seems that people who have physical therapy early on are not as likely to need other interventions to treat their pain and disability. A physical therapist can help you set realistic goals and get you back to the things you love to do most.

Physical therapy is a safe and effective treatment for knee pain, but unfortunately very few individuals with knee pain received physical therapy interventions. Medications, injections, and surgeries are options for treating knee pain but due to their risks, costs, and/or effectiveness, giving more conservative options an opportunity first may be the best route. Keep those knees happy and healthy with a good combination of aerobic and strengthening exercises. Exercises can be custom tailored to meet your individual needs.



Knee Pain Without Trauma: Why Treatment Order Matters

Knee Pain Without Trauma: Why Treatment Order Matters




Stevans JM, Fitzgerald GK, Piva SR, Schneider M. Association of early outpatient rehabilitation with health service utilization in managing Medi­care beneficiaries with nontraumatic knee pain: retrospective cohort study. Phys Ther. 2017;97:615–624.