The guidelines provided by the New York State Workers Compensation Board offer general principles for the use of medications in the context of knee injuries. These directives aim to assist healthcare professionals in determining appropriate strategies for prescribing medications as part of a comprehensive care plan for individuals with knee injuries.
Healthcare practitioners specializing in medications for knee injuries can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for utilizing medications in the treatment of knee injuries in their patients.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the use of medications for knee injuries should involve collaboration between the patient and their healthcare provider.
First-Line Medications for Most Patients
For the majority of patients, ibuprofen, naproxen, or other older generation NSAIDs are suggested as initial medications. Acetaminophen (or its analog paracetamol) may be a reasonable substitute for NSAIDs in patients ineligible for NSAIDs, although existing evidence indicates that acetaminophen is slightly less effective. NSAIDs are demonstrated to be as effective as opioids (including tramadol) for pain relief and exhibit fewer impairing effects.
NSAIDs for Treatment of Knee Pain (Acute, Subacute, or Chronic)
Recommended for the treatment of acute, subacute, or chronic knee pain. NSAIDs are advised for these conditions, and over-the-counter (OTC) options should be tried first. Frequency and duration of use may vary based on individual patient needs. Discontinuation should be considered upon symptom resolution, lack of efficacy, or the development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use with cytoprotective drugs such as misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors in patients at high risk of gastrointestinal bleeding. This is especially relevant for patients with a history of prior gastrointestinal bleeding, elderly individuals, diabetics, and smokers. Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended, with doses and frequency as per manufacturer guidelines. Discontinuation may be necessary due to intolerance, adverse effects, or discontinuation of NSAID treatment.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should discuss the risks and benefits of NSAID therapy for pain. Acetaminophen or aspirin are considered safer first-line therapies regarding cardiovascular adverse effects. If NSAIDs are needed, non-selective ones are preferred over COX-2 specific drugs. In patients taking low-dose aspirin for cardiovascular disease prevention, NSAIDs should be taken at least 30 minutes after or eight hours before the daily aspirin to minimize potential counteraction of aspirin’s beneficial effects.
Acetaminophen
Recommended for knee pain treatment, especially in patients with contraindications for NSAIDs. Indicated for all patients with knee pain, including acute, subacute, chronic, and post-operative cases. Dose and frequency should follow the manufacturer’s recommendations and may be used on an as-needed basis. Caution is advised to avoid hepatic toxicity when exceeding four grams per day. Discontinuation is warranted upon pain resolution, adverse effects, or intolerance.
Topical Medications
Recommended for specific patients to address pain associated with acute, subacute, or chronic knee pain, encompassing topical creams, ointments, and lidocaine patches.
Rationale for Recommendation:
Topical drug delivery, including capsaicin, topical lidocaine, topical NSAIDs, and topical salicylates and nonsalicylates, may be deemed acceptable for treatment in selected patients. Prescription of a topical agent should come with precise instructions for application and a maximum allowable number of daily applications to achieve the desired benefit while avoiding potential toxicity. The long-term effects of these agents are generally unknown, making episodic use potentially preferable. These treatments are suitable for patients who favor topical applications over oral medications. Localized skin reactions may occur based on the specific medication used, and prescribers should be mindful of the potential for toxic blood levels with topical medications.
Capsaicin serves as a safe and effective alternative to systemic NSAIDs, although its use is constrained by a local stinging or burning sensation that typically diminishes with regular application. Patients are advised to apply the cream using a plastic glove or cotton applicator on the affected area to prevent inadvertent contact with eyes and mucous membranes. Long-term use of capsaicin is discouraged.
Topical lidocaine is only recommended when neuropathic pain is documented. A trial period of no more than four weeks may be considered, with documented functional gains as a criterion for additional use.
Topical NSAIDs, such as diclofenac gel, may achieve potentially therapeutic tissue levels. The low level of systemic absorption can be advantageous, allowing topical use in situations where systemic administration is relatively contraindicated (e.g., in patients with hypertension, cardiac failure, peptic ulcer disease, or renal insufficiency).
Topical salicylates or nonsalicylates, like methyl salicylate, do not appear to be more effective than topical NSAIDs overall. They may be employed for a short-term course, especially in patients with chronic conditions for whom systemic medication is relatively contraindicated or as an adjunct to systemic medication.
Opioids
Not Recommended – for acute, subacute, or chronic knee pain.
Recommended – for limited use (not exceeding seven days) for postoperative pain management as adjunctive therapy alongside more effective treatments.
Indications: For post-operative pain management, a short-term prescription of opioids is recommended as an adjunct to more efficacious treatments, particularly NSAIDs and acetaminophen. This is especially relevant during the night.
Frequency/Duration: Prescribed as needed throughout the day, with a later transition to only nighttime use before gradually tapering off completely.
Rationale for Recommendation: In cases where some patients do not experience sufficient pain relief with NSAIDs, judicious use of opioids may be beneficial, especially for nocturnal use. Opioids are suggested for brief and selective use in post-operative patients, primarily at night, to facilitate post-operative sleep.
Minor Tranquilizer / Muscle Relaxants
Not Recommended
