A 62-year-old Indian woman presents with a 3-year history of progressive pain and stiffness in both knees, worse in the morning and after prolonged sitting. She has a BMI of 28 kg/m², works as a schoolteacher, and reports morning stiffness lasting 15–20 minutes. On examination, both knees show crepitus on flexion-extension, mild effusion, and varus deformity of the right knee. X-ray of both knees shows joint space narrowing, osteophytes, and subchondral sclerosis. Which of the following is the most appropriate initial management?

Explanation

## Diagnosis & Clinical Context **Key Point:** This patient has primary osteoarthritis (OA) of the knees with radiographic confirmation (joint space narrowing, osteophytes, subchondral sclerosis). The morning stiffness is mild (15–20 min, not >1 hour), and she is overweight with occupational risk factors. ## Initial Management Strategy **High-Yield:** The stepwise approach to OA management is: 1. **Non-pharmacological:** Weight reduction, activity modification, physiotherapy 2. **Pharmacological:** Topical NSAIDs first, then oral NSAIDs if needed 3. **Intra-articular:** Corticosteroid or hyaluronate injection for symptomatic relief 4. **Surgical:** Joint replacement only after conservative measures fail (typically >6–12 months) **Clinical Pearl:** Intra-articular corticosteroid injection is indicated when: - OA is confirmed radiographically - Patient has functional limitation and pain despite NSAIDs - Effusion is present (as in this case) - Patient is not yet a candidate for surgery **Key Point:** Weight reduction is critical in lower-limb OA because each 1 kg reduction decreases knee loading by ~4 kg per step. Combined with intra-articular injection, this addresses both mechanical and inflammatory components. ## Why This Approach Works | Component | Rationale | |-----------|----------| | Intra-articular corticosteroid | Reduces synovial inflammation, provides 3–6 months relief | | Weight reduction | Decreases mechanical load on knees, slows progression | | Physiotherapy (implied) | Strengthens quadriceps, improves proprioception | | Avoid early surgery | Patient is still functional; surgery reserved for end-stage OA | **Mnemonic:** **RICE + WRIST** for OA management: - **R**est / activity modification - **I**ntra-articular injections - **C**ontrol weight - **E**xercise / physiotherapy - **W**arm therapy - **R**eassess regularly - **I**ncrement NSAIDs if needed - **S**urgery (last resort) - **T**opical agents first [cite:Robbins 10e Ch 24]