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Review
. 2025 Jan;25(1):e13408.
doi: 10.1111/papr.13408. Epub 2024 Sep 1.

9. Chronic knee pain

Thibaut Vanneste  1   2   3 , Amy Belba  1   2   4 , Gezina T M L Oei  5   6 , Pieter Emans  7 , Loic Fonkoue  8   9 , Jan Willem Kallewaard  6   10 , Leonardo Kapural  11 , Philip Peng  12 , Michael Sommer  2   3 , Bert Vanneste  13 , Steven P Cohen  14   15 , Jan Van Zundert  1   2   3
Affiliations
Review

9. Chronic knee pain

Thibaut Vanneste et al. Pain Pract. 2025 Jan.

Abstract

Introduction: Chronic knee pain is defined as pain that persists or recurs over 3 months. The most common is degenerative osteoarthritis (OA). This review represents a comprehensive description of the pathology, diagnosis, and treatment of OA of the knee.

Methods: The literature on the diagnosis and treatment of chronic knee pain was retrieved and summarized. A modified Delphi approach was used to formulate recommendations on interventional treatments.

Results: Patients with knee OA commonly present with insidious, chronic knee pain that gradually worsens. Pain caused by knee OA is predominantly nociceptive pain, with occasional nociplastic and infrequent neuropathic characteristics occurring in a diseased knee. A standard musculoskeletal and neurological examination is required for the diagnosis of knee OA. Although typical clinical OA findings are sufficient for diagnosis, medical imaging may be performed to improve specificity. The differential diagnosis should exclude other causes of knee pain including bone and joint disorders such as rheumatoid arthritis, spondylo- and other arthropathies, and infections. When conservative treatment fails, intra-articular injections of corticosteroids and radiofrequency (conventional and cooled) of the genicular nerves have been shown to be effective. Hyaluronic acid infiltrations are conditionally recommended. Platelet-rich plasma infiltrations, chemical ablation of genicular nerves, and neurostimulation have, at the moment, not enough evidence and can be considered in a study setting. The decision to perform joint-preserving and joint-replacement options should be made multidisciplinary.

Conclusions: When conservative measures fail to provide satisfactory pain relief, a multidisciplinary approach is recommended including psychological therapy, integrative treatments, and procedural options such as intra-articular injections, radiofrequency ablation, and surgery.

Keywords: chronic knee pain; corticosteroids; genicular nerves; hyaluronic acid; osteoarthritis; radiofrequency treatment; spinal cord stimulation.

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Conflict of interest statement

The authors declare no conflicts of interest. Jan Van Zundert and Leonardo Kapural are Editorial Board members of Pain Practice and co‐author of this article. To minimize bias, he was excluded from all editorial decision‐making related to the acceptance of this article for publication.

Figures

FIGURE 1
FIGURE 1
Anatomical variations of the genicular nerves that innervate the knee joint capsule—reproduced with permission of Philip Peng Educational Series A. Lateral view. B. Anterior view. C. Medial view D. Posterior view.,
FIGURE 2
FIGURE 2
Innervation of the anterior knee capsule including possible target points for radiofrequency ablation—reproduced with permission of McCormick et al. (A) Anterior view, (B) lateral view, and (C) medial view. (A) Nerve to vastus lateralis, (B1) Lateral branch of nerve to vastus intermedius, (B2) Medial branch nerve to vastus intermedius, (C) Superior lateral genicular nerve, (D1) Nerve to vastus medialis, (D2) Superior medial genicular nerve, (E) Inferior lateral genicular nerve, (F) Infrapatellar branch of saphenous, (G) Recurrent fibular nerve, (H) Inferior medial genicular nerve, and (I) Terminal articular branch of the common fibular nerve.
FIGURE 3
FIGURE 3
Clinical practice algorithm for treatment of chronic knee pain due to osteoarthritis. NSAID, Non‐steroidal anti‐inflammatory drugs; OA, osteoarthritis; RF, radiofrequency.
See this image and copyright information in PMC

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