BACKGROUND: This study had been formulated to evaluate and compare the analgesic effect of preemptive (PE), postoperative (PO), and combined knee intra-articular injection (IAI) of levobupivacaine and tramadol after knee arthroscopy. MATERIALS AND METHODS: A total of 220 patients assigned for therapeutic knee arthroscopy were divided into four equal groups. Patients in Group C received IAI of 20 mL (0.5%) levobupivacaine preoperative, meanwhile patients in Group PE received IAI of 18 mL (0.5%) levobupivacaine with 100 mg tramadol (2 mL). Patients in Group PO received IAI of 18 mL (0.5%) levobupivacaine with 100 mg tramadol (2 mL) postoperatively, whereas patients in Group PE/PO received IAI of 19 mL (0.25%) levobupivacaine with 50 mg tramadol (1 mL) preoperatively and postoperatively. Numeric rating scale (NRS) had been used to assess pain sensation. Duration till the first request of rescue analgesia and number of requests were recorded. RESULTS: NRS scores were significantly higher in Group C compared to other groups and in Group PE in comparison to PO and PE/PO groups. Frequency of rescue analgesia requests was significantly higher in Group C with significantly higher mean times of requests, while was significantly lower in Group PE/PO with significantly lower mean times of requests when compared to groups PE and PO. CONCLUSIONS: PE levobupivacaine and tramadol IAI provided satisfactory level of PO analgesia after therapeutic arthroscopy. However, combined PE and PO levobupivacaine and tramadol IAI of half dose provided PO analgesia superior to that provided by either PE or PO full-dose IAI.