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Knee Osteoarthritis

Original Editors - Fien Selderslaghs, Laura Van Der Perren, Mirabella Smolders, Liese Magnus

Top Contributors - Mirabella Smolders, Laura Van Der Perren, Hamelryck Sascha, Abbey Wright, Laura Ritchie, Lucinda hampton, Kim Jackson, Jessica Davis, Fien Selderslaghs, Rachael Lowe, Bo Hellinckx, Venugopal Pawar, Vidya Acharya, Admin, Ophélie Schraepen, Candace Goh, Feebe Robyns, 127.0.0.1, Joni Roesems, Khloud Shreif, Saemeh Eldaly, Simisola Ajeyalemi, Alaa Abou Khzam, Saud Alghamdi, Jonathan Wong, Rishika Babburu, Robin Tacchetti, Aminat Abolade, Sai Kripa, Jess Bell, Evan Thomas, Michelle Lee, Rucha Gadgil, Barb Clemes, Kai A. Sigel, Anthony Mertens, Jelien Wouters, Arthur Devoldere and WikiSysop

Introduction

Knee osteoarthritis (OA), also known as degenerative joint disease, is typically the result of wear and tear and progressive loss of articular cartilage. It is most common in elderly people and can be divided into two types, primary and secondary:

  • Primary osteoarthritis - is articular degeneration without any apparent underlying cause.
  • Secondary osteoarthritis - is the consequence of either an abnormal concentration of force across the joint as with post-traumatic causes or abnormal articular cartilage, such as rheumatoid arthritis (RA).

Osteoarthritis is a painful, chronic joint disorder that primarily affects not only the knees but also hands, hips and spine. The intensity of the symptoms vary for each individual and usually progress slowly.

Common clinical symptoms include

  • Intermittent or constant knee pain that is gradual in onset and worsens with activity
  • Morning stiffness of the knee lasting less than 30 minutes and swelling
  • Pain after prolonged sitting or resting
  • Crepitus or a cracking sound with joint movement
  • Knee locking or giving way
  • Difficulty walking, climbing stairs, and/or performing household chores[1]

Treatment for knee osteoarthritis begins with conservative methods and progresses to surgical treatment options when conservative treatment fails. While medications can help slow the progression of RA and other inflammatory conditions, there are currently no proven disease-modifying agents for the treatment of knee OA.[2]

[3]

Epidemiology

OA is the most common disease of the joints worldwide, with the knee being the most commonly affected joint in the body. [4] It mainly affects people over the age of 45.

OA can lead to pain and loss of function, but not everyone with radiographic findings of knee OA will be symptomatic: in one study only 15% of patients with radiographic findings of knee OA were symptomatic[2][4].

  • OA affects nearly 6% of all adults
  • Women are more commonly affected than men[4]
  • Roughly 13% of women and 10% of men 60 years and older have symptomatic knee osteoarthritis.[2]
  • Among those older than 70 years of age, the prevalence rises to as high as 40%.[2]
  • Prevalence will continue to increase as life expectancy and obesity rises.[5]

Etiology

Knee OA is classified as either primary or secondary, depending on its cause[4]:

  1. Primary knee OA is the result of articular cartilage degeneration without any known reason. This is typically thought of as degeneration due to age as well as wear and tear.
  2. Secondary knee OA is the result of articular cartilage degeneration due to a known reason. Possible Causes of Secondary Knee OA:
    • Obesity
    • Joint hypermobility or instability
    • Malpositioning of the joint e.g. valgus/varus posture
    • Previous injury to the joint e.g. fracture along articular surface (tibial plateau fracture)
    • Congenital defects
    • Immobilisation and loss of mobility
    • Family history
    • Metabolic causes e.g. rickets
    • Infectious arthritis
    • Psoriatic arthritis
    • Hemophilia
    • Paget disease
    • Sickle cell disease
    • Scoliosis
    • Hemochromatosis
    • Chondrocalcinosis
    • Ochronosis
    • Wilson disease
    • Gout
    • Pseudogout
    • Acromegaly
    • Avascular necrosis[6]

Risk Factors

Risk factors of knee osteoarthritis can be categorized to modifiable and non-modifiable risk factors. Modifiable risk factors include BMI, trauma to the knee joint, muscle weakness or imbalance, metabolic conditions, and occupation which requires prolonged sitting and knee bending. Non-modifiable risk factors on the other hand include gender, age, family history, and race.[6]

Relevant Anatomy

The knee (art. genus) is a synovial joint, which consists of 2 articulations.

OA can occur in either or both of these articulations of the knee, it is usual that the patellofemoral joint is affected first.[8]

Pathological Process

The process of osteoarthritis affects the articular cartilage (mainly type II) that covers the articular surfaces of bone[2].

Articular cartilage is normally maintained in a healthy equilibrium of chemical reactions, however, when OA starts to develop the reactions are disrupted leading to changes in the collagen of the cartilage[9][10]:

  1. Disruption in the equilibrium which results in the disorganised pattern of collagen, and loss of articular cartilage elasticity.
  2. This results in cracking and fissuring of the cartilage which leads to erosion of the articular surface.[2]
  3. Cartilage that has been damaged, cannot recover.
  4. The cartilage will continue to wear away
  5. Once the cartilage has worn away; bony surfaces will start to be affected
  6. The bone will expand and spurs (osteophytes) will develop.

It is common for ligament laxity and muscle atrophy to also occur as the disease progresses. [11]

Characteristics/Clinical Presentation

Signs of knee OA are:

  • Pain upon movement
  • Stiffness, particularly early morning stiffness
  • Loss of range of movement
  • Pain after prolonged sitting or lying
  • Pain on joint line palpation
  • Joint enlargement.[12]

Diagnosis

Image 2: medial joint space is more narrow than the lateral joint space

The diagnosis can be established by clinical examination, and it can be confirmed by X-rays.

Knee OA can be sub-divided into 5 grades:

  • Grade 0: This is the “normal” knee health
  • Grade 1: Very minor bone spur growth and is not experiencing any pain or discomfort.
  • Grade 2: This is the stage where people will experience symptoms for the first time. They will have pain after a long day of walking and will sense a greater stiffness in the joint. It is a mild stage of the condition, but X-rays will already reveal greater bone spur growth. The cartilage will likely remain at a healthy size.
  • Grade 3: Moderate OA. Frequent pain during movement, joint stiffness will also be more present, especially after sitting for long periods and in the morning. The cartilage between the bones shows obvious damage, and the space between the bones is getting smaller.
  • Grade 4: This is the most severe stage of OA. The joint space between the bones will be dramatically reduced, the cartilage will almost be completely gone and the synovial fluid will be decreased. This stage is normally associated with high levels pain and discomfort during walking or moving the joint.[13]

Diagnostic Tests

Blood Tests; to help determine the type of arthritis

Physical examination: see below

X-ray: A basic X-ray is used to research breakdown of cartilage, narrowing of joint space, forming of bone spurs and to exclude other causes of pain in the affected joint.

Arthrocentesis: This is a procedure which can be performed at the doctor’s office. A sterile needle is used to take samples of joint fluid which can then be examined for cartilage fragments, infection or gout.

Arthroscopy: is a surgical technique where a camera is inserted in the affected joint to obtain visual information about the damage caused to the joint by the OA.

MRI. Magnetic resonance imaging (MRI). Provides a view that offers better images of cartilage and other structures to detect early abnormalities typical of osteoarthritis[14].

Radiographic Findings of OA

  • Joint space narrowing
  • Osteophyte formation
  • Subchondral sclerosis
  • Subchondral cysts[2]
  • Early stages of OA shows a minimal unequal joint space narrowing.
  • In severe OA the joint line may disappear completely (see image 2).[12]

Treatment/Management

Treatment for knee OA can be broken down into conservative and surgical management.

Initial treatment always begins with conservative modalities and moves to surgical treatment once conservative management has been exhausted. There is a wide range of conservative modalities available for the treatment of knee OA.

The main focus in OA management is on promoting self-management, reducing pain, optimise function, and modifying the disease process and its effects.[15]

Conservative Treatment Options

The primary treatment for OA knee conservatively is exercise therapy within physiotherapy.[16] Physiotherapy normally involves

  • Patient education
  • Exercise therapy
  • Activity modification
  • Advice on weight loss
  • Knee bracing
    • The first-line treatment for all patients with symptomatic knee osteoarthritis includes patient education and physiotherapy. A combination of supervised exercises and a home exercise program have been shown to have the best results. These benefits are lost after 6 months if the exercises are stopped.[16]
    • Current research indicates that aerobic exercise is likely the most effective form of exercise for enhancing pain relief, physical function, walking ability, and overall quality of life in individuals with knee osteoarthritis.[17]
    • Weight loss is valuable in all stages of knee OA. It is indicated in patients with symptomatic OA with a body mass index greater than 25. The best recommendation to achieve weight loss is with diet control and low-impact aerobic exercise.
    • Research suggests that any amount of weight lost is likely to yield huge benefits. Furthermore, it has been shown that every 1% of weight loss was associated with a 2% reduced risk of knee replacement and a 3% reduced risk of hip replacement. [18]
    • Knee bracing in OA can be used. Offloading-type braces which shift the load away from the involved knee compartment. This can be effective when there is a valgus or varus deformity.

Other non-physiotherapy based interventions include pharmacological management[2]:

    • Drug therapy alongside physiotherapy should be the first-line treatment for patients with symptomatic OA. There are a wide variety of NSAIDs available, however, caution should be used when prescribing NSAIDs due to their side effects.[19]
    • Glucosamine and chondroitin sulfate are available as dietary supplements. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage. No strong evidence exists that these supplements are beneficial in knee OA.
    • Intra-articular corticosteroid injections may be useful for symptomatic knee OA.
    • Intra-articular hyaluronic acid injections (HA) injections are another inject-able option. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Differential Diagnosis[2]

Examination

Subjective Assessment

Take a proper history of pain including when the pain started if it was gradual or sudden, if there was any previous injury to the same knee.

The common subjective symptoms of knee OA are:

  • Early morning stiffness
  • Dull achy pain
  • Pain after sitting
  • Pain after increased activity
  • Reduced mobility
  • Difficulty weight bearing on the affected leg
  • Decrease in the abilities of daily functioning
  • Sleep may be affected (screen red flags appropriately)

Patients might also experience difficulty walking, climbing stairs, and/or performing household chores (especially those involving standing, sitting, or walking for long periods of time). Some patients might also report giving way or locking of the knee joint.[1]

Objective Assessment

After a thorough subjective assessment it may be clear the diagnosis of the patient already, however, it is always necessary to perform an objective assessment to rule out differential diagnoses and provide objective outcome measures such as range of movement (ROM).

  • Observation of the knee: it may be enlarged, swollen or red if the OA is very reactive or irritated.
  • Observation in general: movement patterns at rest and when performing simulations of daily activities such as getting up from and down on a chair
  • Gait assessment: use of walking aids may be required due to pain, is there any stiffness during gait, is there significant reduced weight bearing of the affected knee.
  • Palpation: swelling, temperature changes, joint line tenderness may all be present in an acutely aggravated OA knee
  • ROM: flexion and extension may be limited due to stiffness or formation of osteophytes in the joint
  • Strength: reduced strength is normal in an OA knee due to pain and deconditioning
  • Normal functional activities: such as climbing stairs may be affected
  • Balance: may be affected due to pain, this needs to be assessed to rule out falls risk.

Several outcome measures for patients with knee osteoarthritis are present in the literature. The most commonly used is the Western Ontario and McMaster University (WOMAC) OA index. The WOMAC index was developed by Bellamy et al. in 1982. According to a systematic review, WOMAC has excellent reliability and good validity. The WOMAC is scale divided into three subcategories (pain, stiffness, and physical function) and 24 total items where each them is rated according to 5-point ordinal scale.[21]

Physiotherapy Management

Physiotherapy should be started with all patients with a diagnosis of OA[22].

Pain is a common symptom that occurs at different intensities depending on the individual, it is not necessarily related to severity of OA progression[23].

Exercise has been proven to be effective as pain management and also improves physical functioning in the short term.[12][24] Exercises have to take place under the supervision of a physiotherapist initially and when properly instructed these exercises can be performed at home, though research has shown that group exercise combined with home exercise is more effective.[25]  

Role of Physiotherapy

Education

  • Understanding what OA is
  • Explaining pain
  • Explain long term management of OA
  • Educate regarding activity modification
  • Role of weight loss
  • Promote active, healthy lifestyle

Exercise

  • Reduces knee pain and inflammation.
  • Normalises knee joint range of motion.
  • Strengthens lower kinetic chain
  • Reduces risk of cardiovascular disease
  • Improves proprioception, agility and balance.
  • Promotes physical function

Land-based exercises are ideal for most people and are strongly recommended.[26] Aquatic exercise, stationary cycling, and walking are safe and effective activities that do not cause undue stress on the knee joint.[15]

Exercise has also been found to be beneficial for other co-morbidities and overall health. Walking, resistance training, cycling, pilates, yoga and Tai Chi are examples of such exercises. An individualised exercise program should be set by a physiotherapist initially, taking into account the patient's goals and hobbies to ensure long term exercise compliance.

Movement or physical activity is the best medicine for people suffering from knee osteoarthritis. Performing physical activity may not only improve your joint mobility, it can also improve your overall quality of life and can help reduce depression.[15] Individuals with knee OA commonly engage in strengthening their knee muscles, neglecting however hip muscle strengthening. On assessing patients with knee OA they would usually be presented with hip muscle weakness and are more prone to increase in medial compartment loading on the knee joint. Research has proven that patients with knee pain will benefit following hip strengthening exercises. Potential benefits includes quick pain relief and better hip strength. It is important to strengthen the hip in knee OA because hip strengthening exercises tend to improve the mechanics of your lower limb and reduce stress on the knee.[27]

Muscle strengthening exercises that target the quadriceps of patients with knee OA has been shown to improve pain as well as disability[28]. Hip muscle strengthening should not be overlooked when treating patients with knee OA. In fact a systematic review reported high-quality evidence that hip abductor muscle strengthening has positive effects on pain and function among patients with knee OA[29]. A study that compared hip and knee strengthening exercises to platelet-rich plasma and hyaluronic acid combination therapy reported exercises were superior to the combination therapy in terms of improving gait, pain, as well as function among patients with knee OA[30].

In addition to muscle strengthening exercises, flexibility exercises are also recommended for patients with knee OA. Among patients with knee OA, the flexibility of hamstring muscles is often affected. Thus, the addition of hamstring stretching to muscle strengthening has added value in terms of decreasing pain and improving function among patients with knee OA[31]. In a study which compared two home exercise program with one consisting of stretching and strengthening exercises and the other of strengthening exercises only, there was a significant improvement in pain and function in favor of the first home exercise program[31]. In addition to that, proprioceptive Neuromuscular Facilitation (PNF) stretching of the hamstring muscles of people with knee OA have been shown to be effective at reducing pain, improving hamstring muscle flexibility, and general health among patients with knee OA[32].

A new systematic review published in the journal Rheumatology Advances in Practice aiming to evaluate factors related to fatigue in individuals with hip and or knee OA found out that there is strong or moderate evidence that high numbers of co-morbidities or illness burden and modifiable factors, such as high depressive symptoms, low levels of self-reported physical function, high pain and low physical activity levels, are associated with greater fatigue, making these factors possible targets for fatigue reduction in hip and/or knee OA populations. The review showed there was moderate evidence of no association between sociodemographic factors (age, education, race, living situation or circumstances), BMI, radiographic OA severity and fatigue; and conflicting evidence for the association between poor performance-based physical function, high anxiety, high joint stiffness, poor sleep and low social support with higher fatigue.[33]

The video below gives 5 home exercises for people with knee OA.

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[34]

Other Interventions

There are various forms of therapeutic interventions that may or may not be helpful for patients with various degrees of evidence to support them:

  • Hydrotherapy - this may be particularly helpful if pain is very high and analgesia is not tolerated. It can be useful to build up strength and reduce stiffness around the knee joint in a non-weight bearing position.[35] [36]
  • Taping - works to offload the joint similar to bracing, this is useful in the short term. A systematic review shows elastic taping leads to no significant change in WOMAC score for improvement of pain in patients with primary knee osteoarthritis and alternative conservative treatments to elastic taping should be explored if OA knee pain persists for more than 21 days.[37]
  • Manual therapy - effective to improve ROM[38]According to a systematic review, manual therapy (mobilisation with movement, passive joint mobilisation, patellar mobilisation therapy ) and exercises effectively reduce knee pain and increase functionality. However, further research is needed to determine the long-term effects of manual therapy on knee OA.[39] Patellar mobilisation has been shown to improve WOMAC scores, pain, stiffness, and the function among individuals with knee OA[40]. Hip and knee targeted manual therapy in conjunction with exercise was able to improve WOMAC scores in addition to physical performance scores[41].
  • Massage - may be useful to control pain in some subjects, but this has low evidence to show its effectiveness[42]
  • Bracing
  • Electrotherapy -such as muscle stimulation to improve quadricep strength and  TENS as it has some evidence to show it can help with pain reduction [43]. A randomised controlled trial published in 2019 reported that wearing a TENS machine on the affected knee joint supplying a symmetrical biphasic current with sweep mode from 1 to 250 Hz and a pulse width of 60 μs was able to improve pain and the 6MWT distance[44]. Another study published in the same year showed that TENS applied with low intensity pulsed ultrasound was better than TENS alone at improving pain and disability caused by knee OA[45]. A third study published in 2020 showed that TENS current with the same parameters as the first study mentioned improved the ability to climb stairs among people with mild knee OA[46]. Concerning interferential current, a recent systematic review and meta-analysis of randomized controlled trials reported that interferential current therapy improves short-term and long-term pain as well as short-term function[47].
  • Dry needling -A systematic review and meta-analysis of randomised controlled trials showed that there is very low quality evidence that dry needling has positive effects on pain and disability in the short-term[48].
  • Toe-out gait modification -Gait modification in the form of increasing toe-out during walking can have positive effects on knee OA. A study published in 2023 reported that toe-out gait decreased medial meniscus extrusion associated with the second peak of knee adduction angle[49]. Increased medial meniscus extrusion seems to increase the stress on the medial compartment of the knee joint contributing to increased pain and the progression of knee OA[50]. A pilot feasibility study published in the year 2014 showed that a 10 week of toe-out gait retraining of individuals with knee OA decreased pain and improved WOMAC index scores[51].
  • Therapeutic Ultrasound -A systematic review suggests that the use of therapeutic ultrasound in conjunction with other physiotherapy interventions might provide pain relief and improvement in function among patients with knee OA however the evidence is limited due to the small number of studies included in the review as well as the low methodological quality of these studies. As for the parameters of the therapeutic ultrasound for knee OA please refer to the ones employed in the studies included in this review.[52]
  • Low-Level Laser Therapy (LLLT) -LLLT according to a systematic review have been shown to reduce pain and improve function among patients with knee OA. For more information about the parameters employed please refer to the protocols of studies included in this review.[53]

The Use of Electrophysical Aagents in Knee Osteoarthritis Rehabilitation

  • Transcutaneous Electrical Nerve Stimulation (TENS): The optimal duration of a TENS treatment for the duration of post-stimulation analgesia and degree (VAS scores) of pain reduction is 40 minutes. TENS 100 Hz dual channel continuous mode with a 200 s pulse width.[54]
  • Therapeutic ultrasound: Patients receiving US treatment with the following parameters 1 MHz 1 W/cm2 Continuous 8 min showed significant improvement in morning stiffness, 6 min walking distance, and all pain scales (VAS, WOMAC, Lequesne, SF-36), but (Yeğin et al., 2017) noted that more thorough research on bigger patient groups may clarify the function of US in the management of knee OA.[55]
  • Pulsed Electromagnetic Fields: The authors of this Cochran Review present that to date, there is evidence suggesting electromagnetic field therapy provides mild symptom relief from pain to individuals with osteoarthritis. More research will determine if it improves function or quality of life clinically for the affected individual.[56]
  • Neuromuscular Electrical Stimulation (NMES): Within the Systematic Review by (Giggins et al,. 2012), of 409 participants, inconclusive evidence (level D) was found that neuromuscular electrical stimulation significantly affects quadriceps femoris muscle strength, function, and pain measures in knee osteoarthritis. They discovered, nevertheless, that there is uncertainty regarding the use of neuromuscular electrical stimulation to treat osteoarthritis in the knee.As a result, future research in this area needs to specify exactly what neuromuscular electrical stimulation does for this population. (Sabharwal et al., 2024). conducted a randomised controlled trial discovered that adding exercises to the NMES unit could be very helpful as enhances function, risk of falls, range of motion, balance, and pain management.[57][58]
  • Short-wave therapy (SWT): systematic review and meta-analysis was conducted by (Lee et al., 2014). This review shows that Pulse SWT was highly effective for both pain relief and functional improvement, while Continuous SWT was ineffective for both. Capacitive SWT significantly affects muscle strength, functional improvement, and pain reduction. The outcomes of capacitive and continuous SWT were stronger muscles.[59]
  • Extracorporeal Shockwave Therapy (ESWT): (Li etal., 2018) discovered that ESWT with the following parameters might be safe and effective for treating patients with knee OA: 3000 pulses at a frequency of 15 Hz with 0–11 mJ/mm2 applied over the joint line with 5 points of synovial region of the medial side.[60]
  • High-Power Laser Therapy (HPLT): ( Justina et al., 2018) in a systematic review discovered that the laser fluence for a single treatment varied from 0.51 to 120 J/cm2. In a single treatment, the total energy transferred varied between 1250 and 3000 J. HILT was found to be helpful in treating knee OA.[61]
  • Low Level Laser Therapy (LLLT): In 2024, one systematic review and meta-analysis established what the best parameters were in the treatment of knee OA patients with LLLT for symptoms of knee osteoarthritis. Among these, the 904–905 nm wavelength did present potential benefits in lessening knee OA pain; however, the overall quality of the evidence was low. Noticeably better reduction of knee OA pain was done with LLLT wavelengths of 904– 905, 785–850 nm. [62]
  • Interferential Current Therapy (IFC): An RCT published in 2021 found that the following parameters improved the intensity of pain in knee osteoarthritis: Interferential current plus photobiomodulation or isolated photobiomodulation with the following parameters: Amplitude: strong but not painful; pulse frequency: carrier at 4000 Hz and Amplitude Modulated Frequency (AMF) at 50-100 Hz; Electrodes: 4 placed with quadripolur configuration to cover area of pain 30 min/d 3 d/wk.[63]
  • Electroacupuncture: In a 2024 RCT, the promising points of electroacupuncture treatment were ST35, EX-LE5, LR8, GB33, and an Ashi point-the area where the patient feels the most pain. [64]
  • Phonophoresis: Patients with knee OA who were treated with the following guidelines saw a greater improvement in pain and function after administering Dexamethasone gel with therapeutic ultrasound: Continuous mode; 1 MHz; 1 W/cm2; 10 min.[65]
  • Iontophoresis: (Ajediran., 2014) set the parameters as follows: 50 ml of a 5% ibuprofen solution was used to saturate the negative electrode, and water was used to moisten the positive electrode. In the treatment of knee OA impairments, continuous galvanic current with current density = 0.48 mA/cm2, frequency = 8000 Hz, phase interval = 5 µs, phase duration = 125 µs, duty cycle = 95%, and treatment duration = 30 minutes proved to be very beneficial.[66]
  • Diadynamic: (Patrícia et al., 2024) demonstrated that exercise programs that included the diadynamic with the following parameters resulted in noticeably higher improvements in pain and disability than those that only received exercises. Four-by-nine-cm stationary plate electrodes are positioned on the knee's medial and lateral sides. The treatment lasts 8 minutes on each side and consists of a series of distinct diadynamic currents, including four minutes of diphase currents and 4 minutes of long period currents. The intensity, which typically amounts to 15 mA, is dependent on each patient's unique reactions. Ten minutes is the maximum.[67]

Medical Management

If conservative management is not sufficient at controlling pain, surgical interventions can be explored.The most common forms of surgery for this condition are (from least to most invasive):

  • Therapeutic Injections
  • Arthroscopy - with the goal to remove osteophytes and any degenerative meniscal tears (this should not be considered if no osteophytes are present on XR)[68]
  • High tibial Osteotomy - if the patient meets the pre-operative functional level
  • Patellofemoral joint arthroplasty - if only the patellofemoral joint is affected, and tibiofemoral joints are healthy
  • Unicompartmental knee arthroplasty - if only one compartment (medial or lateral) is affected
  • Total knee replacements

The below video gives a good guide to both surgical and non surgical options and why or when they are offered.

[69]

Conclusion

Knee OA is best managed initially by conservative management. Failing this intervention and with positive radiographic evidence of OA surgical options can be considered to reduce pain in the long term and improve quality of life.

  • OA has no cure and thus attempts should be made to prevent progression of the disease.
  • Treatment for knee OA begins with conservative methods and progresses to surgical treatment options when conservative treatment fails.
  • A multi-disciplinary team approach should be taken to promote healthy lifestyle and control pain i.e. physiotherapist, dietitian and pharmacist
  • Orthopaedic specialists should be referred to if pain becomes unmanageable.

Resources

Verses Arthritis - patient resources, also offers free handouts for healthcare professionals

NICE Osteoarthritis in over 16s: diagnosis and management

References

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  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Hsu H, Siwiec RM. Knee Osteoarthritis.2019 Available from:https://www.ncbi.nlm.nih.gov/books/NBK507884/ (last accessed 28.2.2020)
  3. ↑ rBioventus Stages of knee OA Available from: https://www.youtube.com/watch?v=BBqjltHNOrc&feature=youtu.be (last accessed 17.11.2019)
  4. ↑ 4.0 4.1 4.2 4.3 Michael JW, Schlüter-Brust KU, Eysel P. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Deutsches Arzteblatt International. 2010 Mar;107(9):152.
  5. ↑ Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine. 2020 Dec 1;29:100587.
  6. ↑ 6.0 6.1 Hsu H, Siwiec RM. Knee Osteoarthritis [Internet]. Nih.gov. StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507884/
  7. ↑ Jennifer Reft. Knee Osteokinematics and Arthokinematics. Available from: http://www.youtube.com/watch?v=EyhiCvWER0Y [last accessed 07/12/2014]
  8. ↑ Brukner P, Clarsen B, et al. Brukner & Khan's Clinical sports medicine 5th edition. McGraw Hill Education; 2017; p777
  9. ↑ Buckwalter JA, Mankin HJ, Grodzinsky AJ. Articular cartilage and osteoarthritis. Instructional Course Lectures-American Academy of Orthopaedic Surgeons. 2005;54:465.
  10. ↑ Pearle AD, Warren RF, Rodeo SA. Basic science of articular cartilage and osteoarthritis. Clinics in sports medicine. 2005 Jan 1;24(1):1-2.
  11. ↑ E. Schulte, et al., General anatomy and musculoskeletal system, Atlas of Anatomy, 2006: 372-373
  12. ↑ 12.0 12.1 12.2 RK Arya, Vijay Jain, Osteoarthritis of the knee joint: An overview, Journal Indian Academy of Clinical Medicine, 2013, 14(2): 154-62
  13. ↑ Lespasio MJ, Piuzzi NS, Husni ME, Muschler GF, Guarino AJ, Mont MA. Knee osteoarthritis: a primer. The Permanente Journal. 2017;21.
  14. ↑ Osteoarthritis Diagnosis Arthritis Foundation Available from: https://www.arthritis.org/about-arthritis/types/osteoarthritis/diagnosing.php (last accessed 17.11.2019)
  15. ↑ 15.0 15.1 15.2 Schlenk EA, Xiaojun Shi BS. Evidence based practices for osteoarthritis management. American Nurse Today 2019;14.
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  18. ↑ Salis Z, Sainsbury A, Keen HI, Gallego B, Jin X. Weight loss is associated with reduced risk of knee and hip replacement: a survival analysis using Osteoarthritis Initiative data. International Journal of Obesity [Internet]. 2022 Jan 11;46(4):874–84.
  19. ↑ Aweid O, Haider Z, Saed A, Kalairajah Y. Treatment modalities for hip and knee osteoarthritis: A systematic review of safety. Journal of Orthopaedic Surgery. 2018 Nov 8;26(3):2309499018808669.
  20. ↑ E. RINGDAHL, et al., Treatment of Osteoarthritis, American Family Physician, 2011, 83(11):1287-1292.
  21. ↑ Samuel AJ, Kanimozhi D. Outcome measures used in patient with knee osteoarthritis: With special importance on functional outcome measures. International Journal of Health Sciences [Internet]. 2019;13(1):52–60. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6392485/
  22. ↑ National Institute for Health and Care Excellence (NICE). Management of osteoarthritis [internet]. [London]: NICE 2019 [updated 2020, cited May 2020] (NICE pathways). Available from: https://pathways.nice.org.uk/pathways/osteoarthritis#path=view%3A/pathways/osteoarthritis/management-of-osteoarthritis.xml&content=view-node%3Anodes-core-treatments-information-exercise-and-weight-loss
  23. ↑ M. Elboim-Gabyzon, N. Rozen, and Y. Laufer. Gender Differences in Pain Perception and Functional Ability in Subjects with Knee Osteoarthritis. ISRN Orthopedics. Volume 2012, Article ID 413105, 4 pages
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  30. ↑ Ma C, Li X, Pan Y, Tian H, Wang Z, Zhang X, et al. The efficacy of the leg swing and quadriceps strengthening exercises versus platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: A retrospective comparative study. Medicine [Internet]. 2023 Sep 15 [cited 2023 Nov 14];102(37):e35238.
  31. ↑ 31.0 31.1 Suzuki Y, Iijima H, Tashiro Y, Kajiwara Y, Zeidan H, Shimoura K, et al. Home exercise therapy to improve muscle strength and joint flexibility effectively treats pre-radiographic knee OA in community-dwelling elderly: a randomized controlled trial. Clinical Rheumatology. 2018 Aug 30;38(1):133–41.
  32. ↑ Anjum N, Sheikh RK, Omer A, Anwar K, Khan MMH, Aftab A, et al. Comparison of instrument-assisted soft tissue mobilization and proprioceptive neuromuscular stretching on hamstring flexibility in patients with knee osteoarthritis. PeerJ [Internet]. 2023;11:e16506. Available from: https://pubmed.ncbi.nlm.nih.gov/38054019/?fbclid=IwAR2NFlgQYPFvarwrfmDjP7fsiVt76Q_gZs3FNkx0LtBohTOges_d_EMSsz4
  33. ↑ Fawole HO, Idowu OA, Abaraogu UO, Dell’Isola A, Riskowski JL, Oke KI, Adeniyi AF, Mbada CE, Steultjens MP, Chastin SF. Factors associated with fatigue in hip and/or knee osteoarthritis: a systematic review and best evidence synthesis. Rheumatology advances in practice. 2021;5(1):rkab013.
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  36. ↑ Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Physical therapy. 2007 Jan 1;87(1):32-43.
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  40. ↑ Sit RWS, Chan KKW, Zou D, Chan DCC, Yip BHK, Zhang DD, et al. Clinic-Based Patellar Mobilization Therapy for Knee Osteoarthritis: A Randomized Clinical Trial. The Annals of Family Medicine [Internet]. 2018 Nov [cited 2019 Aug 13];16(6):521–9. Available from: http://www.annfammed.org/content/16/6/521.full
  41. ↑ Abbott JH, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis and Cartilage. 2013 Apr;21(4):525–34.
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  43. ↑ Mascarin NC, Vancini RL, dos Santos Andrade M, de Paiva Magalhães E, de Lira CA, Coimbra IB. Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis: prospective clinical trial. BMC musculoskeletal disorders. 2012 Dec 1;13(1):182.
  44. ↑ Shimoura K, Iijima H, Suzuki Y, Aoyama T. Immediate Effects of Transcutaneous Electrical Nerve Stimulation on Pain and Physical Performance in Individuals With Preradiographic Knee Osteoarthritis: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation [Internet]. 2019 Feb [cited 2019 Sep 5];100(2):300-306.e1. Available from: https://www.sciencedirect.com/science/article/pii/S0003999318313728
  45. ↑ Iijima H, Eguchi R, Shimoura K, Yamada K, Aoyama T, Takahashi M. Transcutaneous Electrical Nerve Stimulation Improves Stair Climbing Capacity in People with Knee Osteoarthritis. Scientific Reports. 2020 Apr 29;10(1).
  46. ↑ Iijima H, Eguchi R, Shimoura K, Yamada K, Aoyama T, Takahashi M. Transcutaneous Electrical Nerve Stimulation Improves Stair Climbing Capacity in People with Knee Osteoarthritis. Scientific Reports. 2020 Apr 29;10(1).
  47. ↑ Chen HL, Yang FA, Lee TH, Liou TH, Escorpizo R, Chen HC. Effectiveness of interferential current therapy in patients with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Scientific Reports. 2022 Jun 11;12(1).
  48. ↑ Jiménez-del-Barrio S, Medrano-de-la-Fuente R, Hernando-Garijo I, Mingo-Gómez MT, Estébanez-de-Miguel E, Ceballos-Laita L. The Effectiveness of Dry Needling in Patients with Hip or Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Life. 2022 Oct 11;12(10):1575.
  49. ↑ Hashizume T, Ishii Y, Ishikawa M, Nakashima Y, Kamei G, Iwamoto Y, et al. Toe-out gait inhibits medial meniscus extrusion associated with the second peak of knee adduction moment during gait in patients with knee osteoarthritis. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology. 2023 Jul 1;33:13–9.
  50. ↑ Hashizume T, Ishii Y, Ishikawa M, Nakashima Y, Kamei G, Iwamoto Y, et al. Toe-out gait inhibits medial meniscus extrusion associated with the second peak of knee adduction moment during gait in patients with knee osteoarthritis. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology. 2023 Jul 1;33:13–9.
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  53. ↑ Stausholm MB, Naterstad IF, Joensen J, Lopes-Martins RÁB, Sæbø H, Lund H, et al. Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials. BMJ Open [Internet]. 2019 Oct [cited 2019 Nov 11];9(10):e031142. Available from: https://bmjopen.bmj.com/content/9/10/e031142
  54. ↑ Cheing, G. L. Y., Tsui, A. Y. Y., Lo, S. K., & Hui-Chan, C. W. Y. (2003). OPTIMAL STIMULATION DURATION OF TENS IN THE MANAGEMENT OF OSTEOARTHRITIC KNEE PAIN. Journal of Rehabilitation Medicine, 35(2), 62–68. https://doi.org/10.1080/16501970306116
  55. ↑ Yeğin, T., Altan, L., & Aksoy, M. K. (2016). The Effect of Therapeutic Ultrasound on Pain and Physical Function in Patients with Knee Osteoarthritis. Ultrasound in Medicine & Biology, 43(1), 187–194. https://doi.org/10.1016/j.ultrasmedbio.2016.08.035
  56. ↑ Li, S., Yu, B., Zhou, D., He, C., Zhuo, Q., & Hulme, J. M. (2013). Electromagnetic fields for treating osteoarthritis. Cochrane Library. https://doi.org/10.1002/14651858.cd003523.pub2
  57. ↑ Giggins, O., Fullen, B., & Coughlan, G. (2012). Neuromuscular electrical stimulation in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Clinical Rehabilitation, 26(10), 867–881. https://doi.org/10.1177/0269215511431902
  58. ↑ Sabharwal, J., & Joshi, S. (2024). Effectiveness of neuromuscular exercises and neuromuscular electrical stimulation on pain, function and balance in patients with knee osteoarthritis – a randomised controlled trial. Comparative Exercise Physiology, 20(3), 263–271. https://doi.org/10.1163/17552559-20230047
  59. ↑ Lee, J. H. I. (2014). Effectiveness of shortwave therapy in management of knee osteoarthritis : A systematic review and meta-analysis of randomized controlled trials. https://koreascience.kr/article/JAKO201435051110558.page
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  61. ↑ Wyszyńska, J., & Bal-Bocheńska, M. (2018). Efficacy of High-Intensity Laser Therapy in Treating Knee Osteoarthritis: A First Systematic Review. Photomedicine and Laser Surgery, 36(7), 343–353. https://doi.org/10.1089/pho.2017.4425
  62. ↑ Fan, T., Li, Y., Wong, A. Y. L., Liang, X., Yuan, Y., Xia, P., Yao, Z., Wang, D., Pang, M. Y. C., Ding, C., Zhu, Z., Li, Y., & Fu, S. N. (2024). A systematic review and network meta-analysis on the optimal wavelength of low-level light therapy (LLLT) in treating knee osteoarthritis symptoms. Aging Clinical and Experimental Research, 36(1). https://doi.org/10.1007/s40520-024-02853-0
  63. ↑ Alqualo-Costa, R., Rampazo, É. P., Thome, G. R., Perracini, M. R., & Liebano, R. E. (2021). Interferential current and photobiomodulation in knee osteoarthritis: A randomized, placebo-controlled, double-blind clinical trial. Clinical Rehabilitation, 35(10), 1413–1427. https://doi.org/10.1177/02692155211012004
  64. ↑ Wang, X., Wang, R., Liu, Q., Shi, G., Mi, B., Liu, C., Tu, J., & Lin, J. (2024). Electroacupuncture versus exercise in patients with knee osteoarthritis: Study protocol for a randomized controlled trial. PLoS ONE, 19(6), e0305105. https://doi.org/10.1371/journal.pone.0305105
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  67. ↑ Alfredo, P. P., Johnson, M. I., Bjordal, J. M., Santos, A. T. S., Peres, G. B., Steagall, W., Junior, & Casarotto, R. A. (2024). Efficacy of diadynamic currents as an adjunct to exercise to manage symptoms of knee osteoarthritis in adults: A randomized controlled clinical trial. Clinical Rehabilitation, 38(7), 920–931. https://doi.org/10.1177/02692155241236611
  68. ↑ National institute for health and care excellence (NICE). Osteoarthritis: care and management [internet]. [London]. NICE; 2008. [updated 2014 Feb, cited May 2020], Clinical guideline [CG177] Available from: https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#referral-for-consideration-of-joint-surgery-2
  69. ↑ Mayo Clinic Mayo Clinic's Approach to Knee Arthritis - Both Surgical and Non-Surgical Available from: https://www.youtube.com/watch?v=4Mk9GZ7-Dz8 (last accessed 17.11.2019)
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