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Knee osteoarthritis-Management

Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide.
Holistic approachAssess the impact on 
○ quality of life
○ occupation
○ mood
○ relationship
○ leisure activities

 Make a plan of management with the patient
 Take into account the co-morbidities Discuss risks and benefits of treatment options
Core treatmentsNICE recommends advice on core treatment to all people with clinical OA which includes
 Assess to appropriate information
○ offer verbal and written info
○ ensure that information sharing is an ongoing integral part of the management and not just a single event during presentation
 Activity and exercise Interventions to achieve weight loss if 
overweight or obese
Education and self-managementOffer accurate verbal and written information to all people with OA to enhance understanding of the condition and it management and counter misconceptions such as that it is inevitable progressive and cannot be treated Agree individualized self- management strategies with the person and ensure positive behavioural changes as below.
Thermotherapy – use of heat or cold should be considered as an adjunct to core treatments
Non-pharmacological management
Exercise and manual therapyExercise as a core treatment irrespective of age , co-morbidity , pain severity or disability
○ local muscle strengthening and
○ general aerobic fitness
 Consider manipulation and stretching as an adjunct to core treatments – particularly of hip OA
Weight LossOffer interventions to achieve weight loss as a core treatment for obese and overweight people
Electrotherapy-NICE supports use of TENS machine as an adjunct to core 
treatments for pain relief
Aids or devicesOffer advice on appropriate footwear People with OA who have biomechanical joint pain or instability should be considered for bracing / joint supports / insoles as an adjunct to core treatments Assistive devices e.g walking stick and tap turners should be considered for people who have specific problems with ADLs
Not recommended-Natreceuticals- NICE does not support the use of glucosamine or chondroitin products in OA management Acupuncture
Pharmacological managementInitial treatment can include paracetamol and topical NSAIDs If not effective consider use of oral NSAIDs / COX2 inhibitors
 ( undertake a NSAID risk assessment ) and stop use of topical NSAIDs Opiates such as codeine if no contraindications Topical capsaicin NICE does not recommend use of rubifacients
Intrarticular injectionsNICE recommends use of intra-articular corticosteroid injections as an adjunct to core treatments for the relief of moderate to severe pain
○ corticosteroids have marker anti-inflammatory effect
○ it is assumed that the analgesic benefit is in some way related to their anti-inflammatory effect
○ evidence shows short-term reduction in OA pain and the effects have been best demonstrated for knee OA , although their is some data of efficacy in hip and hand OA
○ risks associated with intra-articular corticosteroid injections are generally small
 Intra-articular hyaluronans injection use is not recommended by NICE
Referral for joint surgeryEnsure that core non surgical options have been offered NICE suggests to base decision on referral thresholds on discussions between patient representatives , referring clinicians and surgeons , rather than using scoring tools for prioritization Consider referral for joint surgery for people with OA who experience joint symptoms Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain Patient specific factors including age , sex , smoking , obesity and comorbidities – should not be barriers to referral for joint surgery When discussing the possibility of joint surgery , check that the person has been offered at least the core treatments for osteoarthritis and give them information about
○ the benefits and risks of surgery and potential consequences of not having surgery ( look for leaflets under links )
○ recovery and rehabilitation after surgery
○ how having a prosthesis might affect them
○ how care pathways are organized in their local area
Other agencies –A referral to musculoskeletal / physiotherapy is often suggested in local guidelines – check local services and refer as needed In addition the following services may also be considered
○ occupational therapy
○ podiatry
○ pain clinic
○ psychology or mental health services
Joint replacement –Joint replacement is the removal of the articular surfaces from a painful joint and their replacement with synthetic material usually metal and plastic More than 120,000 are performed in the UK annually
 Knee surgery can be
○ Total knee replacement – considered if evidence of exposed bone present in atleast one of knee joint compartments

○ Partial knee replacement – only one of the compartment of the arthritic knee is replaced
Partial replacement can also provide good outcome but the survival is lower than TKR but the advantages are – faster recovery , reduced morbidity and reduced 90 day mortality

○ High tibial osteotomy – removing or adding bone to realign the limb and offload the knee ( technically demanding )

○ Knee arthroscopy – lavage and debridement for patients with a h/o mechanical symptoms like knee locking
 Most patients the additional risk of mortality as a consequence of surgery , compared to continuing conservative treatment is small 95 % of hip and knee replacements would continue functioning well into the 2nd decade after surgery with the majority providing lifelong pain free function It may not work for everyone and 1 in 5 patients are not satisfied with their joint replacement and a few do not get much improvement in pain following joint replacement
Follow up and review –Offer regular f/u- agree on the timing interval of reviews and 
○ monitor symptoms and impact of OA on ADLs and QOL
○ monitor long term course of condition
○ check patients knowledge , concerns , preferences and ability to access services
○ check if treatment is effective and tolerable
○ support for self management
 Consider and annual review – if they have more than 1 of the following
○ troublesome joint pain
○ more than 1 joint with symptoms
○ more than 1 comorbidity
○ taking regular medication for OA


Arthritis Research UK 36 page booklet on Knee Osteoarthritis – a complete resource
Information on Knee replacement from NHS Inform
Versus Arthritis page on Knee OA with exercises
Arthritis action
Arthritis action on exercise and OA
Physical activity factsheet from arthritisaction
Orthoinfo on TKR
Orthoinfo printable exercise programme 8 page leaflet an excellent resource
Orthoinfo on Knee arthritis–conditions/arthritis-of-the-knee/
NHS on Knee replacement
Knee OA leaflet with an exercise programme from East Lancashire Hospitals
AAOS Patient Education Booklet on total knee replacement ( for sale )
Knee strengthening exercises – from University Hospital Southampton
A single page ( double sided ) printable exercise leaflet for Hip and Knee pain from Dartmouth-Hitchcock
Knee steroid injection leaflet from Versus Arthritis
Steroid injection information from Arthritis Society
NICE Guideline on  osteoarthritis
Arthritis and musculoskeletal alliance ( ARMA )
MSK Knowledge Hub
Osteoarthritis Research Society International Guideline for the non-surgical management of knee osteoarthritis
American College of Rheumatology on Osteoarthritis
European League Against Rheumatism on knee OA EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)
BMC Rheumatology open access article General practitioners’ views on managing knee osteoarthritis: a thematic analysis of factors influencing clinical practice guideline implementation in primary care
An updated algorithm recommendation for the management of knee
osteoarthritis from the European Society for Clinical and Economic Aspects of
Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)
National Joint Registry UK

  1. Osteoarthritis : care and management CG 177 Feb 2014
  2. CKS NHS Osteoarthritis revised June 2018
  3. PubMed Osteoarthritis: Care and Management in Adults
  4. Commissioning guide RCS Painful osteoarthritis of the knee–painful-oa-knee-guide-final-2017.pdf



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