The purpose of this blog is to discuss treatment options for those experiencing knee osteoarthritis.
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What is Knee Osteoarthritis?
Osteoarthritis (OA) is typically described as a degenerative form of osteoarthritis that breaks down the cartilage of the knee joint. However, knee OA is actually “a complex chronic disease, frequently compounded by the presence of multimorbidity” (Hunter and Bierma-Zeinstra in 2019). What this means is that even though knee OA affects the local cartilage of the knee joint, a host of factors may affect the overall severity and magnitude of symptoms associated with knee OA, such as obesity, diabetes, prior joint trauma, age, and genetics to name a few (Herrero-Beaumont et al in 2024). Common signs and symptoms of knee OA include pain, stiffness, reduced range of motion, and muscle weakness.
The prevalence of knee OA increases as we age, even in people with no symptoms. In a systematic review and meta-analysis by Culvenor et al in 2019, between 19-43% of asymptomatic older adults (>40 years old) have findings of knee OA on MRI. These results suggest that the structural findings on someone’s MRI do not automatically correlate with their level of pain or function. However, there is still a sizable portion of the population diagnosed with knee OA that are symptomatic and do notice limitations in their strength, function, and overall quality of life.
In the upcoming sections, I will outline the recommended non-operative management options for knee OA.
Non-Operative Management Options For Knee Osteoarthritis
Non-operative management is considered the first line treatment for knee OA. With the assistance of your healthcare team, these management options may include one or more of the following (Gibbs et al in 2023):
- Education about prognosis and self-management strategies
- Aerobic and strengthening exercise
- Weight loss
- Non-steroidal anti-inflammatory drugs
- Corticosteroid injections
Trialing all or some of these non-operative management strategies is recommended before individuals consider surgical management (i.e. a partial or total knee replacement). Depending on the severity of your symptoms, these interventions may significantly delay, or completely eliminate, the need for surgery.
What is NOT Recommended for Knee Osteoarthritis?
Before I dive further into the non-operative treatment options, I do want to emphasize what interventions are not currently recommended for the management of knee OA. The systematic review by Gibbs et al in 2023 established that, across multiple hip and knee OA clinical practice guidelines, there was a consistent and strong recommendation against the use of both stem cell injections and knee arthroscopy procedures. A recent Cochrane review by O’Connor et al in 2022 states that, “arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a a placebo procedure” for the management of knee OA. The Osteoarthritis Research Society International (OARSI) also recommends against the use of stem cell therapies and PRP Injections for the management of knee OA.
Treatments such as dry-needling, taping, bracing, ice, heat, and massage all fall into the gray zone. They typically don’t land in the “Must Do” recommendations with most Knee OA Clinical Practice Guidelines, but they generally don’t provide much harm either. Most of these treatments are low cost, low risk, and may provide temporary symptom relief. They are not necessary and they should not replace the higher priority options. But, if you find them helpful, they are okay to incorporate into your daily or weekly routine.
What Exercises Should You Do For Knee Osteoarthritis?
Aerobic and strengthening exercise is considered one of the primary non-operative management strategies for knee OA. There is no one specific type of exercise that reigns supreme in regards to the management of knee OA. Resistance training, aerobic exercise, aquatic exercise, tai chi, and yoga have all demonstrated improvements in pain and function in adults with knee OA (Conley et al in 2023 and Zampogna et al in 2020).
Exercise and activity selection should be based on your personal preferences and availability of specific equipment and resources. It is recommended that you find a group of exercises and activities you enjoy, and consistently commit to, while also aiming to meet or exceed the national and World Health Organization physical activity guidelines. These recommendations include:
- A minimum of 150-300 minutes of moderate-intensity aerobic physical activity or at least 75-150 minutes of vigorous-intensity aerobic physical activity (or a combination of the two)
- At least 2x per week of muscle-strengthening activities at moderate or greater intensity, involving all major muscle groups.
When you are exercising, mild to moderate levels of knee discomfort are safe and do not indicate damage or worsening of your knee OA. However, if you notice that your knee experiences one or more of the following during or after exercise: significant swelling, a decrease in knee range of motion compared to your baseline, and/or pain that surpasses your symptom threshold, this indicates your knee joint is not currently tolerating the specific forces, ranges of motion, or total duration of activity you are asking of it.
If this rings true for any of your desired activities, you may need to adjust one or more of the following variables: tempo (slow the movement down), range of motion (decrease the total distance the knee joint has to move through), intensity (decrease the total weight / load of the activity), duration (decrease the total time spent performing the activity), or frequency (decrease the amount of time per week you perform this activity or exercise). These simple modifications will often allow you to perform the movements and activities you enjoy, instead of completely removing them from your daily or weekly routine.
Here are some examples of muscle strengthening activities that you can perform at home:
Squats: With or without assistance from your upper body, slowly lower yourself to a chair and stand back up. You can slowly increase the difficulty by lowering the height of the object you squat to, removing any upper body assistance, or adding weight.
Step-Ups: With or without assistance from your upper body. You can slowly increase the difficulty by removing any upper body assistance, increasing the height of your step, or adding weight.
Bridges: These can be done single leg or double leg. Push one leg or both legs down into the ground and reach your hips towards the ceiling. To increase the difficulty, progress from two legs to one leg and increase the repetitions per set.
Calf Raises: These can be performed single leg or double leg. Standing next to a wall, chair, or countertop for hand support. If this is too easy, progress from double leg, to two up one down, to single leg. To make this even harder, hold a weight in one hand.
Split Squats: With or without assistance from your upper body, slowly lower your back leg towards the ground and stand back up. If this is too difficult, add an object such as a pillow underneath your back knee in order to reduce the range of motion. To increase the difficulty, remove the pillow below your knee, limit the assistance from your upper body, or add weight.
Here are some of examples of aerobic exercises that you can perform in or around your home:
Walking: You can walk in your home, around your neighborhood, on a trail, or on a treadmill. Slowly increase the distance and/or the speed of your walking over time.
Swimming: You can swim and/or or participate in water based aerobic classes. Similar to walking, slowly increase the distance and/or the speed of your swimming over time.
Biking: You can use a stationary bike or recumbent bike in your home or gym. You can also go for an outdoor bike ride. Over time, increase the duration and/or the intensity of your biking.
Running: If you prefer running, modify the overall volume, intensity, and frequency in order to remain within a tolerable threshold of symptoms. If necessary, you can supplement some of your running volumes with other forms of cardiovascular exercise (such as walking, swimming, or biking). Recreational running is not something you need to completely avoid (particularly if you really enjoy it and find an appropriate dosage that you can tolerate) (Dhillon et al in 2023, Timmins et al in 2016, Alentorn- Geli et al in 2017).
Here is an example of what a sample week may look like for you:
Monday: Walk for 10 minutes, one time in the morning and one time in the evening. Perform squats to a chair for 2 sets of 10 repetitions and then perform calf raises for 2 sets of 12 repetitions.
Tuesday: Bike for 20 minutes. Perform step-ups for 2 sets of 10 repetitions and then perform bridges of 2 sets of 15 repetitions.
Wednesday: Go for a longer walk with your family or friends, perform yard work, or garden.
Thursday: Walk for 10 minutes, one time in the morning and one time in the evening. Perform squats to a chair for 2 sets of 10 repetitions and then perform calf raises for 2 sets of 12 repetitions.
Friday: Bike for 20 minutes. Perform step-ups for 2 sets of 10 repetitions and then perform bridges of 2 sets of 15 repetitions.
As this routine feels easier, slowly increase the frequency, difficulty, duration, or the total number of activities you are performing on a daily / weekly basis.
3 months down the road, your plan may evolve into this:
Monday: Walk for 30 minutes, one time in the morning and one time in the evening. Perform weighted squats to a chair for 3 sets of 10 repetitions and then perform single leg calf raises for 3 sets of 12 repetitions.
Tuesday: Bike for 45 minutes. Perform step-ups for 3 sets of 10 repetitions with dumbbells in each hand and then perform single leg bridges of 3 sets of 15 repetitions.
Wednesday: Go for a longer walk with your family or friends, perform yard work, or garden.
Thursday: Walk for 30 minutes, one time in the morning and one time in the evening. Perform weighted squats to a chair for 3 sets of 10 repetitions and then perform single leg calf raises for 3 sets of 12 repetitions.
Friday: Bike for 45 minutes. Perform step-ups for 3 sets of 10 repetitions with dumbbells in each hand and then perform single leg bridges of 3 sets of 15 repetitions.
There are endless exercises and activities that you can choose depending on your personal preferences and equipment access. Here are a few examples of substitutions you can make: water aerobics instead of biking, machines and free weights at a gym instead of home based exercises, and yoga or tai chi instead of yard work. The primary goal is finding a combination of cardiovascular exercises, muscle strengthening exercises, and activities that challenge your balance that you can perform multiple times per week.
Should You Try To Lose Weight?
There are currently four clinical practice guidelines strongly recommending weight loss, or the management of one’s weight, for people who are either overweight or obese with knee OA (Conley et al in 2023). The Royal Australian College of General Practitioners Guideline for the management of knee and hip osteoarthritis recommend a minimum weight loss target of 5-7.5% of bodyweight for those classified as overweight or obese. The focus should likely be on developing and maintaining healthy habits that improve your overall well-being. Weight loss may result from incorporating regular exercise into your weekly routine and making changes to your dietary choices, but it may not be necessary to chase a specific number on the scale (Lim et al in 2022). Pharmacological strategies for the management of overweight or obesity may be beneficial for certain individuals, however these medications should be discussed with your healthcare team.
Should You Use NSAIDs?
Three clinical practice guidelines strongly recommend the use of oral NSAIDs for people with knee OA (unless contraindicated based on past medical history and current medication intake) and three clinical practice guidelines strongly recommend the use of topical NSAIDs for knee OA (Conley et al in 2023). NSAID type, frequency, and dosage should be discussed with your healthcare provider.
Should You Receive A Corticosteroid Injection?
The OARSI Guidelines made a “conditional” recommendation for the use of corticosteroid injections for the management of knee OA, noting the risks may outweigh the benefits. The Core Recommendations for Osteoarthritis Care from the American College of Rheumatology by Conley et al in 2023 list these injections under the “Could Do” treatments. A Cochrane review by Juni et al in 2015 found that, “intra-articular corticosteroids may cause a moderate improvement in pain and a small improvement in physical function, but the quality of the evidence is low and results are inconclusive. Intra-articular corticosteroids appear to cause as many side effects as a placebo.” Ultimately, corticosteroid injections are not a homerun for the long-term management of knee OA. They may provide short-term pain relief, but they should be used judiciously. If corticosteroids are used regularly, they may provide more harm than good (Kompel et al in 2019).
When Is A Total Knee Replacement Recommended?
There is no straightforward answer here. This largely depends on how limiting your knee OA symptoms impact your quality of life and valued physical activities. Hunter and Bierma-Zeinstra in 2019 suggest that the “referral of patients with end-stage osteoarthritis to a surgeon should be considered if all appropriate conservative options, delivered for 6 months, have been unsuccessful. Furthermore, the decision to refer to an orthopaedic surgeon should be made if patient quality of life is greatly reduced because of end-stage osteoarthritis.” Ultimately, a knee replacement is an elective procedure and you are in charge of deciding if or when a knee replacement is right for you.
Summary
Here are the 8 main takeaways from this blog:
- Knee OA involves multi-system and systemic factors (such as comorbidities) that significantly influence the magnitude of knee OA symptoms (Herrero-Beaumont et al in 2024).
- The prevalence of knee OA increases as we age and imaging findings do not directly correlate with the severity of someone’s knee pain or loss of function (Culvenor et al in 2019).
- Non-operative management is the first line treatment for knee OA and there are a host of self-management strategies (such as exercise, weight loss, and NSAIDs) that can be implemented (Gibbs et al in 2023).
- Knee arthroscopies, PRP injections, and stem cell injections are NOT recommended for the management of knee OA (Gibbs et al in 2023, O’Connor et al in 2022, The Osteoarthritis Research Society International (OARSI)).
- Exercise is strongly recommended for knee OA and is listed as a key self-management strategy. Find exercises and activities that you enjoy, attempt to meet or exceed the national and World Health Organization physical activity guidelines, and limit activities that significantly worsen your symptoms. Knee pain does not inherently equal further damage to the knee joint and exercising with a tolerable level of symptoms is completely safe.
- Weight loss can be a beneficial self-management strategy for people who are overweight or obese. The Royal Australian College of General Practitioners Guideline for the management of knee and hip osteoarthritis recommend a minimum weight loss target of 5-7.5% of one’s bodyweight for those classified as overweight or obese.
- Multiple clinical practice guidelines recommend the use of oral NSAIDs for managing knee OA symptoms. NSAID type, frequency, and dosage should be discussed with your healthcare provider.
- Corticosteroid injections are not considered a homerun for the long-term management of knee OA, may provide short-term pain relief, should be used judiciously, and may provide more harm than good, particularly if they are used repeatedly (Kompel et al in 2019).
Want to learn more? Check out some of our other similar blogs:
Improving Knee Flexion Range of Motion, Improving Knee Extension Range of Motion, Exercises for Knee Pain
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