Evidence‑Based Management of Knee Osteoarthritis

Core Non‑Pharmacological Interventions

Structured exercise programs that emphasize quadriceps strengthening and aerobic conditioning reduce knee pain and improve function, with benefits lasting 2–6 months. 1
Aggressive weight‑loss strategies for overweight or obese patients lower mechanical joint stress and decrease the risk of osteoarthritis progression. 2
Providing written and oral education that osteoarthritis is treatable and not inevitably progressive improves patient confidence and self‑management. 1

Assessment for shock‑absorbing footwear and the use of knee braces or insoles in patients with biomechanical knee pain or instability yields significant pain reduction and functional gains. 2

Local heat or cold applications may be employed, although supporting evidence is limited. 1
Transcutaneous electrical nerve stimulation (TENS) can be considered as an adjunctive pain‑relief modality. 2
Electroacupuncture and standard acupuncture are not recommended due to insufficient evidence. 1

Regular‑dose acetaminophen (up to 4 g/day) is the recommended first‑line oral analgesic for knee osteoarthritis because of its favorable safety profile. 2
Topical non‑steroidal anti‑inflammatory drugs (NSAIDs) should be added or substituted before oral NSAIDs; they provide clinical efficacy with a better safety profile. 1
Topical capsaicin is an additional option for localized pain control. 2

If pain persists despite acetaminophen and topical NSAIDs, oral NSAIDs or selective COX‑2 inhibitors should be introduced at the lowest effective dose for the shortest duration. 1
Either a standard NSAID or a COX‑2 inhibitor (excluding etoricoxib 60 mg) may be selected based on patient factors. 1
Co‑prescription of a proton‑pump inhibitor is advised to mitigate gastrointestinal risk. 2
Prior to initiating oral NSAIDs or COX‑2 inhibitors, clinicians should evaluate age‑related gastrointestinal, hepatic, and cardiorenal risk factors. 1

Intra‑articular corticosteroid injections are appropriate for patients with moderate to severe knee pain, particularly when joint effusion is present, offering effective symptom relief with relatively minor adverse effects. 2

Patients should be instructed to avoid “peaks and troughs” of activity and to adopt paced activity schedules to maintain consistent joint loading. 1

Periodic, individualized reviews should assess functional status, quality of life, occupational demands, mood, relationships, and leisure activities to guide ongoing management. 2
Management plans should be developed collaboratively with the patient, ensuring shared decision‑making. 2

The American College of Rheumatology recommends regular exercise programs focusing on both joint-specific strength and range of motion exercises, as well as general aerobic conditioning, to significantly reduce pain and improve function in patients with advanced knee osteoarthritis 3, 4
Exercise can be either supervised or offered as a home-based program, and both aerobic and resistance exercise regimens have shown effectiveness in improving function, gait, and decreasing pain in patients with knee OA 3
Weight reduction is strongly recommended for patients with knee OA who are overweight or obese, as it has been shown to reduce the risk of knee OA progression and improve symptoms 3, 4, 5
The use of assistive devices such as canes can decrease weight burden and provide stability, and knee braces have demonstrated significant pain reduction and functional improvements in patients with knee OA 4, 5
Patient education regarding disease process, coping skills, and self-management strategies is essential for patients with knee OA, and self-management programs have shown long-term improvements in symptoms and function 3, 4

The European League Against Rheumatism recommends paracetamol as the first-line oral analgesic for mild to moderate pain in patients with knee OA, due to its favorable safety profile 3, 6, 7
Topical NSAIDs and capsaicin have clinical efficacy and safety for knee OA and should be considered early in the treatment plan 3, 5
Oral NSAIDs should be considered in patients unresponsive to paracetamol, and for patients with increased gastrointestinal risk, either non-selective NSAIDs with gastroprotective agents or selective COX-2 inhibitors should be used 3, 5
Opioid analgesics, including duloxetine, may be considered for patients with knee OA who have not responded to other pharmacological treatments, but their use is limited by significant risks 5, 8

Joint replacement should be considered in patients with radiographic evidence of knee OA who have refractory pain and disability despite comprehensive non-surgical management, according to the American Academy of Orthopaedic Surgeons 3, 9, 7