Management of Knee Osteoarthritis

Non-Pharmacological Interventions

• Quadriceps strengthening exercises are recommended for patients with knee osteoarthritis, as part of a comprehensive treatment plan that includes aerobic exercise, resistance training, and neuromuscular training, as recommended by the American College of Rheumatology and the American Geriatrics Society 1, 2, 3, 4, 5, 6, 7
• Weight loss is strongly recommended for overweight patients (BMI >28 kg/m²), with explicit weight-loss goals and structured meal plans, resulting in clinically important functional improvement measured by WOMAC function scale 2, 3, 5, 7
• Patients should be encouraged to participate in self-management educational programs to better manage their condition, and to use assistive devices such as walking sticks and appropriate footwear with shock-absorbing properties when necessary 6, 5, 7
• Patellar taping is suggested for short-term relief of pain and improved function, and physical modalities such as local heat and cold applications may also be beneficial 7
• Aerobic exercise, such as low-impact activities, is recommended for 30 minutes per day, 3-5 times per week, at moderate intensity (60-80% of maximum heart rate), and High-Intensity Interval Training (HIIT) may also be beneficial for improving cardiovascular fitness and reducing symptoms 5, 6
• Aquatic exercises are particularly beneficial for deconditioned patients, those with difficulty performing weight-bearing exercises, and provides pain relief through warm water, reduces joint loading through buoyancy, and may help reduce depression and isolation as a group activity 4
• Raising chair and toilet seat heights can help reduce hip pain, and using a walking stick on the contralateral side can reduce pain 5

Pharmacological Interventions

• Acetaminophen/Paracetamol is recommended as the preferred medication for long-term oral analgesia, with a moderate strength of evidence, according to the American College of Rheumatology 8, 9
• Oral NSAIDs, such as ibuprofen, are recommended as first-line therapy for patients with osteoarthritis, especially when inflammation and stiffness are present, with a moderate strength of evidence, according to the American College of Rheumatology 9
• Duloxetine may be considered as an adjunct therapy for severe or refractory pain/stiffness in patients with osteoarthritis, starting at 30 mg/day and gradually increasing to 60 mg/day, with a moderate strength of evidence 9, 10
• Tramadol may be appropriate for patients with osteoarthritis when other options fail, and opioid analgesics are reserved for severe OA pain refractory to other treatments, with a moderate strength of evidence 9, 4
• Corticosteroid injections are recommended for acute exacerbations, especially with effusion, and intra-articular hyaluronic acid injections are conditionally recommended for patients with contraindications to NSAIDs or those who remain symptomatic despite NSAID use, with a moderate strength of evidence 8, 10, 3

Surgical Interventions

• Total joint replacement is strongly recommended for end-stage disease not responding to conservative measures, with a high strength of evidence, according to the American College of Rheumatology and other authorities 1, 9, 11
• Joint-preserving procedures, such as osteotomy, are considered for younger adults with symptomatic OA, especially with dysplasia or varus/valgus deformity, with a moderate strength of evidence, according to the European League Against Rheumatism and other authorities 12, 13
• Partial meniscectomy or loose body removal may be considered in specific cases, and realignment osteotomy may be considered in appropriate cases, with a moderate strength of evidence 7

Monitoring and Assessment

• Regular assessment of pain control and functional status is necessary to monitor treatment efficacy and adjust treatment as needed, with a moderate strength of evidence, according to the American College of Rheumatology and other authorities 14, 7, 15, 10, 12, 9, 16
• Monitoring for medication side effects, particularly with NSAIDs, is crucial to minimize adverse effects, with a moderate strength of evidence, according to the European League Against Rheumatism and other authorities 14, 10