Effective knee osteoarthritis treatment – practical tips that deliver results

Knee Osteoarthritis (OA) is one of the most common and highly-researched forms of OA, yet patients often get oversimplified, generalised treatment recommendations (e.g. exercise, pain management, or surgery). As physiotherapists, we should be educating our patients on the available treatment options and guide them in managing their OA effectively. Further, because the impact of knee OA is multifactorial, a multipronged treatment approach is often warranted. In this blog, we’ll walk through expert physio Allison Ezzat’s Practical on knee OA management, including:

• First, second, and third-line treatment options
• Exercise prescription
• Manual therapy and taping techniques

If you’d like to see exactly how expert physio Allison Ezzat manages knee OA, watch her full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

Treatment options

First-line treatments

Exercise is essential in the management of knee OA, and should be considered the cornerstone of treatment. An exercise program should develop both strength and power. Below are some numbers to follow:

• Strength = 8-12 repetitions x 3 sets
• Power = 4-5 repetitions x 4-5 sets (maximise speed during the concentric phase)
• Perform these exercises 2-3 x per week

NOTE: When exercising, the patient may experience some pain, but this should not exceed a 5/10 rating and should return to baseline within 24 hours.

Education is equally crucial in managing knee OA. Patients should be informed about the pathophysiology of OA, but we also need to address common misconceptions, such as the belief that pain during movement indicates structural damage. Further, we can reframe exercise by discussing the benefits of joint loading for tissue health. A crucial pillar of education for both knee OA and overall health is to promote weekly, moderate-intensity physical activity, starting with at least 45 minutes per week and ideally working up to 150 minutes. This physical activity can be anything from dancing to swimming.

Lastly, for certain patients, we may need to refer them out to a physician or dietitian for weight management. Excess body fat not only increases mechanical loading on the knee, but also creates low-level inflammation which may exacerbate OA symptoms.

Second-line treatments

Second-line treatments consist primarily of tools to decrease pain in the short term. These tools are not “necessary”, but they help patients better participate in exercise by keeping pain at manageable levels, and they can be used to complement first-line treatments. Patient preference and treatment efficacy can drive which of these second-line treatments you employ.

The tools that have essentially no side effects and would be considered low-risk include manual therapy, taping, bracing, orthotics, and acupuncture.

Pain medications and cortisone injections also temporarily relieve pain, however they do have side effects. Cortisone injections specifically carry the risk of cartilage damage with repeated use and should therefore be used cautiously.

Third-line treatments

The last line of treatment for knee OA is joint replacement surgery, for which approximately 80-90% of patients have positive outcomes. An important point is that exercise pre-surgery leads to better post-surgical outcomes, so regardless of the treatment path chosen, exercise is crucial. Our role is to educate the patient and support them before and after surgery so they are well prepared.

Exercise prescription

Therapeutic exercises are crucial for building muscle mass and strength of the lower extremities. These exercises are typically single-joint and simple to execute without supervision. Therapeutic exercises for the lower-limb should target knee flexion, knee extension, hip abduction, ankle plantarflexion, and hip extension. In the below video from her Practical, Allison shows a bridge progression to challenge the hip extensors:

Functional and core training should also be a part of a well-rounded exercise program. Functional training consists of exercises that resemble movements performed in daily life, whereas core training consists of exercises that strengthen the trunk musculature.

For functional training, the primary movements to use are squats, lunges, and step-ups. Squat variations include box squats, staggered stance squats, single-leg squats, and squats with added external load. Allison uses a staggered stance squat to bias one leg, see her demonstrate this in the below excerpt from her Practical:

Lunge variations include forward, backward, and side lunges. Step-ups are also an excellent exercise, as many patients struggle with negotiating stairs. They can be progressed by increasing the range of motion and/or adding external load.

For core training, Allison recommends focusing on isometric training such as planks and marching. The front plank is a great beginner core exercise; start with 3 x 10-second holds and gradually increase to 3 x 60-second holds, with options to advance by incorporating unilateral hip extension. The same progression can also be used with the side plank, and can be intensified with hip abduction of the top leg.

Manual therapy and taping

Manual therapy and taping are effective tools for reducing pain during exercise. Manual therapy improves range of motion and alleviates discomfort, while rigid taping can lessen pain in specific movements, making workouts more manageable. There are countless variations of manual and taping techniques, check out Allison’s full Practical to see her top ones! Some especially useful manual techniques include posterior tibial glides (to improve knee flexion) and anterior tibial glides (to improve knee extension). See Allison demonstrate a posterior tibial glide in this snippet from her Practical:

For taping, an excellent option is using rigid tape to promote a medial patellar glide and/or superior tilt of the patella. After taping, have the patient perform a painful movement pattern. If their pain decreases by about 25%, you’ve identified the right taping technique for that patient!

Wrapping up

The knee OA management toolbox has many options. However, the fundamental, first-line tools in knee OA management are exercise, education, and weight management (if indicated) – even if the patient chooses surgery in the longer-term. Physios play an integral role in patient education and developing individualised exercise programs to help them reach their goals. Keeping up to date with the best options for the management of knee OA helps us ensure we are doing everything we can to help our patients get back to the activities they love.

To learn how to guide your patients, check out the full knee OA management Practical from expert physiotherapist, Allison Ezzat.