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Knee · treated under Orthopaedic Physiotherapy

Knee Osteoarthritis

Also called Knee OA, Wear and tear of the knee, Degenerative knee.

An aching, stiff knee whose whole joint is changing, not wearing out. The X-ray grade is a poor guide to pain, and the treatment that changes its course is strength, not rest.

Written by , BPT, MPT · MIAP License No. 69386

Updated · Awaiting clinical review

A physiotherapist examining a patient's knee with the leg held straight

What it is

Osteoarthritis of the knee is a change in the whole joint, not a wearing away of one part of it. The cartilage that covers the ends of the bones softens and thins, the bone underneath thickens, the lining of the joint becomes inflamed from time to time, and the muscles around the knee weaken. It is the commonest form of arthritis and the usual reason for a painful knee in later life. In a community survey of 5,000 people across five sites in India, 28.7% had osteoarthritis of the knee on X-ray, and the figure was higher among women, at 31.6% [1].

The phrase people are given, wear and tear, is the least helpful part of the diagnosis. It suggests a joint being used up, and it leads to the one response that reliably makes things worse: using the knee less. Cartilage is living tissue that adapts to load, and the trials that have scanned it before and after exercise programmes did not find that loading harmed it [2]. That is why both major international guidelines put exercise first, ahead of tablets, injections and surgery [3][4], and why the rest of this page reads the way it does.

How it presents

  • A deep ache in or around the knee, worse after use and easier with rest, rather than a sharp pain
  • Stiffness first thing in the morning that eases within half an hour, and again after sitting for a while
  • Pain on stairs, especially coming down, and with squatting, kneeling and rising from a low chair or the floor
  • Grinding, creaking or clicking as the knee bends, which is common and not a sign of damage on its own
  • Swelling after a heavier day, and a knee that feels full or tight rather than hot
  • A knee that slowly loses a little straightening or bending, and a thigh that looks thinner than the other side
  • Good days and bad days, with flares that last days to a few weeks and then settle

Pain on the inner side of the knee is typical, because the inner compartment carries more of the load. Stiffness that lasts well over an hour in the morning, several joints hurting at once, or a knee that is hot and red point away from osteoarthritis and towards an inflammatory arthritis, which needs a different route.

Who gets it and why

Osteoarthritis is a process the joint goes through, not a quantity of cartilage you have used up. Age is the biggest factor, because tissue repairs more slowly and the muscles that protect the joint weaken. Then come the things that raise the load on the joint or change how it is shared: body weight, a previous injury such as a meniscal tear or a ligament rupture, a knee that is bow-legged or knock-kneed, and years of work spent squatting, kneeling or lifting. In the Indian survey, osteoarthritis on X-ray was associated with age, female sex, obesity and sedentary work [1].

Notice what is not on that list. Ordinary use, walking, stairs and recreational exercise do not wear a knee out. Cartilage has no blood supply of its own; it takes its nutrition from being compressed and released as you move, so a knee that is loaded regularly and moderately is better fed than one that is protected. Sedentary work was among the factors associated with knee osteoarthritis in India [1], and the exercise trials that measured cartilage on MRI did not find it thinning faster in the people who trained [2].

Risk factors

  • Age, which was associated with knee osteoarthritis in the Indian survey [1]
  • Being a woman: 31.6% of women had knee osteoarthritis on X-ray, against 28.7% of people overall [1]
  • Obesity, which raises the load on the joint with every step and was associated with knee osteoarthritis in the Indian survey [1]
  • A previous knee injury, particularly a torn meniscus or a ligament rupture, or previous knee surgery
  • Years of occupational squatting, kneeling, climbing or heavy lifting
  • Sedentary work, which was associated with knee osteoarthritis in the Indian survey [1], and weak thigh muscles

How it is diagnosed

Knee osteoarthritis is diagnosed from the story and the examination, and in a typical case it does not need an X-ray to confirm it: activity-related knee pain in someone past middle age, with morning stiffness that eases within half an hour, is osteoarthritis until something suggests otherwise. The examination adds what a scan cannot. How far the knee bends and straightens, how strong the thigh is against the other side, whether the joint is swollen, how you rise from a chair and manage a step, and whether the pain is coming from the knee at all rather than from the hip or the back, which both refer pain there.

An X-ray tells us less than most people expect. In a systematic review of population studies, the proportion of people with knee pain who had osteoarthritis on X-ray ranged from 15% to 76%, and the proportion of people with osteoarthritis on X-ray who had knee pain ranged from 15% to 81% [5]. Grade, in other words, is a poor guide to pain. Plenty of people with a report that says severe change walk comfortably, and plenty with a mild-looking film are in a lot of pain. The review's conclusion is ours: an X-ray result should not be used on its own to judge a painful knee [5]. The examination, and what the knee can and cannot do, decide the treatment.

When imaging earns its place

An X-ray earns its place when the picture does not fit, when a knee has stopped responding to a proper course of treatment, or when a surgeon needs it to plan an operation. An MRI is rarely useful for osteoarthritis: it commonly finds meniscal tears and cartilage changes in knees of this age that do not hurt, and the finding seldom changes the plan. A hot, swollen knee, a knee that locks, or pain after a fall needs imaging and sometimes blood tests, for different reasons.

What the evidence says

Treatment by treatment, with the studies behind each verdict numbered to the sources at the end of the page.

  • Exercise and strength training

    Core treatment

    The current Cochrane review pools 139 trials and more than 12,000 people. Against no treatment or usual care, exercise improved pain by about 13 points on a 100-point scale and function by about 12; against a placebo or attention control the gap was smaller, about 9 points for pain [6]. The review is candid that those gains sit close to the threshold people notice, and two of its findings shape how we plan: no type of exercise beat another, and the benefit did not track the number of sessions prescribed [6]. What matters is that the thigh and hip are trained, progressively, for months.

  • Education plus supervised exercise

    Core treatment

    The Danish GLA:D programme, education and supervised neuromuscular exercise delivered by trained physiotherapists, is tracked in a national registry. In 9,825 people, pain fell by 12 points on a 100-point scale at three months and by 14 at twelve months, fewer people were taking painkillers, and fewer were off sick a year on [7]. Both major guidelines make education and structured land-based exercise the core of treatment [3][4].

  • Weight loss, if you carry extra

    Core treatment

    In the IDEA trial, 454 overweight adults over 55 with knee osteoarthritis were followed for 18 months. Those on a diet and exercise programme lost 10.6 kg on average, about 11% of body weight, and had less pain and better function than those who dieted or exercised alone; the exercise-only group lost 1.8 kg [8]. The compressive force through the knee was lower in the diet group than in the exercise-only group [8]. The ACR guideline notes that benefits begin at around 5% of body weight and keep growing beyond it [3].

  • Hands-on treatment

    Helps alongside

    Joint mobilisation and soft-tissue work ease pain and stiffness for a while and make the exercise possible; they do not change the joint. The ACR guideline conditionally recommends against adding manual therapy to exercise, because the few trials show little extra benefit [3]. In a trial of 156 people, though, a physiotherapy programme built around hands-on treatment and exercise left people with less pain and disability at one year than a steroid injection did, by 19 points on a 240-point scale [9]. We use it as the way in, not the plan.

  • Braces, insoles and a stick

    Helps alongside

    A brace that unloads the worn side of the knee is strongly recommended by the ACR for people whose knee is unstable or painful enough to warrant one and who can put up with wearing it, and so is a walking stick [3]. Wedged insoles, which tilt the foot to shift load across the knee, are conditionally recommended against, because the trials do not show a clear benefit [3]. None of these builds strength, so they sit beside the programme, not in place of it.

  • Paracetamol and anti-inflammatories

    Helps alongside

    Paracetamol is conditionally recommended against by OARSI [4] and only conditionally for by the ACR, which notes that its effect in trials is very small and whose patient panel found it ineffective for most people [3]. Anti-inflammatory gel rubbed into the knee is strongly recommended by both guidelines and is the safer first choice; oral anti-inflammatories work but are not advised for people with heart disease or frailty [3][4]. Tablets make the programme tolerable. They are not the programme.

  • Corticosteroid injection

    Use with caution

    A steroid injection helps for a few weeks. In the Cochrane review of 27 trials, the benefit was moderate at one to two weeks, small at three months and gone by six [10]. Repeating them is a different matter: in a two-year trial of 140 people injected every three months, the steroid group lost more cartilage than the saline group and had no less pain [11]. One injection to get through a flare or to start rehabilitation is reasonable; a schedule of them is not.

  • Hyaluronic acid injection

    Avoid

    Widely offered, and the best trials do not support it. A review of 89 trials found that when only the large, properly blinded trials were counted, 18 of them with 5,094 people, the benefit was too small to matter, while the risk of serious adverse events was higher [12]. The ACR guideline conditionally recommends against it for the knee [3].

  • Keyhole surgery (arthroscopy)

    Avoid

    Washing out or trimming a degenerative knee, including a worn meniscus, gives a benefit of 3 to 5 points on a 100-point pain scale at three and six months and nothing after that, with no improvement in function, and it carries the risks of any operation, including clots and infection [13]. The review's authors concluded that the findings do not support the practice in middle-aged and older people with knee pain, with or without osteoarthritis on X-ray [13].

  • Knee replacement

    Second line

    For the right knee at the right time, an excellent operation. In the Danish trial, 100 people eligible for replacement were randomised to replacement plus twelve weeks of non-surgical treatment or to the non-surgical treatment alone; the surgery group improved twice as much at one year, 32.5 against 16.0 points [14]. It also had four times as many serious adverse events, 24 against 6, and most of the non-surgical group had not had a replacement a year later [14]. Surgery is for severe pain and disability that a proper course of treatment has not shifted, not a response to an X-ray.

Read as a whole, the evidence points one way. Exercise, education and, where it applies, weight loss are the treatments that change the course of the condition, and they are the ones both guidelines put first [3][4]. Tablets and hands-on treatment make the programme tolerable. A single injection has a place in a flare; repeated injections, hyaluronic acid and keyhole surgery do not. Replacement is a good operation for the minority whose knee is severe and has not responded, and even among people already judged eligible for it, most who did the non-surgical programme had not needed it a year later [14].

How we treat it

At The Rym Space, Bagalur

  1. 1

    Assessment

    How the knee behaves through a day, what it stops you doing, and what you have tried. We measure bend and straightening, test thigh and hip strength, watch you rise from a chair and manage a step, and check the hip and back, which both refer pain to the knee.

  2. 2

    A plan you start that day

    What the X-ray does and does not mean, in plain words. Two or three exercises matched to what the knee tolerates today, a walking dose that does not flare it, and how to tell an ordinary next-day ache from a setback. Straight advice on pain relief that fits your health.

  3. 3

    Week 1: settle the knee

    3 to 5 sessions close together. Hands-on treatment for a stiff or guarded joint, swelling brought down, the first exercises checked and progressed, and the day's load trimmed to what the knee accepts. The aim of the week is a knee calm enough to be trained.

  4. 4

    Week 2 onwards: build strength

    Progressive strengthening for the thigh, hip and calf: sit to stand, step-ups and single-leg work, loaded a little more each week. Sessions space out as the home programme carries the work. Weight, sleep and daily activity are part of the conversation where they are relevant to you.

  5. 5

    Months 2 to 3: make it yours

    Load taken up to the things you want back: stairs, floor sitting, a long walk, a game. The programme is trimmed to a short routine you can run alone, two or three times a week, for the long term, because strength that is not maintained is lost.

  6. 6

    Discharge, or the next tier

    Done when pain is manageable, function is back and you know how to handle a flare. A knee that has not improved after a full course, or stays severe despite it, means a conversation about the next step, an injection or an orthopaedic opinion, and we will say so.

What to expect, and when

Ranges, not promises. Where a figure comes from a study, the study is numbered.

First 2 to 4 weeks
A calmer knee and a clearer idea of what it tolerates. Some people notice a change after the first sessions, from hands-on treatment and from understanding the problem; strength has not changed yet.
By 3 months
In the GLA:D registry, pain was down by around 12 points on a 100-point scale at three months [7]; the pooled Cochrane trials, measured at the end of their programmes, found 9 to 13 points [6]. Stairs and getting out of chairs are usually easier by now.
By 12 months
In the GLA:D registry the improvement in pain was held at twelve months, at 14 points, with fewer people on painkillers [7]. In the trial of physiotherapy against a steroid injection, the physiotherapy group had less pain and disability at one year [9].
The years after
Osteoarthritis does not follow a straight line downhill. Most people have flares and settled spells, and the grade on the X-ray is a poor guide to how much a knee will hurt [5]. In the Danish trial, most of those eligible for a replacement who did the non-surgical programme had not had surgery a year later [14].

Pain and strength move on different clocks. Pain often eases within weeks, from understanding the problem and from hands-on treatment; the strength that keeps it eased takes months of training to build, which is why people who stop at week four conclude that exercise did not work. Flares will happen, and a flare is not the arthritis progressing.

When to be seen sooner

Signs that this is something else, or that it needs looking at now rather than after a few weeks of self-care.

  • A knee that is hot, red and swollen, especially with fever or feeling unwell, which can be an infected joint and needs same-day medical assessment
  • A sudden, very painful, swollen knee with no injury behind it, which may be gout or pseudogout rather than osteoarthritis
  • Knee pain after a fall or a twisting injury, or a knee that locks and cannot be straightened, until a fracture or a displaced meniscal tear is excluded
  • Morning stiffness that lasts well over an hour, several joints painful at once, or a family history of inflammatory arthritis, which need a rheumatology route
  • Pain that is constant, worse at night and unrelated to activity, or weight loss and night sweats alongside it
  • Pain, swelling or warmth in the calf below the knee, which needs a blood clot excluded
  • A knee that has not begun to improve after a full course of treatment, which changes the plan rather than the urgency

Common questions

My X-ray says grade 3. How bad is that?
It says what the joint space looks like, not how much it hurts or what it can do. Across the population studies, anywhere from 15% to 81% of people with osteoarthritis on X-ray had knee pain [5]. Grade does not decide the treatment; the examination does.
Will exercise wear the knee out faster?
No. Trials that scanned the cartilage on MRI before and after exercise programmes did not find that loading harmed it [2], and exercise is the first-line treatment in both major guidelines [3][4]. Some ache during and after training that settles within a day is expected. Sharp pain, or swelling that lasts days, means the dose is too high, not that exercise is wrong.
Should I have an injection?
One steroid injection is reasonable to get through a bad flare or to make the exercise possible, and the benefit lasts a few weeks [10]. Repeated injections every three months were linked to faster cartilage loss with no extra pain relief in a two-year trial [11]. We do not suggest hyaluronic acid injections, because the best trials show no worthwhile benefit [12].
Do I need a knee replacement?
Most people do not, and the ones who do can usually tell: severe pain most days, sleep disturbed, walking badly limited, and a proper course of treatment behind them. In the Danish trial, even among people already eligible for surgery, most who took the non-surgical route had not had a replacement a year later [14]. If you do need it, the strength you build now is not wasted; it is what the recovery afterwards is built on.
Which exercises are best?
None has been shown to beat the others [6], which is freeing: the best exercise is the one aimed at what your knee cannot do, at a dose you can repeat. For most people that means the thigh and hip, sit to stand, step-ups and single-leg work, progressed over weeks, plus a walking dose. Tai chi is strongly recommended in the ACR guideline and yoga conditionally [3].
Should I stop walking, stairs and sitting on the floor?
Reduce what flares it; do not remove it. Sedentary work was one of the factors associated with knee osteoarthritis in the Indian survey [1]. Floor sitting and deep squatting are hard on a stiff knee, so we work towards them rather than banning them, because they are part of life here.

Further reading

Sources

Guidelines, systematic reviews and trials only. Each number in the text links to the entry here.

  1. 1.Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop. 2016;50(5):518-522. pubmed.ncbi.nlm.nih.gov ↗
  2. 2.Bricca A, Juhl CB, Steultjens M, Wirth W, Roos EM. Impact of exercise on articular cartilage in people at risk of, or with established, knee osteoarthritis: a systematic review of randomised controlled trials. Br J Sports Med. 2019;53(15):940-947. pubmed.ncbi.nlm.nih.gov ↗
  3. 3.Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2020;72(2):149-162. pubmed.ncbi.nlm.nih.gov ↗
  4. 4.Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-1589. pubmed.ncbi.nlm.nih.gov ↗
  5. 5.Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008;9:116. pubmed.ncbi.nlm.nih.gov ↗
  6. 6.Lawford BJ, Hall M, Hinman RS, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2024;12:CD004376. pubmed.ncbi.nlm.nih.gov ↗
  7. 7.Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA:D): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC Musculoskelet Disord. 2017;18(1):72. pubmed.ncbi.nlm.nih.gov ↗
  8. 8.Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013;310(12):1263-1273. pubmed.ncbi.nlm.nih.gov ↗
  9. 9.Deyle GD, Allen CS, Allison SC, et al. Physical therapy versus glucocorticoid injection for osteoarthritis of the knee. N Engl J Med. 2020;382(15):1420-1429. pubmed.ncbi.nlm.nih.gov ↗
  10. 10.Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015;10:CD005328. pubmed.ncbi.nlm.nih.gov ↗
  11. 11.McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975. pubmed.ncbi.nlm.nih.gov ↗
  12. 12.Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E, Reichenbach S. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med. 2012;157(3):180-191. pubmed.ncbi.nlm.nih.gov ↗
  13. 13.Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015;350:h2747. pubmed.ncbi.nlm.nih.gov ↗
  14. 14.Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606. pubmed.ncbi.nlm.nih.gov ↗

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