CLINICAL Osteoarthritis, Knee (Nonoperative Management)

REVIEW
Indexing Metadata/Description
› Title/condition: Osteoarthritis, Knee (Nonoperative Management)
› Synonyms: Knee osteoarthrosis (nonoperative management); knee osteoarthritis
(nonoperative management); osteoarthrosis, knee (nonoperative management)
› Anatomical location/body part affected: Articular cartilage of knee joint; medial,
lateral, or patellofemoral knee compartments, medial compartment more often affected
than lateral(1)
› Area(s) of specialty: Orthopedic rehabilitation, home health
› Description
• Knee osteoarthritis (OA) is characterized by slow degeneration of intraarticular cartilage
that progresses to involve subchondral synovium and bone. The development of chronic
pain and joint stiffness interfere with activities of daily living (ADLs) and reduce
health-related quality of life (HRQoL)(23)
• Many patients and health-care providers accept the pain and disability of knee OA
as inevitable consequences of a progressive disease that eventually require joint
replacement. However, knee joint injury associated with obesity and impaired muscle
function is amenable to secondary prevention strategies and rehabilitation.(66) In clinical
guidelines, the most strongly recommended non-drug, non-operative interventions for
knee or hip OA are exercise and weight loss(67)
• Authors of a 2015 Cochrane Review found high-quality evidence from 44 trials (N =
3,537 participants with knee OA) that land-basedexercise training significantly reduced
pain and improved physical function to a moderate degree(68)
• This Clinical Review focuses on nonoperative treatment strategies specifically for
OA of the knee. See Clinical Review…Knee Pain: Unspecified Site – Conservative
Management; Item Number: T709121for cases that involve knee pain not due to OA
› ICD-9 codes
Authors
Rudy Dressendorfer, BScPT, PhD • 715.16 osteoarthrosis, localized, primary, involving lower leg
Cinahl Information Systems, Glendale, CA • 715.26 osteoarthrosis, localized, secondary, involving lower leg
Amy Lombara, PT, DPT • 715.36 osteoarthrosis, localized, not specified whether primary or secondary, involving
Cinahl Information Systems, Glendale, CA
lower leg
• 715.96 osteoarthrosis, unspecified whether generalized or localized, involving lower leg
Reviewers
Diane Matlick, PT › ICD-10 codes
Cinahl Information Systems, Glendale, CA • M17 gonarthrosis [arthrosis of knee]
Andrea Callanen, MPT • M17.0 primary gonarthrosis, bilateral
Cinahl Information Systems, Glendale, CA
• M17.1 other primary gonarthrosis
Rehabilitation Operations Council
Glendale Adventist Medical Center,
• M17.2 post-traumatic gonarthrosis, bilateral
Glendale, CA • M17.3 other post-traumatic gonarthrosis
• M17.4 other secondary gonarthrosis, bilateral
Editor • M17.5 other secondary gonarthrosis
• M17.9 gonarthrosis, unspecified
Sharon Richman, MSPT
Cinahl Information Systems, Glendale, CA

(ICD codes are provided for the reader’s reference, not for billing purposes)

March 3, 2017

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
› G-Codes
• Mobility G-code set
–G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8979, Mobility: walking & moving around functional limitation; projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end
reporting
• Changing & Maintaining Body Position G-code set
–G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode, at reporting
intervals, and at discharge or to end reporting
–G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end
reporting
• Carrying, Moving & Handling Objects G-code set
–G8984, Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8985, Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end
reporting
• Self Care G-code set
–G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals
–G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at
discharge or to end reporting
–G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting
• Other PT/OT Primary G-code set
–G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end
reporting
• Other PT/OT Subsequent G-code set
–G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
–G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to
end reporting
›.
G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent
impaired, limited or restricted
CJ At least 20 percent but less than 40 percent
impaired, limited or restricted
CK At least 40 percent but less than 60 percent
impaired, limited or restricted
CL At least 60 percent but less than 80 percent
impaired, limited or restricted
CM At least 80 percent but less than 100
percent impaired, limited or restricted
CN 100 percent impaired, limited or restricted
Source: http://www.cms.gov

.
› Reimbursement: No specific issues or information regarding reimbursement have been identified for OA of the knee.
Reimbursement will depend on individual insurance coverage
› Presentation/signs and symptoms (1,2)
• Persistent knee pain that typically decreases or resolves with rest and increases with range of motion (ROM)(23)
• Morning knee stiffness; joint stiffness often follows inactivity, especially if knee is kept flexed as in sitting for a prolonged
period(1)
• Joint tenderness(23)
• Joint swelling(23)
• Deep ache triggered or aggravated by weight-bearing activity (walking, stair-climbing)
• Joint crepitus
• Postural deformities, such as knee valgus or varus(23)
• Difficulty with squatting or kneeling due to knee pain and weakness
• Occasional “giving-way” when stepping down or during other activities due to pain-related muscle inhibition
• Knee malalignment resulting from progressive joint degeneration and laxity
• Gait abnormalities: likely secondary to pain, weakness, and reduced flexibility

Causes, Pathogenesis, & Risk Factors

› Causes:
• Degeneration of articular cartilage, associated with(3)
–knee damage resulting from direct trauma
–knee microtrauma : “wear-and-tear” due to repetitive physical stress (e.g., obesity, work-related, malalignment)
–charcot joint
–prior inflammatory or septic arthritis of the knee
–congenital abnormalities of knee joint
–pathological disorders: endocrine, metabolic, neuropathic
–avascular necrosis
–Paget’s disease
• Familial predisposition: genetic risk factors are unclear, but twins with OA share increased risk(23)
• Sedentary lifestyle may reduce cartilage extracellular matrix synthesis, which is promoted by daily physical activity(69)
› Pathogenesis
• The hallmark of advanced knee OA on arthroscopic exam is focal ulcerated cartilage with exposed bone at the articular
surfaces and osteophytes at the joint margins(1,2,3)
• Progressive changes associated with OA(1,2)
–Synovial inflammation
–Slowly progressive softening of articular cartilage
–Narrowing of joint space
–Osteophyte formation
–Subchondral sclerosis
–Cysts
• Radiographic features found to develop over 5 years in a study of 1,002 Dutch participants with early knee OA(48)
–Joint width space: reduced minimum width and medial width; increased lateral width
–Increased varus angle
–Increased osteophyte area
 –Increased eminence height
–Increased bone density
• Lower-extremity pain and muscle weakness contribute to gait deficits and reduce kinetic efficiency in early knee OA(49)
• Weight loss may decrease overloading of the knee in overweight persons. Authors of a randomized controlled trial (RCT, N
= 192 obese participants with knee OA)in Denmark found that significant weight reduction (mean, 12.8 kg) followed by a
1-year maintenance program was associated with improved knee symptoms and function(70)
› Risk factors
• Nonmodifiable
–Age: > 50 years of age(3,23)
–Sex: Women more often than men, approximately 2:1 ratio(2,23)
–Hormonal status(1,23)
–Geographic(1,23)
–Genetic: there is a 39% to 65% heritability rate in studies of twin women with OA,and a concordance rate of 0.64 in
monozygotic twins(23)
–Offspring of patients with severe knee OA are at an increased risk of prevalent pain and worsening knee pain(83)
–History of knee surgery(7) or traumatic knee injury(8)
–Anatomical and biomechanical factors that contribute to malalignment in the lower extremities
- Leg length discrepancy (2 cm, or more) is associated with progressive knee OA; based on a longitudinal cohort study in
the United States that included 1,583 patients with baseline and follow-upradiographs of the knee(11)
- Joint laxity(23)
- Proprioceptive impairments(23)
• Modifiable
–Obesity(8,9)
–Tobacco use(1,3)
–Nutritional deficiencies (e.g., vitamin D deficiency)(23)
–Presence of crystal arthropathies (e.g., gout)(23)
–Physically demanding work or occupational loading of the knee(8,10)
- Authors of a systematic review of the literature published between 1946 and April 2011 found moderate evidence that
regular combined heavy lifting and kneeling is a risk factor for knee OA. The odds risk ratio varied from 1.8 to 7.9.
However, there is limited evidence to support that isolated occupational heavy lifting, kneeling, or stair climbing are risk
factors(62)

Overall Contraindications/Precautions
› No direct evidence contraindicates aerobic or strengthening exercise for knee OA(4)
› Current practice guidelines recommend quadriceps strengthening for patients with knee OA.(43,44) However, authors of
a prospective, longitudinal cohort study (N = 230) in the United States found that among 171 without advanced OA in
either knee, those who had high quadriceps strength at baseline were significantly more likely to have increased progression
of knee OA and laxity over 18 months than those with low quadriceps strength. This finding indicates that specific
strengthening exercises should be used for some patients to enhance joint protection(12)
› Consult with physician if increased pain and swelling or continuing episodes of giving-way occur despite therapy
› Swelling due to a ruptured popliteal cyst can mimic a deep vein thrombosis (DVT); refer any patient with calf swelling or
other signs/symptoms that are consistent with a DVT to emergency services. For more information, see Clinical Review…
Popliteal Cysts in Adults; Item Number: T708425
› See specific Contraindications/precautions to examination under Assessment/Plan of Care
Examination
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness
- When did symptoms of knee OA begin?
- Did a traumatic event precipitate symptoms?
- Does history indicate gradually worsening knee pain and function during daily activities (e.g., walking, squatting,
kneeling, and stepping down)?
–Course of treatment
- Authors of an epidemiological study (N = 12,806patients who underwent total knee arthroplasty [TKA] in 2009) in the
United States found that 43.5% were administered intraarticular corticosteroids, 15.4% received visco supplementation
injections, 2.6% received an unloader brace, and 0.52% had acupuncture during the 5 years preceding TKA(45)
- Medications for current illness/injury: Determine what medications clinician has prescribed; are they being taken?
Are the medications effectively controlling the patient’s symptoms?
- Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for mild to moderate
pain.(43,44) Topical rather than oral NSAIDS are preferred for patients ≥ 75 years(23)
- Patients older than 60 years at risk for gastrointestinal (GI) bleed may be prescribed proton pump inhibitors (PPIs) or
COX-2 inhibitors instead of traditional NSAIDs(23)
- Physicians should consider prescribing naproxen in patients with known cardiovascular risk factors since ibuprofen
can render aspirin ineffective as a cardioprotective agent by interfering with the aspirin-binding site on platelets(23)
- Patients may be prescribed mild opioids such as tramadol if NSAIDs and acetaminophen are unable to adequately
reduce pain levels(23)
- Opioid analgesics are only recommended for patients with severe pain unresponsive to other treatment modalities(23)
- The nerve growth factor blocker tanezumab was found to be more effective than placebo for reducing pain in patients
with knee OA during a 32-week randomized, double-blind phase III trial (N = 690)(50)
- Glucosamine and chondroitin
- Authors of a 2010 systematic review and meta-analyses (N = 3,803 persons with hip or knee OA) found that
glucosamine and/or chondroitin were ineffective for reducing pain or delaying progression of joint space
narrowing(13)
- The American College of Rheumatology 2012 clinical practice guidelines conditionally recommend against using
glucosamine or chondroitin for patients with knee OA(44)
- Clinical practice guidelines do not recommend for or against the use of intraarticular hyaluronic acid (IAHA) for
patients with mild or moderate knee OA.(43,44) However, authors of an RCT (N = 769) in France found that the
intermediate molecular weight (MW) IAHA product Go-On was found to be more effective than the low MW product
Hyalgan(51)
- Diagnostic tests completed
- Radiographs are typically the first step and have high diagnostic value. Plain radiographs typically confirm narrowing
of the medial knee joint space, subchondral sclerosis, and osteophyte formation(23)
- Laboratory tests to assist with differential diagnosis. These can include rheumatoid factor, erythrocyte sedimentation
rate (ESR), complete blood count (CBC), and antinuclear antibody tests(23)
- Magnetic resonance imaging (MRI) can be used to rule out other sources of pain, including synovial thickening, joint
effusion, bone marrow edema, bony attrition, periarticular lesions, and internal derangement(23)
- Musculoskeletal ultrasound is emerging as an alternative, fast, and inexpensive modality to identify joint damage, the
presence of osteophytes, joint effusions, and noninflammatory synovial proliferation(23)
- In some cases, arthrocentesis can be performed to examine the synovial fluid; it is typically normal or
noninflammatory in character(23)
- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or
complementary therapies (e.g., acupuncture, Tai Chi, weight loss management, over-the-counter orthotics) and whether
or not they help. Patients may report the use of topical over-the-counter NSAIDs or capsaicin(23)
 - Acupuncture
- Authors of a double-blind multicenter RCT (N = 116,35 to 82 years of age) in the United States compared the effects
of classical Chinese acupuncture, modern semi-standardized acupuncture, and nonspecific needling (control)(65)
- The only systematic difference across the three treatment groups was the location of needling points. All three
methods used the same technique and type of needles. Only one knee per patient was treated. Ear and hand
acupuncture was not allowed. Each session involved 10 points +/- 2 points to be stimulated. The needles were
rotated immediately after insertion and again after 15 minutes. Needles were withdrawn after 30 minutes
- A significantly greater increase in knee ROM was found after classical Chinese acupuncture (10.3°) compared to
modern acupuncture (4.7°)
- A significant decrease in pain was found for all 3 treatments, with a patient response rate of 48% (nonspecific
needling), 64% (modern acupuncture), and 73% (classical acupuncture)
- Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions
and what specific treatments were helpful or not helpful such as aquatic therapy, patellar strapping/taping, or thermal
modalities
–Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased):
Patients with knee OA typically complain of deep ache triggered or aggravated by weight-bearing activity (walking,
stair-climbing) and pain that lessens with rest. Joint stiffness often follows inactivity, especially if knee is bent for a
prolonged period, as in sitting
–Body chart: Use body chart to document location and nature of symptoms
–Nature of symptoms: Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,
numbness, tingling). Symptoms may include swelling, morning stiffness, giving-way, and deep ache. In general, are
symptoms getting better, worse, or staying the same?
–Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and
at the moment (specifically address if pain is present now and how much)
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of wakings/night. Patients with OA are often awakened at night from the pain(14)
–Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/or
symptoms that could be indicative of a need to refer to physician (e.g., dizziness, bowel/bladder/sexual dysfunction,
saddle anesthesia)
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe _______________________
• Medical history
–Past medical history
- Previous history of same/similar diagnosis: Any previous arthritis or lower-extremity orthopedic problems or injury?
- Comorbid diagnoses: Ask patient about health problems, including diabetes, cancer, heart disease, complications of
pregnancy, psychiatric disorders, orthopedic disorders, etc.
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask patient about other symptoms he or she may be experiencing
• Social/occupational history
–Patient’s goals: Document what the patient hopes to accomplish with therapy and in general
–Vocation/avocation and associated repetitive behaviors, if any: Does the patient participate in recreational or
competitive sports? What does the patient’s work require? Is the patient able to perform work duties?(15)
–Functional limitations/assistance with ADLs/adaptive equipment: Inquire about functional limitations (e.g., impaired
walking, squatting, kneeling, stepping down).(2) Document use of adaptive/assistive devices. Canes and walkers are the
most commonly prescribed assistive devices(23)
–Living environment: Stairs, number of floors in home, with whom patient lives, caregivers, etc. Identify if there are
barriers to independence in the home; any modifications necessary?
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Anthropometric characteristics: Circumferential measurements for swelling/edema. Document height and weight and
calculate body mass index (BMI) based on age and sex
–The American Academy of Orthopaedic Surgeons 2013 guideline strongly recommends that clinicians discuss weight
management or recommend referral for weight loss and nutritional counseling with patients whose BMI is 30, or more(64)
• Assistive and adaptive devices: Evaluate need for, proper fit, and use of ambulatory assistive device or bracing
• Balance: If knee OA is unilateral, compare 1-leg stand of affected extremity to contralateral extremity; assess reaction to
challenges in standing position. Use standardized tests such as the Berg Balance Scale, Tinetti Balance Test, Sit to Stand
Test, Romberg or sharpened Romberg test, and Single Limb Balance Test
–Authors of a systematic review (N = 1086) and meta-analysisfound that people with knee OA are more likely to have
reduced scores in the Step Test, Single Leg Stance Test, Functional Reach Test, Tandem Stance Test, and Community
Balance and Mobility Scale compared to healthy controls(75)
• Cardiorespiratory function and endurance
–Assess vital signs as indicated
–Assess endurance with 6-minute walk for distance test (6MWT)
• Circulation: In older patients, check distal pulses to assess if vascular insufficiency is contributing to ambulatory problems
• Ergonomics/body mechanics: Document altered body mechanics due to lower extremity impairments
• Functional mobility (including transfers, etc.): Use 10-meter walk test(10MWT), Timed Up & Go (TUG) test, sit-to-stand
test, and standardized stair-climbing test for outcome measures
• Gait/locomotion
–Perform thorough gait analysis; safety can be assessed with the Dynamic Gait Index (DGI)
–Gait abnormalities can include reduced self-selected walking speed, lateral trunk lean, shortened stride length, and
prolonged stance phase(16,17)
–Observe for bent knee on heel strike, and for knee thrust medially or laterally during gait(14)
• Joint integrity and mobility: Assess for tibiofemoral joint laxity and patellofemoral mobility
–Varus and valgus stress tests in full extension and 30˚ of knee flexion; patients with medial inflammation and varus
deformity commonly have medial pseudolaxity (a sensation of valgus laxity as the varus deformity is manually corrected
with knee extended in supine position)
–Anterior and posterior drawer tests for cruciate ligament insufficiency, as indicated
–Patella glides: medial, lateral, inferior, superior, and patellar tilt
• Muscle strength
–Manual muscle testing (MMT) for strength of the trunk and bilateral lower extremities. Isokinetic testing to assess
torque in knee extension and flexion can provide more detailed information on knee strength. Quadriceps weakness or
inhibition of the quadriceps and imbalance in the quadriceps-hamstring strength relationship due to pain is a determinant
of disability in knee OA(18)
–Note patient’s complaint of pain or increased symptoms with muscle testing
–Authors of a pilot study in the United States examined the effects of hip and knee strength on the kinematics of the
sit-to-stand test(61)
- Study included 8 adults clinically diagnosed with knee OA compared to a control group of 7 adults
- Subjects with knee OA had decreased hip abductor, hip extensor, and quadriceps peak force associated with increased
peak tibial abduction angles during sit-to-stand and increased stress on the patellofemoral joint. A moderate inverse
relationship between peak tibial abduction angle and peak hip abductor force was present
- There was no difference between peak adduction angle and peak hip external rotator force
- Suboptimal dynamic tibiofemoral alignment and proximal hip and knee muscle weakness may cause increased
patellofemoral stress and contribute to the progression of knee OA
• Observation/inspection (including skin assessment): 14)
–Observe lower extremities for muscle atrophy
–Document presence of any skin breakdown, previous lower extremity surgical incision sites, or swelling
–Presence of a popliteal cyst
• Palpation
–Assess patellofemoral joint for tenderness, crepitus, increased temperature/warmth, and soft tissue edema. Palpate and
observe for suboptimal patellar tracking with active knee ROM
–May be able to palpate osteophytes that are located proximal to femoral condyles
 • Posture
–Assess patient for a leg length discrepancy using the supine to sit test. Document if it is a true or functional leg length
discrepancy and use a tape to measure the amount of discrepancy
–Assess patient’s standing posture, paying particular attention to the alignment of the lower extremities. Document any
varus or valgus at the knees or ankles, metatarsal abduction, patellar malalignment, or hallux valgus. Document patient’s
standing trunk and pelvis alignment (increased lumbar lordosis, increased anterior/posterior pelvic tilt) and assess foot
alignment in subtalar neutral position, if indicated
• Range of motion
–Assess ROM in knee flexion and extension. Is reduced ROM due to muscle shortening or stiffness?
–Assess flexibility of entire lower extremity
• Self-care/activities of daily living (objective testing): Assess if disability interferes with self-care or instrumental ADLs,
such as with the Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS)(2)
• Sensory testing: Assess proprioception in the involved lower-extremity joints
• Special tests specific to diagnosis
–For assessment of meniscal injuries, see Clinical Review…Meniscal Injuries (Nonsurgical Management); Item Number:
T708409
–The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (with pain and function subscales) can
be used to assess pain, disability, and joint stiffness(10,19)
–The Dutch McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR) is a self-assessment of function that
is valid and responsive in patients with knee OA(20)
–The Arthritis Impact Measurement Scales (AIMS) can be used to assess pain as well as physical and psychological
disability(19)
–Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire: (range, 0-100; higher scores
indicate greater improvement)
–Short Form (36) Health Survey (SF-36) can be used to measure HRQoL

Assessment/Plan of Care
› Contraindications/precautions
• Patients with this diagnosis are at risk for falls; follow facility protocols for fall prevention and post fall prevention
instructions at bedside, if inpatient. Ensure that patient and family/caregivers are aware of the potential for falls
and educated about fall prevention strategies. Discharge criteria should include independence with fall prevention
strategies
• Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard to
modalities. Rehabilitation professionals should always use their professional judgment
• Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The summary
presented below is meant to serve as a guide, not to replace orders from a physician or a clinic’s specific protocols
• Cryotherapy contraindications(21)
–Raynaud’s syndrome
–Cryoglobulinemia
–Cold urticaria
–Paroxysmal cold hemoglobinuria
–Impaired circulation
• Cryotherapy precautions(21)
–Hypertension – cold can lead to an increase in blood pressure
–Hypersensitivity to cold
–Avoid aggressive treatment with cold modalities over an acute wound
–Avoid placement over superficial nerves for extended periods (> 1 hour)
–Cold may be counterproductive if being used to facilitate muscle relaxation and reduce pain in patients who do not
tolerate the modality
• Thermotherapy contraindications(21)
–Decreased circulation
 –Decreased sensation
–Acute/subacute traumatic and inflammatory conditions
–Skin infections
–Impaired cognition or language barrier
–Malignancy
–Tendency for hemorrhage or edema
–Heat rubs
• Whirlpool contraindications(21)
–Severe epilepsy
–Certain dermatologic conditions
–Surface infections
–Uncontrolled bowels
–Acute rheumatoid arthritis
–Venous ulcers
–Tissues damaged by x-ray therapy
–Peripheral vascular disease
–Reduced thermal sensation
–Respiratory impairments
–Cardiac impairments
–Active bleeding
–Malignancy
–Recent fever
–Acute inflammatory conditions
• Whirlpool precautions (*some are only relevant if entire body is immersed)(21)
–Impaired sensation
–Confusion or limited cognition
–Infection
–New skin grafts
–Certain medications
–Alcohol consumption (recent)*
–Decreased strength/ROM/endurance/balance*
–Urinary incontinence*
–Fear of water*
–Respiratory impairments
–Pregnancy*
–Multiple sclerosis*
–Impaired thermal regulation*
–Seasickness
–History of edema, when warm/hot water immersion
• Electrotherapy contraindications/precautions (in some cases, when approved by the treating physician, electrotherapy
may be used under some of the circumstances listed below when benefits outweigh the perceived risk)(21)
–Stimulation through or across the chest
–Cardiac pacemakers
–Implanted stimulators
–Over carotid sinuses
–Uncontrolled hypertension/hypotension
–Peripheral vascular disease
–Thrombophlebitis
–Pregnancy
–Over pharyngeal area
–Diminished sensation
–Acute inflammation
 –Seizure history
–Confused patients
–Immature patients
–Obesity
–Osteoporosis
–Malignancy
–Used in close proximity to diathermy treatment
• Therapeutic ultrasound contraindications(21)
–Over the region of a cardiac pacemaker
–Over the pelvis, abdominal and lumbar regions during pregnancy
–Over the eyes and testes
–Infection or bleeding in the area
–Tumor present in the area
–DVT or thrombophlebitis in the area
–Over the heart, stellate or cervical ganglia
–Over epiphyseal plates
• Therapeutic ultrasound precautions(21)
–Sensory deficits
–Individuals who cannot communicate effectively (e.g., impaired cognition, language barrier)
–Circulatory impairments
–Plastic or metal implants
–Note: Always decrease ultrasound intensity if the patient complains of discomfort
• Pulsed shortwave therapy contraindications(22)
–Pacemakers
–Pregnancy
–Active bleeding
–Malignancy
–Active tuberculosis
–Treatment over abdomen and pelvis during menstruation
–Severe circulatory compromise
–Radiation therapy (in last 6 months) in region to be treated
–Impaired cognition or uncooperative/noncompliant patients
• Pulsed shortwave therapy precautions(22)
–Avoid epiphyseal regions in children
–Avoid specialized tissues (e.g., eye and testes)
–Metal implants – believed to be safe when administering a low dose (< 5 Watts mean power)
› Diagnosis/need for treatment:
• Evidence-based clinical practice guidelines for nonoperative (i.e., nonarthroplasty) treatment of knee OA include
recommendations for physical therapy that involves pain management, low-impact aerobic fitness exercises, lower
extremity strengthening, ROM, flexibility, gait training, balance and proprioception training, and functional mobility
training(43,44)
• In the United States, the majority of patients with symptomatic knee OA do not receive physical therapy prior to TKA. In
a reference group of 12,806 patients undergoing TKA in 2009, only 10% of subjects received physical therapy during the
preceding 5 years.(45) Additionally, authors of a 2013 systematic review (N = 1,314) found that many persons self-manage
knee OA pain and disability without seeking preventive or rehabilitative care until TKA is their only choice for resolving
the pain(46)
• Patients can benefit from physical therapy to maximize their functional mobility and symptom reduction while awaiting a
TKA, especially those with severe functional impairments and disabilities(47)
› Rule out
• Patellofemoral syndrome
• Septic arthritis(23)
 • Rheumatoid arthritis(23)
• Crystalline arthropathy (e.g., gout)(3)
• Ipsilateral hip arthritis(64)
• Stress fracture, insufficiency fracture(64)
• Symptomatic metabolic bone disease(64)
• Neoplasm(64)
• Neuropathy(64)
• Bursitis around knee(23)
• Cyst around knee
• Tendonitis around knee(23)
• Ankle or foot deformity(64)
• Ligament sprain or tear
• Osteochondritis dissecans/osteonecrosis(64)
• Referred pain from hip or back(3)
› Prognosis
• Ongoing conservative management may postpone the need for surgical intervention.(43,44,67) However, opinions vary on
whether nonoperative therapies can reliably improve HRQoL in patients with symptomatic OA of the knee.(52) Prognosis is
variable depending on the extent of OA and its impact on the patient’s overall quality of life and functional abilities
• Authors of a prospective cohort study (N = 237 persons with knee or hip OA) in the Netherlands found that increased knee
pain and reduced ROM at 1-year follow-up were prognostic factors for functional decline at 3 years(24)
• Advanced joint laxity, loss of medial joint space, and proprioceptive impairment are linked to poor functional outcome with
nonoperative treatment(5,6)
• Surgical intervention should be delayed until conservative management is no longer effective for controlling the patient’s
primary complaints and OA has negatively impacted HRQoL and physical functioning in ADLs(23)
› Referral to other disciplines (as indicated)
• Nutritionist to address dietary approaches to weight loss
• Orthotist for bracing in an effort to decrease load on the knee
• Podiatrist for foot care, as indicated
› Other considerations
• Authors of a cohort study of community-based older adults (N = 143) found that despite having two or more conventional
risk factors for knee OA (e.g., high BMI, knee malalignment and reduced ROM) none had radiographic evidence of OA
in either knee. Women with bilateral genu valgum had significantly greater BMI than women with genu varus or neutral
alignment. Men and women with either genu varus or valgus had decreased ROM compared to individuals with neutral
knee alignment, but most of them (88.6%) had malalignment of at least one knee(59)
• Age and outdoor temperature may influence the unsupervised physical activity level of people with knee OA. Authors of a
small study (N = 38) in Canada found that during 1 week of accelerometry monitoring, younger age and warmer maximum
daily temperatures were associated with more activity(53)
• Intra-articular injection of corticosteroid before starting an exercise training program may not provide additional benefit
for patients with knee OA. Authors of an RCT (N = 100) in Denmark found no significant differences in pain (KOOS) or
objective measures of physical function and inflammation between the group that received 40 mg methylprednisolone (n =
50) and the placebo-control group (n = 50) after 12 weeks of supervised training (3 times per week), compared to baseline
or at 12 weeks post-trainingfollow-up(71)
• Researchers from a study in Spain found that injection of a platelet rich plasma via intra-articular and intraosseous
injections to the subchondral bone was found to minimize pain (VAS) and improve knee joint function (KOOS
questionnaire) in patients with severe knee OA(76)
› Treatment summary
• Consult nonoperative treatment guidelines from the American Academy of Orthopaedic Surgeons and the American
Academy of Rheumatology(43,44)
• Treatment should be appropriate for the stage of OA: Is pain inflammatory and present at rest or is pain only with
movement (i.e., mechanical in origin)?
• Therapeutic exercise
–Authors of a 2008 Cochrane review with meta-analysis found that aerobic and/or strengthening exercise training reduces
knee pain and improves physical function in patients with knee OA.(25) Evidence is lacking to indicate that any specific
type of exercise is superior to another type
–Authors of a 2008 systematic review found that exercise and weight reduction may improve pain and function in patients
with knee OA(26)
–Authors of an RCT (N = 106 patients with knee OA) in Taiwan found that after an 8-week exercise program, both
the weight-bearing group and the non-weight-bearing group improved WOMAC function scores and walking speed
compared to the non-exercise control group(27)
–Authors of an RCT (N = 159 persons with knee OA) in the Netherlands found that upper leg muscle strengthening was
associated with significantly improved physical function (WOMAC subscale, TUG test) and knee stabilization(72)
–Authors of a 2015 systematic review of 15 RCTs (N = 1,482 persons with knee OA) found that strength, aerobic, and Tai
Chi training programs improved balance and falls risk, whereas water-based exercise training did not improve balance
outcomes(73)
–Authors of a 2015 systematic review (N = 1239 patients with knee OA) found that exercise can improve overall HRQOL
(assessed by SF-36) in patients with knee OA(78)
–Authors of a 2016 systematic review (N = 2991 of which N = 1530 in exercise group and N = 1461 in control group)
found that exercise interventions that focus on increasing strength and flexibility can improve physical pain and function
and have a positive effect on walking ability including total distance walked, amount of time walked, and increased gait
velocity(80)
• Manual therapy: Limited evidence supports the benefit of manual therapy for improving pain and function in patients with
knee OA, based on 1 systematic review and 1 meta-analysis(54)
• Whole-body vibration (WBV)
–Authors of a 2015 systematic review with meta-analysis of 5 RCTs (N = 170) found moderate to high levels of evidence
that shows 8 to 12 weeks of WBV training can significantly improve physical function as measured by the WOMAC
physical function scale, 6MWT, and Berg Balance Scale(81)
• Tai Chi
–Authors of a 2013 systematic review with meta-analysis of 5 RCTs (N = 2,523) found moderate evidence that supports
Tai Chi as an effective treatment intervention for short-termimprovement of pain, physical function, and joint stiffness in
persons with knee OA(60)
• Modalities
–Authors of an RCT (N = 46) in Turkey found that regular use of moist heat (20 minutes/day, every other day for 4 weeks),
in addition to routine medication use, improved WOMAC pain and function scores and HRQoL in patients with knee
OA(28)
–Authors of an RCT (N = 36) in the United States found that the combination of transcutaneous electrical stimulation
(TENS) and exercise may improve quadriceps activation more than exercise only in patients with knee OA (55)
–Authors of an RCT (N = 84) in Brazil found that pulsed shortwave therapy (PSWT) may reduce pain scores and improve
function(Lysholm Knee Scoring Scale) in patients with knee OA(29)
–Authors of a 2015 systematic review with meta-analysis of 27 trials found insufficient evidence to support electrical
stimulation therapies such as interferential current (IFC), transcutaneous electrical nerve stimulation (TENS), and
neuromuscular electrical stimulation (NMES) for treating pain in patients with knee OA(74)
–Authors of an RCT (N = 100) in Turkey found that using ultrasound for 8 minutes provided better results in reducing
pain, improving physical function, and reducing depressive symptoms compared to using ultrasound for only 4
minutes(77)
- Outcome measures used for this study were the VAS, WOMAC, and Beck depression index
• Frequency and intensity of US treatment were 1 Mhz at 1.5 watt/cm2 Knee taping
 –Authors of a double-blind RCT (N = 87 patients with knee OA) in Australia found that knee taping improved pain
and disability compared to sham taping or no taping, and the benefits of taping persisted at 3 weeks after stopping
treatment(37)
- Outcome measures: VAS for pain, perceived rating of change, WOMAC, and SF-36
- Taping provided medial glide, medial tilt, and anteroposterior tilt to the patella. Tape was also applied to unload either
the infrapatellar fat pad or the pes anserinus
- The sham-taping control group was superficial taped to provide sensory input only; the no-taping control group received
no treatment
–Authors of a research study in Korea found that kinesiology taping can decrease pain and increase ROM resulting in
overall improvements with ADLS(82)
- Thirty patients with knee OA (treatment group N = 15 and control group N = 15)
- Patients received treatment 3x/ week for 4 weeks
- Control group received only hotpack treatment for 20 minutes along with general physical therapy using interference
wave therapy at 100bps for 15 minutes
- Experimental group also received general physical therapy, but were also given kinesiology tape applied to the
hamstring muscles, anterior tibialis, quadriceps femoris, and gastrocnemius
- Objective measures used in this study was the K-WOMAC(Korean WOMAC), VAS, and goniometric measurements
• Orthotics
–Authors of an RCT (N = 200 people with knee OA) in Australia found that laterally wedged insoles did not improve pain,
function, or ROM compared to flat insoles(30)
–Authors of a study (21 people with knee OA) in Egypt found that laterally wedged insoles did not reduce medial knee
joint loading or change knee adduction moment during gait(31)
–Medial wedge insoles can be trialed for subjects with valgus knee alignment.(23)For example, authors of a study (N
= 42 patients with medial knee OA) in Denmark found that wearing customized laterally wedged insoles improved
pain, function, and HRQoL. VAS score after 30 minutes of physical activity was significantly reduced after wearing the
laterally wedged insoles. Significant changes were also found for secondary outcomes as measured by the Oxford Knee
Score and the EQ-5D (European Quality of Life tool). This study lacked a control group(56)
–Authors of a randomized crossover trial (N = 80 patients with knee OA) in the United States found that valgus knee brace
combined with neutral foot orthoses and motion-control shoes worn for 12 weeks improved WOMAC pain and function
scores(57)

.
Problem Goal Intervention Expected Progression Home Program
Chronic knee pain and Decrease pain intensity Electrotherapeutic Reduced reliance on Implement home
edema and edema modalities modalities for pain and program to address pain
_ edema reduction and edema as indicated
TENS may suppress and appropriate for
pain during exercise each patient(33)
and gait reeducation(32)
_
Physical agents and
mechanical modalities
_
Heat can be used to
relieve stiffness; ice
when acutely inflamed;
whirlpool and contrast
baths for pain and
edema
_
_
Patient education
_
Educate patient on pain
management and joint
protection(33)
_
_
Therapeutic exercise
_
Include various types
of exercise training,
as indicated and
appropriate for each
patient(34)
_
Manual therapy
_
Massage therapy
may be effective for
improving symptoms of
knee pain, stiffness and
function.(40)
_
Knee taping may be
effective(37)
_
_
(Please see Treatment
summary, above)
Reduced knee ROM/ Increase/maintain pain- Electrotherapeutic Progress as indicated Educate the patient
lower extremity free full ROM; increase modalities on the prevention
flexibility; stiffness lower extremity _ of contractures and
flexibility and stiffness Pulsed ultrasound implement a ROM/
applied to medial and/ flexibility program for
or lateral knee joint line home(36)
prior to exercise may
increase ROM(35)
_
_
Manual therapy
_
Soft-tissue
mobilization, passive
ROM, and stretching
shortened muscles(40)
Reduced quadriceps Increase/maintain Electrotherapeutic Isometrics to Implement a home
strength sufficient strength modalities progressive resistive program to address
_ _ _ exercise as indicated muscle weakness
_ _ EMS in cases of muscle and knee instability
Knee instability Increase articular (e.g., quadriceps) as indicated and
stability, with atrophy appropriate for each
less reliance on _ patient(33)
biomechanical devices _
Therapeutic exercise
_
Include various
strengthening activities
as indicated and
appropriate for each
patient
_
_
(Please see Treatment
summary, above)
Proprioceptive and Age-appropriate Prescription, Progress as indicated Implement a
balance deficits proprioception and application of devices home program to
balance reactions and equipment address balance and
_ proprioceptive deficits
_ as indicated and
Neoprene sleeve appropriate for each
may compensate for patient
proprioceptive deficits
related to muscular
fatigue(38)
_
_
Consider knee brace
that assists to unload
the varus stress on the
knee
_
_
Proprioceptive
exercise
_
May improve foot
posture and lower limb
alignment(74)
_
_
Various high-level
balance activities, as
indicated
Reduced walking Improve gait mechanics Functional training Progress as indicated Implement a home
speed with faulty gait and walking speed _ program to address
mechanics Functional training to gait deviations and
_ reduce any disability in decreased endurance
_ gait and stairs as indicated and
Reduced stamina _ appropriate for each
_ patient
Bracing may be used
to unload the knee
as indicated and
appropriate(39)
_
_
Therapeutic exercise
_
Include various
strengthening and
aerobic activities
as indicated and
appropriate for each
patient(34)
_
_
(Please see Treatment
summary, above)
Impaired function in Independent in ADLs Manual therapy Progress as indicated Implement a home
ADLs _ program to address
Massage therapy impaired ADLs
may be effective for as indicated and
improving WOMAC appropriate for each
scores for symptoms of patient(33)
pain and stiffness and
physical function(40)
_
_
Therapeutic exercise
_
Include various
strengthening activities
as indicated and
appropriate for each
patient(34)
_
_
_
(Please see Treatment
summary, above)
Obesity/Overweight Self-management Weight reduction N/A Instruction and
in exercise program _ encouragement
adherence and weight Found to improve on home exercise
maintenance outcomes for knee pain program(33)
and functional status,
especially in advanced
cases of knee OA(36)

Desired Outcomes/Outcome Measures

› Decreased pain intensity
• VAS, WOMAC, IKDC, KOOS, MACTAR
› Decreased edema
• circumferential measurements
› Increased/maintained pain-free full ROM
• Goniometric measurements
› Increased/maintained sufficient strength
• MMT, isokinetic testing
› Improved mobility with less reliance on biomechanical devices
• TUG test
› Age-appropriate proprioception and balance reactions
• Berg Balance Scale, Tinetti Balance Test, Sit to Stand Test, Romberg or sharpened Romberg test, and Single Limb Balance
Test
› Improved gait mechanics and walking speed
• DGI,6MWT
› Independent in ADLs
› KOS-ADLS, AIMS
› Self-management in exercise program adherence and weight maintenance
• Re-assessment

Maintenance or Prevention
› There is no cure for knee OA, but regular therapeutic exercise can ameliorate knee pain(41)
› The 2012 National Guideline Clearinghouse, Guideline Summary NGC-9966, Ottawa Panel evidence-based clinical practice
guidelines for aerobic walking programs in the management of knee OA recommend(63)
• Aerobic walking programs to help relieve pain and promote remodeling without increasing stress in the affected joint
• High-intensity activities should be avoided to reduce risk of relapse and injury. Individuals with OA should limit exercise
intensity to a moderate and safe level
• For more information, refer to the NGC-9966 guideline summary
› Prevention
• Maintain healthy weight and general physical fitness
• Vitamin D supplementation
–Authors of an RCT (N = 107 women with knee OA) in India found a daily oral vitamin D supplement over 12 months of
intervention was associated with significantly lower knee pain (mean of 0.26 on a VAS and 0.55 on the WOMAC). Pain
levels increased in the control group that received a placebo pill (mean of 0.13 on the VAS and 1.16 on the WOMAC).
Knee function improved in the vitamin D group by a mean of 1.36 compared to the placebo group with a mean of
+0.69. Vitamin D supplementation was associated with significant improvements in serum total calcium and alkaline
phosphatase. Researchers concluded there is a small but statistically significant clinical benefit for vitamin D treatment in
patients with knee OA(58)
–Authors of another RCT (N = 413) in Tasmania found that vitamin D supplementation did not provide any significant
changes in MRI-measured tibial cartilage or WOMAC knee pain scores over 2 years. Patients in the experimental group
were given oral vitamin D3 (50000 IU) for 2 years and the control group receiving only placebo pills. Tibial cartilage was
 measured using an MRI machine and pain assessment scores were measured using the WOMAC. Researchers concluded
that there were no significant differences between the experimental group and control group in regards to WOMAC pain
scores or tibial cartilage volume(79)
• Prevent sports-related injuries to the knees (e.g., appropriate conditioning, skills, and technique for specific sport; limit
high-impact activities; proper equipment)

Patient Education
› Therapists should educate all patients on the importance of weight control and exercise(42)
› U.S. National Library of Medicine, Medline Plus,“Osteoarthritis,” https://medlineplus.gov/osteoarthritis.html

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

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