AAOS Clinical Practice Guideline Summary

AAOS Clinical Practice Guideline Summary:

Management of Osteoarthritis of the Knee
(Nonarthroplasty), Third Edition

Robert H. Brophy, MD
Yale A. Fillingham, MD
ABSTRACT

Management of Osteoarthritis of the Knee (nonarthroplasty) Evidence-

From the Washington University School of
Medicine, Chesterfield, MO (Brophy), and the
Rothman Orthopaedic Institute, Thomas
Jefferson University, Philadelphia, PA
(Fillingham).
Brophy or an immediate family member serves
as a board member, owner, officer, or committee
member of AAOS, American Orthopaedic
Association, and American Orthopaedic Society
for Sports Medicine; serves on editorial or
governing board of American Journal of Sports
Medicine, Journal of the American Academy of
Orthopaedic Surgeons; Vice Chair, National
Football League Musculoskeletal Committee.
Fillingham or an immediate family member has
received royalties from Exactech and Medacta;
serves as a paid consultant to Exactech,
Johnson & Johnson, and Medacta; has stock or
stock options held in Parvizi Surgical Innovations;
and serves as a board member, owner, officer, or
committee member of AAOS and American
Association of Hip and Knee Surgeons.
This clinical practice guideline was approved by
the American Academy of Orthopaedic Surgeons
Board of Directors on August 31, 2021.
The complete document, Management of
Osteoarthritis of the Knee (nonarthroplasty)–Third
Edition Evidence-Based Clinical Practice
Guideline, includes all tables and figures and is
available at www.aaos.org/oak3cpg.
J Am Acad Orthop Surg 2022;30:e721-e729
DOI: 10.5435/JAAOS-D-21-01233
Copyright 2022 by the American Academy of
Orthopaedic Surgeons.
Based Clinical Practice Guideline is based on a systematic review of
published studies for the nonarthroplasty treatment of osteoarthritis of
the knee in adults (ages 17 years and older). The purpose of this
clinical practice guideline is to evaluate current best evidence
associated with treatment. The scope of this guideline contains
nonpharmacologic and pharmacologic interventions for symptomatic
osteoarthritis of the knee, including surgical procedures less invasive
than knee arthroplasty. It does not provide recommendations for
patients with rheumatoid arthritis, arthritis of other joints, or other
imflammatory athropathies. This guideline contains 29
recommendations to assist all qualified and appropriately trained
healthcare professionals involved in the nonarthroplasty management
of osteoarthritis of the knee and provide information for patients. In
addition, the work group highlighted the need for better research into
intra-articular corticosteroid, hyaluronic acid, and platelet-rich plasma
detailing osteoarthritis characterization, including subgroup analyses
and osteoarthrosis severity stratification, and clinically relevant
outcomes with control subjects for bias and cost-effectiveness
analysis. Studies comparing outcomes in patients with mild-to-
moderate knee osteoarthritis and an MRI confirmed meniscal tear
who have undergone partial meniscectomy after failing to improve
with a course of conservative treatment (nonsteroidal anti-
inflammatory drugs, steroid injection, and physical therapy) versus
those who have undergone partial meniscectomy without a dedicated
course of conservative treatment. Prospective randomized trials or
prospective cohort studies are still needed to establish efficacy of
individual oral nonsteroidal anti-inflammatory drugs within specific
subgroups and populations to tailor systemic medications to help
increase efficacy and decrease the risk of adverse effects.

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AAOS OAK 3 Clinical Practice Guideline Summary

Overview and Rationale symptomatic osteoarthritis of the knee.1 Furthermore,

the CPG represents a call for continued research to
The American Academy of Orthopaedic Surgeons (AAOS),
better understand the optimal indications for and the
with input from representatives from the American
utility of treatment options for osteoarthritis of the knee
Orthopaedic Society for Sports Medicine, the American
before knee arthroplasty, especially efforts to establish
Association for Hip and Knee Surgeons, The Knee Society,
efficacy within specific subgroups and to identify factors
the American Academy of Family Physicians, the American
that could discriminate between responders and non-
Physical Therapy Association, the Arthroscopic Associa-
responders for specific treatments. An exhaustive liter-
tion of North America, the International Cartilage Repair
ature search was conducted resulting initially in more
Society, the American Medical Society for Sports Medicine,
than 2,400 papers for full-text review. The papers were
and the American Society of Regional Anesthesia and Pain,
then graded for quality and determined whether the
recently published their clinical practice guideline (CPG),
publication aligned with the patients, interventions, and
Management of Osteoarthritis of the Knee (non-
outcomes of concern. For CPG PICO (ie, population,
arthroplasty), third edition.1 This CPG was approved by
intervention, comparison, and outcome) questions that
the AAOS Board of Directors in August 2021. The pur-
returned no evidence from the systematic literature
pose of this CPG is to assist physicians, surgeons, and
review, the work group used the established AAOS CPG
other healthcare professionals who care for patients with
methodology to generate two companion consensus
osteoarthritis of the knee in making treatment decisions
statements for alternative nonsurgical treatments, sur-
that improve the quality and efficacy of care.
gical treatments on the effectiveness of dry needling, and
Osteoarthritis (of any joint) was the primary diagnosis
the use of free-floating interpositional devices in the
for 23.7 million ambulatory care visits in 2013. An esti-
management of symptomatic osteoarthritis of the knee.
mated 32.5 million adults in the US, 14% of the American
In summary, the AAOS Management of Osteo-
population, suffered from symptomatic knee osteoarthritis
arthritis of the Knee (nonarthroplasty) CPG involved
between 2008 and 2014. The incidence of knee osteo-
reviewing more than 14,400 abstracts and more than
arthritis in the United States is estimated at 240 persons per
2,400 full-text articles to develop 27 recommendations
100,000 per year. Worldwide prevalence of radiographi-
supported by 617 research articles meeting stringent
cally confirmed symptomatic knee osteoarthritis (OA) is
inclusion criteria. Each recommendation is based on a
estimated to be 3.8% overall, increasing with age to more
systematic review of the research related topic, which
than 10% in the population older than 60 years.
resulted in eight recommendations classified as high,
Risk factors of the condition increase with age, espe-
eight recommendations classified as moderate, and 11
cially in women. Although women represent 51% of the
as limited. The strength of recommendation is assigned
general population in the United States, they represent
based on the quality of the supporting evidence. The
78% of the patients diagnosed with osteoarthritis
strength of recommendation also takes into account the
between 2008 and 2014. Genetics and hereditary vul-
quality, quantity, trade-offs between the benefits and
nerability, elevated body mass, certain occupations, and
harms of a treatment, and magnitude of a treatment’s
traumatic knee injuries are other factors that increase
effect.
one’s risk of developing the disease.
Individuals with osteoarthritis of the knee often complain
of joint pain, stiffness, and difficulty with purposeful move-
ment. Older adults with self-reported osteoarthritis visit their Guideline Summary
physicians more frequently and experience greater func- Dietary supplements have long been seen as an alternative
tional limitations than others in the same age group. The goal to medications for the symptomatic management of knee
of the treatment is to provide pain relief and improve the osteoarthritis. The current guidelines focused on the eval-
patient’s functioning. Most interventions are associated uation of glucosamine, chondroitin, turmeric, ginger
with some potential for adverse outcomes, especially if extract, and vitamin D. Most of the evidence demonstrated
invasive or surgical. Because the clinical research usually either some improvement or no change in patient outcomes
does not differentiate between the sexes, it is possible that for those with osteoarthritis of the knee. Although the evi-
future research may result in a better understanding of dence does not consistently demonstrate a benefit to dietary
how a patient’s sex alters treatment benefits and harms. supplements, the risks involved are relatively minimal with
Therefore, the AAOS developed an evidence-based the primary barrier being expense because dietary supple-
CPG to aid practitioners in the treatment of patients with ments are typically an out-of-pocket expense to patients.

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The lack of reproducibility in the evidence and the vari-
ability between dietary supplement manufactures with
limited oversight by the United States Food and Drug
Administration continues to limit the strength of the rec-
ommendation and hinder future research.
Oral nonsteroidal anti-inflammatory drugs (NSAIDs)
and acetaminophen have been widely adopted in the
treatment of knee osteoarthritis. The evidence would
support the use of NSAIDs and acetaminophen because
these oral medications consistently demonstrate improved
pain and function in patients with knee osteoarthritis. For
nonselective and selective cyclooxygenase-2 oral NSAIDs,
both are effective medications. Although selective
cyclooxygenase-2 oral NSAIDs were developed to reduce
gastrointestinal adverse events, we found no notable dif-
ference in the risk of a gastrointestinal adverse event with
nonselective NSAIDs. Despite the effectiveness of acet-
aminophen and NSAIDs, it is important to understand the
appropriate prescribing for the medications because each
medication carries a black box warning from the FDA.
Finally, oral narcotics (including tramadol) should not be
used in the treatment of knee osteoarthritis because of the
notable increase in medication-related adverse effects with
no consistent improvement in pain and function.
Intra-articular injections are widely used by patients,
with the most common injections being corticosteroid,
hyaluronic acid, and platelet-rich plasma. Controversy
exists over the effectiveness of each intra-articular injec-
tion. Among the options for intra-articular injections,
corticosteroid had considerable evidence with 19 high-
quality and six moderate-quality studies supporting the
use of intra-articular corticosteroid, although the dura-
tion of benefits was often only 3 months. Platelet-rich
plasma is an alternative with two high-quality studies
and one moderate-quality study supporting reduced pain
and improved function in patients with knee osteo-
arthritis; however, the evidence demonstrated inconsis-
tency with a worse treatment response in patients with
severe knee osteoarthritis. In addition, concerns have
been raised for platelet-rich plasma regarding the cost
and safety profile. Although intra-articular hyaluronic
acid is commonly used to treat knee osteoarthritis, it was
not consistently supported by the 17 high-quality and 11
moderate-quality studies. The recommendation does
recognize the potential for hyaluronic acid to benefit
patients as the calculated number needed to treat was 17
patients; however, the current evidence does not identify
the subset of patients who benefit from hyaluronic acid to
explain the observed inconsistency in the evidence. As a
result, the recommendation was against the routine use
of hyaluronic acid in patients with knee osteoarthritis.
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Robert H. Brophy, MD and Yale A. Fillingham, MD
Review Section: AAOS Clinical Practice Guideline Summary
Sustained weight loss has been shown to benefit pain and,
to a lesser extent, function in overweight and obese patients
with knee osteoarthritis. Although there is some evidence
that exercise may be better than diet to achieve this weight
loss,2,3 the preferred approach is to use diet and exercise.4,5
There is no risk or downside to sustained weight loss and
obvious other health benefits. Patients may not always be
motivated and even when they are; it can be challenging to
achieve and maintain meaningful weight loss. Despite this
challenge, there is little controversy regarding this recom-
mendation. There is a need for larger, randomized clinical
trials, particularly studies focused on function and quality
of life in patients with knee osteoarthritis and the cost-
effectiveness of weight loss interventions.
Exercise and physical therapy are excellent modalities to
address pain and function in patients with knee osteo-
arthritis. There is strong evidence that exercise, including
unsupervised, supervised, and aquatic, improve pain and
function in these patients. Studies do not establish a clear
benefit from supervised exercise compared with unsuper-
vised exercise.6-9 Similarly, it is not clear that aquatic
exercise is better than land-based exercise in patients with
knee osteoarthritis, although one study reported that pa-
tients treated with aquatic exercise had less pain with
walking than patients treated with land-based exercise.10
Adding neuromuscular training programs may improve
function and/or walking speed but does not reduce pain
compared with exercise and may cause a temporary
increase in knee pain or muscle soreness.11-15 Supervised
and aquatic exercise, as well as neuromuscular training
programs, may have cost and access challenges, especially
compared with unsupervised exercise programs.
Meniscus tears in patients with knee osteoarthritis
are a particularly challenging clinical complication. For
the majority of patients with knee osteoarthritis, partic-
ularly with more advanced osteoarthritis, the meniscus
tear is a result of the degenerative process rather than an
independent cause of clinical symptoms. These patients
are unlikely to get much, if any, improvement from the
surgical treatment of the meniscus tear. Contrarily, a
small number of truly obstructing displaced meniscus
tears are a primary cause of predominantly mechanical
symptoms and warrant treatment for that reason. In a
subset of patients with mild-to-moderate knee osteo-
arthritis, meniscal tears may be a notable contributor to
patient symptoms. These are the patients who may be
candidates for arthroscopic partial meniscectomy after
failing nonsurgical treatment, such as physical therapy,
corticosteroid or other intra-articular injections, or
other modalities. If symptoms do not respond to these
treatments, arthroscopic partial meniscectomy is an
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AAOS OAK 3 Clinical Practice Guideline Summary
appropriate and effective treatment, with a substantial
percentage of patients randomized to nonsurgical treat-
ment who cross over in published trials.16,17 There does
not seem to be any negative effect of trying nonsurgical
treatment before undergoing arthroscopic partial
meniscectomy.
In summary, this guideline summarizes the best rec-
ommendations the work group felt were possible on the
basis of the current published evidence for the non-
arthroplasty treatment of knee osteoarthritis. The rec-
ommendations herein are just that—they are intended as
principles of treatment rather than prescriptive, as if
correct or ideal for every patient irrespective of disease
severity, location in the joint, and symptoms. As per any
evidence-based recommendation, the physician team
should also rely on their own clinical judgment, experi-
ence, available resources, and desires of their patients and
patients’ families. Furthermore, these recommendations
were limited in some areas, as noted herein, based on low
quality or inadequate evidence, and highlight areas
requiring diligent future study and investigation. Our
hope is that these recommendations will serve as a useful
template for both clinical and shared decision-making
with patients and patients’ families affected by knee
osteoarthritis and that future research will permit revi-
sion, refinement, improvement, and expansion of these
recommendations toward this worthy end. These efforts
can then further serve to help guide our nonarthroplasty
treatment of patients with knee osteoarthritis toward the
goal of providing each patient with both the best treat-
ment options and the best outcome for their specific
clinical manifestation of the disease.
Recommendations
This summary of recommendations of the AAOS Man-
agement of Osteoarthritis of the Knee (nonarthroplasty)
Evidence-Based CPG contains a list of evidence-based
treatment recommendations. Discussions of how each
recommendation was developed and the complete evi-
dence report are contained in the full guideline at http://
www.aaos.org/oak3cpg. Readers are urged to consult
the full guideline for the comprehensive evaluation of
the available scientific studies. The recommendations
were established using methods of evidence-based
medicine that rigorously control for bias, enhance
transparency, and promote reproducibility.
The summary of recommendations is not intended to
stand alone. Medical care should be based on evidence, a
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physician’s expert judgment, and the patient’s circum-
stances, values, preferences, and rights. For treatment
procedures to provide benefit, mutual collaboration
with shared decision-making between patient and
physician/allied healthcare provider is essential.
A strong recommendation means that the quality of
the supporting evidence is high. A moderate recommen-
dation means that the benefits exceed the potential harm
(or that the potential harm clearly exceeds the benefits in
the case of a negative recommendation), but the
quality/applicability of the supporting evidence is not as
strong. A limited recommendation means that there is a
lack of compelling evidence that has resulted in an
unclear balance between benefits and potential harm. A
consensus recommendation means that expert opinion
supports the guideline recommendation although there is
no available empirical evidence that meets the inclusion
criteria of the guideline’s systematic review.
Strength of Recommendations Descriptions
Lateral Wedge Insoles
Lateral wedge insoles are not recommended for patients
with knee osteoarthritis.
Strength of recommendation: Strong.
Implication: Practitioners should follow a Strong
recommendation unless a clear and compelling rationale
for an alternative approach is present.
Canes
Canes could be used to improve pain and function in
patients with knee osteoarthritis.
Strength of recommendation: Moderate.
Implication: Practitioners should generally follow a
Moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
Braces
Brace treatment could be used to improve function, pain,
and quality of life in patients with knee osteoarthritis.
Strength of recommendation: Moderate.
(downgrade)
Implication: Practitioners should generally follow a
Moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
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 Robert H. Brophy, MD and Yale A. Fillingham, MD

Review Section: AAOS Clinical Practice Guideline Summary

Strength of
Recommendation Overall Strength of Evidence Description of Evidence Quality Strength Visual
Strong Strong Evidence from two or more “High”
quality studies with consistent
findings for recommending for or
against the intervention. Also
requires no reasons to downgrade
from the EtD framework
Moderate Moderate or Strong Evidence from two or more
“Moderate” quality studies with
consistent findings or evidence from
a single “High” quality study for
recommending for or against the
intervention. Also requires no or
only minor concerns addressed in
the EtD framework.
Limited Limited, Moderate, or Strong Evidence from one or more “Low”
quality studies with consistent
findings or evidence from a single
“Moderate” quality study
recommending for or against the
intervention. In addition, higher
strength evidence can be
downgraded to limited because of
major concerns addressed in the EtD
framework.
Consensus No reliable evidence There is no supporting evidence, or
higher quality evidence was
downgraded because of major
concerns addressed in the EtD
framework. In the absence of reliable
evidence, the guideline work group
is making a recommendation based
on their clinical opinion.

EtD = Evidence-to-Decision

efits and potential harm. Patient preference should have a

Oral/Dietary Supplements substantial influencing role.
The following supplements may be helpful in reducing
pain and improving function for patients with mild-to-
moderate knee osteoarthritis; however, the evidence is Topical Treatments
inconsistent/limited, and additional research clarifying
Topical NSAIDs should be used to improve function and
the efficacy of each supplement is needed.
quality of life for the treatment of osteoarthritis of the
• Turmeric
knee, when not contraindicated.
• Ginger extract
Strength of recommendation: Strong.
• Glucosamine
Implication: Practitioners should follow a Strong
• Chondroitin
recommendation unless a clear and compelling rationale
• Vitamin D
for an alternative approach is present.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise Supervised Exercise
clinical judgment, and be alert for emerging evidence that Supervised exercise, unsupervised exercise, and/or
clarifies or helps to determine the balance between ben- aquatic exercise are recommended over no exercise to

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AAOS OAK 3 Clinical Practice Guideline Summary
improve pain and function for the treatment of knee
osteoarthritis.
Strength of recommendation: Strong.
Implication: Practitioners should follow a Strong
recommendation unless a clear and compelling rationale
for an alternative approach is present.
Neuromuscular Training
Neuromuscular training (ie, balance, agility, and coor-
dination) programs in combination with exercise could
be used to improve performance-based function and
walking speed for the treatment of knee osteoarthritis.
Strength of recommendation: Moderate.
(downgrade)
Implication: Practitioners should generally follow a
Moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
Self-Management
Patient education programs are recommended to
improve pain in patients with knee osteoarthritis.
Strength of recommendation: Strong.
Implication: Practitioners should follow a Strong
recommendation unless a clear and compelling rationale
for an alternative approach is present.
Patient Education
Patient education programs are recommended to
improve pain in patients with knee osteoarthritis.
Strength of recommendation: Strong.
Implication: Practitioners should follow a Strong
recommendation unless a clear and compelling rationale
for an alternative approach is present.
Weight Loss Intervention
Sustained weight loss is recommended to improve pain
and function in overweight and obese patients with knee
osteoarthritis.
Strength of recommendation: Moderate.
(downgrade)
Implication: Practitioners should generally follow a
Moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
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Manual Therapy
Manual therapy in addition to an exercise program may
be used to improve pain and function in patients with
knee osteoarthritis.
Strength of recommendation: Limited.
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Massage
Massage may be used in addition to usual care to improve
pain and function in patients with knee osteoarthritis.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Laser Treatment
FDA-approved laser treatment may be used to improve
pain and function in patients with knee osteoarthritis.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Acupuncture
Acupuncture may improve pain and function in patients
with knee osteoarthritis.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between
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benefits and potential harm. Patient preference should
have a substantial influencing role.
Transcutaneous Electrical Nerve
Stimulation
Modalities that may be used to improve pain and/or
function in patients with knee osteoarthritis include
a. Transcutaneous electrical nerve stimulation (pain)
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Percutaneous Electrical Nerve
Stimulation/Pulsed Electromagnetic Field
Therapy
Modalities that may be used to improve pain and/or
function in patients with knee osteoarthritis include
a. Percutaneous electrical nerve stimulation (pain and
function)
b. Pulsed electromagnetic field (pain)
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy may be used to
improve pain and function for the treatment of osteo-
arthritis of the knee.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Robert H. Brophy, MD and Yale A. Fillingham, MD
Review Section: AAOS Clinical Practice Guideline Summary
Oral NSAIDs
Oral NSAIDs are recommended to improve pain and
function in the treatment of knee osteoarthritis when not
contraindicated.
Strength of recommendation: Strong.
Implication: Practitioners should follow a strong rec-
ommendation unless a clear and compelling rationale for
an alternative approach is present.
Oral Acetaminophen
Oral acetaminophen is recommended to improve pain
and functions.
Strength of recommendation: Strong.
Implication: Practitioners should follow a strong rec-
ommendation unless a clear and compelling rationale for
an alternative approach is present.
Oral Narcotics
Oral narcotics, including tramadol, result in a notable
increase of adverse events and are not effective at
improving pain or function for the treatment of osteo-
arthritis of the knee.
Strength of recommendation: Strong.
Implication: Practitioners should follow a strong rec-
ommendation unless a clear and compelling rationale for
an alternative approach is present.
Hyaluronic Acid
Hyaluronic acid intra-articular injection(s) is not rec-
ommended for routine use in the treatment of
symptomatic osteoarthritis of the knee.
Strength of recommendation: Moderate.
(downgrade)
Implication: Practitioners should generally follow a
moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
Intra-articular Corticosteroids
Intra-articular corticosteroids could provide short-term
relief for patients with symptomatic osteoarthritis of the
knee.
Strength of recommendation: Moderate.
(downgrade)
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AAOS OAK 3 Clinical Practice Guideline Summary
Implication: Practitioners should generally follow a
moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
Platelet-rich Plasma
Platelet-rich plasma may reduce pain and improve
function in patients with symptomatic osteoarthritis of
the knee.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Denervation Therapy
Denervation therapy may reduce pain and improve
function in patients with symptomatic osteoarthritis of
the knee.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Lavage/Débridement
Arthroscopy with lavage and/or débridement in patients
with a primary diagnosis of knee osteoarthritis is not
recommended.
Strength of recommendation: Moderate.
Implication: Practitioners should generally follow a
Moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
Partial Meniscectomy
Arthroscopic partial meniscectomy can be used for the
treatment of meniscal tears in patients with concomitant
mild-to-moderate osteoarthritis who have failed physical
therapy or other nonsurgical treatments.
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Strength of recommendation: Moderate.
Implication: Practitioners should generally follow a
Moderate recommendation but remain alert to new
information and be sensitive to patient preferences.
Tibial Osteotomy
High tibial osteotomy may be considered to improve pain
and function in properly indicated patients with uni-
compartmental knee osteoarthritis.
Strength of recommendation: Limited.
(downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between ben-
efits and potential harm. Patient preference should have a
substantial influencing role.
Dr. Needling
In the absence of reliable evidence, it is the opinion of the
work group that the utility/efficacy of dry needling is
unclear and requires additional evidence.
Strength of recommendation: Consensus
Implication: In the absence of reliable evidence,
practitioners should remain alert to new information
because emerging studies may change this recommen-
dation. Practitioners should weigh this recommendation
with their clinical expertise and be sensitive to patient
preferences.
Free-Floating Interpositional Devices
In the absence of reliable or new evidence, it is the opinion
of the work group not to use free-floating (unfixed) in-
terpositional devices in patients with symptomatic
medial compartment osteoarthritis of the knee.
Strength of recommendation: Concensus
Implication: In the absence of reliable evidence,
practitioners should remain alert to new information
because emerging studies may change this recommen-
dation. Practitioners should weigh this recommendation
with their clinical expertise and be sensitive to patient
preferences.
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References
References printed in bold type are those published
within the past 5 years.
1. American Academy of Orthopaedic Surgeons Management of
Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical
Practice Guideline. https://www.aaos.org/oak3cpg Published 08/31/2021
2. 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;310:1263-1273.
3. Mihalko SL, Cox P, Beavers DP, et al: Effect of intensive diet and
exercise on self-efficacy in overweight and obese adults with knee
osteoarthritis: The IDEA randomized clinical trial. Translational Behav
Med 2018;9:227-235.
4. Jenkinson CM, Doherty M, Avery AJ, et al: Effects of dietary
intervention and quadriceps strengthening exercises on pain and
function in overweight people with knee pain: Randomised controlled
trial. BMJ 2009;339:b3170.
5. Miller GD, Nicklas BJ, Davis C, Loeser RF, Lenchik L, Messier SP:
Intensive weight loss program improves physical function in older obese
adults with knee osteoarthritis. Obesity (Silver Spring) 2006;14:1219-1230.
6. McCarthy CJ, Mills PM, Pullen R, Roberts C, Silman A, Oldham JA:
Supplementing a home exercise programme with a class-based exercise
programme is more effective than home exercise alone in the treatment of
knee osteoarthritis. Rheumatology (Oxford) 2004;43:880-886.
7. Allen KD, Arbeeva L, Callahan LF, et al: Physical therapy vs internet-
based exercise training for patients with knee osteoarthritis: Results
of a randomized controlled trial. Osteoarthritis Cartilage 2018;26:
383-396.
8. Yilmaz M, Sahin M, Algun ZC: Comparison of effectiveness of the
home exercise program and the home exercise program taught by
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Robert H. Brophy, MD and Yale A. Fillingham, MD
Review Section: AAOS Clinical Practice Guideline Summary
physiotherapist in knee osteoarthritis. J Back Musculoskelet Rehabil
2019;32:161-169.
9. Tunay VB, Baltac G, Atay AO: Hospital-based versus home-based
proprioceptive and strengthening exercise programs in knee osteoarthritis.
Acta Orthop Traumatol Turc 2010;44:270-277.
10. Silva LE, Valim V, Pessanha AP, et al: Hydrotherapy versus
conventional land-based exercise for the management of patients with
osteoarthritis of the knee: A randomized clinical trial. Phys Ther 2008;88:
12-21.
11. Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ:
Agility and perturbation training techniques in exercise therapy for reducing
pain and improving function in people with knee osteoarthritis: A
randomized clinical trial. Phys Ther 2011;91:452-469.
12. Gomiero AB, Kayo A, Abraão M, Peccin MS, Grande AJ, Trevisani
VF: Sensory-motor training versus resistance training among patients
with knee osteoarthritis: Randomized single-blind controlled trial. Sao
Paulo Med J 2018;136:44-50.
13. Apparao P, Sandeep G, Sudhakar S, et al: Effectiveness of stabilization
exercises and conventional physiotherapy in subjects with knee
osteoarthritis. Int J Res Pharm Sci 2017;4:542-548.
14. Bennell KL, Kyriakides M, Metcalf B, et al: Neuromuscular versus
quadriceps strengthening exercise in patients with medial knee
osteoarthritis and varus malalignment: A randomized controlled trial.
Arthritis Rheumatol 2014;66:950-959.
15. Diracoglu D, Aydin R, Baskent A, Celik A: Effects of kinesthesia and
balance exercises in knee osteoarthritis. J Clin Rheumatol 2005;11:
303-310.
16. Katz JN, Brophy RH, Chaisson CE, et al: Surgery versus physical therapy
for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675-1684.
17. van de Graaf VA, Noorduyn JCA, Willigenburg NW, et al: Escape
research group effect of early surgery vs physical therapy on knee
function among patients with nonobstructive meniscal tears: The
ESCAPE randomized clinical trial. JAMA 2018;13:1328-1337.
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