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Knee Osteoarthritis Cite this Page

Hunter Hsu; Ryan M. Siwiec.

Author Information and Affiliations In this Page

Last Update: September 4, 2022. Continuing Education Activity

Introduction
Continuing Education Activity Go to:
Etiology
Knee osteoarthritis (OA), also known as degenerative joint disease of the knee, is typically the result of
Epidemiology
wear and tear and progressive loss of articular cartilage. It is most common in the elderly. Knee
Pathophysiology
osteoarthritis can be divided into two types, primary and secondary. Primary osteoarthritis is articular
degeneration without any apparent underlying reason. Secondary osteoarthritis is the consequence of Histopathology
either an abnormal concentration of force across the joint as with post-traumatic causes or abnormal History and Physical
articular cartilage, such as rheumatoid arthritis (RA). Osteoarthritis is typically a progressive disease
Evaluation
that may eventually lead to disability. The intensity of the clinical symptoms may vary from each
individual. However, they typically become more severe, more frequent, and more debilitating over Treatment / Management

time. The rate of progression also varies for each individual. Common clinical symptoms include knee Differential Diagnosis
pain that is gradual in onset and worse with activity, knee stiffness and swelling, pain after prolonged Prognosis
sitting or resting, and pain that worsens over time. Treatment for knee osteoarthritis begins with
Complications
conservative methods and progresses to surgical treatment options when conservative treatment fails.
While medications can help slow the progression of RA and other inflammatory conditions, no proven Postoperative and Rehabilitation Care
disease-modifying agents for the treatment of knee osteoarthritis currently exist. This activity Deterrence and Patient Education
highlights the role of the interprofessional team in caring for patients with this condition.
Pearls and Other Issues
Objectives: Enhancing Healthcare Team Outcomes

Identify the etiology of knee osteoarthritis. Review Questions

References
Review the appropriate history, physical, and evaluation of knee osteoarthritis.

Outline the management options available for knee osteoarthritis.

Bulk Download
Describe interprofessional team strategies for improving communication to advance medical
Bulk download StatPearls data from FTP
care and improve outcomes for knee osteoarthritis.

Access free multiple choice questions on this topic.

Related information
PMC
Introduction Go to:
PubMed
Knee osteoarthritis (OA), also known as degenerative joint disease, is typically the result of wear and
tear and progressive loss of articular cartilage. It is most common in the elderly. Knee osteoarthritis can
be divided into two types, primary and secondary. Primary osteoarthritis is articular degeneration Similar articles in PubMed
without any apparent underlying reason. Secondary osteoarthritis is the consequence of either an Abstracts of Presentations at the Association of Clinical
abnormal concentration of force across the joint as with post-traumatic causes or abnormal articular Scientists 143(rd) Meeting Louisville,
[AnnKYClin
May Lab
11-14,2022.
Sci. 2022]
cartilage, such as rheumatoid arthritis (RA). Arthroscopic lavage and debridement for osteoarthritis of
the knee: an evidence-based
[Ont Health
analysis.
Technol Assess Ser....]
Osteoarthritis is typically a progressive disease that may eventually lead to disability. The intensity of
Review The clinical features of rheumatoid arthritis.
the clinical symptoms may vary for each individual. However, they typically become more severe,
[Eur J Radiol. 1998]
more frequent, and more debilitating over time. The rate of progression also varies for each individual.
Review Diagnosis and Treatment of Hip and Knee
Common clinical symptoms include knee pain that is gradual in onset and worse with activity, knee
Osteoarthritis: A Review. [JAMA. 2021]
stiffness and swelling, pain after prolonged sitting or resting, and pain that worsens over time.
Review Intra-Articular Injections in Knee Osteoarthritis: A
Treatment for knee osteoarthritis begins with conservative methods and progresses to surgical
Review of Literature. [J Funct Morphol Kinesiol. 2021]
treatment options when conservative treatment fails. While medications can help slow the progression
of RA and other inflammatory conditions, no proven disease-modifying agents for the treatment of See reviews...

knee osteoarthritis currently exist.[1][2][3] See all...

Etiology Go to:
Recent Activity
Knee osteoarthritis is classified as either primary or secondary, depending on its cause. Primary Turn Off Clear
knee osteoarthritis is the result of articular cartilage degeneration without any known reason. This is Knee Osteoarthritis - StatPearls
typically thought of as degeneration due to age as well as wear and tear. Secondary
knee osteoarthritis is the result of articular cartilage degeneration due to a known reason.[4][5] Osteoarthritis - StatPearls

Possible Causes of Secondary Knee OA

Osteoarthritis: care and management
Posttraumatic
Protozoa: Structure, Classification, Growth, and
Postsurgical Development - Medical Microbiol...

Congenital or malformation of the limb Cell Viability Assays - Assay Guidance Manual

Malposition (varus/valgus)
See more...
Scoliosis

Rickets

Hemochromatosis

Chondrocalcinosis

Ochronosis

Wilson disease

Gout

Pseudogout

Acromegaly

Avascular necrosis

Rheumatoid arthritis

Infectious arthritis

Psoriatic arthritis

Hemophilia

Paget disease

Sickle cell disease

Risk Factors for Knee OA

Modifiable

Articular trauma

Occupation – prolonged standing and repetitive knee bending

Muscle weakness or imbalance

Weight

Health – metabolic syndrome

Non-modifiable

Gender - females more common than males

Age

Genetics

Race

Epidemiology Go to:

Knee osteoarthritis is the most common type of arthritis diagnosed, and its prevalence will continue to
increase as life expectancy and obesity rises. Depending on the source, roughly 13% of women and
10% of men 60 years and older have symptomatic knee osteoarthritis. Among those older than 70 years
of age, the prevalence rises to as high as 40%. The prevalence of knee osteoarthritis in males is also
lower than in females. Interestingly, not everyone who demonstrates radiographic findings of
knee osteoarthritis will be symptomatic. One study found that only 15% of patients with radiographic
findings of knee OA were symptomatic. Not factoring in age, the incidence of symptomatic
knee osteoarthritis is roughly 240 cases per 100,000 people per year.[6][7]

Pathophysiology Go to:

Articular cartilage is composed primarily of type II collagen, proteoglycans, chondrocytes, and water.
Healthy articular cartilage constantly maintains an equilibrium between each of the components so that
any degradation of cartilage is matched by synthesis. Healthy articular cartilage is thus maintained. In
the process of osteoarthritis, matrix metalloproteases (MMPs), or degradative enzymes, are
overexpressed, disrupting the equilibrium and resulting in an overall loss of collagen and
proteoglycans. In the early stages of osteoarthritis, chondrocytes secrete tissue inhibitors of MMPs
(TIMPs) and attempt to increase the synthesis of proteoglycans to match the degradative process.
However, this reparative process is not enough. The loss in equilibrium results in a decreased amount
of proteoglycans despite increased synthesis, increased water content, the disorganized pattern of
collagen, and ultimately loss of articular cartilage elasticity. Macroscopically these changes result in
cracking and fissuring of the cartilage and ultimately erosion of the articular surface.[8]

Although knee osteoarthritis is closely correlated with aging, it is important to note that
knee osteoarthritis is not simply a consequence of aging but rather its own disease. This is supported
by the differences seen in cartilage with both osteoarthritis and aging. Furthermore, the enzymes
responsible for cartilage degradation are expressed in higher amounts in knee osteoarthritis, whereas
they are at normal levels in the normal aging cartilage.

Histopathology Go to:

Cartilage Changes in Aging [9]

Water content – decreased

Collagen – same

Proteoglycan content – decreased

Proteoglycan synthesis – same

Chondrocyte size – increased

Chondrocyte number – decreased

Modulus of elasticity – increased

Cartilage Changes in OA

Water content – increased

Collagen – disorganized

Proteoglycan content – decreased

Proteoglycan synthesis – increased

Chondrocyte size – same

Chondrocyte number – same

Modulus of elasticity – decreased

Matrix Metalloproteases

Responsible for cartilage matrix degradation

Stromelysin

Plasmin

Aggrecanase-1 (ADAMTS-4)

Collagenase

Gelatinase

Tissue Inhibitors of MMPs

Control MMP activity preventing excess degradation

TIMP-1

TIMP-2

Alpha-2-macroglobulin

History and Physical Go to:

Patients typically present to their healthcare provider with the chief complaint of knee pain. Therefore,
it is essential to obtain a detailed history of their symptoms. Pay careful attention to the history as knee
pain can be referred from the lumbar spine or the hip joint. It is equally important to obtain a detailed
medical and surgical history to identify any risk factors associated with secondary knee OA.

The history of the present illness should include the following:

Onset of symptoms

Specific location of pain

Duration of pain and symptoms

Characteristics of the pain

Alleviating and aggravating factors

Any radiation of pain

Specific timing of symptoms

Severity of symptoms

The patient's functional activity

Clinical Symptoms of Knee OA

Knee Pain

Typically of gradual onset

Worse with prolonged activity

Worse with repetitive bending or stairs

Worse with inactivity

Worsening over time

Better with rest

Better with ice or anti-inflammatory medication

Knee stiffness

Knee swelling

Decreased ambulatory capacity

Physical examination of the knee should begin with a visual inspection. With the patient standing, look
for periarticular erythema and swelling, quadriceps muscle atrophy, and varus or valgus deformities.
Observe gait for signs of pain or abnormal motion of the knee joint that can indicate ligamentous
instability. Next, inspect the surrounding skin for the presence and location of any scars from previous
surgical procedures, overlying evidence of trauma, or any soft tissue lesions.

Range of motion (ROM) testing is an essential aspect of the knee exam. Active and passive ROM with
regard to flexion and extension should be assessed and documented.

Palpation along the bony and soft tissue structures is an essential part of any knee exam. The palpatory
exam can be broken down into the medial, midline, and lateral structures of the knee.

Areas of Focus for the Medial Aspect of the Lnee

Vastus medialis obliquus

Superomedial pole patella

Medial facet of the patella

Origin of the medial collateral ligament (MCL)

Midsubstance of the MCL

Broad insertion of the MCL

Medial joint line

Medial meniscus

Pes anserine tendons and bursa

Areas of Focus for the Midline of the Knee

Quadricep tendon

Suprapatellar pouch

Superior pole patella

Patellar mobility

Prepatellar bursa

Patellar tendon

Tibial tubercle

Areas of Focus for the Lateral Aspect of the Knee

Iliotibial band

Lateral facet patella

Lateral collateral ligament (LCL)

Lateral joint line

Lateral meniscus

Gerdy’s tubercle

A thorough neurovascular exam should be performed and documented. It is important to assess the
strength of the quadriceps and hamstring muscles as these often will become atrophied in the presence
of knee pain. A sensory exam of the femoral, peroneal, and tibial nerve should be assessed as there
may be concomitant neurogenic symptoms associated. Palpation of a popliteal, dorsalis pedis, and
posterior tibial pulse is important as any abnormalities may raise the concern for vascular problems.

Other knee tests may be performed, depending on the clinical suspicion based on the history.

Special Knee Tests

Patella apprehension – patellar instability

J-sign – patellar maltracking

Patella compression/grind – chondromalacia or patellofemoral arthritis

Medial McMurray – a medial meniscus tear

Lateral McMurray – lateral meniscus tear

Thessaly test – a meniscus tear

Lachman – anterior cruciate ligament (ACL) injury

Anterior drawer – ACL injury

Pivot shift – ACL injury

Posterior drawer – posterior cruciate ligament (PCL) injury

Posterior sag – PCL injury

Quadriceps active test – PCL injury

Valgus stress test – MCL injury

Varus stress test – LCL injury

Evaluation Go to:

In addition to a thorough history and physical, radiographic imaging is required. The recommend
views include standing anteroposterior (AP), standing lateral in extension, and a skyline view of the
patella. A standing 45-degree posteroanterior (PA) view of the knee may be obtained, which gives a
better assessment of the weight-bearing surface of the knee. Occasionally, long leg standing films will
be obtained to view the degree of deformity and overall alignment of the lower extremity. It is
important to understand that radiographs of the knee must be obtained with the patient standing. This
gives an accurate representation of the joint space narrowing present. Often, films will be taken with
the patient supine, which gives a false sense of joint space and alignment and should not be used to
evaluate suspected knee OA.[10][11][12]

Radiographic Findings of OA

Joint space narrowing

Osteophyte formation

Subchondral sclerosis

Subchondral cysts

Treatment / Management Go to:

Treatment for knee osteoarthritis can be broken down into non-surgical and surgical management.
Initial treatment begins with non-surgical modalities and moves to surgical treatment once the non-
surgical methods are no longer effective. A wide range of non-surgical modalities is available for the
treatment of knee osteoarthritis. These interventions do not alter the underlying disease process, but
they may substantially diminish pain and disability.[9][13][12]

Non-Surgical Treatment Options [10]

Patient education

Activity modification

Physical therapy

Weight loss

Knee bracing

Acetaminophen

Nonsteroidal anti-inflammatory drugs (NSAIDs)

COX-2 inhibitors

Glucosamine and chondroitin sulfate

Corticosteroid injections

Hyaluronic acid (HA)

The first-line treatment for all patients with symptomatic knee osteoarthritis includes patient education
and physical therapy. A combination of supervised exercises and a home exercise program have been
shown to have the best results. These benefits are lost after 6 months if the exercises are stopped. The
American Academy of Orthopedic Surgeons (AAOS) recommends this treatment.

Weight loss is valuable in all stages of knee osteoarthritis. It is indicated in patients with symptomatic
arthritis with a body mass index greater than 25. The best recommendation to achieve weight loss is
diet control and low-impact aerobic exercise. There is moderate evidence for weight loss based on the
AAOS guidelines.

Knee bracing in osteoarthritis includes unloader-type braces that shift the load away from the involved
knee compartment. This may be useful in the setting where either the lateral or medial compartment of
the knee is involved, such as in a valgus or varus deformity.

Drug therapy is also the first-line treatment for patients with symptomatic osteoarthritis. A wide variety
of NSAIDs are available, and the choice should be based on physician preference, patient acceptability,
and cost. The duration of treatment with NSAIDs should be based on effectiveness, adverse effects,
and past medical history. There is strong evidence for NSAID use based on the AAOS guidelines.

Glucosamine and chondroitin sulfate are available as dietary supplements. They are structural
components of articular cartilage, and the thought is that a supplement will aid in the health of articular
cartilage. No strong evidence exists that these supplements are beneficial in knee OA; in fact, there is
strong evidence against the use according to the AAOS guidelines. There are no major downsides to
taking the supplement. If the patient understands the evidence behind these supplements and is willing
to try the supplement, it is a relatively safe option. Any benefit gained from supplementation is likely
due to a placebo effect.

Intra-articular corticosteroid injections may be useful for symptomatic knee osteoarthritis, especially
where there is a considerable inflammatory component. The delivery of the corticosteroid directly into
the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic
effects of the steroid.

Intra-articular hyaluronic acid injections (HA) injections are another injectable option for knee
osteoarthritis. HA is a glycosaminoglycan found throughout the human body and is an important
component of synovial fluid and articular cartilage. HA breaks down during the process of
osteoarthritis and contributes to the loss of articular cartilage as well as stiffness and pain. Local
delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in
the joint. Depending on the brand of HA, it can either be produced from avian cells or bacterial cells in
the laboratory and therefore must be used with caution in those with avian allergies. While this is a
prevalent treatment option, it is not highly supported in the literature, and there is strong evidence
against its use based on the AAOS guidelines.

Surgical Treatment Options [13]

Osteotomy

Unicompartmental knee arthroplasty (UKA)

Total knee arthroplasty (TKA)

A high tibial osteotomy (HTO) may be indicated for unicompartmental knee osteoarthritis associated
with malalignment. Typically an HTO is done for varus deformities where the medial compartment of
the knee is worn and arthritic. The ideal patient for an HTO would be a young, active patient in whom
arthroplasty would fail due to excessive component wear. An HTO preserves the actual knee joint,
including the cruciate ligaments, and allows the patient to return to high-impact activities once healed.
It does require additional healing time compared to an arthroplasty, is more prone to complications,
depends on bone and fracture healing, is less reliable for pain relief, and ultimately does not replace
cartilage that is already lost or repair any remaining cartilage. An osteotomy will delay the need for
arthroplasty for up to 10 years.

Indications for HTO

Young (less than 50 years old), active patient

Healthy patient with good vascular status

Non-obese patients

Pain and disability interfering with daily life

Only one knee compartment is affected

A compliant patient who will be able to follow postoperative protocol

Contraindications for HTO

Inflammatory arthritis

Obese patients

Knee flexion contracture greater than 15 degrees

Knee flexion less than 90 degrees

If the procedure will need greater than 20 degrees of deformity correction

Patellofemoral arthritis

Ligamentous instability

A UKA also is indicated in unicompartmental knee osteoarthritis. It is an alternative to an HTO and a

TKA. It is indicated for older patients, typically 60 years or older, and relatively thin patients, although,
with newer surgical techniques, the indications are being pushed.

Indications for UKA

Older (60 years or older), lower demand patients

Relatively thin patients

Contraindications for UKA

Inflammatory arthritis

ACL deficiency

Fixed varus deformity greater than 10 degrees

Fixed valgus deformity greater than 5 degrees

Arc of motion less than 90 degrees

Flexion contracture greater than 10 degrees

Arthritis in more than one compartment

Younger, higher activity patients or heavy laborers

Patellofemoral arthritis

A TKA is the surgical treatment option for patients failing conservative management and those
with osteoarthritis in more than one compartment. It is regarded as a valuable intervention for patients
who have severe daily pain along with radiographic evidence of knee osteoarthritis.

Indications for TKA

Symptomatic knee OA in more than one compartment

Failed non-surgical treatment options

Contraindications for TKA

Absolute

Active or latent knee infection

Presence of active infection elsewhere in the body

Incompetent quadriceps muscle or extensor mechanism

Relative

Neuropathic arthropathy

Poor soft-tissue coverage

Morbid obesity

Noncompliance due to major psychiatric disorder or alcohol or drug abuse

Insufficient bone stock for reconstruction

Poor health or presence of comorbidities that make the patient an unsuitable candidate for major
surgery and anesthesia

Patient’s poor motivation or unrealistic expectations

Severe peripheral vascular disease

Advantages of UKA vs. TKA

Faster rehabilitation and quicker recovery

Less blood loss

Less morbidity

Less expensive

Preservation of normal kinematics

Smaller incision

Less post-surgical pain and shorter hospital stay

Advantages of UKA vs. HTO

Faster rehabilitation and quicker recovery

Improved cosmesis

Higher initial success rate

Fewer short-term complications

Lasts longer

Easier to convert to TKA

Differential Diagnosis Go to:

Any potential cause of local or diffuse knee pain should be considered in the differential diagnosis of
knee osteoarthritis.

Hip arthritis

Low back pain

Spinal stenosis

Patellofemoral syndrome

Meniscal tear

Pes anserine bursitis

Infections arthritis

Gout

Pseudogout

Iliotibial band syndrome

Collateral or cruciate ligament injury

Prognosis Go to:

Strong evidence shows that age, ethnicity, BMI, the number of co-morbidities, MRI-detected
infrapatellar synovitis, joint effusion, and both radiographic and the baseline of OA severity are
predictive for clinical progression of knee osteoarthritis.[14] The most severe cases will result in total
knee arthroplasty.[15]

Complications Go to:

Complications associated with non-surgical treatment are largely associated with NSAID use.

Common Adverse Effects of NSAID Use

Stomach pain and heartburn

Stomach ulcers

A tendency to bleed, especially while taking aspirin

Kidney problems

Common Adverse Effects of Intra-Articular Corticosteroid Injection

Pain and swelling (cortisone flare)

Skin discoloration at the site of injection

Elevated blood sugar

Infection

Allergic reaction

Common Adverse Effects of Intra-Articular HA Injection

Injection site pain

Muscle pain

Trouble walking

Fever

Chills

Headache

Complications Associated with HTO

Recurrence of deformity

Loss of posterior tibial slope

Patella baja

Compartment syndrome

Peroneal nerve palsy

Malunion or nonunion

Infection

Persistent pain

Blood clot

Complications Associated with UKA

Stress fracture of the tibia

Tibial component collapse

Infection

Osteolysis

Persistent pain

Neurovascular injury

Blood clot

Complications Associated with TKA

Infection

Instability

Osteolysis

Neurovascular injury

Fracture

Extensor mechanism rupture

Patellar maltracking

Patellar clunk syndrome

Stiffness

Peroneal nerve palsy

Wound complications

Heterotopic ossification

Blood clot

Postoperative and Rehabilitation Care Go to:

Postoperative and rehabilitation care after a TKA is aimed at restoring the highest possible range of
mobility in and full muscular control of the operated knee. Adequate rehabilitation is an important
requirement for successful TKA.[9] The specific rehabilitation program following a TKA is somewhat
controversial and varies from surgeon to surgeon. Bed mobility, transfer training, and bedside exercises
begin the same day as surgery. Full weight-bearing, typically with a walker, under the supervision of a
therapist, is also allowed. Active range of motion (ROM), terminal knee extensions, straight leg raises,
and muscle strengthening exercises begin postoperative day one. Gait training and transfers continue as
well. In general, the patient must demonstrate safe ambulation with an assistive walking device on flat
ground and stairs, the ability to safely transfer from bed to seated and standing positions, and adequate
pain control prior to being discharged from the hospital. Patients are typically discharged to home or a
skilled nursing facility. This is based on individual needs in consultation with social work. Discharge to
home is greatly preferred if possible.

The typical hospital stays for a TKA is 1 to 2 nights, depending on the patient. The first postoperative
visit is at the two-week mark, where a wound check is performed, and surgical staples are removed if
present. Outpatient physical therapy will begin at this time if not begun already. The patient increases
their ambulation, independence in their activities of daily living, works on their ROM and works on
their quadriceps strength. Patients can resume driving when they can operate the pedals safely and
rapidly. This usually takes 4 to 6 weeks. Return to work usually takes 4 to 10 weeks, depending on the
work obligations. Patient follow-up is routinely at 6 weeks, 3 months, and one year after surgery. Once
strength, mobility, and balance are regained, patients can resume low-impact sporting activities. High-
impact activities are discouraged.

Deterrence and Patient Education Go to:

Patient education centers around non-medication and medication-based approaches. Non-medication

approaches include weight loss, orthoses/bracing to correct joint alignment, exercise and physical
therapy, and support groups. Medication compliance needs to be emphasized; sometimes, patient
compliance wanes as symptomatic control from the drug occurs. Patients need to understand the
disease has no cure and the likely progression that can take place, particularly with non-compliance to
the therapeutic recommendations.

Pearls and Other Issues Go to:

The best predictor of final postoperative ROM following TKA is preoperative ROM, and patients
should be aware of this before TKA.

Enhancing Healthcare Team Outcomes Go to:

Knee osteoarthritis (OA) is best managed by an interprofessional team that consists of an

orthopedic surgeon, rheumatologist, physical therapist, dietitian, pain specialist, internist, nursing staff,
physical therapist, and pharmacist. The disorder has no cure, and thus attempts should be made to
prevent the progression of the disorder. The patient should be referred to a dietitian for weight loss and
physical therapy to regain joint function and muscle strength. Treatment for knee osteoarthritis begins
with conservative methods and progresses to surgical treatment options when conservative treatment
fails. The pharmacist should look at the patient's medications to ensure there are no interactions and
that the dosing and indications are all correct. While medications can help slow the progression of RA
and other inflammatory conditions, no proven disease-modifying agents for the treatment of
knee osteoarthritis currently exist. [Level 2]

Employing interprofessional collaboration and information sharing regarding the patient's case will
drive better outcomes and increase the chances of avoiding TKA. [Level 5]

Review Questions Go to:

Access free multiple choice questions on this topic.

Comment on this article.

References Go to:

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Joint Arthroplasty: The Orthopedic Surgeon's Perspective? J Arthroplasty. 2019 Jul;34(7S):S30-
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