Move Forward Guide
Physical Therapist's Guide to
Osteoarthritis of the Knee
Osteoarthritis of the knee (knee OA) is the inflammation and degeneration of the bones that form the knee joint (osteo=bone, arthro=joint, itis=inflammation). The diagnosis of knee OA is based on 2 primary findings: radiographic evidence of changes in bone health (through medical images such as x-ray and MRI) and an individual’s symptoms (how you feel). Approximately 14% of adults aged 25+ and 34% of adults aged 65+ are diagnosed with radiographic osteoarthritis. Specifically, about 16% of adults aged 45+ have knee OA.
What is Osteoarthritis of Knee?
Osteoarthritis of the knee (knee OA) is a progressive disease causing inflammation and degeneration of the knee joint that worsens over time. It affects the entire joint, including bone, cartilage, ligament, and muscle. Its progression is influenced by age, body mass index (BMI), bone structure, genetics, strength, and activity level. Knee OA also may develop as a secondary condition following a traumatic knee injury. Depending on the stage of the disease and whether there are associated injuries or conditions, knee OA can be managed with physical therapy. More severe or advanced cases may require surgery.
How Does it Feel?
Individuals who develop knee OA experience a wide range of symptoms based on the progression of the disease. Pain occurs when the cartilage covering the bones of the knee joint wears down. This narrows the space between the bones and causes friction. Because the knee is a weight-bearing joint, your activity level, and the type and duration of your activities usually have a direct impact on your symptoms.
Symptoms of knee OA may include:
- Worsening pain during or following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position
- Pain or stiffness after sitting with the knee bent or straight for a prolonged period of time
- A feeling of popping, cracking, or grinding when moving the knee
- Swelling following activity
- Tenderness to touch along the knee joint
Typically these symptoms do not occur suddenly or all at once, but instead they develop gradually over time. Sometimes individuals do not recognize they have osteoarthritis because they cannot remember a specific time or injury that caused their symptoms. If you have had worsening knee pain for several months that is not responding to rest, it is best to seek the advice of a medical provider.
How Is It Diagnosed?
Knee OA is diagnosed by 2 primary methods. The first is based on your symptoms and a clinical examination. Your physical therapist will ask you questions about your medical history and activity routine. He or she will perform a physical exam to measure your knee's movement (range of motion), strength, mobility, and flexibility. You might also be asked to perform various movements to provoke the pain you are experiencing.
The second tool used to diagnose knee OA is diagnostic imaging. Your physical therapist may refer you to a physician, who will order x-rays of the knee in a variety of positions to assess the effect of weight-bearing (walking, standing, etc) on your knee joint. If more severe joint damage is suspected, an MRI may be ordered to look more closely at the overall status of the joint and surrounding tissues.
How Can a Physical Therapist Help?
Your physical therapist will design an individualized treatment program specific to the exact nature of your condition and your goals.
Range of Motion
Often, abnormal motion of the knee joint can lead to a progression of OA when there is more contact between, and wear on, the bones. Your therapist will assess your motion compared with expected normal motion and the motion of the knee on your uninvolved leg.
Strengthening the muscles around your knee will be an essential part of your rehabilitation program. Individuals with OA who adhere to strengthening programs have been shown to have less pain and an improved overall quality of life. There are several factors that influence the health of a joint: the quality of the cartilage that lines the bones, the tissue within and around the joints, and the associated muscles. Due to the wear and tear on cartilage associated with knee OA, maintaining strength in the muscles near the joint is crucial to preserve joint health. For example, as the muscles along the front and back of your thigh (quadriceps and hamstrings), cross the knee joint, they help control the motion and forces that are applied to the bones.
Strengthening the hip and core muscles also can help balance the amount of force on the knee joint, particularly during walking or running. The “core” refers to the muscles of the abdomen, low back, and pelvis. A strong core will increase stability through your body as you move your arms and legs. Your physical therapist will assess these different muscle groups, compare the strength in each limb, and prescribe specific exercises to target your areas of weakness.
Physical therapists are trained in manual (hands-on) therapy. Your physical therapist will gently move and mobilize your muscles and joints to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. In patients with knee OA, the addition of manual therapy techniques to exercise has been shown to decrease pain and increase function.
Your physical therapist may recommend therapeutic modalities, such as ice and heat, to aid in pain management.
Compressive sleeves placed around the knee may help reduce pain and swelling. Devices such as realignment braces are used to modify the forces placed on the knee. These braces can help "unload" certain areas of your knee and move contact to less painful areas of the joint during weight-bearing activities.
Physical therapists are trained to understand how to prescribe exercises to individuals with injuries or pain. Since OA is a progressive disease, it is important to develop a specific plan to perform enough activity to address the problem while avoiding increases in stress on the knee joint. Activity must be prescribed and monitored based on type, frequency, duration, and intensity, with adequate time allotted for rest and recovery. Your physical therapist will consider the stage and extent of your arthritis and prescribe an individualized exercise program to address your needs and maximize the function of your knee.
What if I Need Surgery?
In some cases of knee OA, the meniscus (shock absorber of the knee) may be involved. In the past, surgery to repair or remove parts or all of this cartilage was common. Current research, however, has shown in a group of patients who were deemed surgical candidates, 60-70% of those who participated in a physical therapy program, instead of surgery, did not go on to have surgery. Further, after 1 year those outcomes were unchanged. This study suggests that physical therapy may be an effective alternative for those patients who would like to avoid surgery.
Sometimes conservative management strategies are not successful. When these strategies fail surgical intervention such as arthroscopy or a total knee replacement, may be recommended. There are many factors to consider when determining the appropriate surgical treatment, including the nature of your condition, and your age, activity level, and overall health. Your physical therapist will refer you to an orthopedic surgeon to discuss your surgical options.
Real Life Experiences
Luke is a 50-year-old businessman who has just moved his family to the city so he can start a new job. For the last 2 months, Luke has been working hard carrying heavy boxes and moving furniture up and down stairs. He has also worked late into the night installing appliances.
After starting his new job last week, sitting through numerous orientation sessions and meetings, Luke notices that his right knee is really hurting. He is used to occasional knee discomfort, but this is the worst it has felt in a long time. During his junior year at college, he suffered a significant knee injury while playing basketball, which required surgery.
These days, Luke coaches his son’s Little League team, works out several times each week, and plays pick-up basketball with his friends. But occasionally, particularly after long road trips, his knee pain flares up, and he has to resort to medication, icing, and rest. These bouts are starting to occur more regularly. Luke decides it's time to find a physical therapist.
During his first appointment, Luke’s physical therapist asks him questions regarding his medical history, prior injuries, current symptoms and complaints, and goals for physical therapy. She examines his knee motion, strength, balance, and walking mechanics. She also uses special tests and measures to determine the nature of Luke’s pain, ruling out any other possible conditions.
Based on her findings, Luke's physical therapist determines his current knee pain is a result of post-traumatic osteoarthritis. She explains that his history of significant knee injury in college puts him at risk of developing OA at a young age. The recent increased demand on his knee joint during his move is likely responsible for the current flare-up of pain and swelling.
Over the next 6 weeks, Luke works with his physical therapist 2 times a week to decrease his joint pain and improve his knee motion and full-body flexibility. She uses manual therapy techniques to improve the mobility of his knee joint. She prescribes a progressive exercise program to strengthen the muscles of his hip, knee, and core. She tailors this program so that Luke can complete it daily based on the equipment available at his office gym facility.
Six weeks later, Luke is able to climb and descend stairs, squat, and jog without pain. He can sit through a full day of meetings without noticing stiffness or swelling in his knee. On his last day of therapy, Luke’s physical therapist provides him with a detailed home program and suggestions for maintaining the improvements he has made. With the summer approaching, he's preparing to coach his son's baseball tournaments--and take his family to the beach!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with knee osteoarthritis and after knee replacement surgery. Some physical therapists have a practice with an orthopedic focus.
- A physical therapist who is a board-certified orthopedic clinical specialist. This therapist will have advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with arthritis.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of arthritis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
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. Article Summary on PubMed.
Segal NA. Bracing and orthoses: a review of efficacy and mechanical effects for tibiofemoral osteoarthritis. PM R. 2012;4(5 Suppl):S89–S96. Article Summary on PubMed.
Jansen MJ, Viechtbauer W, Lenssen AF, et al. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review. J Physiother. 2011;57:11–20. Article Summary on PubMed.
Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport. 2011;14:4–9. Article Summary on PubMed.
Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States, part II. Arthritis Rheum. 2008;58:26–35. Free Article.
Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis; classification of osteoarthritis of the knee: diagnostic and therapeutic criteria committee of the American Rheumatism Association. Arthritis Rheum. 1986;29:1039–1049. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Acknowledgements: Laura Stanley, PT, DPT, SCS