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American Academy of Orthopaedic SurgeonsOrthopaedic Surgery2021advanced

Non-Arthroplasty Treatment of Osteoarthritis of the Knee

Published by American Academy of Orthopaedic Surgeons · GRADE Evidence-to-Decision Framework

29Recommendations
620References
2Tables
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Summary

AI-generated

Osteoarthritis results from an imbalance between breakdown and repair of the tissues in the synovial joint organ. This guideline systematically reviews evidence to make clinical recommendations for non-arthroplasty management.

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Key Takeaways

  • 1
    Lateral wedge insoles, oral narcotics, and arthroscopy with lavage/debridement are strongly/moderately not recommended.
  • 2
    Strong recommendations support the use of topical NSAIDs, oral NSAIDs, oral acetaminophen, supervised exercise, self-management, and patient education.
  • 3
    Hyaluronic acid injections are not recommended for routine use.
  • 4
    Moderate recommendations support canes, braces, neuromuscular training, weight loss intervention, intra-articular corticosteroids, and partial meniscectomy for specific indications.

What's New in This Version

This guideline replaces the 2nd edition completed in 2013. A significant change is the adoption of the GRADE Evidence-to-Decision Framework (April 2019) to incorporate additional factors into the strength of recommendations. For example, the 2013 edition strongly recommended against the use of viscosupplementation, whereas this 2021 update downgrades it to a Moderate recommendation against routine use, noting some subsets of patients might benefit.

Key Recommendations

Lateral Wedge Insoles

  • 1

    Lateral wedge insoles are not recommended for patients with knee osteoarthritis.

    StrongEvidence: HighTreatment

Canes

  • 2

    Canes could be used to improve pain and function in patients with knee osteoarthritis.

    ModerateEvidence: Moderate to HighTreatment

Braces

  • 3

    Brace treatment could be used to improve function, pain, and quality of life in patients with knee osteoarthritis.

    ModerateEvidence: Moderate to HighTreatment

Oral/Dietary Supplements

  • 4

    The following supplements may be helpful in reducing pain and improving function for patients with mild to moderate knee osteoarthritis: Turmeric, Ginger extract, Glucosamine, Chondroitin, Vitamin D.

    LimitedEvidence: Low to ModerateTreatment

Topical Treatments

  • 5

    Topical NSAIDs should be used to improve function and quality of life for treatment of osteoarthritis of the knee, when not contraindicated.

    StrongEvidence: HighTreatment

Supervised Exercise

  • 6

    Supervised exercise, unsupervised exercise, and/or aquatic exercise are recommended over no exercise to improve pain and function for treatment of knee osteoarthritis.

    StrongEvidence: HighTreatment

Neuromuscular Training

  • 7

    Neuromuscular training (i.e. balance, agility, coordination) programs in combination with traditional exercise could be used to improve performance-based function and walking speed for treatment of knee osteoarthritis.

    ModerateEvidence: Moderate to HighTreatment

Self-Management

  • 8

    Self-management programs are recommended to improve pain and function for patients with knee osteoarthritis.

    StrongEvidence: HighTreatment

Patient Education

  • 9

    Patient education programs are recommended to improve pain in patients with knee osteoarthritis.

    StrongEvidence: HighTreatment

Weight Loss Intervention

  • 10

    Sustained weight loss is recommended to improve pain and function in overweight and obese patients with knee osteoarthritis.

    ModerateEvidence: Moderate to HighTreatment

Manual Therapy

  • 11

    Manual therapy in addition to an exercise program may be used to improve pain and function in patients with knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Massage

  • 12

    Massage may be used in addition to usual care to improve pain and function in patients with knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Laser Treatment

  • 13

    FDA-approved laser treatment may be used to improve pain and function in patients with knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Acupuncture

  • 14

    Acupuncture may improve pain and function in patients with knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Transcutaneous Electrical Nerve Stimulation

  • 15

    Transcutaneous Electrical Nerve Stimulation may be used to improve pain in patients with knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Percutaneous Electrical Nerve Stimulation/Pulsed Electromagnetic Field Therapy

  • 16

    Percutaneous Electrical Nerve Stimulation (pain and function) or Pulsed Electromagnetic Field Therapy (pain) may be used to improve pain and/or function in patients with knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Extracorporeal Shockwave Therapy

  • 17

    Extracorporeal shockwave therapy may be used to improve pain and function for treatment of osteoarthritis of the knee.

    LimitedEvidence: Low to ModerateTreatment

Oral NSAIDs

  • 18

    Oral NSAIDs are recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.

    StrongEvidence: HighTreatment

Oral Acetaminophen

  • 19

    Oral acetaminophen is recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.

    StrongEvidence: HighTreatment

Oral Narcotics

  • 20

    Oral narcotics, including tramadol, result in a significant increase of adverse events and are not effective at improving pain or function for treatment of osteoarthritis of the knee.

    StrongEvidence: HighTreatment

Hyaluronic Acid

  • 21

    Hyaluronic acid intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee.

    ModerateEvidence: Moderate to HighTreatment

Intra-articular Corticosteroids

  • 22

    Intra-articular (IA) corticosteroids could provide short-term relief for patients with symptomatic osteoarthritis of the knee.

    ModerateEvidence: Moderate to HighTreatment

Platelet-rich Plasma

  • 23

    Platelet-rich plasma (PRP) may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.

    LimitedEvidence: Low to ModerateTreatment

Denervation Therapy

  • 24

    Denervation therapy may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.

    LimitedEvidence: Low to ModerateTreatment

Lavage/Debridement

  • 25

    Arthroscopy with lavage and/or debridement in patients with a primary diagnosis of knee osteoarthritis is not recommended.

    ModerateEvidence: Moderate to HighTreatment

Partial Meniscectomy

  • 26

    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.

    ModerateEvidence: Moderate to HighTreatment

Tibial Osteotomy

  • 27

    High tibial osteotomy may be considered to improve pain and function in properly indicated patients with unicompartmental knee osteoarthritis.

    LimitedEvidence: Low to ModerateTreatment

Dry Needling

  • 28

    In the absence of reliable evidence, it is the opinion of the workgroup that the utility/efficacy of dry needling is unclear and requires additional evidence.

    ConsensusEvidence: No EvidenceTreatment

Free Floating Interpositional Devices

  • 29

    In the absence of reliable or new evidence, it is the opinion of the work group not to use free-floating (un-fixed) interpositional devices in patients with symptomatic medial compartment osteoarthritis of the knee.

    ConsensusEvidence: No EvidenceTreatment

Scope & Objectives

Clinical Topic

Osteoarthritis of the Knee

Objectives

Provide recommendations that will help practitioners to integrate the current evidence and clinical practice for non-arthroplasty treatment of knee osteoarthritis.

Target Patient Population

Adults (ages 17 years and older) who have been diagnosed by a trained healthcare provider with osteoarthritis of the knee and are undergoing treatment.

Target Providers

Orthopaedic surgeonsHealthcare providers

Patient Criteria & Setting

Therapeutic Area

Orthopaedics / Rheumatology

Guideline Scope

TreatmentManagement

Exclusion Criteria

  • Rheumatoid arthritis
  • Osteoarthritis of other joints
  • Other inflammatory arthropathies

Special Populations

Overweight and obese patients

Evidence Grading

System: GRADE Evidence-to-Decision Framework

Evidence Levels

StrongEvidence from two or more 'High' quality studies with consistent findings.
LimitedEvidence from one or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings, or evidence from a single 'High' quality study.
ConsensusThere is no supporting evidence, or higher quality evidence was downgraded due to major concerns addressed in the EtD framework. Based on clinical opinion.

Recommendation Strength

StrongNot likely to change with future research. High confidence in the recommendation.
LimitedChange is possible or anticipated with future research. Lower confidence.
ModerateLess likely to change with future research. Moderate confidence.
ConsensusImpact of future research is unknown. Recommendation relies on work group clinical opinion.

Safety & Contraindications

Contraindications

  • Stage 4-5 chronic kidney disease
  • Coronary artery disease
  • Congestive heart failure
  • Pacemakers
  • Pregnancy

Authors & Contributors

American Physical Therapy AssociationAmerican Association of Hip and Knee Surgeons

Guideline Features

Flowcharts includedBased on systematic reviewMultidisciplinaryDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Osteoarthritis ManagementNon-Operative CareOrthopaedic GuidelinesPain ManagementEvidence-Based Medicine