About Knee Osteoarthritis
Knee osteoarthritis (OA) is a prevalent, chronic joint condition characterized by progressive articular cartilage degeneration, subchondral bone remodeling, and varying degrees of synovial inflammation. It commonly presents with activity-related knee pain, stiffness after periods of rest, functional limitation, and crepitus, with symptoms often exacerbated by prolonged weight-bearing, stair use, or deep knee flexion.
The etiology of knee OA is multifactorial and reflects the interaction of age-related tissue changes, previous knee injury, biomechanical factors (e.g., malalignment), excess body mass, muscle weakness, metabolic factors, and cumulative mechanical loading. Structural changes do not consistently correlate with symptom severity or functional impact, and clinical presentation varies widely across individuals.
Knee OA affects physical function, participation in daily life, and quality of life, with outcomes influenced by biological, psychological, and social factors.
About CCG Care Pathways
Purpose
CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.
Development
Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.
Principles of Conservative Care
Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.
Disclaimer
CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.
Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.
Knee Osteoarthritis Care Pathway
1. Record Keeping
Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.
Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.
Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.
Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.
Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.
Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.
Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.
2. Informed Consent
- Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
- Key Aspects:
- Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
- Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time.
- Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
- Patient understanding and agreement:
- Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
- Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
- Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
- Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
- Apply cultural awareness and trauma-informed care principles.
- Sociodemographic information: Age, gender, sex, race/ethnicity.
- Main complaint: Description of knee pain, stiffness, swelling, symptom behavior, aggravating and easing factors, and functional limitations.
- Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
- Health, lifestyle, and history: Past medical conditions, medications, supplements, prior knee injury or surgery, hospitalizations, physical activity and exercise history, occupational demands, diet, sleep habits, footwear, and work or school environment.
- Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
- Previous treatments and responses: Prior conservative or medical treatments, perceived benefit, adherence, and adverse effects.
- Beliefs and expectations: Understanding of knee OA, expectations regarding recovery and care, concerns about progression or activity participation.
- Flag considerations: Screen for red flags, orange flags, and psychosocial (yellow) factors.
Outcomes Assessments:
- Pain: Use pain scales (e.g., NRS) and diagrams.
- Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS, WOMAC).
- Recovery: Use self-rated recovery scales.
- Quality of life: Assess using tools such as SF-12.
- Work/school status: Monitor return to activities.
- Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
- Patient feedback: Gather and integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Referral
ACTION: Refer immediately to emergency care:
- Trauma / fracture: Sudden onset following trauma, inability to bear weight, deformity, or hemarthrosis, particularly in individuals with diminished bone integrity.
- Infection: Suspected septic arthritis or osteomyelitis presenting with acute monoarticular pain, swelling, warmth, fever, inability to bear weight, or severe pain with passive motion.
- Deep vein thrombosis: Posterior knee or calf pain, unilateral swelling, warmth, or edema.
ACTION: Refer to appropriate medical provider:
- Inflammatory arthritis: Suspected reactive arthritis or rheumatoid arthritis.
- Avascular necrosis or other bone pathology: Progressive pain and functional decline not consistent with typical OA presentation.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral
Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.
ACTION: Refer for immediate care (emergency department, medical/mental health provider):
- Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.
- Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
- Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.
ACTION: Refer to appropriate medical/mental health provider:
- Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).
ACTION: Co-management by non-medical/mental health providers:
- Triage: Ensure primary management by medical/psychiatric providers.
- Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
- Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
6. Yellow Flags: Psychosocial Factors that May Delay Recovery
Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.
Factors:
- Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
- Social: Lack of family/social support, limited connections.
- Socioeconomic: Employment status, financial stress, litigation/compensation.
- Environmental/cultural: Social inequality, unsafe/unsupportive environments.
- Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
- Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.
ACTION: Co-management by non-medical/mental health providers:
- Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).
- Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
- Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
7. Physical Examination
- Observation: Posture, alignment, swelling, muscle bulk, gait pattern, balance, and functional movement strategies.
- Range of motion (ROM): Assess active, passive, and resisted knee ROM in flexion, extension, internal rotation, and external rotation.
- Palpation: Examine for joint line tenderness, swelling, tightness, or temperature changes, and soft tissues of the knee region.
- Neurological examination: Performed when neurological symptoms are reported or suspected.
- Special/Orthopedic Tests: Perform as clinically indicated.
- Advanced Diagnostics: Radiography is indicated if Ottawa Knee Rules criteria are met. Otherwise, radiography is not typically indicated. Advanced imaging may be considered in complicated or refractory cases.
8. Clinical Presentation for Knee Osteoarthritis (Altman et al., 1986)
Knee OA commonly presents with activity-related knee pain, stiffness after periods of inactivity (typically <30 minutes), functional limitation, and crepitus. Symptoms may fluctuate over time and vary in severity.
Common clinical features include:
- Knee pain aggravated by weight-bearing activities, stair use, or prolonged activity
- Morning or post-rest stiffness of short duration
- Reduced knee range of motion
- Functional difficulty with walking, transfers, or stair negotiation
- Variable joint swelling or effusion
- Crepitus during knee movement
- Bony enlargement or localized tenderness
- Absence of marked joint warmth
Structural severity on imaging does not reliably predict pain intensity, functional limitation, or symptom burden.
Clinical classification of knee OA may be informed by established criteria (e.g., Altman criteria); however, diagnosis is primarily clinical and should be interpreted in the context of the individual’s symptoms, function, and goals.
9. Conservative Treatment Considerations for Knee Osteoarthritis (Kolasinski et al., 2019)
Approach to Treatment
The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. Management plans should be tailored to the individual’s needs, goals, and preferences, taking into account clinical presentation, response to care, and contextual factors.
Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most relevant components based on the clinical context.
This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.
While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.
Strong recommendations
- Exercise
- Regular land-based or aquatic exercise, delivered in supervised or independent formats.
- Self-efficacy and self-management programs
- Multidisciplinary, group–based programs incorporating skill-building (e.g., goal setting, problem-solving, positive thinking), education about osteoarthritis and medications, joint protection strategies, and fitness and exercise planning.
- Weight loss interventions
- Recommended for individuals who are overweight or obese, as even modest weight reduction is associated with clinically meaningful improvements in pain and function.
- Tai Chi
- A mind-body practice combining slow, controlled movements, balance, breathing, and relaxation.
- Cane
- Recommended when knee OA significantly affects ambulation, joint stability, or pain, warranting use of an assistive device.
- Tibiofemoral knee brace
- Recommended when knee OA substantially affects ambulation, joint stability, or pain, and when the individual can tolerate the burden associated with bracing.
- Topical/oral NSAIDs
- For pain management, with selection guided by individual risk factors and preferences.
- Intra-articular corticosteroid injections
- For short-term relief of pain and inflammation.
Conditional recommendations
- Heat or therapeutic cooling
- Adjunctive modalities for short-term relief of pain and stiffness.
- Cognitive behavioural therapy
- To improve pain, function, and quality of life by addressing maladaptive pain-related thoughts and behaviors.
- Acupuncture
- Evidence suggests small improvements in pain and function, with effects potentially influenced by contextual and placebo-related factors.
- Kinesiotaping
- A short-term adjunct to reduce pain and improve function; benefits are modest and evidence quality is limited.
- Balance training
- As part of an exercise program to improve proprioception, reduce fall risk, and enhance functional performance.
- Patellofemoral knee brace
- Recommended when knee OA significantly affects ambulation, joint stability, or pain, warranting use of an assistive device.
- Yoga
- A mind–body intervention combining physical postures, breathing techniques, and relaxation or meditation
- Radiofrequency ablation
- Recommended in selected individuals with persistent pain; may provide longer-lasting analgesia than intra-articular injections, though evidence is limited.
- Acetaminophen, duloxetine, tramadol
- Acetaminophen: conditionally recommended for short-term or episodic use.
- Duloxetine: conditionally recommended for chronic knee OA pain.
- Tramadol: conditionally recommended only when other therapies are ineffective or contraindicated due to safety concerns.
- Topical capsaicin
- May provide modest pain relief through peripheral nociceptor desensitization; local skin irritation is the most common adverse effect.
10. Risk and Prognostic Factors for Knee OA (Berteau et al., 2022; Zheng et al., 2015; de Rooij et al., 2016; Bastick et al., 2015)
The development, symptom burden, and progression of knee osteoarthritis (OA) are influenced by a combination of biological, mechanical, psychological, and social factors. Identification of these factors supports realistic goal setting, individualized care planning, and appropriate monitoring over time.
Risk factors
- Non-modifiable factors
- Increasing age
- Female sex
- Genetic predisposition
- Race/ethnicity, reflecting differences in OA prevalence, symptom severity, and access to care
- Prior joint injury or surgery
- History of knee trauma (e.g., ligament or meniscal injury)
- Previous knee surgery
- Mechanical and biomechanical factors
- Malalignment (varus or valgus)
- Abnormal joint loading patterns
- Muscle weakness, particularly of the quadriceps
- Reduced neuromuscular control
- Body weight and metabolic factors
- Overweight or obesity
- Metabolic conditions associated with systemic inflammation
- Occupational and activity-related factors
- Repetitive or sustained knee loading
- Occupations or activities involving frequent kneeling, squatting, or heavy lifting
- Psychological and social factors
- Depression, anxiety, or pain catastrophizing
- Low self-efficacy
- Limited social support
- Barriers related to access to care or resources
Prognostic considerations
- Knee OA has a variable and often fluctuating clinical course, and symptom severity does not reliably correlate with radiographic findings.
- Many individuals experience meaningful improvements in pain, function, and quality of life with appropriately matched conservative care.
- Persistent pain or functional limitation is more likely in the presence of:
- High baseline pain or disability
- Obesity or low physical activity levels
- Psychological distress or maladaptive pain beliefs
- Multiple comorbidities
- Adverse social determinants of health
- Engagement in physical activity, adherence to exercise and self-management strategies, and alignment of care with patient goals are associated with more favourable outcomes.
11. Ongoing Follow-up
- Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
- Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
- Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
- Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
- Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
- Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
- Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
- Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
- Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
- Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
- Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan
References
- Brophy RH, Fillingham YA. AAOS clinical practice guideline summary: management of osteoarthritis of the knee (nonarthroplasty). JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2022 May 1;30(9):e721-9.
- Altman R, et al. Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1986 Aug;29(8):1039-49.
- Kolasinski SL et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & rheumatology. 2020 Feb;72(2):220-33.
- Conley B et al. Core recommendations for osteoarthritis care: a systematic review of clinical practice guidelines. Arthritis care & research. 2023 Sep;75(9):1897-907.
- Berteau JP. Knee pain from osteoarthritis: pathogenesis, risk factors, and recent evidence on physical therapy interventions. Journal of Clinical Medicine. 2022 Jun 7;11(12):3252.
- Zheng H, Chen C. Body mass index and risk of knee osteoarthritis: systematic review and meta-analysis of prospective studies. BMJ open. 2015 Dec 1;5(12):e007568.
- de Rooij M et al. Prognosis of pain and physical functioning in patients with knee osteoarthritis: a systematic review and meta‐analysis. Arthritis care & research. 2016 Apr;68(4):481-92.
- Bastick AN et al. Prognostic factors for progression of clinical osteoarthritis of the knee: a systematic review of observational studies. Arthritis research & therapy. 2015 Jun 8;17(1):152.