Osteoarthritis Part Two: Understanding Management, Treatment, and Next Steps

Posted on by Emer McCamley

Welcome back to part two of our osteoarthritis (OA) series where we are going to focus on management and what you can do!

If you are reading this blog and you think you may have osteoarthritis or you may have already been told you have by a healthcare professional and aren’t sure what to do, then do come in and see one of our specialist musculoskeletal physiotherapists who will be able to help you understand your problem, how to manage it and help you work towards your goals.

How is OA diagnosed? Do I need an X-ray?

We learnt in part one what OA is, but how is it diagnosed? Many of you may be wondering if an X-ray is needed to diagnose OA but the answer is no. This is because there is a difference between the changes that can be seen on an X-ray, known as radiographic OA, and the symptoms that someone is experiencing, known as symptomatic OA [1]. As mentioned in part one of this series, research has shown that knee pain itself is an inaccurate measure of the extent or severity of OA changes that can be seen on an X-ray [1]. So just because these changes have taken place, does not mean they will be painful, and just because someone is experiencing pain, does not mean they will have severe OA changes within their joint [1].

Clinical guidelines such as the National Institute for Health and Care Excellence (NICE), actually advocate against routine use of imaging for diagnosing OA because there is no evidence it is beneficial for diagnosis [2] [3]. Furthermore, research has shown that receiving an X-ray based diagnosis and explanation of knee OA may reinforce existing misconceptions about OA (which we’ll discuss further in part 3 of this series), and may have potentially undesirable effects on individuals beliefs about management which can lead poorer outcomes [2].

Is an X-ray ever needed with OA?

Absolutely. According to the NICE guidelines an X-ray is indicated if there are “atypical features” which may include: a history of recent trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms, if the joint becomes hot and swollen, or if there are concerns of an infection or malignancy [3].

Diagnosis

Ok so, if an X-ray isn’t used for diagnosis, then how is OA diagnosed? The NICE guidelines advise that OA can be diagnosed using the following criteria [3]:

 AND

AND

As well as this criteria, during clinical examination individuals may also have swelling, reduced movement when bending and/or straightening their knee joint and may have joint line tenderness or pain.

So, what can we do?

Despite OA being common, each person is an individual so management should be tailored as such and guided by their individual symptoms, physical function and goals. According to the NICE guidelines the first line of treatments are: exercise, weight management and information and support [3]. Let’s look at these treatments in more depth.

1)     Exercise

Exercising with knee OA and OA in any joint is safe and beneficial to do. However, sometimes exercising can be painful and understandably this can be off putting. So, where do we start? Well during your Physiotherapy appointment your Physiotherapist will perform different tests to assess your muscle strength, your physical function and how you move to help guide the best management plan for you. What is often found in individuals who are experiencing knee pain and have OA is that they have weaker thigh (quadricep) muscles. This is relevant because research shows that weakness in these muscles can lead to knee pain and reduced shock absorption within the knee [4] [5]. So, if these muscles are found to be weaker the great news is we can put together an exercise programme to help you build strength in these muscles.

As well as building strength we may need to implement a strategy known as “load management”. In part one, we discussed that our knee may have a reduced tolerance to continuous loading so may need to consider more recovery time in between bouts of exercise [6]. This is one aspect of load management, another is where we load the knee joint enough to increase its tolerance to load and to help build strength, but not too much that we flare up or aggravate the knee joint. This can be a delicate balance that may be trial and error to begin with but in time with the support of your Physiotherapist, you will become the expert at managing this.

And how about pain and exercise? Is it safe to do? Absolutely! Pain is not a measure of harm and experiencing pain does not mean that we are worsening or progressing knee OA. We know that the changes that occur with OA happen slowly overtime so pain can be better described as a protective mechanism. Pain lets us know when our joints have reached their capacity to what they can tolerate and they may need a short rest from that activity or a modification.

Your Physiotherapist will work with you to tailor your exercises, provide guidance on load management and pain monitoring strategies, and help empower you to keep active and working back towards your goals.

2)     Weight Management

Increased weight puts more load through our joints so losing weight can take some of that demand on our joints away. The NICE guidelines advise that any weight loss will help improve function, quality of life and pain and that 10% is likely to be better than 5% [3]. Increased weight also results in an increased amount of adipose tissue (body fat) in the body which creates low level inflammation in our joints and throughout our body that can contribute to OA symptoms. Furthermore, losing weight will not only benefit OA symptoms but have a positive impact on our overall health as well [6].

3)     Information and support

The third first line of treatment is information and support. This includes helping you understand what OA is, how it is managed and what you may expect along the way. Your Physiotherapist may share with you some online resources such as the NICE guidelines OA management infographic, the Arthritis UK charity website or the NHS knee osteoarthritis shared decision making tool to help you with your understanding of OA and how to manage.

So, we understand what the first line of treatments are but sometimes pain can be unmanageable and a barrier to those treatments, so what can we do in these instances?

If someone is struggling with pain, pharmacological management (the use of pain relief) is recommended alongside exercise and weight management [3]. If needed, the NICE guidelines recommend the following pain relief:

For further information regarding pain relief, do speak to your pharmacist or GP who will be able to help you with what form of pain relief will work best for you as recommended by the NICE guidelines.

Are there any other management options?

Yes of course, alongside the first line of treatment approach of exercise, weight management and information and support, there are other tools that can be used to compliment and support these evidence based treatments if needed. I have put some examples below:

And what about injections and surgery?

Some people may experience more severe pain that they find that over the counter or prescribed pain relief alongside keeping active, managing their weight and following a tailored exercise programme doesn’t help. In those cases, a corticosteroid injection may be offered to get on top of the pain in the short term, the effect of the injection can last from 2 weeks up to around 3 months [3]. This then allows you to keep active which we know has long term benefits.

For some who have tried the first line of treatment approach, pain relief, additional options and injections they may still experience pain and functional limitations that impact their quality of life and prevent them for participating in the activities they enjoy. These individuals may be candidates for a total knee replacement. If think you may need a knee replacement but aren’t sure then again do come in and see one of our specialist musculoskeletal physiotherapists for an assessment. You can also speak to your GP who will likely refer you to a Physiotherapist or to an Orthopaedic team for assessment.

In summary

OA can be really well managed with exercise, weight management and information and support. Pain relief, knee braces, walking aids, manual therapy, injections, and surgery are additional options if needed. If you’re unsure where to start, come in and see one of our specialist musculoskeletal physiotherapists who will be able to help you understand your problem, how to manage it and help you work towards your goals. Stay tuned for part 3 of this series where we will discuss common myths, misconceptions, and frequently asked questions!

References

1             Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskelet Disord. 2008;9:116. doi: 10.1186/1471-2474-9-116

2             Lawford BJ, Bennell KL, Ewald D, et al. Effects of X-ray–based diagnosis and explanation of knee osteoarthritis on patient beliefs about osteoarthritis management: A randomised clinical trial. PLOS Medicine. 2025;22:e1004537. doi: 10.1371/journal.pmed.1004537

3             Osteoarthritis in over 16s: diagnosis and management.

4             Glass NA, Torner JC, Frey Law LA, et al. The relationship between quadriceps muscle weakness and worsening of knee pain in the MOST cohort: a 5-year longitudinal study. Osteoarthritis and Cartilage. 2013;21:1154–9. doi: 10.1016/j.joca.2013.05.016

5             Ferenczi MA, Bershitsky SY, Koubassova NA, et al. Why Muscle is an Efficient Shock Absorber. PLoS One. 2014;9:e85739. doi: 10.1371/journal.pone.0085739

6             Belluzzi E, El Hadi H, Granzotto M, et al. Systemic and Local Adipose Tissue in Knee Osteoarthritis. Journal of Cellular Physiology. 2017;232:1971–8. doi: 10.1002/jcp.25716