OA Knee: Clinical Care Standards

Osteoarthritis: It is one of the most common chronic joint conditions in Australia and the fourth most common presentation to GPs. It is more prevalent in women than men and tends to be a disease of older people with 25% of those over the age of 65 years reporting joint symptoms.

The typical presentation is of knee pain, with or without stiffness and swelling around the joint. Patients often have difficulty with walking, climbing stairs, standing from a sitting position and getting in and out of cars.  These physical limitations may hinder participation in work, leisure and social activities, and can contribute to psychological distress, including depression.

Although joint replacement surgery is an effective and very successful operation, it is important to remember that OA is not an inevitable part of ageing, is not necessarily progressive and that symptoms and physical limitations can often be well managed conservatively for prolonged periods of time.

Steps in managing knee OA

1. Comprehensive assessment
   When a patient presents with knee pain or other symptoms of OA, a comprehensive assessment should include:
   • A thorough history and examination looking for symptoms and signs of OA.  Consider using validated tools such as the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Timed Up and Go or 30-second chair test – click here for more. This will help with monitoring change in symptoms over time.
   • Ask how the symptoms affect the patient’s ability to do their usual daily activities and participate in work, leisure and social activities.
   • Assess for the presence of comorbidities (for example, hypertension, obesity, depression, cardiovascular disease, renal disease or gastrointestinal disease) and any psychosocial factors that may affect the patient’s quality of life and their ability to manage their symptoms.
   • Assess for atypical features that may indicate alternative or additional diagnoses: a history of trauma, malignancy, prolonged morning joint-related stiffness, rapidly worsening symptoms or the presence of a hot swollen joint. Consider whether pain may be referred from hip or spine pathology
2. Diagnosis
   A diagnosis of knee OA is a clinical diagnosis.  There is no need to order xrays unless the diagnosis is in question (eg insufficiency fracture or malignancy)
   • If xrays are considered necessary, weight bearing images are required
   • There is no need for CT scans, ultrasounds or MRIs
3. Education and self-management
   Patients should be well educated in all aspects of their knee OA so they can be fully involved in management decisions. Self-management can improve pain control and functional status.
   • Develop a management plan together with agreed treatment goals. The plan may include exercises specific to their condition, pacing activities, management of painful episodes, management of medicines, strategies for protecting the knee joints, weight loss guidance, where to find further information, and contact details of support groups
   • Monitor and adjust the plan as the patient’s condition and needs change 
   • Refer to other clinicians, services and resources that may help them self-manage their condition
4. Weight loss and exercise
   In overweight patients with knee OA, weight loss can reduce knee pain and improve function which may then reduce the need for medication or surgery.
   • Help patients to set achievable weight and exercise goals based on their needs and preferences.  Refer for support as required.
   • 5% or greater weight loss over a 20-week period, has been shown to be associated with improved function.
5. Medications
   A range of options are available.  Use a trial-based approach. Encourage continued non-pharmacological measures such as exercise, weight loss and joint protection.
   • Topical analgesics such as NSAIDS or capsaicin
   • Oral analgesics such as paracetamol or NSAIDS.  Avoid opiates.
   • Intra-articular injections of steroids or hyaluronan  may provide short term relief
6. Review
   Always review patients with knee OA in order to monitor symptoms, function and psychosocial wellbeing and to review medication needs.  Optimise management as required.
   • If the patient has severe persistent functional impairment, despite optimised conservative management, rule out other possible causes (such as referred pain from hip or spine pathology), arrange weight-bearing X-ray imaging of the knee and then refer for specialist assessment.
7. Surgery
   Surgery should be considered for patients not responding to conservative management.
   • Patients should have weight-bearing plain xrays with the following views - lateral, anteroposterior (AP), Rosenberg and skyline views
   • Joint-conserving surgery (eg high tibial osteotomy) or joint replacement surgery will be considered
   • There is no place for arthroscopy in the treatment of knee OA unless there is true mechanical locking or some other indicator.

KEY POINTS

• Osteoarthritis is one of the most common chronic joint conditions in Australia
• Initial assessment by GPs includes assessment of joint symptoms, extent of physical limitations and their effect on work, leisure and social activities and the psychosocial impact of these limitations
• Being overweight doubles a person’s risk of developing knee OA. Obesity increases the risk more than fourfold
• Losing a moderate amount of weight can improve symptoms and physical capabilities
• Knee OA can be diagnosed on clinical grounds alone
• Conservative management including non-pharmacological and pharmacological treatments are first line approaches
• There is no place for knee arthroscopy in the treatment of knee OA
• Once conservative management is no longer effective in managing symptoms and functional impairment, referral to an Orthopaedic Surgeon for joint replacement surgery is warranted.

Dr Robert Molnar is an Orthopaedic (Hip and Knee) surgeon with special clinical interests in hip and knee trauma, hip and knee replacement surgery and revision arthroplasty for failed, painful or infected prosthetic joints. Dr Molnar’s expertise is also in arthroscopic surgery of the hip and knee such as ACL reconstruction, sports knee surgery, labral repair and femero-acetabular impingement (FAI) hip surgery.

To learn more or contact Dr Molnar, click here to view his online profile.