Rehabilitation of Knee Osteoarthritis
Exercise therapy combined with weight loss (for overweight/obese patients) forms the foundation of knee osteoarthritis rehabilitation, with strong evidence supporting low-impact aerobic exercise, quadriceps strengthening, and patient education programs as first-line interventions. 1
Core Rehabilitation Components
Exercise Therapy (Strongest Evidence)
Low-impact aerobic exercise is strongly recommended and should include walking, cycling, or swimming performed for 30-60 minutes on most days of the week. 1, 2 The evidence demonstrates statistically significant pain reduction (effect size 0.52) and disability improvement (effect size 0.46), with benefits sustained for 2-6 months after treatment cessation. 1, 2, 3
Quadriceps strengthening exercises are strongly recommended as they produce significant improvements in both pain and function. 1, 4, 2 These should be performed at least 3 times per week with gradual intensity increases over several months. 2
Neuromuscular training programs (balance, agility, coordination) combined with exercise receive moderate strength recommendations for improving performance-based function and walking speed. 1
Supervised exercise programs are superior to self-directed programs, with at least 12 supervised sessions recommended for optimal results. 2 Individually delivered programs tend to produce greater pain reduction and functional improvement compared to class-based or home-based programs. 2, 3
Weight Loss (For Overweight/Obese Patients)
Sustained weight loss of at least 5% of body weight is strongly recommended for patients with BMI ≥25 kg/m². 1, 4 Combining dietary modification with exercise provides optimal results, with the diet-plus-exercise combination showing superior improvements in self-reported function, pain, 6-minute walk distance, and stair-climb time compared to either intervention alone. 4, 5
Patient Education and Self-Management
Patient education programs receive a strong recommendation for improving pain in knee osteoarthritis. 1 These programs should include individualized education packages, coping skills training, activity modifications, and goal-setting strategies. 1, 4, 2
Additional Rehabilitation Modalities
Manual Therapy and Massage
Manual therapy added to an exercise program receives limited strength recommendation for improving pain and function. 1 Massage in addition to usual care may be used to improve pain and function, though evidence strength is limited. 1
Range-of-Motion Exercises
Range-of-motion and flexibility exercises are recommended to address joint stiffness and limited motion, though based primarily on expert opinion. 1, 2 These low-cost interventions have minimal associated harms and should focus on gentle stretching of muscles around the knee joint. 2
Physical Modalities (Limited Evidence)
The following modalities may be used but carry limited strength recommendations: 1
- Transcutaneous electrical nerve stimulation (TENS) for pain
- Percutaneous electrical nerve stimulation for pain and function
- FDA-approved laser treatment for pain and function
- Pulsed electromagnetic field therapy for pain
Assistive Devices
Tibiofemoral bracing for tibiofemoral knee OA receives strong recommendation, while patellofemoral bracing for patellofemoral OA is conditionally recommended. 1 Walking sticks and appropriate insoles may provide symptomatic relief. 4 Lateral wedge insoles are not recommended (moderate strength). 4
Critical Implementation Points
Pain during exercise should not prevent participation, as clinical trials demonstrate improvements even in patients experiencing pain during activity. 2 However, high-impact exercises should be avoided as they may increase joint damage. 2
Exercise programs should be modified if they significantly exacerbate pain, maintaining focus on low-impact aerobic exercise and gentle strengthening. 2 The relatively low cost of exercise interventions and their additional health benefits beyond knee OA support their use as first-line therapy. 1
Aquatic exercises in warm water provide additional pain relief through buoyancy that reduces joint loading. 2
Common Pitfalls to Avoid
Do not prescribe lateral wedge insoles, as they are specifically not recommended despite their historical use. 4
Do not delay exercise therapy due to patient pain complaints—evidence shows benefit even with concurrent pain. 2
Do not rely solely on home-based programs without initial supervision—at least 12 supervised sessions significantly improve outcomes. 2
Do not recommend exercise without addressing weight loss in overweight/obese patients (BMI ≥25), as the combination produces superior results to either intervention alone. 1, 5