Non-Arthroplasty Treatment of Osteoarthritis of the Knee
Publication Date: September 1, 2021
Last Updated: March 14, 2022
Recommendations
Lateral Wedge Insoles
Lateral wedge insoles are not recommended for patients with knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Canes
Canes could be used to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Moderate
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Braces
Brace treatment could be used to improve function, pain, and quality of life in patients with knee osteoarthritis
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Oral/Dietary Supplements
The following supplements may be helpful in reducing pain and improving function for patients with mild to moderate knee osteoarthritis; however, the evidence is inconsistent/limited and additional research clarifying the efficacy of each supplement is needed.
• Turmeric
• Ginger extract
• Glucosamine
• Chondroitin
• Vitamin D
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Topical Treatments
Topical NSAIDs should be used to improve function and quality of life for treatment of osteoarthritis of the knee, when not contraindicated.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Supervised Exercise
Supervised exercise, unsupervised exercise, and/or aquatic exercise are recommended over no exercise to improve pain and function for treatment of knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Neuromuscular Training
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.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Self-Management
Self- management programs are recommended to improve pain and function for patients with knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Patient Education
Patient education programs are recommended to improve pain in patients with knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Weight Loss Intervention
Sustained weight loss is recommended to improve pain and function in overweight and obese patients with knee osteoarthritis.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Manual Therapy
Manual therapy in addition to an exercise program may be used to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Massage
Massage may be used in addition to usual care to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Laser Treatment
FDA-approved laser treatment may be used to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Acupuncture
Acupuncture may improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Transcutaneous Electrical Nerve Stimulation
Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include:
a. Transcutaneous Electrical Nerve Stimulation (pain)
Strength of Recommendation: Limited rad(ed)owng
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Percutaneous Electrical Nerve Stimulation/Pulsed Electromagnetic Field
Therapy
Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include:
a. Percutaneous Electrical Nerve Stimulation (pain and function)
b. Pulsed Electromagnetic Field Therapy (pain)
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy may be used to improve pain and function for treatment of osteoarthritis of the knee.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Oral NSAIDs
Oral NSAIDs are recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Oral Acetaminophen
Oral acetaminophen is recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Oral Narcotics
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.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Hyaluronic Acid
Hyaluronic acid intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Intra-articular Corticosteroids
Intra-articular (IA) corticosteroids could provide short-term relief for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Platelet-rich Plasma
Platelet-rich plasma (PRP) may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Denervation Therapy
Denervation therapy may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Lavage/Debridement
Arthroscopy with lavage and/or debridement in patients with a primary diagnosis of knee osteoarthritis is not recommended.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a
single “High” quality study for recommending for or against the intervention. Also requires no or only minor
concerns addressed in the EtD framework.
Partial Meniscectomy
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.
Strength of Recommendation: Moderate
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Tibial Osteotomy
High tibial osteotomy may be considered to improve pain and function in properly indicated patients with unicompartmental knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Dry Needling
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.
Strength of Recommendation: Consensus
Description: Evidence there is no supporting evidence, or limited level evidence was downgraded due to major
concerns addressed in the EtD framework. In the absence of reliable evidence, the guideline work group is making a
recommendation based on their clinical opinion.
Free Floating Interpositional Devices
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.
Strength of Recommendation: Consensus
Description: Evidence there is no supporting evidence, or limited level evidence was downgraded due to major
concerns addressed in the EtD framework. In the absence
Lateral wedge insoles are not recommended for patients with knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Canes
Canes could be used to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Moderate
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Braces
Brace treatment could be used to improve function, pain, and quality of life in patients with knee osteoarthritis
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Oral/Dietary Supplements
The following supplements may be helpful in reducing pain and improving function for patients with mild to moderate knee osteoarthritis; however, the evidence is inconsistent/limited and additional research clarifying the efficacy of each supplement is needed.
• Turmeric
• Ginger extract
• Glucosamine
• Chondroitin
• Vitamin D
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Topical Treatments
Topical NSAIDs should be used to improve function and quality of life for treatment of osteoarthritis of the knee, when not contraindicated.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Supervised Exercise
Supervised exercise, unsupervised exercise, and/or aquatic exercise are recommended over no exercise to improve pain and function for treatment of knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Neuromuscular Training
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.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Self-Management
Self- management programs are recommended to improve pain and function for patients with knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Patient Education
Patient education programs are recommended to improve pain in patients with knee osteoarthritis.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Weight Loss Intervention
Sustained weight loss is recommended to improve pain and function in overweight and obese patients with knee osteoarthritis.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Manual Therapy
Manual therapy in addition to an exercise program may be used to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Massage
Massage may be used in addition to usual care to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Laser Treatment
FDA-approved laser treatment may be used to improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Acupuncture
Acupuncture may improve pain and function in patients with knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Transcutaneous Electrical Nerve Stimulation
Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include:
a. Transcutaneous Electrical Nerve Stimulation (pain)
Strength of Recommendation: Limited rad(ed)owng
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Percutaneous Electrical Nerve Stimulation/Pulsed Electromagnetic Field
Therapy
Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include:
a. Percutaneous Electrical Nerve Stimulation (pain and function)
b. Pulsed Electromagnetic Field Therapy (pain)
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy may be used to improve pain and function for treatment of osteoarthritis of the knee.
Strength of Recommendation: Limited (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Oral NSAIDs
Oral NSAIDs are recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Oral Acetaminophen
Oral acetaminophen is recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Oral Narcotics
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.
Strength of Recommendation: Strong
Evidence from two or more “High” quality studies with consistent findings for recommending for or against the
intervention. Also requires no reasons to downgrade from the EtD framework.
Hyaluronic Acid
Hyaluronic acid intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Intra-articular Corticosteroids
Intra-articular (IA) corticosteroids could provide short-term relief for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Moderate (downgrade)
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Platelet-rich Plasma
Platelet-rich plasma (PRP) may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Denervation Therapy
Denervation therapy may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Lavage/Debridement
Arthroscopy with lavage and/or debridement in patients with a primary diagnosis of knee osteoarthritis is not recommended.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a
single “High” quality study for recommending for or against the intervention. Also requires no or only minor
concerns addressed in the EtD framework.
Partial Meniscectomy
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.
Strength of Recommendation: Moderate
Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High”
quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed
in the EtD framework.
Tibial Osteotomy
High tibial osteotomy may be considered to improve pain and function in properly indicated patients with unicompartmental knee osteoarthritis.
Strength of Recommendation: Limited (downgrade)
Description: Evidence from one or more “Low” quality studies with consistent findings or evidence from a single
“Moderate” quality study recommending for or against the intervention. Also, higher strength evidence can be
downgraded to limited due to major concerns addressed in the EtD Framework.
Dry Needling
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.
Strength of Recommendation: Consensus
Description: Evidence there is no supporting evidence, or limited level evidence was downgraded due to major
concerns addressed in the EtD framework. In the absence of reliable evidence, the guideline work group is making a
recommendation based on their clinical opinion.
Free Floating Interpositional Devices
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.
Strength of Recommendation: Consensus
Description: Evidence there is no supporting evidence, or limited level evidence was downgraded due to major
concerns addressed in the EtD framework. In the absence
Recommendation Grading
Overview
Title
Non-Arthroplasty Treatment of Osteoarthritis of the Knee
Authoring Organization
American Academy of Orthopaedic Surgeons
Endorsing Organization
American Association of Hip and Knee Surgeons
Publication Month/Year
September 1, 2021
Last Updated Month/Year
February 8, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Target Patient Population
Patients with knee osteoarthritis
Target Provider Population
Orthopedic surgeons
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Home health, Hospital, Outpatient
Intended Users
Physical therapist, physician, nurse, nurse practitioner, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Rehabilitation
Diseases/Conditions (MeSH)
D020370 - Osteoarthritis, Knee
Keywords
nonpharmacological treatment, physical therapy, osteoarthritis, nonsteroidal anti-inflammatory drugs (NSAIDs), knee pain
Source Citation
American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Knee (Non- Arthroplasty) Evidence-Based Clinical Practice Guideline. https://www.aaos.org/oak3cpg Published 08/31/2021