Rehabilitation of a patient with osteoarthritis of the knee joints

Osteoarthritis (OA) is characterised by cartilage destruction with subsequent joint space loss, osteophyte formation and subchondral sclerosis. It is the most common joint disease of older adults and the major cause of knee, hip and back pain.

OA is not, by definition, an inflammatory disease, although synovial hypertrophy and joint effusions are typical. Progression involves chondrocyte regulation of the extracellular matrix, genetic influences, local mechanical factors and inflammation.

Musculoskeletal disorders are the commonest cause of disability in old people — almost 60% of people aged ≥65 report arthritis or chronic joint symptoms. High BMI is associated with an increased risk of knee OA in older persons.

Indian context: the pooled prevalence of knee OA among elderly Indians is about 47%. Contributing factors specific to India: squatting, cross-legged floor sitting, Indian-style toilets, heavy manual labour, obesity and postmenopausal status.

The good news that drives the whole programme: pathological OA changes occur against a background of age-related loss of flexibility that is itself reversible. Exercise increases joint flexibility and improves the strength, size and resilience of cartilage, ligaments and muscles. Arthritic patients should be encouraged to develop physical fitness and set realistic goals.

History: nature and duration of disability, pain (site, pattern, aggravating and relieving factors), comorbidities, drugs that affect mobility, motivation and psychological factors, and the home environment. Examination: skin, cardiopulmonary status, musculoskeletal assessment — muscle tone and strength (MRC 0–5, especially knee extension), joint range of motion, foot deformities and lesions — neurological deficits, and levels of mobility: bed mobility, transfers, standing balance, gait, stair climbing, and pain with movement.

Investigations: plain radiography remains the main modality for assessing severity and progression; MRI and ultrasound are more accurate and comprehensive but not needed routinely.

Outcome tools: WOMAC (pain, stiffness, physical function), Timed Up and Go, 30-second chair stand, 6-minute walk test, and Barthel Index/FIM.

The goal is to restore function and prevent further disability, using a restorative philosophy of care: careful assessment of function and underlying capability, realistic goals, prevention of secondary disability and the complications of immobility, evaluation and adaptation of the environment, and ongoing motivation of both patient and caregivers.

Non-pharmacological management should be the focus of intervention — weight loss, physical therapy to strengthen the related musculature, local ice and heat, and exercise programmes to maintain strength and function.

Physiotherapy objectives: relieve pain; evaluate, maintain and improve joint range of motion; improve strength, endurance, motor skills and coordination; improve gait and stability; assess the need for and teach the use of assistive devices. Modalities: active exercise (isometric and isotonic) and passive exercise, sitting exercise programmes, heat (hot packs, paraffin, diathermy, ultrasound), hydrotherapy and TENS.

A practical knee OA exercise prescription:

Quadriceps strengthening — static quadriceps sets, straight-leg raises, inner-range quadriceps, progressing to sit-to-stand and step-ups

Hip abductor and extensor strengthening — reduces the adduction moment across the knee

Daily range-of-motion exercises — particularly important in restoring function in arthritic joints

Balance and proprioceptive training — the knee is unstable and falls risk is high

Low-impact aerobic exercise — walking, cycling, aquatic exercise

Flexibility — hamstring and calf stretching; avoid fixed flexion contracture

Adherence is the biggest problem, not the prescription. Compliance with range-of-motion exercise is low at all ages. Joining others in group activities adds a social component and increases compliance — hence supervised group programmes rather than a printed home sheet.

Weight management: weight-loss therapy improves physical function, quality of life and the medical complications of obesity in older persons, but must minimise muscle and bone loss. Primary approach is lifestyle change with a modest energy reduction of 500–700 kcal/day, and regular physical activity is particularly important in obese older people to preserve muscle and bone mass.

Time the analgesia to the exercise. Because OA pain is typically exacerbated by exercise, it is best to medicate beforehand — this single measure converts a failed physiotherapy session into a successful one.

Pharmacological adjuncts: simple analgesics, topical and oral NSAIDs, intra-articular corticosteroid injection, viscosupplementation. Glucosamine and chondroitin show no evidence of significant pain improvement beyond a possible placebo effect, and vitamin D does not reduce pain or repair structural damage. Refractory pain is best managed by a multidisciplinary pain team.

Footwear: patients with painful knees benefit from soft-soled shoes with cushioned heels (e.g. jogging shoes). A rocker-bottom shoe reduces forefoot pain by assisting weight transfer from posterior to anterior. Metatarsalgia is reduced by an internal pad placed proximal to the MTP joints, and medial arch collapse by a medial arch-supporting orthosis.

Walking stick rules:

A cane held in the contralateral hand reduces weight on an arthritic hip

For knee pain, the patient should experiment with holding the cane in either hand — the contralateral rule is not automatic for the knee

Cane length must equal the distance from the wrist crease to the floor — a wrong length creates secondary problems in other joints

Ferrules (stick rubbers) must be checked regularly and replaced when worn, to reduce the risk of falls

Occupational therapy and the home: a home-based assessment by an occupational therapist is often invaluable. Simple ergonomic measures and aids — tap turners, zipper pulls, sock pulls, stretch laces, long-handled shoe-horns and Velcro fasteners — notably reduce joint strain and consequent pain. Add raised toilet seat, grab bars, shower chair, raised chair and bed heights, and first-floor living. In the Indian setting, converting an Indian-style squatting toilet to a Western-style commode is one of the highest-yield single modifications.

Physical modalities — know the evidence limits. Heat, including baths and spas, has traditionally been used for arthritic joints. There is no evidence that hydrotherapy produces measurable functional improvement in arthritic joints, although it does promote self-confidence. Use these as adjuncts that enable exercise, not as treatments in their own right.

Surgery: total knee arthroplasty is reserved for severe symptoms and functional failure despite optimal conservative care, requiring pre-operative optimisation (prehabilitation, quadriceps strengthening, weight and comorbidity control) and structured post-operative rehabilitation. Arthroscopic surgery for knee OA has been shown in a controlled trial to be of no benefit.

Honest evidence position: there is little evidence for the efficacy of structured multidisciplinary rehabilitation programmes in musculoskeletal disorders generally. Time-limited, goal-directed multidisciplinary rehabilitation is of proven benefit only in chronic back pain, other chronic pain, and after hip fracture in frail older people — which is why exercise, weight loss and self-management, not the programme label, carry the evidence in knee OA.

Guideline consensus — the “core set” OARSI emphasises a core set of non-pharmacological management for all patients: formal exercise (aerobic, strengthening, neuromuscular, aquatic or mind-body), weight reduction in overweight or obese patients, and continuing education. Assistive devices such as bracing and walkers are recommended only in select cases. Pharmacological therapy is adjunctive — oral and topical NSAIDs, with short-course intra-articular corticosteroid if these fail. Critically for geriatrics: for individuals with cardiovascular comorbidities or frailty, no oral NSAID is recommended; for gastrointestinal comorbidity, COX-2 inhibitors or an NSAID plus PPI.

ACR/Arthritis Foundation — the specific do’s and don’ts Strongly recommended for knee and hip OA: exercise, self-efficacy and self-management programmes, weight loss, and use of a cane. Tai chi is strongly recommended; yoga is conditionally recommended for knee OA. The guideline strongly recommends against TENS, and conditionally recommends against manual therapy, massage, modified shoes and weighted insoles, and (for knee OA) against pulsed vibration therapy.

The biggest single change — GLP-1 receptor agonists (STEP 9, NEJM 2024) The STEP 9 trial randomised 407 adults with obesity (mean age 56, 81.6% women, mean BMI 40.3) and moderate knee OA with moderately severe pain 2:1 to once-weekly subcutaneous semaglutide 2.4 mg or placebo, alongside physical activity and lower-calorie diet counselling, for 68 weeks. Body weight fell by 13.7% versus 3.2% (treatment difference −10.5; P<0.001), and the WOMAC pain score improved by −41.7 versus −27.5 (treatment difference −14.2, 95% CI −20.0 to −8.3; P<0.001). SF-36 physical function also improved more with semaglutide (+12.0 vs +6.5 points; P<0.001). This may reduce the need for NSAIDs and opioids; an earlier trial of liraglutide 3.0 mg showed no significant pain difference. Exam framing: in the obese older patient with knee OA, weight loss is now a pharmacologically achievable rehabilitation intervention — but its role in frail, sarcopenic elders is unproven and it must be paired with resistance exercise and protein adequacy to protect muscle.

GLA:D® — the reference model for structured OA rehabilitation The Danish GLA:D programme delivers guideline-aligned group education and supervised exercise therapy for hip or knee OA through 2–3 education sessions of 90 minutes plus 12 supervised neuromuscular exercise sessions of 60 minutes, twice weekly for six weeks. Around 6000 participants enrol annually across nearly 300 Danish physiotherapy clinics, with a national registry at baseline, 3 and 12 months.

Digital delivery and injectables A 2025 single-blind RCT randomised 42 older adults (mean age 68.4) with mild-to-moderate knee OA to a sensor-augmented telerehabilitation system (electromyographic and inertial sensing) or conventional face-to-face physiotherapy for eight weeks. Systematic reviews in 2024–2025 support digitally delivered exercise and telerehabilitation for pain, strength and balance; the limiting factor is digital readiness. Recent reporting indicates platelet-rich plasma shows no long-term advantage over standard care in early knee OA.

Indian epidemiology and a practical intervention target A 2025 systematic review and meta-analysis (14 studies, 5029 participants) found the pooled prevalence of knee OA among elderly persons in India to be 47% (95% CI 38.4–55.8%), attributing the burden partly to strenuous manual labour and cultural practices such as sitting cross-legged and squatting. A 2024 community study in rural South India found knee OA in more than one-third of adults aged ≥40, with predictors including obesity, diabetes, hypertension, sedentary lifestyle, menopause and use of Indian-style toilets; the authors recommend affordable alternatives to squatting toilets, knee-strengthening exercise tailored to postmenopausal women, and better rural access to physical therapy.

The OA vicious cycle: pain → activity avoidance → muscle weakness → joint instability → more pain → deconditioning → lost independence.

Age-related joint stiffness is reversible — exercise improves strength, size and resilience of cartilage, ligaments and muscle.

Give the analgesic before exercise, because OA pain is exacerbated by activity.

OA stiffness lasts minutes; inflammatory stiffness lasts hours.

Quadriceps + hip abductor strengthening + aerobic exercise + weight loss is the core prescription.

Compliance is the limiting factor — group exercise improves it.

Cane length = wrist crease to floor; check and replace worn ferrules.

For hip pain hold the cane contralaterally; for knee pain, try either hand.

Soft-soled shoes with cushioned heels for painful knees; rocker-bottom sole for rigid forefoot.

OT aids: tap turners, zipper pulls, sock pulls, stretch laces, long-handled shoe-horn, Velcro fasteners.

Hydrotherapy improves confidence, not measurable joint function.

Glucosamine, chondroitin and vitamin D do not reduce OA pain.

Avoid oral NSAIDs in the frail or cardiovascularly comorbid elder — topical NSAIDs first.

Arthroscopic surgery for knee OA is of no benefit.

STEP 9 (2024): semaglutide 2.4 mg → 13.7% weight loss and WOMAC pain −41.7 vs −27.5.

GLA:D dose: 12 supervised neuromuscular exercise sessions over 6 weeks + education.

India: knee OA affects about 47% of elderly — target squatting, cross-legged sitting and Indian-style toilets.