What is knee OA?
Structural changes:
Knee osteoarthritis is more than just wear and tear of the knee cartilage. The mechanism of OA is not fully understood, however it involves progressive softening and loss of articular cartilage, subchondral bone sclerosis (thickening), cyst formation (bone breakdown) and the development of osteophytes (odd bone growth).
With the advent of more detailed imaging studies, particularly magnetic resonance imaging (MRI), OA is now widely recognised as a disease involving the whole joint including ligaments, menisci, synovium (synovitis), and joint capsule as well (3).
It can be classed into 4 stages using the Kellgran and Lawrence scale:
It is important to understand that people with structural changes alone, do not necessarily have knee OA. Studies have shown that less than 50% of those with radiographic OA had knee pain (4). In other words you can have changes in your knees articulating surfaces (wear and tear) and still be completely pain free. Not to say there is no correlation between joint changes and symptoms, some studies show that bone marrow lesions (deep to the joint contact surface), and synovitis (joint capsule inflammation), are findings that align more closely with people with pain.
The point of the above information is that the wear and tear that we typically see using an X-ray poorly correlates with pain and that OA is a disease of the whole knee joint.
How to conservatively manage KOA?
The most recent systematic review looking at The effect of exercise on knee osteoarthritis, found that exercise programs are a safe and effective way to improve pain, strength and QoL in people with OA.
The evidence suggests that pilates, aerobic and strengthening exercise programs performed for 8–12 weeks, 3–5 sessions per week; each session lasting 1 h appear to be effective (5).
Aerobic, strength, and pilates has all shown to be better than control for reducing pain in people with knee OA. Furthermore, the evidence suggests that exercise intervention can improve function, especially of daily living tasks.
Common misconceptions
It’s a common misconception that load bearing exercises further damage the knee in OA, several RCTs have looked at the effect of exercise programs that involve 8-12 reps of weighted squats, lunges and other function lower limb exercises to find the positive effects discussed above. These should be done within tolerable levels.
People commonly think that running leads to wear and tear, and can eventually lead to OA. The association between running and knee OA is not crystal clear. There is some evidence that a history of running is protective not harmful, and some research suggests it may show higher rates of OA in elite runners. Generally it is considered healthy for your knee joint, and should be continued.
Although it may be intuitive to protect from further damage, in the case of knee OA exercise is paramount in its management. This may seem counterintuitive, however a whole field of literature points to exercise as the most feasible and safe long term management solution for knee OA. Building a program can be challenging when considering your symptoms. See one of our physios for help with this.
Large numbers of arthroplasties are performed due to KOA; in 2015, 54,277 total knee arthroplasty (TKA) surgeries were performed in Australia due to KOA .
Bricca, A., Juhl, C. B., Steultjens, M., Wirth, W., & Roos, E. M. (2019). Impact of exercise on articular cartilage in people at risk of, or with established, knee osteoarthritis: A systematic review of randomised controlled trials. British Journal of Sports Medicine, 53(15), 940–947.
Loeser RF, Goldring SR, Scanzello CR, Goldring MB. Osteoarthritis: a disease of the joint as an organ. Arthritis Rheum. 2012;64:1697–1707. doi: 10.1002/art.34453.
Hannan MT, Felson DT, Pincus T. Analysis of the discordance between radiographic changes and knee pain in osteoarthritis of the knee. J Rheumatol. 2000;27:1513–1517.
Raposo, F., Ramos, M., & Lúcia Cruz, A. (2021). Effects of exercise on knee osteoarthritis: A systematic review. Musculoskeletal Care. doi:10.1002/msc.1538
Timmins, K. A., Leech, R. D., Batt, M. E., & Edwards, K. L. (2017). Running and Knee Osteoarthritis: A Systematic Review and Meta-analysis. The American journal of sports medicine, 45(6), 1447–1457. https://doi.org/10.1177/0363546516657531
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