Knee Osteoarthritis Management for GPs 2025

Early, Mid, and Late-Stage Knee Osteoarthritis Management

Knee osteoarthritis (OA) is a progressive condition that significantly impacts a patient’s quality of life. As general practitioners, guiding patients through management at different stages of the disease is crucial in optimising function and delaying disease progression. This article outlines evidence-based non-surgical treatment options and provides guidance on when to consider referral for an orthopaedic review. All recommendations align with the latest 2025 guidelines from the Australian Orthopaedic Association (AOA) and the American College of Rheumatology (ACR).

Early-Stage Knee Osteoarthritis: Preventing Progression

In the early stages of knee OA, patients may experience intermittent pain, stiffness (especially in the morning or after inactivity), and mild functional limitations. The goal at this stage is to reduce symptoms, preserve joint function, and slow disease progression.

First-Line Non-Surgical Treatment Strategies

1. Lifestyle Modifications

Weight Management: Excess weight is a significant risk factor for knee OA. A 5-10%25 reduction in body weight can significantly decrease pain and improve function.
Activity Modification: Patients should avoid high-impact activities (e.g., running, jumping) while maintaining an active lifestyle with joint-friendly exercises.

2. Exercise Therapy

Strengthening Exercises: Quadriceps and hamstring strengthening improve joint stability and reduce knee loads.
Low-Impact Aerobic Exercise: Cycling, swimming, and walking help maintain cardiovascular fitness without exacerbating symptoms.
Physiotherapy: A tailored programme can improve biomechanics and movement patterns.
Tai Chi or Yoga: These may provide additional benefits in terms of pain reduction and balance improvement.

3. Pharmacological Management

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Topical NSAIDs (e.g., diclofenac gel) should be the first step for pain relief. If necessary, oral NSAIDs may be considered if no contraindications exist.
Paracetamol: Previously recommended as first-line treatment, current evidence suggests it provides limited pain relief. It can still be used but is often less effective than NSAIDs.
Duloxetine: May be considered for chronic knee OA pain, particularly in patients with central sensitisation or comorbid depression.

4. Supportive Therapies

Bracing and Orthotics: Medial offloading braces or lateral wedge insoles may help in unicompartmental OA.
Walking Aids: A walking stick in the opposite hand can reduce joint loading and improve stability.
Corticosteroid Injections: These can provide short-term relief for acute flare-ups but should not be used repeatedly due to potential cartilage damage.

When to Refer for Orthopaedic Review in Early OA

Symptoms persist despite 3-6 months of optimal conservative management.
Significant functional limitation affecting daily activities or work.
Frequent flare-ups requiring repeated intra-articular steroid injections.
Progressive radiographic evidence of OA despite conservative measures.

Mid-Stage Knee Osteoarthritis: Managing Symptoms and Function

At this stage, patients typically have more persistent pain, mild to moderate functional impairment, and signs of structural progression on imaging. The focus remains on conservative management, with possible escalation of treatment.

Additional Treatment Strategies for Mid-Stage OA

1. Pharmacological Management

NSAIDs (Topical & Oral): Remain the mainstay of pain relief.
Duloxetine: Can be considered in patients with chronic pain symptoms.
Corticosteroid Injections: May provide temporary relief but should be used sparingly.

2. Supplements & Alternative Treatments

Glucosamine & Chondroitin: These supplements are not recommended by current guidelines as they have not shown consistent clinical benefit.
Fish Oil & Omega-3 Fatty Acids: Some studies suggest mild anti-inflammatory effects, but evidence remains inconclusive.
Turmeric (Curcumin): Some small studies suggest mild pain relief, but high-quality evidence is lacking.
Acupuncture: May provide short-term pain relief for some patients but is not considered first-line therapy.
TENS (Transcutaneous Electrical Nerve Stimulation): Not strongly recommended due to a lack of consistent evidence in OA pain management.

When to Refer for Orthopaedic Review in Mid-Stage OA

Increasing pain and functional decline despite maximal conservative management.
Failure of at least two pharmacological treatments.
Significant impact on work or daily activities.

Late-Stage Knee Osteoarthritis: When Surgery Becomes an Option

In late-stage OA, joint degeneration leads to persistent pain, stiffness, and significant functional impairment. Conservative measures often provide diminishing returns, and referral for orthopaedic assessment should be considered.

Indicators of Late-Stage OA

Constant pain, including at rest or at night.
Severe stiffness limiting mobility (e.g., difficulty rising from a chair, climbing stairs).
Visible joint deformity (varus/valgus malalignment).
Marked radiographic changes, such as joint space narrowing and osteophyte formation.

Ongoing Non-Surgical Management

Stronger Analgesia: Short-term use of weak opioids (e.g., tramadol) may be necessary for severe pain, but long-term use should be avoided due to dependence risks.
Radiofrequency Ablation (RFA): An emerging option for some patients with chronic OA pain.
Duloxetine: Can be used for persistent pain in select cases.
Hyaluronic Acid Injections: The latest evidence does not support routine use due to lack of significant long-term benefit.
PRP (Platelet-Rich Plasma) and Stem Cell Therapy: These remain experimental and are not currently recommended outside research settings.

When to Refer for Orthopaedic Review in Late OA

Severe pain unresponsive to non-surgical treatments.
Significant loss of function affecting independence.
Progressive joint deformity.
Radiological confirmation of end-stage OA.

For these patients, surgical options such as total knee replacement (TKR) or unicompartmental knee replacement (UKR) may be appropriate.

Avoiding Low-Value Care

Routine Knee Imaging: X-rays should only be ordered when necessary to confirm OA or assess severity, as MRI is rarely needed in typical OA cases.
Arthroscopic Surgery: Strongly recommended against for knee OA due to lack of long-term benefit.
Long-Term Opioid Use: Not recommended due to risks of dependence and limited pain relief benefits.
Hyaluronic Acid, PRP, and Stem Cell Therapy: Lack of strong evidence means they should not be routinely recommended.

Conclusion

Knee osteoarthritis management should be tailored to the patient’s stage of disease. Early intervention with lifestyle changes, physiotherapy, and pharmacological treatments can help delay progression, while timely referral for orthopaedic assessment ensures patients with severe OA receive appropriate surgical options.

If you have a patient with persistent knee OA symptoms despite optimal conservative care, an orthopaedic review can help determine the next steps, whether it be further non-surgical interventions or consideration of surgical management.

For referrals or more information on knee osteoarthritis management, feel free to contact Dr Oliver Khoo’s clinic.

References

Australian Orthopaedic Association (AOA) Guidelines (2025).
American College of Rheumatology (ACR) OA Management Recommendations (2025).
Kolasinski SL et al., 2019 ACR/Arthritis Foundation OA Guideline, Arthritis Care Res.
Bannuru RR et al., BMJ 2022 Meta-analysis on Viscosupplementation.
ACSQHC Osteoarthritis of the Knee Clinical Care Standard (2024).