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"knee osteoarthritis"[MeSH Terms] AND "physiotherapy" AND "exercise"
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"knee osteoarthritis"[MeSH Terms] AND "physical therapy"[MeSH Terms]
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Diagnosis: Right Knee Osteoarthritis - Kellgren-Lawrence Grade 3-4 (Medial Compartment Predominant)
Radiological Findings (from both views)
Patient: Mrs. Aruna Patil, 52 years, Female | Right Knee AP + Lateral views
| Finding | Description |
|---|---|
| Joint Space | Severe asymmetric narrowing of the medial tibiofemoral compartment (near bone-on-bone); lateral compartment relatively preserved; mild-moderate patellofemoral narrowing |
| Subchondral Sclerosis | Prominent increased bone density beneath the medial femoral condyle and medial tibial plateau |
| Subchondral Cysts | Subtle lucencies (geodes) visible in the medial tibial plateau |
| Osteophytes | Prominent marginal osteophytes at medial and lateral margins of femoral condyles and tibial plateaus; sharpened/elevated tibial spines; patellar pole osteophytes |
| Alignment | Mild varus (genu varum) deformity - secondary to medial compartment destruction |
| Fracture/Dislocation | None |
| Soft Tissue | No significant effusion visible |
Kellgren-Lawrence Grade: 3-4 - Severe narrowing, definite osteophytes, subchondral sclerosis, and cysts with secondary varus deformity.
Physiotherapy Management
Management is structured in phases, following AAOS, ACR, and EULAR guidelines. At 52 years with Grade 3-4 medial compartment OA and varus alignment, the priority is pain relief, function preservation, and load redistribution. Surgery should be reserved if conservative management fails.
Phase 1: Acute / Pain Management (Week 1-3)
Electrophysical Agents (Modalities)
- TENS (Transcutaneous Electrical Nerve Stimulation): 80-100 Hz continuous for pain gate control, 20-30 min/session - reduces analgesic requirement
- IFT (Interferential Therapy): 4-pole technique around the knee, 80-150 Hz, for deep analgesia
- Ultrasound therapy: Pulsed mode (1 MHz, 0.5-1.0 W/cm², 20% duty cycle) over the medial joint line for subchondral bone and cartilage effects
- Ice/cold pack: 15-20 min post-exercise to control any inflammatory flare
- Low-level laser therapy (LLLT): Has evidence for short-term pain reduction in knee OA
Rest and Joint Protection
- Activity modification - avoid prolonged standing, kneeling, squatting, and stair climbing
- Walking aids: a cane in the contralateral hand offloads the affected medial compartment significantly
Phase 2: Active Rehabilitation (Week 3-8)
Strengthening Exercises (Priority - Quadriceps and Hip Abductors)
Strong quadriceps reduce compressive forces across the tibiofemoral joint. Hip abductor weakness causes increased medial compartment loading.
| Exercise | Technique | Sets/Reps |
|---|---|---|
| Quad sets (isometric) | Tighten quad in extension, hold 5-10 sec | 3 × 10 |
| Straight leg raise (SLR) | Supine, lift leg to 45°, slow lowering | 3 × 15 |
| Short arc quads | Pillow under knee, extend fully, hold 5 sec | 3 × 10 |
| Seated terminal knee extension | Using theraband, emphasize last 30° | 3 × 15 |
| Hip abductor strengthening | Side-lying hip abduction, clamshells | 3 × 15 |
| Mini squats / wall slides | 0-30° range, pain-free arc only | 3 × 10 |
| Step-ups | Low step (5-10 cm), eccentric emphasis | 3 × 10 each leg |
| Hamstring curls | Prone, elastic band resistance | 3 × 15 |
| Calf raises | Bilateral/unilateral, for shock absorption | 3 × 15 |
Range of Motion and Flexibility
- Passive/active knee ROM exercises - full extension must be regained first (extension loss is more functionally limiting than flexion loss)
- Heel prop in extension: Towel under heel, allow gravity to restore full extension
- Prone knee extension hang: Gravity-assisted for extension
- Low-load prolonged stretch: For knee flexion recovery
- Hamstring and calf stretching: 30-second holds × 3 repetitions
Aerobic Exercise
- Stationary cycling: Low resistance, high cadence; excellent for knee OA (minimal compressive load, maintains ROM)
- Hydrotherapy / pool walking: Water buoyancy reduces joint load by ~50% in waist-deep water; highly recommended for Grade 3-4 OA
- Walking program: Flat surfaces, well-cushioned footwear; target building toward 150 min/week moderate intensity (ACR/EULAR 2019 recommendation)
- Elliptical trainer: Lower impact than treadmill
Neuromuscular / Proprioceptive Training
OA patients show reduced proprioception and altered gait mechanics. This component directly addresses varus thrust.
- Single-leg balance (on stable then unstable surface): 30-second holds
- Balance board training / wobble board
- Perturbation training: Applied external perturbations during standing/walking
- Tai chi: Strongly recommended in ACR 2019 guidelines; improves balance, reduces falls risk, decreases pain
Phase 3: Functional and Long-Term Management
Manual Therapy
Manual therapy as an adjunct to exercise shows benefit for pain and function (AAOS 2-star recommendation; evidence supports combined use).
- Patellar mobilization (medial and inferior glides): Reduces patellofemoral OA symptoms
- Tibio-femoral joint mobilizations (Kaltenborn Grade I-II): Distraction and AP glides for pain relief
- Soft tissue massage to quadriceps, ITB, and posterior capsule
Orthotic and Assistive Devices
- Valgus unloading knee brace: For medial compartment OA with varus alignment (as in this patient), a valgus brace shifts load from the medial to lateral compartment - reduces pain and improves function
- This is a key device for Mrs. Patil given her varus deformity
- Medial wedge insole: Controversial (AAOS does not recommend lateral wedge; for medial OA with varus, a lateral wedge insole may theoretically help but evidence is weak)
- Foot orthotics: For pes planus or foot alignment issues contributing to medial loading
- Walking stick/cane: Contralateral hand, reduces medial compartment load by 20-30%
Weight Management
- Every 1 kg reduction in body weight reduces compressive knee force by approximately 4 kg during walking
- Physiotherapist role: activity counseling, setting realistic exercise targets as part of a multidisciplinary weight loss plan
Summary of Physiotherapy Programme (Evidence-Based Hierarchy)
| Priority | Intervention | Evidence Level |
|---|---|---|
| Core (mandatory) | Therapeutic exercise (strengthening + aerobic) | AAOS Strong 4★ / ACR Strongly Recommended |
| Core | Patient education and self-management | AAOS Strong 4★ |
| Core | Weight management | AAOS Moderate 3★ |
| Adjunct | Valgus unloader brace | AAOS Moderate 3★ |
| Adjunct | Neuromuscular/balance training combined with exercise | AAOS Moderate 3★ |
| Adjunct | Manual therapy (joint mobilization + massage) + exercise | AAOS Limited 2★ |
| Adjunct | TENS / IFT / LLLT | AAOS Limited 2★ |
| Adjunct | Aquatic/hydrotherapy | ACR Conditionally Recommended |
| Adjunct | Tai chi | ACR Strongly Recommended |
| Not recommended | Lateral wedge insoles alone | AAOS Not Recommended |
Clinical Notes Specific to This Patient
- Age 52, female - postmenopausal status likely; assess bone density (DEXA) to rule out concurrent osteoporosis before loading exercises
- Bilateral assessment needed - left knee also visible on X-ray and should be examined clinically
- Varus alignment - a valgus unloading brace is particularly indicated; refer for brace fitting
- Grade 3-4 severity - if 3-6 months of structured physiotherapy fails to achieve adequate pain control and function, refer to orthopaedic surgeon for consideration of high tibial osteotomy (given her age and unicompartmental disease) or total knee arthroplasty
- Goal setting: Use KOOS (Knee Injury and Osteoarthritis Outcome Score) or WOMAC at baseline and every 4-6 weeks to track progress
- Miller's Review of Orthopaedics 9th Ed. (AAOS CPG Table 5.7, p. 468)
- Firestein & Kelley's Textbook of Rheumatology (OA Management, p. 2213-2215)
- Campbell's Operative Orthopaedics 15th Ed. 2026
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