CME

An update on primary care management of

knee osteoarthritis
Cody Sasek, MPAS, PA-C

ABSTRACT
Primary care providers often make the initial diagnosis and
play an important role in the effective management of knee
osteoarthritis. This article reviews new treatment guidelines
from the American Academy of Orthopedic Surgeons and
discusses when to refer patients to specialists.
Keywords: knee osteoarthritis, guidelines, orthopedic,
musculoskeletal, total knee arthroplasty, hyaluronic acid
injections

Learning objectives
Discuss the primary care approach to evaluation of knee
pain.
Apply the American Academy of Orthopaedic Surgeons
guidelines for treating knee osteoarthritis to patient care.
Recognize indications for orthopedic referral of knee
osteoarthritis.

O
steoarthritis is a common condition, affecting
22% of adults in the United States, with knee
osteoarthritis being most common.1 Nearly half
of adults may develop symptomatic knee osteoarthritis
by age 85 years.2 As the population ages, arthritic condi-
tions are expected to affect an estimated 67 million adults
in the United States by 2030.3 Already, the number of
total knee arthroplasties has increased by 162% from
1991 to 2010.4 An analysis by the CDC showed direct
and indirect costs attributable to osteoarthritis and other
rheumatic conditions in the United States were about
$128 billion in 2003, equivalent to 1.2% of the 2003 US
gross domestic product.5
The cause of knee osteoarthritis is multifactorial and are symptom control and maintenance of appropriate
includes trauma, genetic factors, obesity, and participa- function.
tion in high-impact activities that result in wearing and Patients with knee osteoarthritis often present with
loss of the protective hyaline cartilage joint surface. inflammation, swelling, and mechanical catching symptoms,
Cartilage loss is irreversible, so the goals of management in addition to pain with either loading of the knee or in
extremes of motion. Patients will report pain and stiffness
Cody Sasek is an assistant professor at the University of Nebraska that often worsen when the patient rises from a seated
Medical Center in Omaha, Neb. The author has disclosed no potential position. For patients with patellofemoral compartment
conflicts of interest, financial or otherwise. osteoarthritis, a primary complaint is pain and difficulty
DOI: 10.1097/01.JAA.0000458853.38655.02 with stairs, particularly when descending. As knee osteo-
Copyright 2015 American Academy of Physician Assistants arthritis progresses, patients may also develop night pain.

JAAPA Journal of the American Academy of Physician Assistants www.JAAPA.com 37

Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CME

Key points
Weight-bearing radiographs are essential for evaluating
knee osteoarthritis.
MRI is generally not indicated for knees that are
osteoarthritic.
Guidelines recommend against use of hyaluronic acid
injections.
Tramadol is indicated for treatment of knee osteoarthritis
pain.
Treatment with total knee arthroplasty is effective and
shows good long-term results.
Younger patients with osteoarthritis should be referred
early to an orthopedist.
A

Often, as a result of reflexive inhibition of the quadriceps

secondary to pain, patients may have a sense of their legs
giving way or buckling. Loss of range of motion also may
occur as degenerative changes progress. Symptoms gener-
ally worsen with increases in activity and may result in
significant loss of function and decreased quality of life.

EVALUATION
A thorough history and physical examination are essential.
The physical examination should focus on assessing the
patients gait, leg alignment, and knee range of motion;
testing ligamentous stability; and performing provocative
meniscal testing. Patients with osteoarthritic knees often B
have concomitant meniscal tears. These tears are rarely
the primary source of pain and disability, except in the case
of a torn and locking meniscal fragment. Examination of
the hip is also important, as hip pathology can occasionally
refer pain to the knee. If possible, the diagnosis of internal
derangement of the knee should be avoided because it lacks
specificity.

IMAGING
Radiographs are the primary means of diagnosis for knee
osteoarthritis. Generally, radiographic views should include
bilateral anteroposterior weight-bearing, 45-degree flexion
posteroanterior (Rosenberg view), lateral, and patello-
femoral (Merchant) views. Radiographic findings of osteo-
arthritis include decreased joint space caused by cartilage
wear and thinning, marginal osteophyte formation, flat-
tening of the femoral condyles, subchondral sclerosis, and
cystic formation in the subchondral bone (Figure 1).
Generally, MRI of the knee is unnecessary unless other
pathology, such as osteonecrosis or mechanically locking
meniscal tear, is suspected.
TREATMENT OVERVIEW
In 2013, the American Academy of Orthopaedic Surgeons
(AAOS) revised its initial guidelines on treating knee
osteoarthritis. These practice guidelines are derived from
C
FIGURE 1. Radiographs of the right knee with osteoarthritis.
Anteroposterior standing view (A), Rosenberg or notch view
(B), and Merchant view (C). These radiographs show medial
compartment joint space narrowing, marginal osteophyte
formation, flattening of the medial femoral condyle, asym-
metric varus alignment, and patellofemoral osteoarthritis, most
significant at the medial facet.
evidence-based research and focus largely on treatment
options short of knee replacement. As such, they provide
a framework for management decisions not only in the
orthopedists office, but also for primary care providers.
Recommendations in the AAOS guidelines were based
on the statistical and clinical significance of the supporting
evidence.

38 www.JAAPA.com Volume 28 Number 1 January 2015

Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Strong recommendations were highly likely to be ben-
eficial and had high-quality evidence to support them.
Moderate recommendations had lesser evidence of ben-
efit in the medical literature.
Limited recommendations were those for which the
quality of supporting evidence was unconvincing, or well-
controlled studies showed little clear advantage to one
approach over another.
Inconclusive recommendations are treatments that do
not show significant benefit, but are unlikely to cause harm;
providers should exercise clinical judgment in these
instances, along with consideration of patient preference.
Figure 2 summarizes the AAOS treatment recom-
mendations.
INITIAL TREATMENT
Patient education and self-management are the initial
treatments recommended by AAOS. Self-management
programs in a primary care setting have been shown effec-
tive for knee osteoarthritis.6 These programs should focus
on activity modifications including low-impact aerobics,
careful strengthening, and avoidance of high-impact activ-
ities. Patients who participated in structured, guided
programs including home exercise programs had improved
pain and function scores.7 Water aerobics have been shown
to improve patients pain scores, as has proprioceptive
training.8,9 Several studies have found a significant improve-
ment in patients who participate in a supervised walking
program.10 Recent studies, including by Ebnezar and col-
leagues, show that a combination of yoga and physical
therapy for strengthening was superior to strengthening
alone.11 Patients should be cautioned to avoid extreme
range of motion, particularly in flexion when strengthen-
ing, as this can increase forces dramatically at the knee,
specifically through the patellofemoral joint.
As always, these physical activity recommendations
should be implemented as symptoms dictate, and patients
should avoid activities that increase symptoms. Patients
need to modify high-impact and other activities based on
their symptoms. Educate patients about appropriate activ-
ity modifications and avoidances.
Appropriate physical activity and diet leading to weight
loss received moderate recommendation, particularly in
patients with a body mass index of 25 or more.12,13 Weight
reduction can be important because forces about the knee
can be quite significant, particularly at the patellofemoral
joint: contact pressures can reach about six times body
weight when patients perform deep knee flexion. During
weight lifting and jumping, the force through the patel-
lofemoral joint can be as high as 20 to 25 times body
weight.14 This multiplied effect should reinforce in both
patient and provider the importance of appropriate weight
loss and its effect on additional treatment.
Additional conservative treatment may include the use
of a cane, walker, or knee sleeve. The cane should be held
JAAPA Journal of the American Academy of Physician Assistants
Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
An update on primary care management of knee osteoarthritis
Activity modification/avoidance
Weight loss
Low-impact exercise
Self Knee sleeve
management Cane/walker
NSAIDs
Physical therapy for exercise
programming
Corticosteroid injection
Nonoperative
Acetaminophen
interventions
Tramadol
Arthroscopy if indicated
Growth factor injection
Unloader bracing
Orthopedic Osteotomy
Unicompartmental knee arthroplasty
referral
Total knee arthroplasty
FIGURE 2. Knee osteoarthritis treatment recommendations.
Bolded items showed strong evidence in the AAOS analysis
and guidelines.
in the opposite hand of the most affected knee. Often a
knee sleeve can provide subjective improvement in symp-
toms, which is likely related to compressive effect and
improved neuromuscular feedback. Research by Berry and
colleagues found the use of a simple neoprene knee sleeve
decreased pain and was associated with short-term subjec-
tive improvement.15
Physical therapy referral is often recommended for man-
agement of knee osteoarthritis. Physical therapy programs
focused on strengthening and proprioception have shown
improvement in symptoms.12 The use of physical agent
modalities, including electrical stimulation, shortwave dia-
thermy, transcutaneous electrical nerve stimulation (TENS),
and ultrasound have shown mixed results. Atamaz and
colleagues compared these with sham procedures and found
no significant improvement at 4, 12, or 26 weeks.16 Several
studies have demonstrated evidence that ultrasound treat-
ments provided improvements in both pain and function.17
Due to the available data, the AAOS guidelines did not
recommend for or against the use of physical agent modal-
ities in physical therapy.12 As noted, physical therapy refer-
ral is beneficial for development and monitoring exercise
programming but not for physical agent modality care alone.
Manual therapy, such as joint mobilization, chiropractic
care, joint manipulation, and myofascial release, may
occasionally provide symptom relief, but is not included
www.JAAPA.com 39
CME
as part of the recommendations because none of the
reviewed studies met the AAOS inclusion criteria.12 One
study did find that Swedish massage therapy had statisti-
cally significant results at 8 weeks, but not at 16 weeks.18
Several studies indicated potential for clinical improvement
in patients receiving acupuncture, but none of these studies
showed evidence of statistically significant efficacy.19,20
Nonsurgical attempts to modify forces at the knee joint
include bracing, specifically unloader bracing. Unloader
braces transfer forces away from the involved compartment
of the knee and to less-arthritic areas. In patients with
medial osteoarthritis, a brace is applied to the knee that
creates a valgus force and directs more of the force through
the lateral compartment of the knee. Unloader bracing can
address medial and lateral compartment osteoarthritis.
Studies comparing unloader bracing to neoprene sleeve
use and appropriate self-management programs, and to
self-management alone were unable to show significant
improvement in pain and function with unloader bracing
across these groups.21,22
Studies evaluating the use of lateral wedge insoles versus
neutral insoles in patients with medial osteoarthritis dem-
onstrated no significant difference in pain or function.23
The alteration of foot alignment had no direct effect on
the knee and the anticipated off-loading effect was not
significant in improving symptoms.23
PHARMACOLOGIC TREATMENT
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the
cornerstone of pharmacologic treatment for symptomatic
knee osteoarthritis. NSAIDs are available in oral and
topical forms, and one, ketorolac tromethamine, is available
as a nasal spray. NSAIDs inhibit inflammatory pathways
and cytokine production, reducing pain and swelling. Each
of the nine classes of NSAIDs has a slightly different profile
and pharmacology. Because of this, if one class of NSAIDs
is ineffective in a patient, another class may provide relief.
If an NSAID is indicated, consider cost, adherence, and
adverse reaction profile before prescribing. Also consider
the known risk of cardiovascular events and the gastroin-
testinal (GI) risk, specifically GI bleeding. Older adults
may be at higher risk for these adverse reactions. Patients
who are on long-term anticoagulation also warrant special
consideration, as NSAIDs can increase patients bleeding
risk. Topical NSAID ointments, which have low systemic
absorption, may be an option in these patients. In develop-
ing the AAOS guidelines, no harms analysis was performed
in regards to NSAIDs.12
Traditionally, providers have chosen to begin treatment
with acetaminophen as needed for pain. The current sys-
tematic review showed a lack of clinically significant improve-
ment with the use of oral acetaminophen when compared
with placebo.24 At this time, the AAOS was unable to
recommend the use of acetaminophen, although it may
continue to be useful to treat breakthrough soreness.12
40 www.JAAPA.com
Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Tramadol, another pharmacologic option, is a weak
mu-opioid receptor agonist. Because of the weaker nature
of its opioid action, tramadol has a more tolerable adverse
reaction profile and somewhat less risk of dependency at
lower dosages than more potent opioids. Research by
Fishman and colleagues did not show significant difference
in efficacy between 100 mg, 200 mg, and 300 mg doses of
tramadol.25 Lower-dose tramadol should be used when
indicated because improvement in pain with tramadol is
not dose-dependent, and lower doses minimize the drugs
risks and adverse reactions.
The literature review used in developing the AAOS
guidelines did not uncover significantly relevant studies
relating to the use of opioids or pain patches in the primary
treatment of knee osteoarthritis.12 Because opioids can
cause many adverse reactions (including constipation,
respiratory depression, and death) and have an addictive
potential, they should be reserved for breakthrough pain
on a limited basis, as appropriate.
Glucosamine and chondroitin formulations, either alone
or in various combinations, often are used by patients with
knee osteoarthritis. These formulations are classified as
supplements, so formulations and quality can vary greatly.
Study of glucosamine and chondroitin has not found evi-
dence to indicate that these supplements significantly
improve clinical outcomes.26,27 Because of this, the AAOS
does not recommend use of glucosamine or chondroitin.12
INTRA-ARTICULAR TREATMENT OPTIONS
Osteoarthritis is not only a physical wearing of the joint
surface, but also a chemical and inflammatory process.
Laboratory studies of joint aspirate of osteoarthritic knees
show decreased synovial fluid viscosity and hyaluronic
acid concentration. Hyaluronic acid is a major component
of synovial fluid and one of the fluids main lubricating
components. Additionally, patients with osteoarthritis have
increased inflammatory cytokines and free radicals.
Needle lavage has been attempted to improve these
dynamics. A large-gauge needle is introduced intra-artic-
ularly, aspirating the joint fluid, and cycling sterile saline
through the joint before final fluid aspiration. This proce-
dure has not been shown to produce measurable benefit
for patients in either pain or function.28
Routinely, knee osteoarthritis has been treated in both
primary care and orthopedics offices with intra-articular
corticosteroid injections aimed at reducing inflammation
and pain and improving knee function. These improvements
are often transitory. In a series of three studies used in the
AAOS guidelines, corticosteroids were found to better-
reduce pain than placebo at 4 weeks, but were inferior to
hyaluronic acid injections.29,30 Additionally, intra-articular
corticosteroids were found inferior to needle lavage.31
Due to these findings, the use of intra-articular corticosteroids
was given an inconclusive recommendation by AAOS.12
Corticosteroid injections remain appropriate for use, with
Volume 28 Number 1 January 2015

an understanding of their indications and limitations.
Perhaps the most significant change to the AAOS guide-
lines was the recommendation against the use of hyaluronic
acid injections for osteoarthritis. Hyaluronic acid injections
have become an integral part of the osteoarthritis treatment
algorithm in both primary care and orthopedic offices.
Research has been variable in terms of statistically sig-
nificant effect of these injections. Not all hyaluronic acid
injections are identical; they can vary significantly in
molecular weight, with several formulations being much
lower molecular weight than native hyaluronic acid. Higher
weight (>750 kDa) and cross-linked formulations had
statistically significant improvement, though not to the
level of the minimal clinically significant improvement
threshold used by the AAOS.12 The recommendation against
the use of hyaluronic acid injections was based on this
finding and not on potential harm.12
Another treatment under study is intra-articular injection
of growth factors by platelet-rich plasma preparations. The
plasma preparations are prepared in a variety of ways, but
commonly use autologous blood drawn at the time of injec-
tion through venipuncture. The blood is spun in a centrifuge
to separate the blood elements, with the top platelet layer
being drawn off for injection. This layer of platelets is also
high in growth factors, which play a key role in the control
of inflammatory processes. No consensus exists on specific
formulations and concentrations of platelet-rich plasma
preparations.12 Data on the clinical application of growth
factors or platelet-rich plasma are limited, although some
basic science research has indicated promise.32,33 For these
reasons, platelet-rich plasma injections remain generally
outside the purview of the primary care provider.
REFERRAL
Patients who continue to have significant disability and
symptoms despite appropriate treatment should be referred
to an orthopedic surgeon for consideration for joint replace-
ment surgery. Younger patients with significant osteoar-
thritis should be referred early to an orthopedic surgeon.
Referral is also appropriate if the provider is not comfort-
able with intra-articular injections. Additional criteria for
referral include increased varus or valgus deformities, as
well as patients with chronic or increasing flexion contrac-
ture or loss of flexion to less than 110 degrees. These
factors, specifically deformity, bone loss, and loss of range
of motion, can affect eventual surgical outcomes.
SURGICAL TREATMENT
Routinely, patients present with pathology in addition to
the primary osteoarthritis diagnosis, including torn menisci
or loose bodies (fragments of bone or cartilage free-
floating in the joint space). For these patients, surgical
treatment with arthroscopy is not necessarily indicated,
even in patients with a diagnosis and MRI findings of
meniscal tear.
JAAPA Journal of the American Academy of Physician Assistants
Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
An update on primary care management of knee osteoarthritis
Surgical treatment may be helpful in a subset of patients
with symptomatic osteoarthritis and primary signs and
symptoms of meniscal tearing. Careful patient selection is
key. Indications for surgery are either mechanical catching-
type symptoms from a loose body or new onset, sharper,
stabbing pain consistent with primary meniscal tear. In
patients who did not have these indications, Herrlin and
colleagues demonstrated no significant benefit to treatment
with arthroscopy at 8 weeks and 6 months postoperative.34
The potential benefit, both short- and long-term, should
be weighed against the inherent risks of surgery and recov-
ery, including anesthesia complications, venous thrombo-
embolism, and infection.
Study of less-invasive surgical treatment with arthroscopy
for lavage and/or debridement has been examined in
patients with significant, nonmechanical osteoarthritis
symptoms with the goal of avoiding the lengthy recovery
following total knee arthroplasty. Two studies examined
arthroscopic treatment for patients whose primary diag-
nosis was osteoarthritis. These studies excluded patients
with surgical meniscal tears, loose bodies, or other mechan-
ical pathology. The resulting data did not demonstrate
clinical benefit from either arthroscopic lavage or debride-
ment to treat knee osteoarthritis.35,36
Historically, attempts have been made to surgically insert
free-floating interpositional devices intra-articularly to act
as a spacer between arthritic surfaces. These devices have
had extremely high failure rates due to reoperation, revi-
sion to total knee arthroplasty, or from persistently poor
pain scores postoperatively. The revision rate to total knee
arthroplasty in these patients was 32% at 26 months
postoperative.37 For these reasons, interpositional devices
are not recommended.12
In a limited subset of younger patients with unicompart-
mental osteoarthritis, a valgus or varus producing oste-
otomy may be considered to permanently bring the knee
into better alignment. An osteotomy is a significant pro-
cedure with associated perioperative and postoperative
risks; careful patient selection is key. Bilateral long leg
radiographs can be helpful in determining the degree of
knee alignment abnormality. This procedure is generally
reserved for patients age 50 years and younger who would
benefit considerably from delaying total knee arthroplasty.
Most patients are better treated definitively by prosthetic
resurfacing with total knee arthroplasty or, in some cases,
unicompartmental arthroplasty.
Definitive treatment with total knee arthroplasty is effec-
tive and cost effective, providing patients with improved
function and quality of life with reduced pain. This invasive
surgery, however, is not without risk, so patient education
and recommendation for surgery should be carefully con-
sidered, weighing the risks versus benefits. Recent long-term
series show that after 10 years, more than 95% of total
knee arthroplasty implants are still in place.38 Longer-term
studies have shown near 80% implant survival at 20 years.39
www.JAAPA.com 41
CME
Concerned with the potential need for revision of total
knee arthroplasty in younger patients, some patients and
providers may recommend delaying surgical treatment.
For patients who have failed to improve with other appro-
priate treatment options and who are significantly limited,
total knee arthroplasty should still be considered regardless
of age, on a case-by-case basis.
CONCLUSION
The updated AAOS guidelines provide specific recom-
mendations for various treatment options; however,
clinicians must determine which options are appropriate
for each patient. An inconclusive recommendation in the
guidelines does not preclude the provider from using these
treatment options when appropriate. Specifically, the
recommendation against the use of hyaluronic acid injec-
tions can create a treatment dilemma, especially for
patients who cannot tolerate anti-inflammatory medica-
tions. Because hyaluronic acid injections vary in formu-
lation and effect, ongoing evaluation of their effectiveness
is important. The change in recommendation against
acetaminophen and for the use of tramadol for pain
control likely will affect treatment patterns in primary
care and orthopedic offices, with increased reliance on
NSAIDs.
Primary care providers have much to offer in the team
approach to the management of knee osteoarthritis. Under-
standing current treatment recommendations, along with
appropriate imaging and experience evaluating painful
knees, will help providers manage symptomatic knee
osteoarthritis and know when to refer patients to ortho-
pedic specialists. JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.
org. Successful completion is defined as a cumulative score of at least
70% correct. This material has been reviewed and is approved for 1
hour of clinical Category I (Preapproved) CME credit by the AAPA. The
term of approval is for 1 year from the publication date of January 2015.
REFERENCES
1. Centers for Disease Control and Prevention (CDC). Prevalence
of doctor-diagnosed arthritis and arthritis-attributable activity
limitationUnited States, 2007-2009. MMWR Morb Mortal
Wkly Rep. 2010;59(39):1261-1265.
2. Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of
symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59(9):
1207-1213.
3. Hootman JM, Helmick CG. Projections of US prevalence of
arthritis and associated activity limitations. Arthritis Rheum.
2006;54(1):226-229.
4. Cram P, Lu X, Kates SL, et al. Total knee arthroplasty volume,
utilization, and outcomes among Medicare beneficiaries,
1991-2010. JAMA. 2012;308(12):1227-1236.
5. Yelin E, Murphy L, Cisternas MG, et al. Medical care expendi-
tures and earnings losses among persons with arthritis and other
rheumatic conditions in 2003, and comparisons with 1997.
Arthritis Rheum. 2007;56(5):1397-1407.
42 www.JAAPA.com
Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
6. Coleman S, Briffa NK, Carroll G, et al. A randomised controlled
trial of a self-management education program for osteoarthritis
of the knee delivered by health care professionals. Arthritis Res
Ther. 2012;14(1):R21.
7. Roddy E, Zhang W, Doherty M, et al. Evidence-based recom-
mendations for the role of exercise in the management of
osteoarthritis of the hip or kneethe MOVE consensus.
Rheumatology (Oxford). 2005;44(1):67-73.
8. Silva LE, Valim V, Pessanha AP, et al. Hydrotherapy versus
conventional land-based exercise for the management of patients
with osteoarthritis of the knee: a randomized clinical trial. Phys
Ther. 2008;88(1):12-21.
9. Fitzgerald GK, Piva SR, Gil AB, et al. Agility and perturbation
training techniques in exercise therapy for reducing pain and
improving function in people with knee osteoarthritis: a
randomized clinical trial. Phys Ther. 2011;91(4):452-469.
10. Kovar PA, Allegrante JP, MacKenzie CR, et al. Supervised fitness
walking in patients with osteoarthritis of the knee. A randomized,
controlled trial. Ann Intern Med. 1992;116(7):529-534.
11. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects of
an integrated approach of hatha yoga therapy on functional
disability, pain, and flexibility in osteoarthritis of the knee joint:
a randomized controlled study. J Altern Complement Med.
2012;18(5):463-472.
12. American Academy of Orthopaedic Surgeons. The treatment
of osteoarthritis of the knee2nd edition clinical practice
guideline. May 18, 2013. http://www.aaos.org/Research/
guidelines/GuidelineOAKnee.asp. Accessed October 3, 2014.
13. Muthuri SG, Hui M, Doherty M, Zhang W. What if we prevent
obesity? Risk reduction in knee osteoarthritis estimated through
a meta-analysis of observational studies. Arthritis Care Res.
2011;63(7):982-990.
14. Huberti HH, Hayes WC. Patellofemoral contact pressures. The
influence of q-angle and tendofemoral contact. J Bone Joint Surg
Am. 1984;66(5):715-724.
15. Berry H, Black C, Fernandes L, et al. Controlled trial of a knee
support (Genutrain) in patients with osteoarthritis of the knee.
Eur J Rheumatol Inflamm. 1992;12:30-34.
16. Atamaz FC, Durmaz B, Baydar M, et al. Comparison of the
efficacy of transcutaneous electrical nerve stimulation, interfer-
ential currents, and shortwave diathermy in knee osteoarthritis:
a double-blind, randomized, controlled, multicenter study. Arch
Phys Med Rehabil. 2012;93(5):748-756.
17. Yang PF, Li D, Zhang SM, et al. Efficacy of ultrasound in the
treatment of osteoarthritis of the knee. Orthop Surg. 2011;3(3):
181-187.
18. Perlman AI, Sabina A, Williams AL, et al. Massage therapy for
osteoarthritis of the knee: a randomized controlled trial. Arch
Intern Med. 2006;166(22):2533-2538.
19. Berman BM, Lao L, Langenberg P, et al. Effectiveness of
acupuncture as adjunctive therapy in osteoarthritis of the knee:
a randomized, controlled trial. Ann Intern Med. 2004;141(12):
901-910.
20. Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee
osteoarthritis: a randomized controlled trial of acupuncture,
physiotherapy (supervised exercise) and standard management
for patients awaiting knee replacement. Rheumatology
(Oxford). 2007;46(9):1445-1449.
21. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of
bracing on varus gonarthrosis. J Bone Joint Surg Am. 1999;81
(4):539-548.
22. Brouwer RW, van Raaij TM, Verhaar JA, et al. Brace treatment
for osteoarthritis of the knee: a prospective randomized
multi-centre trial. Osteoarthritis Cartilage. 2006;14(8):777-783.
23. Bennell KL, Bowles KA, Payne C, et al. Lateral wedge insoles for
medial knee osteoarthritis: 12 month randomised controlled
trial. BMJ. 2011;342:d2912.
Volume 28 Number 1 January 2015

24. Miceli-Richard C, Le Bars M, Schmidely N, Dougados M.
Paracetamol in osteoarthritis of the knee. Ann Rheum Dis.
2004;63(8):923-930.
25. Fishman RL, Kistler CJ, Ellerbusch MT, et al. Efficacy and safety
of 12 weeks of osteoarthritic pain therapy with once-daily
tramadol (Tramadol Contramid OAD). J Opioid Manag. 2007;
3(5):273-280.
26. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin
sulfate, and the two in combination for painful knee osteoarthri-
tis. N Engl J Med. 2006;354(8):795-808.
27. Tr T, Bohmov J. Efficacy and tolerance of enzymatic hydro-
lysed collagen (EHC) vs. glucosamine sulphate (GS) in the
treatment of knee osteoarthritis (KOA). Int Orthop. 2011;35
(3):341-348.
28. Bradley JD, Heilman DK, Katz BP, et al. Tidal irrigation as
treatment for knee osteoarthritis: a sham-controlled, randomized,
double-blinded evaluation. Arthritis Rheum. 2002;46(1):100-108.
29. Chao J, Wu C, Sun B, et al. Inflammatory characteristics on
ultrasound predict poorer longterm response to intraarticular
corticosteroid injections in knee osteoarthritis. J Rheumatol.
2010;37(3):650-655.
30. Caborn D, Rush J, Lanzer W, et al. A randomized, single-blind
comparison of the efficacy and tolerability of hylan G-F 20 and
triamcinolone hexacetonide in patients with osteoarthritis of the
knee. J Rheumatol. 2004;31(2):333-343.
31. Arden NK, Reading IC, Jordan KM, et al. A randomised
controlled trial of tidal irrigation vs corticosteroid injection in
knee osteoarthritis: the KIVIS Study. Osteoarthritis Cartilage.
2008;16(6):733-739.
JAAPA Journal of the American Academy of Physician Assistants
Copyright 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
An update on primary care management of knee osteoarthritis
32. Snchez M, Fiz N, Azofra J, et al. A randomized clinical trial
evaluating plasma rich in growth factors (PRGF-Endoret)
versus hyaluronic acid in the short-term treatment of
symptomatic knee osteoarthritis. Arthroscopy. 2012;28(8):
1070-1078.
33. Snchez M, Anitua E, Azofra J, et al. Intra-articular injection of
an autologous preparation rich in growth factors for the
treatment of knee OA: a retrospective cohort study. Clin Exp
Rheumatol. 2008;26(5):910-913.
34. Herrlin SV, Wange PO, Lapidus G, et al. Is arthroscopic surgery
beneficial in treating non-traumatic, degenerative medial
meniscal tears? A five year follow-up. Knee Surg Sports
Traumatol Arthrosc. 2013;21(2):358-364.
35. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized
trial of arthroscopic surgery for osteoarthritis of the knee. N
Engl J Med. 2008;359(11):1097-1107.
36. Moseley JB, OMalley K, Petersen NJ, et al. A controlled trial of
arthroscopic surgery for osteoarthritis of the knee. N Engl J
Med. 2002;347(2):81-88.
37. Sisto DJ, Mitchell IL. UniSpacer arthroplasty of the knee. J Bone
Joint Surg Am. 2005;87(8):1706-1711.
38. Ltzner J, Hbel U, Kirschner S, et al. Long-term results in total
knee arthroplasty. A meta-analysis of revision rates and
functional outcome. Chirurg. 2011;82(7):618-624.
39. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS. Factors
affecting the durability of primary total knee prostheses. J Bone
Joint Surg Am. 2003;85-A(2):259-265.
www.JAAPA.com 43