Osteoarthritis of the Knee Joint is a quite common condition found in Indian Population. This presentation is made to understand how this condition affects patients and what are the different Physiotherapy measures to make the patient functionally independent.

1. OSTEOARTHRITIS
OF KNEE JOINT
-Dr.Aniruddha Barot (PT)
B.P.T., M.P.T.(Musculoskeletal),
C.K.T.T.
AssistantProfessor
SKUM College of
Physiotherapy

2. OVERVIEW
Introduction
Factors responsible for OA knee
Classificationof OA
Clinical classification criteria
Clinical features
Radiographic features
Common structural and functional
impairments
Common activity limitations and
participation restrictions
Physiotherapy management guidelines
Physiotherapy management
References

3.  INTRODUCTION
•Osteoarthritis (OA) is a chronic degenerative disorder primarily affecting the articular
cartilage of synovial joints, with eventual boney remodeling and overgrowth at the margins
of the joints (spurs).
•There is also progression of synovial and capsular thickening and joint effusion.
•Articular cartilage destruction typically is more apparent on the medial than lateral aspect of
the knee.
•OA is more common in the weight bearing joints.i.e. The hip, the knee, the ankle.
•Pain, muscle weakness, medial joint laxity and limitation of joint motion affect function and
lead to disability.
•Deformity such as genu varum commonly develops in the knees.
•Knee instability(the sensation of knee buckling or shifting) is also frequently reported by
individuals with knee oa and significantly contributes to impaired physical function

4.  INTRODUCTION

5.  FACTORS RESPONSIBLE FOR OA
KNEE
1. Excessive weight
2. Female > male
3. Joint trauma
4. Developmental deformities
5. Weakness of quadriceps muscle
6. Abnormal tibial rotation
7. Poor posture
8. Diabetes mellitus
9. Overuse of intra-articular steroid therapy
10. Occupational stress and strain (jobs that require kneeling & squatting with heavy lifting)
11. Hyperparathyroidism

6.  CLASSIFICATION OF OA
•OA is often graded on radiographs according to the criteria of kellgren and lawrence,
using the ordinal scale of 5 levels.
Grade 0: normal radiograph
Grade 1: doubtful narrowing of joint space and possibleosteophytes
Grade 2: definite osteophytes and absent or questionablejoint space narrowing
Grade 3: moderate osteophytes and joint space narrowing, some sclerosis and
possibledeformity
Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosisand
definite deformity.

7.  CLINICAL CLASSIFICATION
CRITERIA FOR KNEE OA
Knee pain
Joint stiffness ≤30 minutes
Crepitus
Bony enlargement
Bony tenderness
No palpable warmth

8.  CLINICAL FEATURES
1. Pain which decreases on walking
2. Poorly localized pain
3. Pain which is dull aching in nature
4. Mild swelling of the knee joint
5. Early morning stiffness
6. Coarse crepitus
7. Minimal tenderness
8. If loose bodies present within the joint then patient can gives h/o locking/giving way of joint
9. Terminal movements of knee are restricted
10. Genu varum deformity may be seen in advanced cases

9.  RADIOGRAPHIC FEATURES
Plain X ray of knee shows following changes:
Loss of joint space
Sclerosis
Subchondral cyst
Osteophytes
Bony collapse
Loose bodies
Deformity and malalignment

10.  COMMON STRUCTURAL AND
FUNCTIONAL IMPAIRMENTS
•With joint involvement, the pattern of restriction at the knee is usually more loss of flexion
than extension.
•When there is effusion, the joint assumes a position near 25º of flexion, the positionat
which there is greatest capsular distensibility. Little motion is possible because of swelling.
•Symptoms of joint involvement, such as distension,stiffness, pain and reflex quadriceps
inhibitionmay cause extensor (quadriceps)lag in which the active range of knee extension
is less than the passive range available.
•Impaired balance responses have also been reported in patients with arthritis.

11.  COMMON ACTIVITY LIMITATIONS
AND PARTICIPATION RESTRICTIONS
•There is pain during motion, weight bearing and gait ; that may interfere with work or routine
ADL.
•There is limitation of or difficulty in controlling, weight bearing activities that involves knee
flexion: such as sitting down on ground, ascending or descending stairs, stoopingor squatting.
•Less participation in leisure and household activities:
Leisure activities Household activities
Walking Dusting
Gardening Washing floors
Swimming Cleaning
Shopping

12.  PHYSIOTHERAPY MANAGEMENT GUIDELINES
PLAN OF CARE INTERVENTION
1. Educate the patient. • Teach about deforming forces and prevention.
• Teach home exercise program to reinforce
intervention & minimize symptoms.
2. Decrease effects of stiffness. • Active ROM
• Joint-play mobilization techniques.
3. Decrease pain from mechanical stress &
prevent deforming forces.
• Splinting &/or assistive equipment to minimize
stress or to correct biomechanics
• Alternate activity with rest.
4. Increase ROM • Stretch muscle, joint or soft tissue restriction with
specific techniques.
5. Improve neuromuscular control, strength
& muscle endurance.
• Low intensity resistance exercise & muscle
repetitions.
6. Improve balance. • Balance training activities.
7. Improve physical conditioning. • Nonimpact or low-impact aerobic exercise.

13. PHYSIOTHERAPY MANAGEMENT
Management- Protection
Phase
Management- Controlled
Motion and Return to Function
Phase

14. MANAGEMENT- PROTECTION
PHASE
A: Control pain and protect the joint:
Patient education:it is important to teach the patient methods to protect the joint, ROM
and muscle setting exercises to maintain mobility & promote blood flow and safe
functional activities that reduce stresses on the knee.
Functionaladaptations:Instruct the patient to minimize stair climbing, use elevated
seats on commodes and avoid deep-seated or low chairs in order to minimize stressful
knee flexion ranges while weight bearing.
If necessary during an acute flair of arthritis, have the patient use crutches, canes or a
walker to distribute the forces through the upper extremities while walking.

15. MANAGEMENT- PROTECTION
PHASE
B: Maintain soft tissue and joint mobility:
Passive,active-assistive or active ROM exercises: use ROM techniques within the limits
of pain and available motion.
Straight leg
raise exercise
Short arc knee
extension
exercise

16. MANAGEMENT- PROTECTION
PHASE
Full arc knee extension
exercise
Prone knee bending
exercise

17. MANAGEMENT- PROTECTION
PHASE
Grade 1 or 2 Joint distraction and anterior/posteriorglides: apply gentle joint
techniques, with the joint in or near resting position(25º flexion).
These techniques are used to inhibit pain as well as maintain joint mobility.
C: Maintain muscle function and prevent patellar adhesions:
 Setting exercises: perform pain-free quadriceps and hamstring setting exercises with the
knee in various pain free positions,quads sets with leg raises and submaximal closed chain
muscle setting exercises.
Quads sets may help to maintain mobility of the patella.

18. MANAGEMENT- PROTECTION
PHASE
• Patient is in supine lying position with
knee extended.
• Ask the patient to push back of the knee
downward hold forabout 6 seconds
then rest up to 10 seconds.
Hamstring setting exercise :
• Patient is in supine lying position.
• A rolled towel placed under knee.
• Instruct the patient to gently push the heel into
the treatment table.
• Hold for few seconds then relax.
Hamstring setting

19. As joint effusion decreases & joint tissues are able to tolerate increased stresses, the goals of
treatment change to deal with the impairments that interfere with functional activities.
A: Educate the patient:
Inform the patient about his/her condition, what to expect regarding recovery and how to
protect the joint.
Instruct the patient to perform active ROM and muscle strengthening techniques frequently
during the day, especially prior to bearing weight, in order to reduce the painful symptoms that
occur with initial weight bearing.
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

20. B: decrease pain from mechanical stress:
Continue use of assistive devices for ambulation, if necessary.
Continue use of elevated seats on commodes and chairs, if needed, to reduce mechanical
stresses imposed when attempting to stand.
C: Increase joint play and ROM:
Joint mobilization:when there is loss of joint play and decreased mobility, joint
mobilization techniques should be used.
Apply grade 3 or 4 sustained or oscillatory techniques to the tibio-femoral or patella-femoral
articulations with the joint positioned at the end of its available range before applying the
mobilization technique.
To increase flexion: place tibia in medial rotation and apply posterior glide.
To increase extension: place tibia in lateral rotation and apply anterior glide.
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

21.  MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

22.  MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE
Stretching techniques:Passive or PNF stretching techniques are used to increase
extensibilityof the muscles and extra-capsular non-contractile tissues that restrict knee
motion.
Use low intensity, long duration stretches within the patient’s tolerance.
Mobilize the patella-femoral and tibio-femoral joints before stretching in order to improve
gliding of the joint surfaces during stretch maneuvers.
Mobilization with movement : MWM may be applied to increase ROM &/or decrease pain
associated with movement by improving joint tracking.
D: Improve muscle performance in supporting muscles:
Progressivestrengthening:begin with multiple angle isometrics to both knee flexors and
extensors & active ROM exercise in open chain & close chain positionsusing a moderate rate
of progression of repetitions & resistance in arcs of pain-free motion.
Exercise intensityshould be within the tolerance of the joint and not exacerbate symptoms.

23. Open chain exercises:
Straight leg
raise exercise
Full arc knee
extension
Prone knee
bending
Short arc knee
extension
Hamstring
curls
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

24. Close chain exercises:
Forward
scooting on a
wheeled stool
Wall slides
Lunge
Unilateral
closed chain
terminal knee
extension
Forward step up on a low stool
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

25. Functionaltraining: climbing steps, sitting down and rising up from chairs and commodes and
using safe body mechanics to lift objects from floor are often compromised in individuals with
arthritis.
It is imperative to strengthen the knee musculature using functional modification activities,
progressing the difficulty as strength improves.
LungeWall slides
Forward step up on a low stool
• Begin with low step height
• Progress to the height the pt. requires for home
• Forward, lateral and backward stepping
• Stay within pain-free
range
• This activity is progressedto
include lunging to pick up
small objects from the floor
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

26. Ambulation:decrease use of assistive devices as quadriceps strength improves to MMT level
4/5 and as gait is normalized and symmetrical.
Practice walking on variety of terrains & up and down ramps & reverse directions, first with
assistance then independently.
E: Improve Cardio-pulmonary Endurance:
swimming, water aerobics and aquatic exercise: provide an environment for improving
muscular and cardio-pulmonary endurance.
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

27. Bicycling:is a low impact form of exercise.
Adjust seat height so the knee goes into complete extension (but not hyperextension) when
the pedal is down.
On a stationary bike, use low resistance.
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

28. High impact activities- with caution: For some patients, progression to
running/jumping rope & other high impact activities can be undertaken as long as the joint
is asymptomatic.
If joint deformity is present & proper biomechanics cannot be restored, the patient
probably cannot progress to these activities.
 MANAGEMENT- CONTROLLED MOTION
AND RETURN TO FUNCTION PHASE

29.  REFERENCES
 Kisner C. Therapeutic Exercises: Foundations and Techniques, 6th Edition.
Jaypee Publications.

30. THANK YOU…