Knee osteoarthritis assessment and treatment — Rapid

Synopsis

Identify clinically typical knee osteoarthritis, separate inflammatory, infective, mechanical and referred alternatives, build core exercise and weight treatment around the person's function, prescribe safely, and escalate appropriately to replacement assessment.

Use NICE's clinical pattern: age at least 45, activity-related joint pain and no or no more than 30 minutes of morning stiffness; do not routinely image a typical presentation.
Assess gait, alignment, effusion, extension and flexion, joint lines, patellofemoral tracking, quadriceps strength, ligament stability and hip and neurovascular sources.
Therapeutic exercise and supported weight management are core treatment; discomfort can initially increase, but regular progressive strengthening and aerobic work improve pain and function.
Offer a topical NSAID for knee osteoarthritis. If ineffective or unsuitable, consider a short oral NSAID with risk review and gastroprotection.
Paracetamol and weak opioids are not routine; reserve infrequent short-term use for when other options cannot be used or have failed, and do not offer strong opioids.
Consider intra-articular corticosteroid for approximately 2 to 10 weeks of relief when other medicines are unsuitable or to support exercise; do not offer intra-articular hyaluronan.
Bracing and insoles are not routine unless instability or abnormal biomechanical loading is present and exercise alone is insufficient; walking aids can improve confidence and unloading.
Refer for replacement when symptoms substantially affect quality of life despite ineffective or unsuitable non-surgical care, without using numerical scores, age, BMI or smoking alone to block referral.

Key red flags

A hot swollen knee with systemic illness or severe passive-movement pain requires urgent aspiration and septic-arthritis treatment sequencing.

A true locked knee that cannot fully extend after an acute mechanical event needs urgent soft-tissue knee assessment rather than routine physiotherapy alone.

Traumatic inability to bear weight, focal bony tenderness or deformity requires fracture assessment before a degenerative pathway.

Calf swelling, absent pulses, foot coolness or new neurological deficit requires vascular and thromboembolic assessment and must not be labelled referred osteoarthritis pain.

Investigation priorities

First-line clinical diagnosisFirst stepFirst line

Recognise a typical syndrome and establish functional baseline.

Management branches

CoreExercise, weight and education first

The clinical pattern is typical and no urgent competing diagnosis is present.

Agree meaningful goals and prescribe progressive knee and hip strengthening, aerobic activity and range work.
Offer sustained weight support when relevant and address walking aids, pacing and participation barriers.
Offer topical NSAID and escalate cautiously only when function remains limited.
Review function, adherence, adverse effects and diagnostic fit at an agreed interval.

Key medicines

Topical NSAIDOffer a licensed topical NSAID preparation for the painful knee at the product's adult frequency, typically applied three or four times daily depending on formulation, for a time-limited trial with review of function and skin tolerance.Check NSAID hypersensitivity, broken skin, pregnancy and concurrent NSAID use; systemic absorption still matters in severe renal, gastrointestinal or cardiovascular risk, and handwashing and product-specific dosing should be explained.

Oral NSAID plus proton-pump inhibitorIf topical treatment is ineffective or unsuitable, use one oral NSAID at the lowest effective licensed dose for the shortest period and co-prescribe gastroprotection such as omeprazole 20 mg orally once daily while the NSAID continues when appropriate.Assess ulcer, bleeding, kidney, liver and cardiovascular risk, frailty, blood pressure, anticoagulants, antiplatelets and pregnancy; never combine oral NSAIDs and stop during dehydration or acute renal deterioration.

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