Since the release of the first Osteoarthritis of the Knee Clinical Care Standard in 2017, evidence has continued to emerge on the benefits and harms of osteoarthritis treatments and we now have a better picture of what constitutes ‘low-value care’.

The landscape of clinical care has also advanced, with the focus firmly on patient-centred, inclusive and culturally safe care.

To address these issues, the Osteoarthritis of the Knee Clinical Care Standard was revised and the update launched in August 2024 by the Australian Commission on Safety and Quality in Health Care (ACSQHC 2024a).

The Clinical Care Standard has been endorsed by 22 organisations, including the APA.

As well as considering new evidence and expanded priorities for reducing low-value care, the revised Clinical Care Standard incorporates practical advice to support effective clinician–consumer communication and promote cultural safety.

It also fosters equity so that people with knee osteoarthritis receive consistent care, regardless of where they live or whether they are accessing care via public or private providers.

Clinical scenario

Physiotherapist and researcher Samantha Bunzli was an invited member of the ACSQHC Review Working Group for the Osteoarthritis of the Knee Clinical Care Standard.

Tom is a 67-year-old man who recently presented to his physiotherapist with a three-month history of knee pain.

The pain is worse with activities such as walking, going up and down stairs and getting out of a car.

Tom’s knee is stiff in the morning for the first 15 minutes after he gets out of bed and it occasionally ‘gives way’ when he is walking.

One of his friends recently had a knee replacement and Tom wants to know if he should also see a surgeon.

He has not tried any specific exercises for his knee and lives a relatively sedentary lifestyle.

His GP did not refer him for an X-ray, advising Tom that based on his history and physical examination, his symptoms were most likely due to knee osteoarthritis.

Tom’s GP recommended that he see his local physiotherapist as part of a multidisciplinary care approach.

Tom is one of over 2.1 million Australians currently living with osteoarthritis (AIHW 2024), a number that is expected to exceed 3.1 million by 2040 (Ackerman et al 2024).

Osteoarthritis of the knee, in particular, is highly prevalent and burdensome.

It is associated with pain and reduced quality of life and is responsible for nearly 60,000 years lived with disability in Australia each year (Ackerman et al 2022).

It interferes with work, family and social roles as well as the ability to manage general health and comorbid conditions.

Health system spending on osteoarthritis care in Australia is enormous.

Current reports put it at $4.3 billion per year, which includes $3.5 billion spent on hospital admissions, $105 million on imaging and $89 million on specialist appointments (AIHW 2023).

Current understanding of knee OA best practice

The Osteoarthritis of the Knee Clinical Care Standard outlines the important components of care that should be offered to all Australians with knee osteoarthritis.

It comprises eight quality statements (scroll down for a quick guide to the eight statements in the Clincal Care Standard) focused on comprehensive assessment and diagnosis, appropriate use of imaging, education and self-management, physical activity and exercise, weight management and nutrition, medicines used to manage pain and mobility, patient review and surgery.  

In line with contemporary evidence and international guidelines, the Clinical Care Standard emphasises the role of clinical diagnosis rather than imaging, which can lead to inappropriate treatment for findings that are not clinically important.

It strongly discourages the prescribing of opioids, given major harms that outweigh any likely benefits, and the use of knee arthroscopy, which also carries risk of harms and has no benefits for knee osteoarthritis.

Referral for consideration of joint replacement surgery is only recommended after optimal non-surgical management has been trialled for an appropriate period of time and there is significant pain and disability.

The updated Clinical Care Standard in practice

If you are a physiotherapist caring for people like Tom, it is important to familiarise yourself with the new Clinical Care Standard to ensure you are delivering high quality, safe and equitable osteoarthritis care.

Let’s consider how the eight quality statements might apply in Tom’s situation.

Applying the Clinical Care Standard to help Tom manage his knee OA

Professor Ilana Ackerman, deputy director of the Musculoskeletal Health Unit at Monash University, was an invited member of the ACSQHC Review Working Group for the Osteoarthritis of the Knee Clinical Care Standard.

Through your thorough clinical assessment, which includes patient-reported measures of pain and function and a psychosocial evaluation (Quality statement 1), you identify a range of factors that are likely to be contributing to Tom’s osteoarthritis experience.

This includes low levels of physical activity and being overweight, something Tom says he has been struggling with.

During the assessment, Tom mentions that he would like an X-ray to determine the extent of ‘damage’ to his knee and you take the opportunity to reinforce his GP’s advice that X-rays are not needed to diagnose knee osteoarthritis (Quality statement 2).

You go on to explain that physical activity is a safe and effective way to manage symptoms and improve function and is important for overall health and wellbeing, including weight management (Quality statements 4 and 5).

Together, you develop a tailored program that includes graduated exercises aligned to Tom’s functional goals and a plan to increase his physical activity, with consideration given to Tom’s preferences for outdoor activities that he enjoys.

You also offer Tom some information about available osteoarthritis education and exercise programs (ACSQHC 2024b), including online, telehealth-delivered and in-clinic offerings (Quality statements 3 and 4).

You plan for a clinical review in three months’ time to reassess Tom’s symptoms and level of function, progress his exercise program and set updated goals that he can work towards (Quality statement 7).

Tom agrees with the proposed plan to focus on non-surgical management strategies and understands that if his symptoms and functional impairment become severe, he can speak to his GP about options for pain control medicines (Quality statement 6) and potentially seeing an orthopaedic surgeon or rheumatologist for their opinion (Quality statement 8).

Resources available

To support you to deliver high quality, safe and equitable osteoarthritis care, each quality statement in the Clinical Care Standard is accompanied by practical advice and explanations, including strategies for effective communication with patients.

Quality statement 4: Physical activity and exercise, for example, includes tips for addressing unhelpful beliefs among patients, such as the common misconception that weight-bearing exercise is harmful.

Recommendations for working with Aboriginal and Torres Strait Islander people with osteoarthritis and their families also feature in the Clinical Care Standard.

These include engaging in effective communication, developing trusting relationships with patients and families, and collaborating with Aboriginal and Torres Strait Islander health workers, health practitioners and community services as part of a multidisciplinary care approach.

Links to helpful frameworks and resources are provided to support you in delivering culturally safe osteoarthritis care.

On the Australian Commission on Safety and Quality in Health Care website, you will find consumer resources in a range of formats that can support your patients in their self-management journey, including resources for Aboriginal and Torres Strait Islander peoples (ACSQHC 2024b).

Finally, communication resources including fact sheets and infographics are also available online (ACSQHC 2024c, ACSQHC 2024d) to raise awareness about the Clinical Care Standard and best practice care for knee osteoarthritis.

Introducing the Osteoarthritis of the Knee Clinical Care Standards: a guide for physiotherapists

This article outlines the care described in the Osteoarthritis of the Knee Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care.

The Standard provides an evidence-based approach to improve timely assessment and optimal management for patients with knee osteoarthritis; to enhance their symptom control, joint function, psychological wellbeing, quality of life and participation in usual activities; and to lessen the disability caused by knee osteoarthritis.

The Standard relates to care that patients aged 45 years and over should receive when they present with knee pain and are suspected of having knee osteoarthritis.

It does not cover management of knee pain due to recent trauma.

Quality statement 1

Comprehensive assessment and diagnosis

A patient with suspected knee osteoarthritis receives a comprehensive, person-centred assessment which includes a detailed history of the presenting symptoms, comorbidities, a physical examination, and a psychosocial evaluation of factors affecting quality of life and participation in activities. A diagnosis of knee osteoarthritis can be confidently made based on this assessment.

Assess the patient including:

• a detailed history of symptoms including pain, joint stiffness and movement; and a medical history to identify comorbidities, modifiable risk factors and response to treatment
• a physical examination and functional assessment of the affected knee(s) including gait, range of motion, joint line tenderness, malalignment or deformities, bony enlargement, effusion, restricted movement and crepitus
• identification of atypical features that may indicate alternative/additional diagnoses including prolonged morning stiffness, rapidly worsening symptoms or a hot, swollen joint
• a psychosocial evaluation to identify factors that may affect the patient’s quality of life and ability to carry out their usual activities.

Identify and address any misconceptions and unhelpful beliefs about knee osteoarthritis and its management, trajectory and treatments.

Consider using tools (for more information, refer to the Clinical Care Standard) to aid assessment and support monitoring of the patient’s condition. Select tools tailored to the patient’s individual needs and goals.

Communication tips

Recognise the impact of the person’s physical symptoms on their life and general wellbeing.

For example:

‘Joint stiffness and pain can interfere with the activities you enjoy. This can affect you emotionally, too. It’s important to know that osteoarthritis does not always get worse with time. With the right management, you can get back to doing the things you enjoy.’

Avoid harmful language that focuses on structural explanations and outdated terms such as ‘wear and tear’ and ‘bone on bone’ that can discourage patients from engaging in exercise and physical activity for fear of causing damage to the knee joint.

Comprehensive assessment of the knee can aid diagnosis of knee osteoarthritis.

Quality statement 2

Appropriate use of imaging

Imaging is not routinely used to diagnose knee osteoarthritis and is not offered to a patient with suspected knee osteoarthritis. When clinically warranted, X-ray is the first-line imaging. Magnetic resonance imaging (MRI), computerised tomography (CT) and ultrasound are not appropriate investigations to diagnose knee osteoarthritis. The limited value of imaging is discussed with the patient, including that imaging results are not required for effective non-surgical management.

Advise the patient that there is a poor correlation between radiological evidence of osteoarthritis and symptom severity.

Reassure the patient that having X-rays or other diagnostic imaging will not change initial treatment. Explain that the treatment plan will be guided by their pain, mobility and function.

Communication tips

Explain why imaging is not needed for diagnosis.

For example:

‘Two people can have the same changes on X-ray but experience the effects on their joints very differently. This tells us that other factors play a role in your knee osteoarthritis experience.’

Avoid comments that may be perceived as judgemental, such as ‘It’s normal for adults to have joint changes on X-ray but most won’t experience symptoms’.

Quality statement 3

Education and self-management

Information about knee osteoarthritis and treatment options is discussed with the patient. The patient participates in developing an individualised self-management plan that addresses their physical, functional, and psychosocial health needs.

Provide clear, comprehensive and current information about knee osteoarthritis and its management in a way that patients can understand, that is culturally appropriate and that is in a format that aligns with their preference (eg, verbal or written).

Involve the patient in developing a tailored plan to address their individual physical, functional and psychosocial needs and goals including:

• strategies to support increased physical activity participation such as pacing, managing flares and pain management techniques
• strategies to improve comfort and mobility, such as the use of walking aids
• weight management guidance
• strategies for optimising overall health, including management of comorbidities
• discussion of non-pharmacological pain management, maintaining participation in usual activities and roles, and the supports and services available
• referral to other clinicians or recommendations for services and resources that might help with self-management
• monitoring and adjustment of the management plan as needed
• involvement of the patient’s family/carers/support team as appropriate.

Document the plan in the patient’s healthcare record.

Communication tips

Provide information that is individualised to the patient’s condition and empowers them to manage their osteoarthritis proactively, using positively framed terms like ‘healthy’, ‘strong’, and ‘active’.

For example:

‘Based on your story, we can identify a range of factors that influence your experience of knee osteoarthritis—things like weight around the belly, muscle weakness, lack of confidence about using your knee and not enough sleep. The good news is that we can address these things. We can work on a plan together for you to be active, strong and healthy so you can participate in the activities you enjoy doing.’

Avoid focusing on joint changes only because this can reinforce unhelpful beliefs that self-management is futile and surgery is the only solution to fix a structural problem.

Physical activity and exercise can help manage knee pain and improve function.

Quality statement 4

Physical activity and exercise

A patient with knee osteoarthritis is advised that being active can help manage knee pain and improve function. The patient is offered advice on physical activity and exercise that is tailored to their priorities and preferences. The patient is encouraged to set exercise and physical activity goals and is recommended services or programs to help them achieve their goals.

Reassure the patient that exercise will not cause damage and is not a risky activity but will help them manage their symptoms and improve their function.

Advise the patient on exercise that is specific to their needs, preferences and clinical context including:

• tailoring exercise activities so that they are of a sufficient dose and duration to manage knee pain and improve strength, function and fitness encouraging them to set realistic and achievable goals for enjoyable physical activity such as muscle strengthening activities, incidental exercise, leisure and sporting activities
• regularly reviewing and progressing physical activity and exercise goals, with consideration of the physical environment, level of support, cultural activities, falls risk and attitudes towards physical activity
• providing clear, comprehensive and current information on modifying usual physical activities to prevent symptoms worsening or aggravating comorbidities.

Refer the patient to other clinicians or recommended services, supports and resources to assist them in achieving their goals including:

• local community programs, groups and activities links to reliable online resources
• other clinicians and multidisciplinary services as appropriate.

Note that passive manual therapies including therapeutic ultrasound and electrotherapy do not play a significant role in the management of knee osteoarthritis.

Communication tips

Use positive terms to communicate the benefits of movement and of building and maintaining strength.

For example:

‘Knee joints are strong—they stay healthy through movement and are designed to be loaded. It’s safe to be active and to move your knee, even if it’s a bit sore at the start. The key is to find the right amount of activity based on what you can do now and what you want to do in the future.’

‘Staying active is the best way to look after your osteoarthritis. It keeps your bones, joints and muscles healthy. It is also good for your general health and wellbeing.’

Avoid comments framed around reducing load, which may communicate the message that weight-bearing activities for knee osteoarthritis are harmful and may discourage physical activity and exercise.

Quality statement 5

Weight management and nutrition

A patient with knee osteoarthritis is advised of the impact of body weight on symptoms. The patient is offered support to manage their weight and optimise nutrition that is tailored to their priorities and preferences. The patient is encouraged to set weight management goals and is referred for any services required to help them achieve these goals.

Acknowledge that weight is influenced by more than just individual-level factors. It is also influenced by access to healthy, culturally appropriate food and safe places to exercise.

Advise patients about the benefits of weight management (losing excess weight or maintaining a healthy weight):

• loss of excess weight can reduce knee pain and improve function for patients with knee osteoarthritis, reducing the need for medicines and surgery, and has benefits for overall health and other comorbidities
• a 5–10 per cent or greater weight loss over 20 weeks is associated with reduced pain and improved quality of life
• a for patients who may require surgery, losing excess weight can reduce anaesthetic risk and improve post- surgical outcomes.

Support patients to maintain a healthy, sustainable weight through exercise and with the assistance of an accredited practising dietitian or GP where additional support is desired.

Communication tips

Approach conversations about weight in a sensitive, empathetic and non-judgemental way and acknowledge the challenges the patient is experiencing in managing their weight.

For example:

‘Losing even a small amount of excess weight can improve your symptoms and improve your general health. Is that something you would like to consider?’

Avoid terms like ‘fat’ or ‘obese’ that may be experienced as stigmatising and avoid using language such as ‘reducing load on the knee’ to talk about excess weight because this can reinforce unhelpful beliefs that joint loading is harmful.

The goal of medicines is to reduce pain to support continuation of daily activities.

Quality statement 6

Medicines used to manage pain and mobility

A patient with knee osteoarthritis is offered medicines to manage their pain and mobility in accordance with the current version of the Therapeutic Guidelines or locally endorsed, evidence-based guidelines. A patient is not offered opioid analgesics for knee osteoarthritis because the risk of harm outweighs the benefits.

Explain to the patient that the goal of medicines is to reduce pain to support continuation of usual daily activities:

• offer information on how medicines can be combined with physical activity and other self-management strategies to improve function and mobility
• help them understand that medicines should not replace self-management strategies such as physical activity and exercise.

Suggest that the patient speak with their GP and pharmacist regarding the management of their medicines, any possible side effects and any potential interactions.

Communication tips

Explain that medicines aren’t the only effective way to manage pain and that where recommended, they are used to supplement self-management strategies.

For example:

‘Medicines can help to control pain so that you can exercise and do your usual activities. But medicines should not replace moving your body, doing exercises to strengthen your knee or losing any excess weight.’

Quality statement 7

Patient review

A patient with knee osteoarthritis receives planned clinical review at agreed intervals, and management is adjusted for any changing needs. A patient who has worsening symptoms and severe functional impairment that persists despite optimal non-surgical management is referred for assessment to a non-general practitioner (GP) specialist or multidisciplinary service.

Review

Decide with the patient how regularly they need a review of their knee osteoarthritis. The review should include:

• undertaking a repeat history, physical examination and psychosocial assessment
• monitoring symptoms and response to treatment using the same tools as at the initial assessment evaluating any adverse effects from treatment (including medications and exercise therapy) reviewing goals and updating the self-management plan as necessary to optimise outcomes
• offering further education, coaching or behaviour change support
• discussing other treatment options as necessary or as requested by the patient.

Recommend that a patient with worsening symptoms and severe persistent functional impairment despite optimal non-surgical management speak with their GP about assessment by a specialist such as a rheumatologist, an orthopaedic surgeon or a sport and exercise physician.

Communication tips

Convey hope and reassurance that the patient can be supported to live well with knee osteoarthritis and can manage their symptoms and improve their level of activity and general wellbeing.

For example:

‘There is good evidence that most people who are physically active and maintain a healthy weight can be healthy and strong and participate in the activities they enjoy without ever undergoing surgery.’

‘Within a few months you should find you are able to do more. While most people can manage their knee osteoarthritis without surgery, for a small number of people, surgery can help.’

Avoid using language that suggests it is inevitable that they will need surgery at some time in the future—this may reinforce the belief that non-surgical management is futile.

Quality statement 8

Surgery

A patient with knee osteoarthritis who has severe functional impairment despite optimal non-surgical management is considered for timely joint replacement surgery or joint-conserving surgery. The patient receives comprehensive information about the procedure and potential outcomes to inform their decision. Arthroscopic procedures are not offered to treat uncomplicated knee osteoarthritis.

Assess whether the patient has participated in appropriate non-surgical management such as 12 weeks of optimal physical activity and exercise.

Suggest that the patient visit their GP to seek advice on whether further treatment such as knee replacement surgery may be helpful in their situation.

Provide the patient with clear and comprehensive information, together with the orthopaedic surgeon, about the expected time for postoperative recovery and rehabilitation in a way that they can understand.

Reinforce that arthroscopic knee procedures (such as debridement and partial meniscectomy procedures) provide little clinical benefit, carry a risk of harm and should not be used for the treatment of uncomplicated knee osteoarthritis.

Communication tips

For the minority of people who do undergo joint replacement, explain that this does not mean they have ‘failed’ non-surgical management. Emphasise that healthy lifestyle behaviours such as physical activity before surgery can assist with postoperative recovery and help improve functional outcomes after surgery.

For example:

‘A minority of people who participate in non-surgical management go on to have joint replacement surgery. Continuing to be physically active so you are healthy and strong before surgery will help you recover afterwards.’

Avoid phrases such as ‘failed non-surgical management’, which may be perceived as placing blame on the patient.

>> Click here for more information and resources about the Osteoarthritis of the Knee Clinical Care Standard from the Australian Commission on Safety and Quality in Health Care. 

>> Samantha Bunzli is a conjoint senior research fellow at Griffith University and the Royal Brisbane and Women’s Hospital. She conducts translational musculoskeletal research and has a background in musculoskeletal physiotherapy.

>> Ilana Ackerman APAM is a professor (research) and deputy director of the Musculoskeletal Health Unit in the School of Public Health and Preventive Medicine at Monash University. She is a musculoskeletal epidemiologist and an experienced orthopaedic physiotherapist.

>> Samantha and Ilana were invited members of the Australian Commission on Safety and Quality in Health Care’s Review Working Group for the Osteoarthritis of the Knee Clinical Care Standard.

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