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Lower Limb MSK

Physio Nexus Academy · Clinical Treatment Framework

Knee Osteoarthritis

Progressive strengthening, aerobic activity and education are core treatments. Manual therapy and modalities can be used for short-term symptom relief to support exercise adherence.

Assess → classifyTreat → reassessLoad → progress

Clinical decision pathway

A structured plan, not a recipe

Clinician-led · Individualised
01

Understand

Screen safety, identify the likely clinical pattern and agree meaningful goals.

02

Select

Choose only interventions that match the patient's impairments and preferences.

03

Reassess

Repeat the same comparable sign or functional task after key interventions.

04

Progress

Build capacity and participation using measurable response, not session count.

Before choosing an intervention

Clinical reasoning

  1. 1Strength and physical activity are the core treatment. Pain does not automatically mean joint damage is worsening.
  2. 2Choose exercise around the patient's functional goals: stairs, walking, sit-to-stand, prayer positions or community mobility.
  3. 3Manual therapy is mainly used to make exercise and movement easier.

A practical starting sequence

First-session workflow

  1. 1Record pain, WOMAC/KOOS, knee ROM, swelling, sit-to-stand and walking tolerance.
  2. 2Assess quadriceps, hip strength and gait.
  3. 3Teach one strength exercise and one functional activity that the patient can continue at home.
  4. 4Discuss pacing and realistic progression.

Assessment & examination

  1. 1Pain, stiffness and activity tolerance
  2. 2Knee ROM and swelling
  3. 3Quadriceps/hip strength
  4. 4Gait, sit-to-stand, stairs and balance
  5. 5Weight, sleep and activity factors where relevant

Red flags & safety screen

  1. 1Hot swollen joint with fever
  2. 2Suspected fracture
  3. 3Acute locked knee
  4. 4Possible DVT after surgery or immobilization

Indication · dosage · response

Manual therapy application

  1. 1Patellar or tibiofemoral mobilization can be used when a clear mobility restriction is relevant.
  2. 2Use Grade I–II for pain-dominant presentations and higher grades for safe stiffness-dominant restriction.
  3. 3MWM can be trialed during squat/step if it immediately reduces pain.

Adapt to irritability and capacity

Exercise prescription & dosage

  1. 1Sit-to-stand or squat-to-chair: 2–3 sets × 6–12 reps, 2–4 days/week.
  2. 2Knee extension or quadriceps strengthening: 2–4 sets × 6–15 reps, progressing resistance.
  3. 3Hip abductor/extensor strengthening: 2–3 sets × 8–15 reps.
  4. 4Calf raises: 2–3 sets × 10–20 reps.
  5. 5Aerobic walking/cycling: build toward 20–30 minutes most days if tolerated.

Modalities & adjuncts

  1. 1Heat: 10–15 minutes for stiffness if helpful.
  2. 2Cold: 10–15 minutes after activity for symptom relief if preferred.
  3. 3TENS can be an adjunct for short-term pain but should not replace strengthening.

Progression & regression rules

  1. 1Increase resistance when the patient completes the top end of the rep range with good form and symptoms settle within about 24 hours.
  2. 2Progress chair height, step height, walking distance and external load gradually.
  3. 3Use function, not pain elimination, as the only progression target.

Home programme

  1. 1Regular physical activity
  2. 2Pacing rather than avoidance
  3. 3Strength program 2–3 days/week as tolerated
  4. 4Weight-management support when appropriate and desired

Outcome measures

  1. 1WOMAC or KOOS
  2. 2NPRS
  3. 330-second sit-to-stand
  4. 4Timed Up and Go
  5. 5Walking tolerance

Common clinical mistakes

  1. 1Avoiding strength training because of crepitus.
  2. 2Using only modalities.
  3. 3Not loading the quadriceps enough to create adaptation.
  4. 4Progressing too fast after a long period of inactivity.

Patient education & self-management

  1. 1Explain that exercise is safe and can improve pain/function even when X-rays show OA.
  2. 2Normalize painless crepitus.
  3. 3Discuss body-weight management sensitively only when relevant and desired.

Referral & escalation

  1. 1Medical review for persistent severe disability, recurrent large effusions or consideration of injection/surgical options

Clinical use & safety note

This is an educational clinical framework, not an individual prescription or a substitute for diagnosis, medical assessment, local protocols or professional judgement. Exercise dose, manual techniques and adjuncts must be adapted to examination findings, irritability, comorbidities, precautions, patient goals and response. Obtain informed consent, work within training and scope, and refer when indicated. Do not apply every intervention listed to every patient.

The PNA treatment principle

The best plan is not the one with the most techniques. It is the one that identifies the patient's main problem, selects a defensible intervention, measures the response and steadily restores meaningful function.