Introduction: A Condition Affecting Millions, Yet Widely Misunderstood
Knee osteoarthritis represents one of the most prevalent musculoskeletal conditions worldwide, affecting approximately 303 million people globally according to the Global Burden of Disease Study (Vos et al., 2020). In the United Kingdom alone, over 4.11 million people live with knee osteoarthritis, a figure that continues to rise with our ageing population and increasing rates of obesity (Versus Arthritis, 2023).
At Bruno Physical Rehabilitation, we regularly meet patients who arrive at our Ipswich clinic with a sense of resignation. Many have been told—often casually, sometimes by well-meaning but misinformed sources—that their knee is "bone on bone," that their cartilage is "worn away," and that a knee replacement is simply a matter of time. This narrative, while understandable given how osteoarthritis has traditionally been explained, is both outdated and, frankly, unhelpful.
The reality is far more nuanced and, importantly, far more hopeful. The vast majority of people with knee osteoarthritis can be managed effectively without surgery. Conservative treatment, centred on exercise and comprehensive rehabilitation, remains the first-line approach recommended by every major clinical guideline. Surgery, when it becomes necessary, should be the last resort rather than an inevitability.
This comprehensive guide will explain what knee osteoarthritis actually is, why the severity on an X-ray often has little bearing on your pain levels, and how evidence-based rehabilitation can transform your function and quality of life. Whether you have recently received a diagnosis or have been living with knee osteoarthritis for years, understanding the true nature of your condition is the first step toward taking control of it.
What Osteoarthritis Actually Is: Rethinking "Wear and Tear"
For decades, osteoarthritis was described as a passive, degenerative condition—the inevitable consequence of a lifetime of use, like tyres wearing down on a car. This "wear and tear" model suggested that rest was protective and activity was harmful. We now know this characterisation is fundamentally incorrect.
In a landmark paper published in The Lancet, Hunter and Bierma-Zeinstra (2019) redefined osteoarthritis as an active, whole-joint disease involving dynamic processes of destruction and attempted repair. Rather than passive wearing away, osteoarthritis involves complex biological processes including inflammation, aberrant tissue remodelling, and changes to multiple joint structures simultaneously.
This reconceptualisation has profound implications for treatment. If osteoarthritis were simply mechanical wearing, then rest would indeed be logical. But because it is an active biological process, the joint requires appropriate loading to maintain tissue health. Cartilage, in particular, is avascular—it has no direct blood supply—and relies on cyclical loading and unloading to receive nutrients through a process called imbibition. A joint that is not moved is a joint that is starving its own tissues.
This is why prolonged rest is now understood to be harmful rather than protective. Avoiding movement leads to muscle atrophy, increased joint stiffness, reduced cartilage nutrition, and typically worsening pain. The mantra in modern osteoarthritis management is clear: motion is lotion. Appropriate, graduated exercise is not just safe for osteoarthritic knees—it is essential.
Understanding Knee Anatomy: The Three Compartments
The knee joint is anatomically divided into three compartments, each of which can be affected by osteoarthritis independently or in combination. Understanding which compartment or compartments are involved helps guide treatment and prognosis.
The Medial Tibiofemoral Compartment
Located on the inner side of the knee, the medial compartment bears approximately 60-70% of the load during walking due to the normal mechanical axis of the leg. This makes it the most commonly affected compartment in knee osteoarthritis. Patients with medial compartment disease often report pain on the inner aspect of the knee, particularly with weight-bearing activities and stairs.
The Lateral Tibiofemoral Compartment
The outer compartment of the knee bears less load in most individuals but can become predominantly affected in those with valgus (knock-knee) alignment or following lateral meniscal injuries. Lateral compartment osteoarthritis is less common but can be equally disabling when present.
The Patellofemoral Compartment
The joint between the kneecap (patella) and the femur is particularly susceptible to osteoarthritis, especially in women and those who have experienced patellar tracking problems or previous injury. Patellofemoral osteoarthritis typically causes pain at the front of the knee, particularly with stairs, squatting, prolonged sitting, and activities requiring deep knee flexion. For a detailed exploration of this specific condition, please see our comprehensive guide on patellofemoral osteoarthritis.
Many patients have what is termed "tricompartmental" osteoarthritis, where all three compartments are affected. However, the degree of involvement often varies, and understanding the predominant compartment helps us target rehabilitation appropriately.
The Four Mechanisms of Osteoarthritis Development
Osteoarthritis develops through several interconnected mechanisms. Understanding these pathways helps explain why the condition behaves as it does and why our treatment approaches target multiple systems simultaneously.
1. Mechanical Overload and Malalignment
When load is distributed unevenly across the joint surface—whether due to obesity, malalignment, muscle weakness, or abnormal gait patterns—focal areas of cartilage experience stress beyond their capacity to adapt. Over time, this leads to structural damage. Importantly, this mechanism is modifiable: correcting alignment issues, optimising muscle function, and addressing excessive body weight can all reduce mechanical overload.
2. Subchondral Bone Remodelling
The bone immediately beneath the cartilage (subchondral bone) plays a crucial role in osteoarthritis. In response to abnormal loading, this bone becomes sclerotic (denser and stiffer), develops cysts, and forms osteophytes (bone spurs) at the joint margins. These changes alter the mechanical environment of the overlying cartilage and contribute to pain through bone marrow lesions, which are strongly associated with symptoms.
3. Synovial Inflammation
Contrary to old beliefs, inflammation is a significant feature of osteoarthritis, albeit different in character from inflammatory arthritis such as rheumatoid disease. The synovial membrane becomes inflamed and produces pro-inflammatory cytokines including interleukin-1β (IL-1β) and tumour necrosis factor-alpha (TNF-α). These signalling molecules perpetuate cartilage degradation, cause pain sensitisation, and create the joint swelling many patients experience. This inflammatory component explains why anti-inflammatory treatments, including MLS Laser Therapy, can be so effective.
4. Muscle Weakness and Arthrogenic Inhibition
Perhaps the most clinically important mechanism from a rehabilitation perspective is the relationship between muscle weakness and joint health. When a joint is painful or swollen, the nervous system reflexively inhibits the surrounding muscles—a phenomenon called arthrogenic muscle inhibition. The quadriceps muscle is particularly affected, and this inhibition can persist even after pain and swelling resolve.
Weak quadriceps fail to absorb shock effectively during walking, running, and stair climbing, meaning more force is transmitted directly to the joint surfaces. This creates a vicious cycle: joint damage causes inhibition, inhibition causes weakness, weakness increases joint loading, and increased loading causes further damage. Breaking this cycle through targeted strengthening is fundamental to successful management.
The Kellgren-Lawrence Grading Scale: Understanding Your X-Ray
When you have a knee X-ray, the degree of osteoarthritis is typically reported using the Kellgren-Lawrence (K-L) grading scale, developed in 1957 and still in widespread use today. Understanding what these grades mean—and, crucially, what they do not mean—is important.
Grade 0: No Radiographic Features
The joint appears normal on X-ray with no evidence of osteoarthritis.
Grade 1: Doubtful
Questionable narrowing of the joint space with possible osteophyte formation. Many clinicians consider this normal variation rather than true osteoarthritis.
Grade 2: Mild
Definite osteophyte formation with possible joint space narrowing. This is typically considered the earliest definite stage of osteoarthritis.
Grade 3: Moderate
Multiple osteophytes, definite joint space narrowing, some sclerosis (bone hardening), and possible deformity of bone ends.
Grade 4: Severe
Large osteophytes, marked joint space narrowing, severe sclerosis, and definite deformity. This is often described colloquially as "bone on bone."
While this grading system provides a standardised way to describe radiographic changes, its clinical utility is limited by a crucial finding: X-ray severity correlates poorly with pain and function.
Why Your X-Ray Grade Does Not Predict Your Pain
One of the most important concepts in modern osteoarthritis management is the discordance between structural changes and symptoms. In a landmark systematic review, Bedson and Croft (2008) found that only approximately 15% of people demonstrate concordance between their radiographic osteoarthritis severity and their pain levels.
This means that some people with severe, Grade 4 "bone on bone" changes on X-ray have minimal pain, while others with relatively minor Grade 2 changes experience significant disability. This finding is not an anomaly—it has been replicated consistently across multiple studies and populations.
How can this be? The answer lies in understanding that pain in osteoarthritis arises from multiple sources, not all of which are visible on X-ray:
- Synovitis: Inflammation of the synovial membrane causes pain but is invisible on plain radiographs.
- Bone marrow lesions: Oedema within the subchondral bone is strongly associated with pain but requires MRI to visualise.
- Capsular and ligamentous structures: Stretching, inflammation, and mechanical irritation of soft tissues contribute to symptoms.
- Muscle dysfunction: Weakness, spasm, and trigger points in surrounding musculature cause significant pain.
- Central sensitisation: In chronic pain states, the nervous system becomes hypersensitive, amplifying pain signals regardless of peripheral tissue status.
The clinical implication is profound: you are not your X-ray. An X-ray showing severe changes does not condemn you to severe pain, nor does it mean surgery is inevitable. Many of the pain generators in osteoarthritis are modifiable through conservative treatment.
Risk Factors: What You Cannot Change and What You Can
Non-Modifiable Risk Factors
Age: The prevalence of knee osteoarthritis increases dramatically with age, with the majority of people over 65 showing radiographic evidence of the condition.
Sex: Women are more commonly affected than men, particularly after menopause, suggesting a hormonal component to disease risk.
Genetics: Family history plays a significant role, with heritability estimates of 40-65% for knee osteoarthritis.
Prior joint injury: Previous meniscal tears, ligament injuries (particularly ACL rupture), and fractures involving the joint surface substantially increase the risk of subsequent osteoarthritis.
Modifiable Risk Factors
Obesity: Excess body weight is the single strongest modifiable risk factor. Each kilogram of body weight adds approximately 4 kg of load to the knee during walking. Weight loss consistently improves symptoms and may slow structural progression.
Quadriceps weakness: Weak thigh muscles fail to protect the joint from impact loading. Strengthening is both preventive and therapeutic.
Malalignment: Varus (bow-legged) or valgus (knock-kneed) alignment concentrates load on one compartment. While alignment itself may not be easily changed, muscle function and gait patterns can be optimised to mitigate its effects.
Sedentary behaviour: Lack of physical activity leads to muscle weakness, cartilage malnutrition, and often weight gain—all of which worsen osteoarthritis outcomes.
Occupational factors: Jobs involving prolonged kneeling, squatting, or heavy lifting increase risk and may need modification.
Recognising the Symptoms of Knee Osteoarthritis
The symptoms of knee osteoarthritis typically develop gradually over months to years, though they may fluctuate in intensity. Key features include:
Use-related pain: Pain typically worsens with activity and improves with rest, at least in early stages. Weight-bearing activities, stairs, and rising from sitting are commonly problematic.
Morning stiffness: Unlike inflammatory arthritis where morning stiffness can last hours, osteoarthritic stiffness typically resolves within 30 minutes of waking and moving.
Gelling: Stiffness and discomfort after periods of inactivity, even during the day, which eases with movement. This is sometimes called "theatre sign"—stiffness after sitting through a film.
Crepitus: Grinding, clicking, or crunching sensations with movement. While often concerning to patients, crepitus is common and does not necessarily indicate severe disease.
Bony enlargement: Visible or palpable swelling at the joint margins due to osteophyte formation.
Reduced range of motion: Difficulty fully straightening or fully bending the knee, which may progress over time.
Episodic flares: Periods of increased pain, swelling, and stiffness, often without clear provocation, reflecting the inflammatory component of the disease.
Diagnosis: How Knee Osteoarthritis Is Confirmed
Knee osteoarthritis is fundamentally a clinical diagnosis, meaning it is based primarily on history and physical examination. The American College of Rheumatology (Altman et al., 1986) established clinical criteria that remain in use: knee pain plus at least three of the following six features:
- Age over 50 years
- Morning stiffness lasting less than 30 minutes
- Crepitus on active motion
- Bony tenderness
- Bony enlargement
- No palpable warmth (distinguishing from inflammatory arthritis)
Weight-bearing radiographs (X-rays taken while standing) are useful for confirming the diagnosis, grading severity, and ruling out other pathology. The weight-bearing position is essential because joint space narrowing may not be apparent on non-weight-bearing images.
MRI is not routinely required for diagnosing osteoarthritis but may be indicated when there is suspicion of additional pathology such as meniscal tears, ligament injury, or bone marrow lesions contributing to pain. MRI is particularly valuable when symptoms are disproportionate to X-ray findings or when there is mechanical locking or giving way suggesting internal derangement.
Evidence-Based Treatment: A Comprehensive Hierarchy
Treatment for knee osteoarthritis should follow a stepped-care approach, beginning with conservative measures and escalating only when necessary. All major clinical guidelines, including those from NICE (2022), emphasise that surgery should be reserved for those who have failed adequate conservative treatment.
Exercise: The Cornerstone of Treatment
Exercise is not just one treatment option among many—it is the foundation upon which all other interventions are built. The Cochrane review by Fransen and colleagues (2015), encompassing 54 randomised controlled trials, demonstrated that exercise therapy produces clinically meaningful improvements in both pain (effect size 0.49) and function in knee osteoarthritis.
The effect size of 0.49 is considered moderate and is comparable to that achieved by oral analgesics, but without the side effects. Exercise benefits include reduced pain, improved function, enhanced muscle strength, better joint stability, improved cartilage nutrition, psychological benefits, and potentially slowed disease progression.
Effective exercise programmes include a combination of:
- Strengthening exercises, particularly for the quadriceps
- Aerobic exercise to improve cardiovascular fitness and assist weight management
- Flexibility exercises to maintain or improve range of motion
- Neuromuscular training to improve balance and proprioception
Biomechanical Assessment
Knee pain rarely exists in isolation. The knee sits between two powerful influence zones—the hip above and the foot below—and dysfunction at either level can profoundly affect knee mechanics. At Bruno Physical Rehabilitation, our biomechanical assessment includes 3D gait analysis, force platform evaluation, single-leg loading tests, and comprehensive assessment of the hip and foot chain.
Weakness of the hip abductors, for example, allows the pelvis to drop during single-leg stance, increasing valgus stress at the knee. Overpronation at the foot can create similar effects. Addressing these factors is often essential for durable improvement. Our article on why knee pain is not always a knee problem explores this concept in depth.
MLS Laser Therapy
Multiwave Locked System (MLS) Laser Therapy represents a significant advancement in photobiomodulation for musculoskeletal conditions. Operating at dual wavelengths of 808nm (continuous) and 905nm (pulsed), MLS laser delivers three key therapeutic effects:
- Anti-inflammatory: Reduces inflammatory mediators and synovial inflammation
- Analgesic: Modulates pain signalling pathways
- Biostimulatory: Enhances cellular metabolism and tissue repair
A comprehensive meta-analysis by Stausholm and colleagues (2019), published in BMJ Open, provided evidence supporting the efficacy of photobiomodulation therapy for knee osteoarthritis. At our clinic, we use MLS Laser Therapy to help settle acute flares, reduce chronic inflammation, and create a window of opportunity for therapeutic exercise.
ALCE Neuromuscular Electrostimulation
ALCE (Advanced Load-Controlled Electrostimulation) Neuromuscular Electrostimulation represents one of our most powerful tools for addressing quadriceps weakness and arthrogenic inhibition. This technology specifically targets Type 2B fast-twitch muscle fibres—the power and strength fibres responsible for explosive joint protection.
Type 2B fibres are critically important for several reasons:
- They generate the rapid, forceful contractions needed to stabilise the knee during unexpected perturbations
- They atrophy rapidly with pain, swelling, and disuse—often within days of joint injury or inflammation
- They are almost impossible to recruit voluntarily when arthrogenic inhibition is present
- Their loss significantly compromises joint protection during daily activities and sport
ALCE uses carrier frequencies up to 1 MHz in certain modalities, with burst frequencies of 75-100 Hz specifically calibrated for Type 2B fibre recruitment. This stimulation bypasses the neural inhibition that prevents normal muscle activation, allowing patients to regain quadriceps volume and function even when voluntary exercise alone would be insufficient. For patients hoping to return to sport, gym training, or simply normal daily activities without limitation, this technology is often transformative.
Therapeutic Ultrasound
Therapeutic ultrasound at 1 MHz frequency is optimal for treating structures at knee depth (3-5 cm from the surface). The treatment produces both thermal and non-thermal effects on periarticular tissues, improving capsular extensibility and preparing the joint for exercise. We often use ultrasound before rehabilitation sessions to enhance the effectiveness of subsequent movement.
TENS and EMS
Transcutaneous Electrical Nerve Stimulation (TENS) provides effective pain modulation through the gate control mechanism described by Melzack and Wall (1965). High-frequency stimulation (80-120 Hz) activates large-diameter sensory fibres that inhibit pain transmission in the spinal cord, providing immediate relief that allows patients to engage more fully with active rehabilitation.
Electrical Muscle Stimulation (EMS) complements our ALCE protocol by providing general muscle activation, improving circulation, and maintaining muscle tone during periods when pain limits voluntary exercise.
Infrared Thermography
Objective measurement of treatment response is essential for evidence-based practice. Infrared thermography allows us to visualise and quantify periarticular inflammation before and after treatment sessions. This provides both clinician and patient with objective feedback on treatment effects and helps guide clinical decision-making.
HRV-Guided Progression
Heart Rate Variability (HRV) monitoring serves as an indicator of systemic inflammation and autonomic nervous system function. In rehabilitation, HRV data helps us guide loading intensity progression, ensuring we challenge the system appropriately without triggering flares. This personalised approach optimises the balance between stimulus and recovery.
Pharmacological Options
While our focus is on active rehabilitation, pharmacological interventions have a role in comprehensive management. NICE guidelines (2022) recommend:
Topical NSAIDs: First-line pharmacological treatment, applied directly over the painful area. They provide effective pain relief with minimal systemic absorption.
Oral paracetamol: May provide modest benefit, though recent evidence questions its efficacy for osteoarthritis pain.
Oral NSAIDs: Effective but associated with gastrointestinal, cardiovascular, and renal risks, particularly in older patients. Should be used at the lowest effective dose for the shortest duration necessary.
Intra-articular injections: Corticosteroid injections can provide short-term relief during acute flares. Hyaluronic acid injections remain controversial, with guidelines varying on their recommendation.
Surgery: The Last Resort
Knee replacement surgery is an effective intervention for patients with severe osteoarthritis who have failed adequate conservative management. However, the landmark study by Skou and colleagues (2018) demonstrated that supervised exercise therapy and education was non-inferior to total knee replacement followed by exercise in patients with moderate-to-severe osteoarthritis. Many patients who believed surgery was inevitable achieved satisfactory outcomes with non-surgical treatment.
For those exploring all options before considering surgery, our guide to preventing knee replacement surgery provides evidence-based strategies. When surgery does become appropriate, optimal preparation improves outcomes—see our article on prehabilitation before knee replacement. And for those who have had surgery, our comprehensive knee replacement rehabilitation protocol guides recovery.
The Quadriceps Imperative: Why Thigh Strength Is Non-Negotiable
If there is one message to take from this guide, it is this: quadriceps strength is the single most important modifiable factor in knee osteoarthritis.
The seminal work of Slemenda and colleagues (1997) demonstrated that quadriceps weakness precedes the development of knee osteoarthritis and is not merely a consequence of the disease. Weak quadriceps fail to absorb the shock of heel strike during walking, transmitting forces directly to the articular cartilage. Over time, this accelerates joint damage.
Conversely, strong quadriceps protect the joint by:
- Absorbing impact forces before they reach the joint surface
- Stabilising the knee during dynamic activities
- Improving proprioception and neuromuscular control
- Reducing joint compression during activities like stair climbing
The challenge is that arthrogenic muscle inhibition—that reflexive neural shutdown we discussed earlier—makes voluntary quadriceps strengthening difficult. Patients are often working hard but making little progress because their nervous system is limiting muscle activation. This is precisely why technologies like ALCE neuromuscular electrostimulation are so valuable: they bypass the inhibition and directly activate muscle fibres that the patient cannot recruit voluntarily.
A comprehensive rehabilitation programme must prioritise quadriceps strengthening from the earliest stages, using whatever methods are necessary to achieve meaningful muscle adaptation.
Our Four-Phase Rehabilitation Protocol at Bruno Physical Rehabilitation
At Bruno Physical Rehabilitation, we guide patients through a structured four-phase rehabilitation protocol, individualised to their specific presentation, goals, and response to treatment.
Phase 1: Settle the Flare
The first priority is to bring acute symptoms under control. This phase typically lasts 1-3 weeks and includes:
- MLS Laser Therapy to reduce inflammation and pain
- TENS for pain modulation
- Gentle range of motion exercises within pain tolerance
- Activity modification guidance
- Infrared thermography to monitor inflammatory response
- Education about the nature of osteoarthritis and the rehabilitation journey
Phase 2: Rebuild the Foundation
Once acute symptoms are controlled, we focus on restoring fundamental function. This phase typically lasts 4-6 weeks and includes:
- ALCE neuromuscular electrostimulation to overcome arthrogenic inhibition and rebuild quadriceps
- Progressive strengthening exercises for the entire lower limb chain
- Therapeutic ultrasound to improve capsular mobility
- Biomechanical assessment and correction of contributing factors
- Gait retraining if abnormal patterns are identified
- Cardiovascular conditioning through low-impact activities
Phase 3: Build Load Tolerance
With a restored foundation, we progressively increase demands on the joint. This phase typically lasts 6-12 weeks and includes:
- Higher-intensity strengthening with progressive resistance
- Sport-specific or activity-specific training as appropriate
- Balance and proprioception challenges
- HRV-guided load progression to optimise recovery
- Continued ALCE sessions for Type 2B fibre development
- Introduction of impact activities if appropriate for patient goals
Phase 4: Independence and Maintenance
The goal of rehabilitation is to equip patients with the knowledge and programme to manage their condition independently. This final phase includes:
- Development of a sustainable home exercise programme
- Self-management strategies for flare episodes
- Activity and lifestyle recommendations
- Periodic reassessment appointments to monitor progress
- Clear criteria for when to seek further input
Key Takeaways
- Knee osteoarthritis affects over 4 million people in the UK, but surgery is not inevitable for most
- Osteoarthritis is an active, whole-joint disease—not simple "wear and tear"—and responds to appropriate treatment
- X-ray severity correlates poorly with pain; you are not your imaging
- Exercise is the cornerstone of treatment, supported by robust evidence from over 54 randomised controlled trials
- Quadriceps strength is the single most important modifiable factor in knee osteoarthritis outcomes
- Arthrogenic muscle inhibition may prevent voluntary muscle activation, requiring technologies like ALCE neuromuscular electrostimulation
- Advanced modalities including MLS Laser Therapy, therapeutic ultrasound, and TENS support active rehabilitation
- A thorough biomechanical assessment is essential—knee pain is often influenced by hip and foot function
- Comprehensive, phased rehabilitation produces durable improvements in pain and function
- Surgery, when necessary, achieves better outcomes when preceded by proper prehabilitation
Take the First Step Toward Better Knee Health
If you are living with knee osteoarthritis—whether newly diagnosed or struggling for years—expert rehabilitation can transform your function and quality of life. At Bruno Physical Rehabilitation in Ipswich, Suffolk, we combine evidence-based exercise prescription with advanced technologies including MLS Laser Therapy, ALCE neuromuscular electrostimulation, and comprehensive biomechanical assessment to deliver personalised care.
You do not have to accept pain and limitation as inevitable. You do not have to wait for surgery. With the right guidance and commitment, most patients achieve meaningful, lasting improvement.
Book an assessment at Bruno Physical Rehabilitation, Ipswich. Let us work together to optimise your knee function and help you return to the activities that matter to you.
References
- Altman, R., Asch, E., Bloch, D., Bole, G., Borenstein, D., Brandt, K., Christy, W., Cooke, T.D., Greenwald, R. and Hochberg, M. (1986) 'Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee', Arthritis and Rheumatism, 29(8), pp. 1039-1049.
- Bedson, J. and Croft, P.R. (2008) 'The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature', BMC Musculoskeletal Disorders, 9, p. 116.
- Fransen, M., McConnell, S., Harmer, A.R., Van der Esch, M., Simic, M. and Bennell, K.L. (2015) 'Exercise for osteoarthritis of the knee', Cochrane Database of Systematic Reviews, (1), CD004376.
- Hunter, D.J. and Bierma-Zeinstra, S. (2019) 'Osteoarthritis', The Lancet, 393(10182), pp. 1745-1759.
- Kellgren, J.H. and Lawrence, J.S. (1957) 'Radiological assessment of osteo-arthrosis', Annals of the Rheumatic Diseases, 16(4), pp. 494-502.
- Melzack, R. and Wall, P.D. (1965) 'Pain mechanisms: a new theory', Science, 150(3699), pp. 971-979.
- National Institute for Health and Care Excellence (2022) Osteoarthritis in over 16s: diagnosis and management. NICE guideline [NG226]. London: NICE.
- Slemenda, C., Brandt, K.D., Heilman, D.K., Mazzuca, S., Braunstein, E.M., Katz, B.P. and Wolinsky, F.D. (1