Osteoarthritis of the Knee Clinical Care Standard

Conduct a comprehensive assessment to identify factors that may affect the patient’s preferred treatment and their recovery. If the clinical signs, symptoms, and findings of a comprehensive assessment are typical of knee osteoarthritis, a diagnosis can be made without imaging or further investigations.

Consider the person’s context as part of a person- centred approach to making a holistic assessment. Ask how their symptoms affect their ability to carry out their usual daily activities and participate in paid and unpaid work, leisure, cultural and social activities. The assessment should include:

• a detailed history of the patient’s symptoms, with particular attention to assessing pain, joint stiffness and movement, and a medical history to identify comorbidities, modifiable risk factors and response to treatment
• physical examination and functional assessment of the affected knee(s) that includes assessing the patient’s 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 or additional diagnoses, such as:
  • a history of past trauma to the knee
  • malignancy
  • prolonged morning joint-related stiffness
  • rapidly worsening symptoms or the presence of a hot swollen joint
  • whether pain may be referred from hip or spine pathology.
• a psychosocial evaluation to identify factors that may affect the patient’s quality of life and their ability to carry out their usual activities, including their mental and emotional health, their social and economic situation, health literacy and beliefs and concerns, readiness to adopt self‑management behaviours, and other emotional, social, cultural and environmental factors.

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

Consider using tools to aid the assessment and support monitoring of the patient’s condition. Select assessment tools tailored to the patient’s individual needs and goals.

Healthcare services should:

• establish and maintain systems to coordinate and support clinicians to provide a comprehensive assessment of patients presenting with suspected knee and that consider assessment of the patient’s:
  • other health conditions and of the psychosocial factors that might affect quality of life and ability to participate in preferred activities
  • ability to access and participate in health services
  • response to treatment.
• provide clinicians with access to continuing education that reinforces the importance of clinical assessment in the diagnosis of knee osteoarthritis and atypical features that suggest an alternative diagnosis
• have assessment tools available to staff to aid assessment and recording of patient-reported outcome measures

If you have pain in your knee and other symptoms such as stiffness and swelling around the joint, you can expect your healthcare provider to assess your situation thoroughly to see if you have osteoarthritis or another condition.

Your knee will be examined, and you will be asked questions about:

• your medical history
• your symptoms
• your mental health and mood
• the ways your knee symptoms affect your daily life and activities most important to you.

Your healthcare provider can then do a comprehensive assessment that will help them make a diagnosis, recommend the best treatment options and support, and share the most useful advice and information.

Consider cultural safety and equity at all stages of assessment and diagnosis.

Refer to Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

Routine imaging is not required to confirm a diagnosis based on an appropriate clinical assessment. This is because degenerative meniscal tears are common in osteoarthritic knees, whether people have symptoms or not. Therefore, detection of meniscal tears does not provide useful additional information and may lead people to pursue inappropriate management such as arthroscopy.

Patients may experience substantial pain with only minor structural changes to joints identified on imaging, while minimal symptoms may accompany more notable (though modest) structural changes.

Imaging may be clinically warranted in some circumstances, such as if the patient presents with atypical features or signs and symptoms that increase suspicion of an alternative diagnosis. X-ray is the preferred first-line imaging modality in these cases.

If imaging is required to investigate alternate diagnoses, explain the reasons for this to the patient and document the reasons on the request form to enable relevant reporting. Imaging results should be interpreted together with clinical findings and functional assessment.

If a patient with suspected knee osteoarthritis requests diagnostic imaging, ask about their concerns and their expectations of imaging. Reassure them that having X-rays or other diagnostic imaging will not change initial treatment, which will be guided by their mobility and function.

Advise the patient that there is a poor correlation between radiological evidence of osteoarthritis and symptoms. Explain that people may have severe pain with only minimal findings on X-ray or MRI because the experience of pain is influenced by many factors. Some of these symptoms are modifiable by changes to activity levels, weight, sleep, or stress management.

For radiologists 

Report imaging findings in line with the Royal Australian and New Zealand College of Radiologists (RANZCR) Clinical Radiology Written Report Guidelines. When reporting imaging studies requested for suspected knee osteoarthritis, include:
•    a comment to the requesting clinician in response to the indication listed on the request, for example, ‘suspected knee osteoarthritis
•    key clinically relevant information to facilitate appropriate treatment planning
•    a diagnosis based on the imaging, using the principles of a hierarchy of diagnosis.
Magnetic resonance imaging is not recommended for initial diagnosis. However, when knee osteoarthritis is observed on MRI, including thinning of the cartilage or degenerative meniscal changes including tears, a finding of ‘knee osteoarthritis’ should be included in the report. This is of greater clinical relevance than the presence of a meniscal tear.
 

Healthcare services should:

• establish policies to minimise inappropriate imaging for suspected knee osteoarthritis, which should:
  • provide guidance on appropriate clinical diagnosis
  • include documentation of the indications for imaging of knee pain and related symptoms
  • use the hierarchy of imaging required
  • recommend commencing with X-ray if imaging is required.
• monitor the appropriateness of imaging requests for knee osteoarthritis
• establish processes that support clinicians to request imaging only when clinically appropriate.

For radiology services

Radiology services should:

• ensure protocols are in place that outline the required imaging for knee pain, including imaging for patients with suspected knee osteoarthritis with atypical features
• ensure that guidelines and requirements for reporting imaging results are in the place that:
  • require a response to the indication for imaging provided on the request from the referring clinician
  • require that key clinically relevant information is included in the report in line with the RANZCR Clinical Radiology Written Report Guidelines.

If your knee pain and other symptoms suggest that you have knee osteoarthritis, you can expect your healthcare provider to confirm this by asking questions about your medical history, symptoms, and situation, and giving you a physical examination.

Most people with knee osteoarthritis do not need X-rays, MRI or CT scans, ultrasound), or blood tests for a healthcare provider to make a diagnosis.

Scans will not help decide your initial treatment and are not the first step for treating knee osteoarthritis. Your ability to move and do the activities you want to do is more important than what is seen on scans. 

Scans can also cause you unnecessary concern if they show changes or tears to the meniscus, which is the cartilage between the bones in your knee. These changes are common for most people with knee osteoarthritis but may not have anything to do with your symptoms. Most changes to the meniscus do not need surgery and it is not always helpful.

If your symptoms are unusual for someone with knee osteoarthritis, your healthcare provider may want to do an X-ray to get a clearer picture. You can expect them to discuss with you what to expect from the X-ray and how it will help with your diagnosis.

If you have diagnosed knee osteoarthritis and are considering surgery, you may need X-rays or other scans at that time.

Consider cultural safety and equity when considering or providing imaging services. 

Refer to Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.
 

Clinical guidance for MRI referral (RACGP)
Clinical Radiology Written Report Guidelines (RANZCR)
Diagnostic Imaging Accreditation Scheme Standards 

Support the patient to self‑manage their condition by:

• providing clear, comprehensive, and current information about knee osteoarthritis and how it is managed, in a way they can understand; this includes in a format that the patient prefers, including verbal or written information, and that is culturally appropriate
• involving the patient in developing a plan which is documented in their healthcare record
• tailoring the plan to address their individual physical, functional, and psychosocial needs and goals by including:
  • strategies to support increased physical activity participation such as pacing activities, management of painful episodes and flares, and pain management techniques
  • strategies for protecting the knee joints such as the use of walking aids
  • weight management and nutrition guidance.
• managing comorbidities and discussing their impact on managing knee osteoarthritis discussing non‑pharmacological pain management and maintaining participation in usual activities and life roles, and supports and services available including allied health services
• referring the patient to other clinicians or recommending services and resources that may help them self‑manage their condition, including providing links to reliable online resources and contact details of support groups
• monitoring and adjusting the plan as the patient’s condition and needs change
• involving the patient’s family, carers, or support people as appropriate, particularly for people who require additional support to self‑manage their condition.

Healthcare services should:

• ensure that systems are in place to offer patients with clear, comprehensive, and current knee osteoarthritis information about their condition and support for self‑management, including developing, monitoring, and revising self‑management plans
• ensure that the systems in place support patients and their clinicians to discuss the plan and any changes to it with other members of the multidisciplinary team, across different health services
• provide clinicians with training and skills (for example, in coaching patients) to support them in managing patients with knee osteoarthritis
• enable remotely delivered or telehealth options to be provided for education and self‑management
• build partnerships and links to organisations that can support patients to increase physical activity.

If you have knee osteoarthritis, you can expect your healthcare to give you information about your condition and the ways they can support you to maintain a healthy knee.

Together, you and your healthcare provider will set appropriate goals and create a plan that is tailored to your needs and priorities. This plan will include things you can do to help your knee pain and other health problems, either on your own or with professional support. This may include exercises and losing weight if necessary, either on your own or with professional help.

For some people, medicines or physical aids, such as knee braces or walking sticks, might be suggested. The plan will also consider how your knee pain affects your daily life and mood.

By working together, you and your healthcare team can address all your needs and help you manage your knee osteoarthritis so you can do the activities you want to do.

Have a tailored approach to health education that reflects the literacy, language, and cultural needs of the individual patient and builds understanding, engagement, and empowerment of Aboriginal and Torres Strait Islander patients. This can be done by establishing links with appropriate health services, community services, and organisations, and having referral processes in place to allow Aboriginal and Torres Strait Islander peoples’ access to a network of suitable service providers that support long term management of their health. 

See also the Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

Provide strategies to reach physical activity goals that are tailored to the patient’s needs and will help them to manage knee pain and improve function. Changes in activity may reduce the need for medicines and avoid surgery, as well as help patients manage chronic comorbidities and improve their overall health.

Reassure the patient that exercise will not cause damage and is not a risky activity. Advise them that physical activity and exercise will help to manage their pain and improve their function.
Provide advice on exercise that is specific to the patient’s needs, preferences, and clinical context. Tailor appropriate exercise goals and activities to a sufficient dosage and duration to improve fitness and strength and minimise pain.

Encourage patients to set realistic and achievable physical activity goals, such as gradually increasing participation in an activity they enjoy, including muscle strengthening activities, incidental activity, and sport. Tailor exercises to provide opportunities for the patient to have positive experiences or an experience of increasing function or mastery.

Regularly review and upgrade physical activity and exercise goals. Review factors such as the physical home environment, level of support, cultural activities, access to safe spaces to exercise, falls risk, and attitudes towards physical activity.

Provide the patient with clear, comprehensive, and current information on how to modify their usual physical activities to prevent symptoms worsening or aggravating any comorbidities. Encourage patients to use tools such as exercise logbooks and to include these interventions and goals in their self‑management plan. Discuss the ways that the use of medicines can allow the patient to participate in physical activity as well as the role of pacing.
Refer the patient to other clinicians or recommended services, supports, and resources – if appropriate and available – that may help them to achieve their goals. This may include:

• local community programs, groups, and activities
• links to reliable online resources
• clinicians such as physiotherapists, exercise physiologists, and sport and exercise physicians, and multidisciplinary services as appropriate.

Passive manual therapies, such as therapeutic ultrasound and electrotherapy, do not play a significant role in the treatment of knee osteoarthritis.

For patients who require surgery, being physically active can help to improve functional outcomes after the operation and optimise their recovery.

Healthcare services should:

• ensure that systems are in place for patients with knee osteoarthritis to receive advice and encouragement on how to achieve physical activity and exercise goals that are tailored to their needs
• ensure that appropriate services are available to support patients achieve these goals, such as multidisciplinary allied health clinics, exercise programs or facilities
• provide patients referred for surgery with access to a health professional who has expertise in exercise, such as a physiotherapist, exercise physiologist, or sport and exercise physician, and who can provide them with appropriate forms of physical activity to optimise their recovery and functional outcomes after the procedure.

If you have knee osteoarthritis, being active by moving your body every day can significantly reduce your pain, strengthen your muscles, improve your mobility and balance, and may reduce the need for medicines.

Feeling some pain or discomfort when exercising is normal and does not mean it is damaging your knee joint. You can expect that your healthcare provider may recommend medicines to use before or after exercise, and they will support you by giving advice on the types of activities and exercises that are best for you, considering your ability, your priorities and what you like to do.

Exercise is safe for your knee, even if you have severe knee osteoarthritis. Your exercises can be adjusted according to your pain, so that you can continue to do them. Even a small amount of physical activity is better than none to improve your general fitness and to strengthen muscles around your joints. Choose a form of physical activity that suits you – this may be group or individual training, supervised or unsupervised, land- or water-based.

You can expect to be encouraged to set physical activity goals, such as gradually increasing an activity you like to do. Your goals will be slowly upgraded as your strength and fitness improve where possible.

You may be recommended to do a specific exercise program or be referred to a specialist clinic or healthcare provider with expertise in exercise such as a:

• local community program, group or activity
• physiotherapist, exercise physiologist or sport and exercise physician
• specialist multidisciplinary service.

Nine out of 10 people with knee osteoarthritis can manage without needing joint replacement surgery.

Even if you do need knee surgery, being physically active leading up to the surgery can improve your ability to recover and return to your usual activities after the operation.

Consider individual needs, cultural safety and local context when discussing physical activity and exercise. 

Refer to Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

Acknowledge to the patient the challenges of losing weight and any previous weight loss attempts. Communicate in a sensitive, empathetic, and non‑judgemental way about how losing excess weight or maintaining weight will help them.

Loss of excess weight reduces knee pain and improves function for patients with knee osteoarthritis, and can improve other comorbidities. These changes may reduce the need for medicines or knee surgery.

If a patient living with excess weight is considering or seeking surgery, explain that weight loss can improve their eligibility for surgery, reduce risks, and improve outcomes.

Be aware of the complex factors that contribute to being above a healthy weight and encourage patients to set realistic and achievable weight goals based on their needs and preferences. If the patient is living with excess weight, advise them that a 5–10% or greater weight loss over a 20-week period is associated with reduced pain and improved quality of life.

Support patients to maintain a healthy, sustainable weight, and to optimise their nutrition by:

• advising them on appropriate interventions such as dietary changes, access to healthy food, exercise, behavioural techniques, medicines or weight management services
• referring them to specific services, if desired by the patient, such as an accredited practicing dietitian or for bariatric surgery.

Encourage patients to include these strategies and their goals in their self‑management plan. Body mass index (BMI) may not always be an appropriate measure for indicating whether a patient is above a healthy weight; other measures may be used, including body composition measurements or waist circumference.

For patients who ultimately require surgery, preventing weight gain or losing weight if they are living with excess weight can help to reduce their anaesthetic risk, improve functional outcomes after the operation, and reduce the costs and treatment burden associated with recovery from knee replacement surgery.

Healthcare services should:

• establish and maintain systems so that patients with knee osteoarthritis receive advice and encouragement on how to achieve weight management goals
• have appropriate services and referral pathways available for patients to support a healthy weight, including dietetic and weight management services.

Everyone living with knee osteoarthritis benefits from a nutritious diet to maintain strong muscles and bones. A healthy diet can help you manage your knee osteoarthritis and reduce the need for medicines. How much it helps will differ for individuals (like many treatment options). You will be encouraged to set weight goals based on your priorities and preferences. 

If you are living with knee osteoarthritis and have excess weight, losing weight will reduce knee pain. It can help with your mobility and improve your ability to do the activities most important to you. It will also help you manage any other health problems. Losing weight can also help delay surgery or even avoid it altogether. If you are living with excess weight or obesity, you may be offered a referral to a dietitian or weight management program to support you to lose weight. 

Should you need knee surgery, and you are living with excess weight, lowering your weight will help to reduce your complications from surgery and anaesthetic and improve results after the operation.

Consider cultural safety and equity for Aboriginal and Torres Strait Islander patients. 

Refer to Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

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 may be combined with physical activity and other self‑management strategies to help the patient improve their function and mobility. Ensure they understand that medicines should not replace self‑management strategies, including physical activity.

Use the current version of the Therapeutic Guidelines or an evidence-based, locally endorsed guideline when recommending or prescribing a medicine to manage knee osteoarthritis. Recommendations regarding use of medicines in knee osteoarthritis are described in the Standard.

Provide clear information to the patient about the recommended medicine, including the expected benefits, dose, duration, possible side effects, and when treatment should be reviewed. Review all other prescription, over-the-counter, and complementary medicines they may be using.

Do not offer opioid analgesics to patients with knee osteoarthritis. Opioids have significant risk of harm which outweigh potential benefits in pain management for knee osteoarthritis.

Opioid analgesics may have a role in very limited circumstances. For example, this may include short‑term use in patients with severe persisting pain not relieved by first-line medicines and optimal non‑surgical interventions, and who are awaiting non‑general practitioner specialist review.

If a patient is already using an opioid analgesic to treat knee osteoarthritis, discuss changes in therapy with them and explain the risks and need to start tapering the dose with a view to stopping the medicine.

Do not offer platelet-rich plasma (PRP), hyaluronan, stem cell treatments, medicinal cannabis, gabapentin or pregabalin, as they are not recommended in knee osteoarthritis.

Healthcare services should:

• provide clinicians with access to the current version of the Therapeutic Guidelines or an evidence-based local guideline to support the quality use of medicines
• establish and maintain systems to support clinicians in providing clear, information to patients about their treatment
• ensure that patients have access to ongoing medicines advice when needed
• monitor prescribing patterns and measure them against the current version of the Therapeutic Guidelines or a locally endorsed, evidence-based guideline
• ensure locally endorsed guidelines – such as HealthPathways or hospital-based policies – are based on the Therapeutic Guidelines and have been through an approval process; and, that any deviations from the Therapeutic Guidelines are accompanied by a clear rationale based on published clinical evidence.

Medicines do not cure knee osteoarthritis, but they can help manage your knee pain so that you can do the things that are important to you. Medicines should not replace other treatments such as healthy diet, exercise, and weight management if these are recommended. 

If you need medicines to help manage your knee pain and mobility, you can expect to receive medicines that are recommended in a current, good-quality medical guideline.
Tell all healthcare providers about all the medicines you are taking, including any herbal medicines and vitamin supplements.

You can expect your healthcare provider to consider your symptoms, any other health problems you have, and any other herbal medicines, vitamin supplements, and over-the-counter medicines you take before recommending medicines for your knee osteoarthritis. They should also consider your preferences.
You can expect your healthcare provider to give you clear information about what each medicine is for, when to take it, how much to take, how long to take it for, and any possible side effects. They should tell you what to do if you experience side effects.

Consider the variation in pharmacological pain management for Aboriginal patients, with studies showing Aboriginal patients are more than twice as likely to be prescribed opioids in primary care than non-Aboriginal patients. 

See also the Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

Decide with the patient how regularly they need a review of their knee osteoarthritis. 

Dedicate an appointment to each review that includes:

• undertaking a repeat history, physical examination, and psychosocial assessment
• monitoring symptoms and response to treatment, using the same tools as used at the initial assessment (such as PROMs)
• reviewing all prescription, over-the-counter, and complementary medicines the patient may be using
• evaluating any side effects from treatment
• monitoring and evaluating healthcare goals included in the patient’s self‑management plan, such as physical activity and weight management goals with adjustments as necessary to optimise treatment outcomes
• offering further education, coaching or behaviour change support for patients to help them maintain or change their management approaches
• discussing other treatment options as necessary or as requested by the patient.

Refer a patient with worsening symptoms and severe persistent functional impairment despite optimal non‑surgical management for:

• weight-bearing X-ray imaging of the knee
• non‑general practitioner specialist assessment, such as a rheumatologist, orthopaedic surgeon, or sports and exercise physician. If referring to an orthopaedic surgeon for assessment, follow recommendations for referral in the RACGP Guideline for the management of knee and hip osteoarthritis.

Healthcare services should:

• establish and maintain systems in place to support and coordinate clinicians to monitor the symptoms, function, and psychosocial wellbeing of patients with knee osteoarthritis and adjust treatment goals as needed
• provide support for timely access to non‑general practitioner specialist doctors, such as rheumatologists, orthopaedic surgeons, or sports and exercise physicians, for further assessment and care when non‑surgical management has been optimised but the patient is still experiencing worsening symptoms and severe functional impairment
• consider supporting systems for clinicians to use tools during appointments dedicated to patient review, such as PROMs
• establish and maintain systems for referrals for consideration of knee replacement surgery in accordance with the RACGP Guideline for the management of knee and hip osteoarthritis general practice and other primary care services.

You can expect your healthcare provider to offer you planned check-ups and reviews to monitor your symptoms and wellbeing and adjust any treatments or medicines if needed. You can decide together how often you have these check-ups and whether they will be face-to-face or telehealth consultations.

At a check-up, you can expect that you might discuss your self‑management plan, including physical activity and any weight management goals. You may be referred to other healthcare providers who can help you achieve your goals, such as a physiotherapist, psychologist, dietitian, exercise physiologist, or specialist doctor.

If the cause of your symptoms is unclear or if you or your healthcare provider are concerned about your pain and mobility despite following your treatment plan, you will be referred for assessment to a doctor specialising in knee osteoarthritis for further assessment. Most often, this will be a rheumatologist, an orthopaedic surgeon, or a sports and exercise physician.

Be flexible in the way you deliver your service to optimise attendance and support the development of trust with individual Aboriginal and Torres Strait patients and communities. Include opportunities for patients to have a carer, family member or friend involved in all aspects of care delivery, including the decision-making and management planning process. 

Provide care that is close to home wherever possible, with service environments that consider the specific needs of the population, including their age, mobility, and cultural needs. 

Consider the use of telehealth or outreach models to support access to health care for people living in rural and remote communities. 

See also the Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

Assess whether the patient has undertaken optimal non‑surgical management, such as 12 weeks of optimal
physical activity and exercise. 

Provide patients with clear and comprehensive information about suitable procedures for them, including the risks and benefits of those procedures, in a way that they can understand. This ensures they can be actively involved in making treatment decisions. 

Explain the expected: 

• level of sedation, such as regional or general anaesthetic
• time for recovery and rehabilitation.

Use PROMs before and after all surgical interventions.

Do not offer arthroscopic procedures as treatment for uncomplicated knee osteoarthritis. 

Arthroscopic procedures, including debridement and partial meniscectomy, provide little or no clinically significant benefit in pain or function and are not indicated as a primary treatment in the management of uncomplicated knee osteoarthritis. Uncomplicated knee osteoarthritis is not accompanied by true mechanical locking, septic arthritis, or inflammatory arthropathy. Meniscal changes, such as tears identified by imaging, do not warrant arthroscopy. This is because patients with knee osteoarthritis often have changes to the meniscus of their knee as part of the condition. Arthroscopy may be indicated if the patient has an alternate diagnosis such as true mechanical locking, septic arthritis, or inflammatory arthropathy requiring synovectomy.

Healthcare services should: 

• establish and maintain systems and referral networks to provide patients with access to appropriate non‑surgical care, so that patients have the best chance of delaying or avoiding surgery
• establish and maintain systems to provide patients with clear evidence-based information about the potential benefits and harms of joint-conserving and joint replacement surgery, including information about recovery from surgery
• have patient information available in a variety of formats
• enable measurement of PROMs before and after all surgical interventions
• establish and maintain systems for patients to receive timely surgical intervention when it is indicated
• have a process to support appropriate, safe, and effective decision making about surgical procedures
• have policies and procedures that specify arthroscopic procedures are not offered for treating uncomplicated knee osteoarthritis.

Most people who are physically active and manage their weight can delay or avoid surgery. If you still have severe pain after you have tried other treatments such as exercises and physical activity recommended by an exercise healthcare professional, or if your knee osteoarthritis is causing you a lot of difficulty, your healthcare provider might suggest you see a surgeon to discuss surgery.

Your surgeon will explain the surgery for you, including the risks, benefits, and results you can expect. It is important for you to have all the information so that you can make the best decision for your treatment. The types of procedures offered will vary depending upon your suitability for surgery and your preferences. Depending on your other medical conditions, you may also need a specialist anaesthetic consultation beforehand.

Knee replacement is a common option. For some people, another type of surgery may be possible that does not remove your knee joint and is known as joint-conserving surgery. The usual type of joint-conserving surgery is called an osteotomy and involves realigning the knee to take pressure off the damaged area.

Consider the needs of a patient who has to travel away from home for surgery and ensure that they have access to adequate support and advocacy whilst in hospital. 

Enable as many steps as possible in the surgical care pathway to take place ‘under one roof’. This can support Aboriginal and Torres Strait Islander people to use specialist services and prevent patients from falling through the transition gaps that exist within this care pathway.

See also the Recommendations on page 8 for considerations when providing care for Aboriginal and Torres Strait Islander peoples.

Supporting delivery of culturally safe and equitable care

• National Safety and Quality Health Service (NSQHS) Standards: User Guide for Aboriginal and Torres Strait Islander Health, which is built around four priority reforms for transforming the way governments work with and for, Aboriginal and Torres Strait Islander peoples to improve outcomes
• National Agreement on Closing the Gap, which is built around four priority reforms for transforming the way governments work with, and for, Aboriginal and Torres Strait Islander peoples to improve outcomes
• Cultural Respect Framework 2016-2026, which commits the Australian Government and all states and territories to embed cultural respect principles into their health systems¹⁵
• Western Australia Centre for Rural Health: Clinical yarning - a patient-centred framework to improve communication in First Nations health care
• Communicating Positively: A Guide to Appropriate Aboriginal Terminology - NSW Health

The Osteoarthritis of the Knee Clinical Care Standard was first released in 2017 in response to findings from the 2015 Australian Atlas of Healthcare Variation (the Atlas). The Atlas identified considerable variation in rates of knee arthroscopy in Australia, despite the limited value of this intervention for degenerative disease due to knee osteoarthritis. The Atlas also noted the importance of appropriate assessment, investigation, and management of knee osteoarthritis. It recommended the development of the Standard to support improved care.

Read more about the scope and goal of this Standard or see further background in the Osteoarthritis of the Knee Clinical Care Standard. 

This Standard applies to care provided in:

• community and primary healthcare services such as general practices, Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs), and allied health services
• all hospital settings, including public and private hospitals, subacute facilities, outpatient clinics, and day procedure services
• private medical clinics. 

The Standard is particularly relevant to:

• Aboriginal and Torres Strait Islander Health Workers and Aboriginal and Torres Strait Islander Health Practitioners
• allied health practitioners including physiotherapists, dietitians, and occupational therapists
• exercise physiologists
• general practitioners and rural generalists
• nurses and nurse practitioners
• orthopaedic surgeons
• pharmacists
• radiologists, radiographers, and sonographers
• rehabilitation physicians
• rheumatologists
• sport and exercise physicians. 

The Standard may also be relevant in other specialist services and residential aged care services. 

Not all quality statements within this standard will be applicable to every healthcare service. Healthcare services should consider their individual circumstances in determining how to apply each statement.

When implementing this Standard, healthcare services should consider: 

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service.

In rural and remote settings, different strategies may be needed to implement the Standard. For example, the use of: 

• hub-and-spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations
• multidisciplinary teams including allied health assistants where clinically appropriate.

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

• early clinical assessment
• diagnosis and ongoing non-surgical management over the course of the condition
• referral to non-general practitioner specialists
• consideration of surgery if indicated.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting.
• Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Osteoarthritis of the Knee Clinical Care Standard has been endorsed by 22 key organisations:

• Arthritis Australia
• Australasian College of Sport and Exercise Physicians (ACSEP)
• Australia and New Zealand Society for Geriatric Medicine (ANZSGM)
• Australian and New Zealand College of Anaesthetists (ANZCA)
• Australian College of Nurse Practitioners (ACNP)
• Australian College of Nursing (ACN)
• Australian College of Rural and Remote Medicine (ACRRM)
• Australian New Zealand Orthopaedic Nurses Alliance (ANZONA)
• Australian Orthopaedic Association (AOA)
• Australian Physiotherapy Association (APA)
• Australian Primary Health Care Nurses Association (APNA)
• Australian Rheumatology Association (ARA)
• Australian Society of Medical Imaging and Radiation Therapy (ASMIRT)
• Council of Remote Area Nurses of Australia (CRANAplus)
• Exercise and Sports Science Australia (ESSA)
• Musculoskeletal Health Australia
• National Aboriginal Community Controlled Health Organisation (NACCHO)
• National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners (NAATSIHWP)
• Osteopathy Australia
• Pharmaceutical Society of Australia (PSA)
• Royal Australasian College of Surgeons (RACS)
• Therapeutic Guidelines Limited.

The Standard is supported by:

• Consumers Health Forum (CHF)
• National Rural Health Alliance (NRHA)
• Royal Australian and New Zealand College of Radiologists (RANZCR).

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Osteoarthritis of the Knee Clinical Care Standard Review Working Group provided expert advice on the development and review of the Standard. In addition, a targeted consultation process was conducted with key stakeholders.

Review working group - Osteoarthritis of the Knee Clinical Care Standard

Many members of the Osteoarthritis of the Knee Clinical Care Standard Review Working Group were involved in the original development of the Standard in 2017. 

The main roles of the Review Working Group were to:

• advise on the continued scope and key components of care within the Standard
• advise on the key sources of evidence to inform the review.
• advise on revisions to quality statements and supporting indicators
• recommend strategies to support the implementation of the updated Standard
• actively support raising awareness of the updated Standard.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence sources underpinning the Standard.

Evidence sources - Osteoarthritis of the Knee Clinical Care Standard | Australian Commission on Safety and Quality in Health Care