Osteoarthritis and the Root Cause Approach: How Avoiding the Problem Often Makes It Worse

Isaac Edmondson
Jul 29
3 min read

Updated: Jul 30

This is the story of a patient of mine and how avoiding the problem altogether made things worse. Throughout this story, I want to highlight some issues I see often in how we manage knee osteoarthritis.

The Flare-Up

I recently had a patient referred to me for a knee "flare-up" after an activity outside their normal routine. They had two weeks of swelling and pain, and I was the first medical professional they saw after the physician they wanted to see had a wait list of a month. This knee was a problem area for 2-3 years, and coaches/trainers had advised them to avoid strength training the area to prevent symptoms (never good!!!).

What We Did

They were lacking knee flexion, so we started a home exercise program: knee flexion range-of-motion work and isometrics to bring down pain and swelling. Over six weeks, they reported a 90% improvement in pain and function, built on a progressive resistance training program, working into compound movements such as squats, deadlifts, and lunges.

This lines up with the evidence. The Knee Osteoarthritis Clinical Practice Guidelines (CPG) shows strong evidence for supervised exercise programs. Throughout, I had them self-monitor symptoms: stay under a pain level of 3, and make sure swelling was trending down. The CPG also shows strong evidence that pain improves with patient education and self-management.

A Second Opinion

They had an appointment with a sports medicine physician they hadn't seen before, and got a second opinion on their care. Here's what happened, and what the evidence actually says about each step:

The physician aspirated the knee. Evidence: temporary improvement in knee function.
The physician gave a corticosteroid injection. Evidence: temporary improvement with short-term relief.
The plan was to move to platelet rich plasma (PRP). Evidence: limited effect on pain reduction and function.
And also to perform a hyaluronic acid injection. Evidence: moderate evidence against repeated use of these injections.

The physician also recommended limiting deep flexion, squats, lunges, leg extensions, and leg press.

This recommendation ran counter to the strong evidence for strength training in knee osteoarthritis.

We had already been running a progressive strength training plan, and it hadn't caused a single setback in their care. Different providers can reasonably land in different places here and this recommendation was based largely on imaging of the knee, rather than how the patient was actually presenting clinically. Biomechanics matter in physical therapy; however, restricting activity based purely on imaging and biomechanics risks losing sight of the individualization each person's plan and care require.

Words matter. My patient heard the classic phrase of "bone on bone" and started doubting their activity levels. It's time we get better at encouraging activity instead of limiting it. The risks of not strength training, including continued frailty, osteoporosis and progression of osteoarthritis are real. That's not worth trading away for unproven or unclear therapies.

Thankfully, I was already in contact with this doctor, and we reached a good agreement on continuing their strength training.

Why Did This Start in the First Place?

I think it comes down to a cycle:

Pain → advice to offload for 2–3 years → feels better → tries activity way outside their norm, now with weaker muscles → pain and swelling return → and the cycle repeats.

A root cause approach would have prevented this from happening in the first place. A good physical therapist would have loaded the patient appropriately in the early stages, even before I saw this patient, decreasing the likelihood of a flare up in the future.

-Dr. Isaac

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AI Disclaimer

All original thoughts. See proof below of handwritten blog post. AI was used in proof reading and cleaning up thoughts.