Physical Therapy-Based Realignment Strategies for Knee Osteoarthritis: A Systematic Review

Knee osteoarthritis (KOA) is a degenerative disorder involving articular cartilage degeneration, causing pain and functional impairment. The condition is most prevalent among individuals in their fourth and fifth decades of life. Biomechanically, musculoskeletal weakness can cause pelvic drop, increasing stress on the knee's medial compartment. While traditional therapy focused on symptomatic relief, current research emphasizes the entire kinetic chain alignment, particularly lumbopelvic stability, lower limb muscle performance to counter joint loading, and abnormal joint reaction forces. The primary objective of this systematic review is to evaluate the current evidence regarding physical therapy-based realignment strategies for individuals diagnosed with KOA. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted across databases, including PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Google Scholar for studies published between 2016 and 2026. The review included 18 randomized controlled trials (RCTs) focusing on conditioning exercises, manual therapy, and realignment strategies. Methodological quality was assessed using the Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. This systematic review of 18 RCTs demonstrates that physical therapy-based realignment strategies significantly alleviate pain and improve functional outcomes in patients with KOA. A core finding is the superior effectiveness of a multifaceted kinetic-chain approach over isolated knee protocols. Specifically, proximal strengthening of the hip and core was shown to be equal or superior to isolated knee exercises in enhancing muscle strength and quality of life. Trunk stabilization exercises (TSE), when integrated with knee strengthening, proved more effective at reducing pain and disability than isolated protocols by improving lumbopelvic stability and preventing compensatory biomechanical alterations. Additionally, manual therapy served as a critical adjunct to accelerate early rehabilitation and sustain clinical benefits. Methodological quality assessment using the RoB 2 tool revealed that while the majority of trials demonstrated a low risk of bias in randomization and reporting, the overall evidence profile carries 'Some Concerns' to 'High Risk'. This is primarily attributed to unavoidable challenges in blinding during physical therapy interventions and outcome measurements, which affected 72% of the included studies. The systematic review concludes that physical therapy interventions utilizing realignment strategies are highly effective for the conservative management of KOA. By transitioning from traditional localized exercises to a multifaceted kinetic-chain approach incorporating proximal hip and core stabilization, clinicians can optimize biomechanical load distribution and neutralize the abnormal joint reaction forces that accelerate cartilage wear. Furthermore, research suggests that even progressive high-impact realignment strategies are safe for individuals with mild KOA, as they enhance bone strength without compromising knee cartilage integrity. Ultimately, these conservative strategies aim to modify the disease's trajectory and restore functional independence, improving the patient's quality of life to such an extent that surgical intervention may be successfully delayed or avoided.