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. 2025 May 31;14(5):1675–1684. doi: 10.4103/jfmpc.jfmpc_1254_24

Prevalence of knee osteoarthritis among elderly persons in India: A systematic review and meta-analysis

Roy Arokiam Daniel 1,✉, Mani Kalaivani 2, Praveen Aggarwal 3, Sanjeev Kumar Gupta 4
PMCID: PMC12178484  PMID: 40547750

ABSTRACT

Background:

Osteoarthritis (OA) is the most common cause of joint pain among the elderly population. It deteriorates their quality of life and poses economic burden to the family and the nation. Furthermore with increasing life expectancy and growing elderly population, the prevalence of OA will eventually increase. There is lack of national-level estimate on the prevalence of OA knee in India. Hence, this systematic review and meta-analysis were conducted to estimate the prevalence of OA knee among elderly persons in India.

Methods:

A systematic electronic search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar to retrieve community-based studies which reported the prevalence of OA knee among elderly persons in India. To estimate the pooled prevalence and heterogeneity, the random effects model and I2 statistic methods were employed. We conducted subgroup analyses based on gender and study setting, criteria, and sensitivity analysis.

Results:

We included 14 studies in this meta-analysis, which comprised a total of 5,029 participants. The pooled prevalence of OA knee among elderly persons in India was 47% (95% CI: 38.4% to 55.8%, I2-97.1%) The subgroup analysis based on gender, criteria used, and study setting did not reveal the cause of heterogeneity. Sensitivity analysis after removing two studies did not change the pooled estimate.

Conclusions:

Almost half the elderly persons in India suffer from OA knee, posing a severe threat to the healthcare system. Hence, the strengthening of primary health care and increased rehabilitation services is needed to reduce the consequences of OA among elderly people.

Keywords: Osteoarthritis, knee, joint pain, elderly, senior citizens, community, India

Introduction

Osteoarthritis (OA) is the most frequent cause of persistent joint pain in the elderly population and the main contributor to disability worldwide.[1] Prevalence increases with age, and it affects women more frequently than males. Although the knee joint is most frequently affected, the condition can also affect the hips, hand, shoulder, and spine.[2] Of all the musculoskeletal disorders, OA accounts for 50% of cases.[3] Knee OA is the leading cause of OA worldwide and gets worse with ageing and obesity.[4] The number of years lived with disability (YLDs) for hip and knee OA was ranked 11th highest in the 2010 Global Burden of Diseases (GBD) survey.[3]

According to a nationally representative Indian survey, joint and pain-related issues are the second and fourth most common reasons for outpatient clinic visits and out-of-pocket expenses among all non-communicable diseases.[5] These not only have an effect on the person’s bodily and psychological well-being, but also put a heavy strain on the family and the nation’s healthcare resources. About 13% of women and 10% of men 60 years and older worldwide have symptomatic knee osteoarthritis[6]; the frequency increases to 40% for people over the age of 70 years.[7] Data from community surveys in rural and urban parts of India show a wide range of prevalence of OA [17-60.6%] among elderly people (>65 years), with point prevalence in rural areas being higher than urban.[8,9]

From about 7.4% in 2001 to almost 19% in 2050, India’s elderly population (aged ≥ 60 years) is expected to grow rapidly.[10] The majority of elderly women (>80%) and men (>40%) are economically dependent, making them vulnerable.[11] The country will undoubtedly face a significant financial and health burden from OA in the near future due to increased obesity rates, longer life expectancies, and limited access to healthcare. A person’s quality of life is significantly impacted by pain and other symptoms of OA, which affect both physical and psychological well-being.[12] Despite the fact that the Government of India has launched a special national programme in 2010 for the health care of the elderly, there are no established guidelines for osteoarthritis at primary care level physicians who will be handling the initial management for chronic illnesses for the elderly population. Additionally, there is no estimate on the prevalence of osteoarthritis in India at the national level. Therefore, we conducted this systematic review and meta-analysis to estimate the prevalence of knee osteoarthritis among the elderly people in India. This information would assist policymakers to craft effective management plans for knee osteoarthritis in the primary care context.

Methods

Data sources and search strategy

A thorough literature search was conducted to find relevant studies that had been published between the time of their inception and 31st December 2023. The following electronic databases were searched using keywords and the Medical Subject Headings (MeSH) system: Without regard to language, Medline was accessed through PubMed, Embase, the Cochrane library, and Google Scholar. The terms “prevalence,” “epidemiology,” “osteoarthritis,” “knee pain,” “elderly,” “senior citizen,” and “India” were employed to build the search strategy. For this study, we adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) standards.[13,14] In addition, we examined the cross-references of all the included studies and various surveys conducted in India.

Ethics approval is not applicable here as it a meta-analysis done from already published articles from the database.

Inclusion and exclusion criteria

The following criteria were used to determine whether studies were eligible: Studies that were 1) population or community-based 2) should have estimated the prevalence of knee osteoarthritis, 3) data was available in the study to estimate the prevalence of knee osteoarthritis among elderly people (≥60 years of age), 4) knee osteoarthritis was diagnosed based on objective assessment, and 5) studies carried out in India. The exclusion criteria were 1) arthritis other than OA such as rheumatoid arthritis, 2) osteoarthritis of other joints, and 3) abstracts, conference proceedings, letters, review articles, editorials, case reports, and experiments without human participants were all excluded.

Study selection, data extraction, and quality assessment

All the records that had been retrieved from the databases were reviewed by two independent reviewers (RAD and SKG) who looked over their titles and abstracts. Only abstracts that met the selection requirements were chosen for the full-text review. Discussions were held to resolve disagreements on the study selection. After ensuring that the most recent and complete version was used, the duplicates were discarded. We searched the collected studies’ reference lists for additional sources. To verify that they matched the inclusion criteria, the retrieved full-text papers went through a subsequent evaluation. We created a data collection form using Microsoft Excel 2013 to extract and compile the required data fields from the selected full-text studies. Author information, year of publication, study location, study design, sampling strategy, sample size, diagnostic criteria for OA knee, and reported total and gender-specific prevalence of OA knee were obtained from the studies. Quality of the selected studies was assessed in accordance with the Critical Appraisal Skills Programme (CASP) guidelines.[15]

Data synthesis and statistical analysis

We provided summary estimates of the prevalence of OA knee among elderly people. For each study, the standard error (SE) of the prevalence was computed using the formula “square root of P x (1-p)/n” based on the prevalence and sample size. To demonstrate the prevalence and a corresponding 95% confidence interval (CI), forest plots were created. The random effects model, weighted by the inverse of the variance, was used in Stata 16.0 (StataCorpLP, College Station, Texas, USA) to carry out the meta-analysis. Heterogeneity was assessed using the I2 statistic (% of residual variance ascribed to heterogeneity). The funnel plot was visually inspected to determine publication bias, and Egger’s test was used to determine the impact of small studies. An analysis of subgroups based on gender and study setting was carried out to explore the observed heterogeneity. After excluding two studies with extremes of sample sizes, sensitivity analysis was carried out to evaluate the changes in the pooled values. To ascertain whether there was a significant variation in the prevalence of OA knee between subgroups, an interaction test was also conducted.

Results

In total, 1251 studies were found in electronic databases. After eliminating 122 duplicates, 1129 studies were reviewed using the selection criteria based on the titles and abstracts, and 1092 were excluded. Finally, 14 studies that fit the inclusion criteria were chosen from 37 studies, as indicated in Figure 1.

Figure 1.

Figure 1

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Flow of selection of studies for meta-analysis

Characteristics of studies included in the meta-analysis

A total of 5,029 elderly people (aged ≥ 60 years) were identified from the studies that made up this review. American College of Rheumatology (ACR) criteria were employed to diagnose osteoarthritis knee in most of the studies included in this study, which were primarily urban in nature. There was one multicentric study conducted by Yadav et al.[16] in 2022. The studies by Sharma et al.[9] and Shraddha et al.[17] had reported the prevalence of osteoarthritis of large joints and mobility issues likely to be knee joints and hence were included in the analysis. Majority of the studies used random sampling to recruit the participants and were conducted in northern India. Of these 14 included studies, four studies were conducted only on elderly females.[18,19,20,21] The characteristics of the studies included in the meta-analysis are shown in Table 1.

Table 1.

Characteristics of the studies included in the meta-analysis

Authors Year Study area Setting Proportion of females Criteria
Joshi et al.[23] 2003 Chandigarh, Panchkula, Haryana Mixed 51 ICD-10
Sharma et al.[9] 2007 Chandigarh Mixed NA Clinical examination
Salve et al.[18] 2010 New Delhi Urban 100 ACR
Kamble et al.[24] 2012 Ahmednagar, Maharashtra Rural 53.8 ACR
Shraddha et al.[17] 2012 Mysore, Karnataka Urban 60.6 Clinical examination
Ajit et al.[22] 2014 Bangalore, Karnataka Urban 52.1 Modified ACR*
Singh et al.[25] 2014 New Delhi Urban 48 ACR
Bhaskar et al.[19] 2016 Kottayam, Kerala Urban 100 ACR
Narasimha et al.[21] 2016 Bangalore, Karnataka Urban 100 ACR
Kulandaivelan et al.[26] 2017 Hisar, Haryana Urban 54.2 Modified Nordic questionnaire
Bala et al.[27] 2020 Srinagar, Jammu Rural 59.1 ACR
Koch and Sharma[20] 2020 Guwahati, Assam Urban 100 ACR
Jaiswal et al.[28] 2021 Faridabad, Haryana Rural 60.1 ACR
Yadav et al.[16] 2022 Multicentric Mixed NA Xray-Kellgren and Lawrence scale
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*NA- Not available

Prevalence of osteoarthritis knee among elderly persons in India

The prevalence of osteoarthritis across the 14 included studies varied, ranging from 15% in a study conducted in Mysore by Shraddha et al.[17] to 70% in a study by Narasimha et al.[21] conducted in Bangalore [Table 2]. The pooled estimate for the prevalence of knee osteoarthritis among elderly individuals in India, using a random effects model, was 47% (95% CI: 38.4% to 55.8%) [Figure 2]. A heterogeneity analysis revealed an I² value of 97.1% with a P value of less than 0.001, indicating significant heterogeneity. The prevalence of osteoarthritis was found to be higher among females (50.7%, 95% CI: 33.3%-67.9%) compared to males (26.2%, 95% CI: 10.5%-45.7%). Although two studies by Sharma et al.[9] and Ajit et al.[22] reported the sex-specific prevalence of osteoarthritis, they did not provide the number of males and females included, and therefore, were excluded from the sex-wise prevalence estimates.

Table 2.

Prevalence of osteoarthritis knee

Authors Year Sample size Total Prevalence (%) Prevalence in males (%) Prevalence in females (%)
Joshi et al.[22] 2003 200 33 23.5 42.2
Sharma et al.[9] 2007 362 56.6 41.6 70.1
Salve et al.[18] 2010 72 64 NA 64
Kamble et al.[23] 2012 494 24.1 18.5 29
Shraddha et al.[17] 2012 526 15.4 13 16.9
Ajit et al.[24] 2014 61 54.1 23.1 77.1
Singh et al.[25] 2014 496 41.1 NA NA
Bhaskar et al.[19] 2016 139 55.4 NA 55.4
Narasimha et al.[21] 2016 30 70 NA 70
Kulandaivelan et al.[26] 2017 352 41.8 NA NA
Bala et al.[27] 2020 136 46.3 NA NA
Koch and Sarma[20] 2020 62 34.5 NA 34.5
Jaiswal et al.[28] 2021 454 64.3 54.1 71.1
Yadav et al.[16] 2022 1645 44.6 NA NA
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*NA- Not available

Figure 2.

Figure 2

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Forest plot of the meta-analysis for prevalence of osteoarthritis knee by sex

Subgroup analysis

Prevalence of osteoarthritis knee based on study setting

Among the 14 studies, eight were conducted in urban areas, three in rural settings, and three in “mixed” areas that included both urban and rural populations. The prevalence of knee osteoarthritis among elderly individuals in rural, urban, and mixed regions was 44.5% (95% CI: 18.5%-72.3%), 49.3% (95% CI: 35.3%-63.4%), and 44.9% (95% CI: 34.5%-55.5%), respectively. We observed no reduction in heterogeneity, and there was no significant difference in heterogeneity across groups, as illustrated in Figure 3 (P value = 0.878).

Figure 3.

Figure 3

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Forest plot of the meta-analysis for prevalence of osteoarthritis knee by study setting

Prevalence of osteoarthritis knee based on criteria used

Of the 14 studies, eight used the American College of Rheumatology (ACR) criteria, while six applied other diagnostic criteria, as shown in Table 1. The prevalence of knee osteoarthritis among elderly individuals was 52.7% (95% CI: 39.7%-65.6%) in studies using ACR criteria and 40.0% (95% CI: 27.4%-53.4%) in those using other criteria. There was no observable decrease in heterogeneity, and the difference in heterogeneity between the two groups was not statistically significant, as shown in Figure 4 (P value = 0.181).

Figure 4.

Figure 4

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Forest plot of the meta-analysis for prevalence of osteoarthritis knee by criteria

Sensitivity analysis

A sensitivity analysis was conducted by excluding two studies with sample sizes of 30 and 1645 by Narasimha et al.[21] and Yadav et al.,[16] respectively. The analysis revealed no significant change in the overall prevalence of knee osteoarthritis among the elderly (45.8% [95% CI: 35.1%-56.7%], I² =97.4%), as shown in Figure 5.

Figure 5.

Figure 5

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Forest plot of the meta-analysis for prevalence of osteoarthritis knee-sensitivity analysis by removing two studies

Quality assessment

Regarding quality assessment, most studies met five or more of the nine quality criteria evaluated. Four studies provided confidence intervals for their primary results.[18,19,25,28] Additionally, eight of the 14 studies had calculated a minimum sample size in advance, as noted in Table 3.

Table 3.

Risk of bias assessment of the studies included in the meta-analysis

Question Joshi et al. (2003) Sharma et al. (2007) Salve et al. (2010) Kamble et al. (2012) Shraddha et al. (2012) Ajit et al. (2014) Singh et al. (2014)
Did the study address a clearly focused question/issue? Yes Yes Yes Yes Yes Yes Yes
Was the research method (study design) appropriate for answering the research question? Yes Yes Yes Yes Yes Yes Yes
Was the method of selection of the participants (employees, teams, divisions, organizations) clearly described? Yes Yes Yes Yes Yes Yes Yes
Could the way the sample was obtained introduce (selection) bias? No No No No No No No
Was the sample of participants representative with regard to the population to which the findings will be referred? Yes Yes Yes Yes Yes Yes Yes
Was the sample size based on pre-study considerations of statistical power? Yes No Yes No No Yes Yes
Was a satisfactory response rate achieved? Yes Yes Yes Yes Yes Yes Yes
Were the measurements (questionnaires) likely to be valid and reliable? Yes Yes Yes Yes Yes Yes Yes
Were confidence intervals given for the main results? No No Yes No No No Yes
Question Bhaskar et al. (2016) Narasimha et al. (2016) Kulandaivelan et al. (2017) Bala et al. (2020) Koch & Sharma (2020) Jaiswal et al. (2021) Yadav et al. (2022)
Did the study address a clearly focused question/issue? Yes Yes Yes Yes Yes Yes Yes
Was the research method (study design) appropriate for answering the research question? Yes Yes Yes Yes Yes Yes Yes
Was the method of selection of the participants (employees, teams, divisions, organizations) clearly described? Yes No Yes No No Yes Yes
Could the way the sample was obtained introduce (selection) bias? No Can’t say No No Can’t say No No
Was the sample of participants representative with regard to the population to which the findings will be referred? Yes Yes Yes Yes Yes Yes Yes
Was the sample size based on pre-study considerations of statistical power? Yes No Yes No No Yes Yes
Was a satisfactory response rate achieved? Yes Yes Yes Yes Yes Yes Yes
Were the measurements (questionnaires) likely to be valid and reliable? Yes Yes Yes Yes Yes Yes Yes
Were confidence intervals given for the main results? Yes No No No No Yes No
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Publication bias

The funnel plot showed symmetry, as displayed in Figure 6, which was further supported by Egger’s test (P value = 0.25), suggesting no publication bias.

Figure 6.

Figure 6

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Forest plot for assessing publication bias

Discussion

This systematic review and meta-analysis of data from 14 cross-sectional studies, which included 5,029 participants, revealed a pooled prevalence of osteoarthritis of knee 47% (95% CI: 38.4%-55.8%) among elderly persons (aged ≥ 60 years) in India with substantial heterogeneity (I2 = 97.1%). The estimated pooled prevalence was higher in urban than in rural settings (49.3% vs 44.5%), and more in females than in men (50.7% vs 26.2%).

A systematic review and meta-analysis conducted by Yahaya et al.[29] in 2021 among adults of lower middle- and low-income countries, estimated the prevalence of osteoarthritis knee as 20.7% (95%CI: 14.7%-27.4%). Another systematic review and meta-analysis by Alenazi et al.[30] in 2021 among Gulf Cooperation Council countries, estimated that the prevalence of osteoarthritis (all joints) in adults as 16.1% (95%CI: 15.0%-17.0%). Another global-level systematic review and meta-analysis conducted by Cui et al.[4] in 2020, estimated the prevalence of osteoarthritis knee among adults aged 15 and over as 16·0% (95% CI, 14·3%-17·8%).

When compared to the studies stated above, the estimate from our study is much larger. A number of factors may have contributed to the greater prevalence of osteoarthritis knee in this study. In our study, one specific age group is taken into account for the analysis. Unlike other studies, ours focused exclusively on the elderly population for the estimation of knee osteoarthritis. The prevalence is higher in our study because OA worsens with age, and additional risk factors for OA, like obesity, recurrent knee injury, muscular weakness, sedentary lifestyle, and joint laxity, are frequently observed in the older population. Also, evidence suggests that OA is more prevalent among women, who make up 60.5% of our sample.

We did not include any other joint problems in this study and solely took into account the osteoarthritis of knee joints. Evidence suggests that the most common kind of OA is knee OA.[31] Also, the prevalence of knee osteoarthritis varies with race and various ethnic groups.[32,33] The stated rise in the burden of OA disease may be a result of longer life expectancy and prolonged exposure to risk factors for arthritis, viz. obesity, work-related variables, joint overuse, mechanical injury, genetics, and gender.[2] Other risk factors that may contribute to India’s increased prevalence of OA knee include the country’s large proportion of rural residents who work in jobs that require strenuous physical labour, cultural practices such as sitting cross-legged or squatting. These elements could therefore have an impact on the prevalence of OA knee in our investigation.

In comparison with mild OA in high-income nations, a higher percentage of people living with moderate to severe OA were observed in India. This might be explained by the higher availability of hip and knee replacement surgeries in high-income nations and the later adoption of surgical treatments in India.[3] Additionally, people with OA are considerably more likely than non-OA patients to develop comorbidities. Obesity, respiratory illnesses, diabetes, hypertension, and other chronic problems can coexist with OA, placing more strain on healthcare services. Comorbidities restrict the use of NSAIDs because of contraindications. As a result of decreased physical activity, which is linked to an increase in mortality, OA itself restricts the management of comorbidities including hypertension and diabetes.[34]

In a prospective study by Palo et al.,[35] which evaluated 1,828 osteoarthritis patients, it was found that the patients had poor quality of life and mental health. Another study by Sharma et al.[36] on elderly people from rural south India revealed that there was a sevenfold higher risk of falling due to impaired balance control due to OA knee. Therefore, reducing consequences is crucial to enhance the quality of life of the elderly people with OA knee. From an economic viewpoint, OA is burdensome, resulting in high direct costs from increased hospital and medical service utilization as well as significant indirect costs from lost productivity of patients and their caregivers. According to a systematic review by Puig-junoy et al.,[37] the entire cost of medical care for osteoarthritis could account for 0.8–1% of a nation’s overall medical spending. The total cost of osteoarthritis may account for 0.25–0.5% of a nation’s gross domestic product (GDP), including non-healthcare expenditures like lost productivity.

Compared to the general population, those with OA have a higher chance of mortality from all causes, particularly from cardiovascular disease.[38] As a result, it is important to screen for it early and treat it well to maximize patients’ mobility and independence and to improve care for them. A clinical examination and X-rays of the affected joints are typically necessary for the diagnosis of OA. Doctors who work in primary care settings are crucial in the diagnosis and management of patients with OA, starting with non-pharmacological treatment and moving on to medicinal therapy and physiotherapy.[1] Establishing the correct diagnosis followed by treatment along with adequate counselling to the patients with OA is required at the primary care setting.

A cross-sectional study by Alharbi et al.[39] revealed that the majority of physicians working in Primary Health Centres (PHCs) lacked adequate knowledge in managing osteoarthritis (OA), highlighting a crucial gap in primary healthcare. Similarly, a study by Østerås et al.[40] demonstrated that after two training workshops on OA management for general physicians and physiotherapists, there was a notable improvement in the quality of care provided to patients with OA. This evidence underscores the importance of implementing a robust service delivery model in primary care, focusing on comprehensive OA management to improve health outcomes for patients with knee OA.[41] To achieve this, strengthening primary healthcare through targeted training of primary care physicians, supported by clear treatment guidelines, is essential. Additionally, at the community level, regular health education activities focused on knee-strengthening exercises and obesity management can significantly enhance the quality of life of OA patients.

Strengths and limitations

For the purpose of identifying community-based studies that have estimated the prevalence of OA knee among elderly people in India, we have carefully examined various electronic databases. We identified 14 studies and collected data from 5,029 participants among them. We employed a standard search strategy, evaluated the potential for bias in each study, looked into heterogeneity with subgroup analysis, and performed sensitivity analysis. The following caveats must be taken into consideration when evaluating the results of this systematic review and meta-analysis. Despite using a comprehensive search approach, we may have missed some grey literature that could have affected the pooled estimate. High levels of heterogeneity between studies indicate substantial variation in population studied and data collection methods. Hence, the pooled prevalence estimate from this analysis must be considered with caution.

Conclusions

This study reveals that OA knee, which affects over half of the elderly people in India, is a significant public health issue. The burden of OA in India is anticipated to rise tremendously as the population ages. Therefore, in order to attain active and healthy ageing, it is crucial to address the various risk factors for OA in order to lessen the burden and its effects by strengthening the primary health care. Treatment facilities for OA need to be augmented.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.

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