## 1 Introduction  
Knee osteoarthritis (KOA) is a highly prevalent clinical syndrome of joint pain accompanied by a varying degree of functional limitation and decreased quality of life. Among adults aged 60 and older, this chronic musculoskeletal illness is present in 10% of men and 13% of women, or in an estimated 250 million persons worldwide [1]. In terms of pathophysiology, KOA is associated with increased levels of inflammation, and it is characterized by loss of articular cartilage and by subchondoral bone changes in terms of turnover, mineralization, and volume [2, 3]. Age and sex are two of the main risk factors associated with knee OA, with women more likely to develop OA than men due to differences in knee anatomy and kinematics [4]. Previous knee injuries, joint malalignment and instability resulting in increased mechanical stress, repetitive actions such as kneeling and heavy lifting, and professional sports activities such as long-distance running are all strong risk factors for knee OA [1, 3, 4]. In this regard, [PERSON] considers sports accidents an important risk factor for the development of post-osteoarthritis trauma, resulting from an alteration of normal biomechanics resulting in the impact of dynamic cartilage loads along lines of non-physiological pressure and a higher level of disability [5; 6]. However, among the risk factors of KOA, overweight and obesity are the most determinant, although they are considered modifiable. Overweight is defined as the presence of a BMI between 25 and 29.9 kg/m\({}^{2}\). Obesity is defined as the presence of a body mass index (BMI) > 30 kg/m\({}^{2}\), with the degree of obesity defined as class I (BMI 30.00-34.99 kg/m\({}^{2}\)), class II (BMI 35.00-39.99 kg/m\({}^{2}\)), and class III (BMI \(\geq\) 40.00 kg/m\({}^{2}\)). The world prevalence of obesity in the last 30 years has increased by 27.5% in adults and 47.1% in children, with a higher prevalence in developed countries in men than women. In Italy, it is estimated that 36.2% of the population is overweight and 10.2% is obese [7; 8]. A 2015 meta-analysis showed that being overweight and being obese are significantly associated with higher knee OA risks of 2.45 and 4.55, respectively, and that the risk of knee OA increases by 35% with a five-point increase in BMI [9]. Excess weight correlates with a higher risk of knee OA both by increasing the load on weight-bearing joints and by collating with the inflammatory milieu caused by metabolic syndrome [10]. Treatment objectives for KOA include pain control, reducing stiffness, and improving mobility and quality of life, with avoidance of toxic pharmacological side effects [11]. The guidelines for KOA management suggest conservative treatment as the first approach to the disease. The conservative treatment aims to reduce pain and consists of the single or synergistic use of drugs such as NSAIDs, infiltrations based on corticosteroids or hyaluronic acid, focal muscle vibration (WBV), oxy-ozone therapy (O\({}_{2}\)-O\({}_{3}\)), platelet-rich plasma injections (PRP), and mesenchymal adipose stem cell (MSC) therapy [12]. Where conservative measures fail, total knee replacement is indicated in patients with severe OA with extensive pain and deformity [13]. Importantly, some studies have suggested that obese patients report worse outcomes and quality of life after surgery, making the need for successful conservative measures all the more pressing [14]. The Osteoarthritis Research Society International (OARSI) periodically updates its guidelines for the nonsurgical management of OA [15]. In its 2019 update, OARSI recommended arthritis education and structured land-based exercise programs, with or without dietary weight management, as the core treatment for KOA. Recommended pharmacological treatment options include topical nonsteroidal anti-inflammatory drugs (NSAID), cyclo-oxygenase 2 (COX-2) inhibitors, and oral NSAIDs.