Three hundred forty-five patients with symptomatic knee osteoarthritis were randomized to receive either a stepped exercise program (STEP-KOA) (n=230) or an arthritis education (AE) control intervention (n=115). The STEP-KOA intervention involved a progressive three-step approach: an internet-based exercise program (step 1), followed by biweekly physical activity coaching (step 2) for non-responders, and in-person physical therapy (step 3) for those still not meeting response criteria. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, with secondary outcomes including objective physical function tests and self-reported physical activity. Outcomes were assessed at 3, 6, and 9 months. Overall, the study found that at 9 months, the STEP-KOA group demonstrated a greater improvement in WOMAC scores compared to the AE group, but there were no significant differences in objective physical function tests or self-reported physical activity. The findings suggest that a stepped care approach may improve patient-reported symptoms of knee osteoarthritis while preserving health system resources.