Knee OA is an important cause of disability worldwide. No effective cure exists and many patients will eventually undergo costly joint replacement. Clinical guidelines emphasize that non-drug nonsurgical treatment should constitute first-line treatment. Exercise therapy is strongly recommended for knee OA. However, overall treatment effects on symptoms are modest at best, which is further compounded by poor adherence in the longer-term. In many patients the disease is also driven by local knee inflammation. Muscle strengthening and aerobic exercise likely have anti-inflammatory effects. However, pain and joint swelling further impair muscle function. Thus, in patients with clinical signs of inflammation beneficial effects of exercise therapy may have been attenuated in previous research. We suggest that adding adequate knee offloading through daily use of flat flexible shoes, to exercise may help attenuate inflammatory responses from daily walking gait, and thus, improve short- and long-term treatment effects from concurrent exercise therapy leading to more effective symptom- and structure modification. In this phase II clinical trial, we will compare clinical symptoms, markers of inflammation and structural disease progression in knee OA patients with clinical inflammation who will undergo aerobic and strengthening exercise, added with daily use of flat flexible shoes, or a conventional walking shoe. Conservative treatment & selfmanagement are research priorities in OA.