OBJECTIVES: Interventions for management of knee osteoarthritis (OA) are broadly classified into four classes: conservative, pharmacological, procedural and surgical. Our study describes the initial treatment strategy used for management of incident knee OA patients. Given the weak evidence on efficacy of hyaluronic acid (HA) and the potential for negative consequences with opioid use, we also compared the characteristics of HA users (with HA non-users) and opioid users (with opioid non-users). METHODS: A cohort study design using IMS Lifelink Plus (2006-2013) claims data was used to compare the characteristics of incident knee OA patients receiving: 1) conservative, 2) pharmacological, 3) procedural, 4) procedural plus pharmacological, 5) surgical with or without other interventions 6) all other combinations and 7) no intervention. Chi-square tests were used to compare the characteristics these 7 groups, and HA users (vs. non-users) and opioid users (vs. non-users). RESULTS:  A cohort of 75,211 incident knee OA patients met our inclusion-exclusion criteria which includes 4,273 (5.68%) patients receiving conservative therapies, 5,699 (7.58%) pharmacological, 20,471 (27.22%) procedural, 9,409 (12.51%) surgical with or without other interventions, 5,855 (7.78%) procedural plus pharmacological, 6,813 (9.06%) treated with other combinations of interventions and 22,691 (30.17%) who did not receive any intervention. Opioids (16.93%) were the most commonly used pharmacological agent, followed by NSAIDs (15.80%). 78% of opioid users were also recipients of surgical or procedural intervention, which is not a first line strategy to manage incident knee OA. Almost 10.5% of incident knee OA patients used HA injections within first 90 days after incident knee OA diagnosis. Both HA users and opioid users  (compared to non-users) also had a higher proportion of patients with other pain conditions CONCLUSIONS:  Although the existing literature and guideline recommendations do not support the use of opioids, HA and other procedural and surgical interventions for the initial management of incident knee OA, these interventions are frequently used.