Compare long-term efficacy and recurrence of Chinese ointment(Co) massage, Tuina, and combined acupuncture for knee osteoarthritis (KOA). A multicenter, prospective, observational real-world study was conducted in multiple cities in China. 2143 KOA patients (83.76 % female) were prospectively assigned by preference to Co (n = 312), Tuina (n = 403), Co+acupuncture (n = 237), or Tuina+acupuncture (n = 1362) groups. Treatments involved 5-10 sessions. The Visual Analog Scale (VAS) assessed the average degree of knee joint pain, while the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Lequesne Index evaluated knee joint dysfunction in terms of functionality and severity. The 2 years recurrence rate of KOA was also calculated. All groups showed significant post-treatment WOMAC, VAS, and Lequesne score reductions. The Co group had the lowest VAS scores at 2-10 months. Recurrence rates (lowest to highest) were Co group, Tuina group, Tuina+acupuncture group, Co+acupuncture group. The overall maximum recurrence rate was 33.97 % at 2 years, stabilizing after 18 months. KL grade II patients had the best long-term outcomes (recurrence 16.16 %-30.85 % over 2-24 months). No serious adverse events occurred. Traditional Chinese medicine (TCM) conservative treatments (Co therapy, Tuina, and combined acupuncture) demonstrated safety for KOA management. Patients with lower KL grades (0-III) derived greater clinical benefit from longer courses (≥10 sessions), with effects sustained for up to 2 years. Co therapy or acupuncture-integrated regimens provided optimal early improvement (within the first 5 sessions) for pain and mobility. Intensive combination protocols offered no additional cumulative benefit for patients with mild symptoms.