Non-Surgical Options — What Actually Works

Part of The Joint Replacement Guide — Phase 2: Considering Surgery · Article 6 of 42 · Hip & Knee

Key Points

  • Non-surgical treatment is the correct starting point for almost everyone with osteoarthritis, and should be tried properly before surgery is considered.
  • Exercise and physiotherapy have the strongest evidence base of any non-surgical treatment — more than most people expect.
  • Weight loss, where relevant, produces a disproportionately large reduction in joint load, particularly at the knee.
  • Combining several approaches together works better than relying on any single one.
  • Pain relief and walking aids are useful support, but don’t treat the underlying joint changes.

Exercise and Physiotherapy — The Cornerstone

It can feel counter-intuitive to be told to exercise a painful joint, but structured exercise is the single most evidence-backed treatment for hip and knee OA that exists. Strengthening the muscles around the joint — particularly the quadriceps at the knee and the hip abductors at the hip — improves shock absorption and joint control, which reduces pain and improves function. Low-impact aerobic exercise such as swimming or cycling helps overall fitness without loading the joint as heavily as running or high-impact sport.

The evidence here isn’t marginal — multiple large reviews of clinical trials consistently show meaningful improvements in both pain and function from structured exercise programmes, comparable in effect to some medications, but without the side effects. A referral to physiotherapy for a properly structured, ideally supervised, programme tends to produce better results than general advice to “stay active”, because the exercises are targeted to your specific joint and movement pattern.

Weight Management

If you’re carrying excess weight, losing even a modest amount can make a real difference. At the knee in particular, the relationship between body weight and joint load is not one-to-one — losing one kilogram can reduce the load passing through the knee with each step by several times that amount, because of how forces are multiplied through the leg during walking. A realistic target of 5–10% of body weight, rather than an ambitious total transformation, is associated with clinically meaningful symptom improvement, and weight loss also appears to have a modest anti-inflammatory effect independent of the mechanical benefit.

Walking Aids and Activity Modification

A walking stick, used in the hand opposite the affected joint, can meaningfully offload the joint and reduce pain during walking — many people are reluctant to use one, but it is a genuinely effective, low-cost intervention. Pacing activity (breaking up longer periods of standing or walking) and appropriate, supportive footwear also help manage day-to-day symptoms.

Pain Relief

Topical anti-inflammatory gels are generally recommended as a first-line option, particularly for the knee, as they provide local pain relief with a lower risk of side effects than tablets. Paracetamol has a more limited evidence base than once thought but may still help some people as part of a combined approach. Oral anti-inflammatory tablets (NSAIDs) can be effective but need to be used cautiously, particularly in older patients or those with stomach, kidney or heart conditions, and are best discussed with your GP. Current guidance generally advises against long-term opioid painkillers for OA, as the evidence for benefit is weak and the risk of dependence and side effects is significant.

In More Depth: What the Evidence Actually Shows

National guidance identifies three “core” treatments that should be offered to essentially everyone with OA, regardless of severity: therapeutic exercise, weight management (where relevant), and structured information and education about the condition. These are described as core precisely because the evidence supporting them is stronger and more consistent than for many other treatments, including some that are more commonly requested, such as injections (covered in the next article). Trials also show that combining approaches — exercise plus weight loss plus education, for example — tends to outperform any single intervention on its own, which is why a good non-surgical management plan usually addresses several of these areas together rather than picking just one.

This article is general information and does not replace individual clinical advice. Please speak to your GP or physiotherapist before starting a new exercise programme, particularly if you have other health conditions.

Sources

  • NICE guideline NG226 — Osteoarthritis in over 16s: diagnosis and management (2022)
  • Cochrane Database of Systematic Reviews — exercise for osteoarthritis of the hip and knee
  • Versus Arthritis — patient information on managing osteoarthritis
  • Chartered Society of Physiotherapy — exercise guidance for osteoarthritis

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