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 usually the starting point for hip and knee osteoarthritis.
Therapeutic exercise is a core treatment and can improve pain, movement and ability to carry out everyday activities.
Exercise should be tailored to the individual. Benefits vary, and improvement usually requires regular participation over time.
For people living with overweight or obesity, weight loss can reduce pain and improve physical function. Any sustainable weight loss may help, and NICE advises that losing 10% of body weight is likely to provide more benefit than losing 5%.
Walking aids and pain medicines can help some people remain active, but they should be selected according to individual needs and risks.
Education, exercise, weight management where appropriate, and symptom-control measures can be used together. However, adding more treatments does not automatically produce a better result.
If appropriate non-surgical treatment is ineffective or unsuitable and symptoms substantially affect quality of life, referral to discuss joint replacement may be reasonable.

Therapeutic Exercise

Being advised to exercise a painful joint can feel counter-intuitive. Some people worry that movement will cause further damage. However, regular therapeutic exercise is recommended for people with osteoarthritis and does not generally damage an osteoarthritic joint.[1]

Exercise can help by:

improving muscle strength
maintaining or improving joint movement
improving balance and confidence
supporting walking and everyday activities
improving general fitness
reducing pain and improving physical function for some people

Research shows that land-based exercise produces improvements in pain and function in knee osteoarthritis, although the average benefits are generally modest and vary between individuals.[2] Recent evidence for hip osteoarthritis also supports small improvements, particularly in physical function, but not everyone experiences a noticeable benefit.[3]

Exercise does not reverse established structural changes, and a lack of improvement does not mean that the person has exercised incorrectly or failed treatment.

What Type of Exercise Is Best?

There is no single programme that is best for everyone. NICE recommends exercise tailored to the person’s needs, such as:

strengthening exercises
aerobic exercise to improve general fitness
exercises to maintain movement
balance or functional exercises

Strengthening may include the muscles at the front of the thigh for knee osteoarthritis and the muscles around the hip and buttock for hip osteoarthritis. Walking, cycling, pool-based exercise and other activities may be suitable depending on symptoms, preferences, health and access to facilities.

“Low impact” does not mean “no load,” and higher-impact activity is not automatically harmful. The appropriate type and amount of exercise depend on the individual. An activity that is manageable and can be continued regularly may be more useful than a theoretically ideal programme that is difficult to sustain.

What If Exercise Hurts?

Pain or discomfort can temporarily increase when beginning or progressing an exercise programme. NICE advises explaining that regular and consistent exercise remains beneficial despite some initial discomfort.[1]

Exercise may need to be adjusted if it causes a substantial or prolonged increase in symptoms. This might involve changing the resistance, range, duration, frequency or type of activity.

Seek professional advice if:

you are unsure which exercises are appropriate
pain is severe or continues to worsen
the joint becomes hot or markedly swollen
you develop new locking, pronounced instability or inability to put weight through the leg
you have another health condition that affects exercise safety

Stop exercising and seek urgent medical help for symptoms such as chest pain, severe breathlessness, collapse or sudden neurological symptoms.

Physiotherapy and Supervised Exercise

Not everyone with osteoarthritis requires one-to-one physiotherapy. Some people can exercise successfully after receiving clear information and an appropriate programme.

Supervised exercise may be particularly helpful when:

the diagnosis or appropriate exercise is uncertain
symptoms make it difficult to begin
movement, strength or balance is substantially limited
previous exercise advice has not helped
another health condition affects exercise
reassurance, progression or monitoring would improve confidence

A physiotherapist can assess movement and function, help select suitable exercises and adjust the programme over time. NICE advises considering supervised sessions rather than requiring them for everyone.[1]

Manual treatments, such as mobilisation or soft-tissue techniques, should not be used as a stand-alone treatment for osteoarthritis. NICE advises considering them only alongside therapeutic exercise.[1]

Weight Management

Weight management should be discussed sensitively and only where relevant. Osteoarthritis is not simply caused by body weight, and people of every body size can develop it.

For people with osteoarthritis who are living with overweight or obesity, NICE advises that weight loss can:

reduce pain
improve physical function
improve quality of life

Any amount of sustainable weight loss is likely to help, although losing approximately 10% of body weight is likely to provide more benefit than losing 5%.[1] These are potential goals rather than mandatory thresholds.

At the knee, body weight and joint load are not directly equivalent. In one biomechanical study involving older adults with overweight or obesity and knee osteoarthritis, each pound of body weight lost was associated with an approximately four-pound reduction in compressive knee load during each step.[4] This is an average study finding, not a calculation that can predict an individual’s pain or outcome.

Weight-management support should be realistic, non-judgemental and tailored to the person. Medication or surgery should not be withheld solely because a person has not reached a particular weight or body-mass-index target. NICE advises that overweight or obesity should not, by itself, prevent referral for consideration of joint replacement.[1]

Walking Aids and Activity Pacing

A walking aid can improve stability, confidence or comfort for some people with lower-limb osteoarthritis. Options include a walking stick, crutches or a walking frame.

A single walking stick is commonly used in the hand opposite the more painful hip or knee, but this is not appropriate in every situation. Correct height and technique matter. A physiotherapist, occupational therapist or another suitably trained professional can help select and adjust the aid.

Using a walking aid is not a sign of failure. It may allow a person to walk farther, remain independent or participate more comfortably in exercise and everyday activities.

Activity pacing can also help. This means balancing activity and rest, dividing demanding tasks into manageable parts, and avoiding a repeated cycle of doing too much on a better day and then needing prolonged recovery.

Comfortable, well-fitting footwear is sensible, but evidence is insufficient to claim that a particular type of shoe routinely treats hip or knee osteoarthritis.

Pain Relief

Medicines should be used alongside non-drug treatment and at the lowest effective dose for the shortest appropriate time. Their purpose is usually to reduce symptoms and support activity; they do not reverse established osteoarthritis.

Topical anti-inflammatory medicines

NICE recommends offering a topical non-steroidal anti-inflammatory drug, or NSAID, for knee osteoarthritis. A topical NSAID may also be considered for osteoarthritis affecting other joints.[1]

These medicines can still cause side effects and may not be suitable for everyone. Follow the product instructions and ask a pharmacist or prescriber if you use other medicines or have relevant health conditions.

Oral anti-inflammatory medicines

An oral NSAID may be considered if topical treatment is ineffective or unsuitable. Before recommending one, the clinician should consider possible effects on the:

stomach and bowel
kidneys
liver
heart and circulation

Other medicines, pregnancy, age and existing medical conditions can affect safety. NICE recommends gastroprotective treatment, such as a proton-pump inhibitor, while an oral NSAID is being taken.[1]

Do not begin regular oral NSAID treatment without checking that it is appropriate for you.

Paracetamol and opioids

NICE does not recommend routinely offering paracetamol or weak opioids for osteoarthritis because evidence of meaningful benefit is limited.[1]

They should generally only be considered for infrequent, short-term relief when other medicines are contraindicated, not tolerated or ineffective. Individual advice is necessary because both can cause harm if used incorrectly.

Strong opioids should not be offered to manage osteoarthritis because their risks outweigh the expected benefits.[1] Opioids can cause drowsiness, constipation, falls, tolerance, dependence and withdrawal symptoms.

Using More Than One Approach

A management plan may include education, exercise, weight management where appropriate, a walking aid and carefully selected pain relief.

NICE advises considering exercise together with education or behaviour-change support as a structured treatment package.[1] This may help some people understand the condition, build confidence and continue exercising.

However, it would be inaccurate to promise that combining several treatments always works better than exercise alone. Research has not shown that every additional therapy provides extra improvement.[5] Each component should have a clear purpose and should be continued only if it is helpful, safe and acceptable to the person.

When to Consider a Surgical Opinion

Non-surgical treatment should be offered and given a reasonable opportunity to help, but every possible treatment does not have to be exhausted.

NICE advises considering referral for joint replacement when:

pain, stiffness, reduced function or progressive deformity substantially affects quality of life; and
suitable non-surgical management has been ineffective or is unsuitable.[1]

A referral does not commit someone to surgery. It provides an opportunity to discuss the diagnosis, available options, expected benefits, limitations and individual risks.

Important Information

This article provides general educational information and does not replace individual advice from a healthcare professional or pharmacist.

Exercise, weight management, walking aids and medicines should be adapted to the individual’s symptoms, preferences, medical history and current treatment. No particular exercise programme, weight change or medicine can be guaranteed to relieve symptoms or prevent surgery.

References

National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226. Published 19 October 2022. Available from: https://www.nice.org.uk/guidance/ng226 [Accessed 14 August 2026].
Lawford BJ, Hall M, Hinman RS, Van der Esch M, Harmer AR, Spiers L, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2024;(12). doi: https://doi.org/10.1002/14651858.CD004376.pub4
Hall M, Lawford BJ, Hinman RS, Dobson F, Spiers L, Kimp A, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2026;(7). doi: https://doi.org/10.1002/14651858.CD007912.pub3
Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 2005;52(7):2026–2032. doi: https://doi.org/10.1002/art.21139
French HP, Cusack T, Brennan A, Caffrey A, Conroy R, Cuddy V, et al. Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicentre randomised controlled trial. Arch Phys Med Rehabil. 2013;94(2):302–314. doi: https://doi.org/10.1016/j.apmr.2012.09.030
Versus Arthritis. Osteoarthritis (OA): causes, symptoms and treatments. Available from: https://www.versusarthritis.org/about-arthritis/conditions/osteoarthritis/ [Accessed 14 August 2026].

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