Knee Osteoarthritis
Knee osteoarthritis is common, and the news is better than most people think. Strengthening the knee — not resting it — is the evidence-based foundation, and when you need more, there are good injection options from steroid to Durolane and Arthrosamid.
Osteoarthritis of the knee
Osteoarthritis (OA) of the knee is a whole-joint condition — the cartilage changes and the joint adapts around it. It typically causes pain, stiffness (worse after rest), occasional swelling, and sometimes creaking or a feeling of the knee giving way. As with the hip, typical cases can be diagnosed clinically without needing a scan (NICE, 2022), and how the knee looks on an X-ray often matters less than how strong and capable it is.
A whole-joint condition — more than “wear and tear”
OA used to be written off as simple “wear and tear”, but that picture is out of date. It is an active process involving the whole joint — cartilage, bone, the lining (synovium), ligaments and the surrounding muscle all change together. The cartilage softens and thins, the bone underneath thickens and forms spurs (osteophytes), and the joint lining can become mildly inflamed. It is not simply the result of “using the joint up”; it is the joint’s repair process not keeping pace with the load placed on it.
What raises the risk
Age, previous joint injury or surgery, family history and genetics, being overweight, the shape and alignment of the joint, and jobs or sports with heavy repetitive loading all increase the risk. Several usually combine — which is also why there is usually something we can change.
Why it is not hopeless
Because OA is an active, living process — not a tyre wearing out — the joint responds to what you do. Loading it well, building the muscles around it and reducing the things that overload it genuinely change how the joint behaves and how much it hurts.
What osteoarthritis looks like on an X-ray
This is an X-ray of a knee with osteoarthritis. The gap between the bones — the cartilage cushion — has narrowed (worse on one side), the bone edges have formed spurs (osteophytes) and the bone has thickened and brightened (sclerosis). But the film matches pain poorly: plenty of people with marked X-ray changes have little pain, and others with mild changes hurt a lot — so we treat how the knee works, not how it photographs.
X-ray: James Heilman, MD, CC BY-SA 4.0, via Wikimedia Commons.
Osteoarthritis is partly a metabolic condition
One of the biggest shifts in understanding OA is that it is not purely mechanical. In many people it is also metabolic. Carrying extra weight loads the joint — but fat tissue is also hormonally active, releasing inflammatory signals (adipokines such as leptin) that drive low-grade inflammation throughout the body and inside the joint. The giveaway is that OA is more common in the hands of people who are overweight — joints that bear no body weight — which can only be a chemical, whole-body effect, not a loading one (Berenbaum, 2013; Courties et al., 2017).
The metabolic OA phenotype
OA clusters with the features of metabolic syndrome — raised blood sugar, blood pressure, cholesterol and central weight. This “metabolic phenotype” tends to be more inflammatory and more stubborn, and it means the joint is reflecting what is happening in the whole body.
Why this is good news
It gives us more levers to pull. Alongside strengthening the joint, improving the metabolic picture — weight, activity, blood sugar, diet — can reduce the inflammatory load on the joint itself. For people who want to go further, our metabolic profiling can map exactly where to focus.
Motion really is lotion
The instinct with a painful joint is to rest it and protect it. For OA, that is usually the wrong move. Cartilage has no blood supply of its own — it is fed by joint fluid being squeezed in and out as you move and load the joint. Movement is literally how cartilage is nourished. Rest it long-term and the cartilage and muscles are starved and weaken; load it sensibly and you keep it healthy.
Exercise is a genuine painkiller
This is not hand-waving. In the Cochrane reviews, supervised exercise reduces OA pain and improves function by an amount comparable to anti-inflammatory tablets in the short term — without the stomach, kidney and heart risks (Fransen et al., 2015). It is one of the most effective treatments we have.
You won’t “wear it out”
A common fear is that staying active speeds the arthritis up. The evidence says the opposite: recreational runners, for example, have lower rates of hip and knee OA than non-runners (Alentorn-Geli et al., 2017). Sensible, progressive loading protects joints — it does not destroy them.
The things that help most are the things you control
The day-to-day choices around the joint often matter more than anything done to it. These are the highest-value changes for most people with knee OA:
Weight, if it applies
It is one of the strongest levers. In the IDEA trial, overweight adults with knee OA who lost 10% of their body weight through diet and exercise had markedly less pain, better function and lower inflammation than those who lost less (Messier et al., 2013). Every pound off the body takes several times that in load off the joint with each step.
Keep moving, every day
Regular physical activity — walking, cycling, swimming, strength work — keeps the joint fed and the muscles strong. The goal is consistency, not intensity: little and often beats occasional and heavy.
Eat to lower inflammation
A broadly Mediterranean pattern — plenty of vegetables, oily fish, olive oil, less ultra-processed food and sugar — supports weight and the metabolic picture, and may dampen the low-grade inflammation that feeds OA.
Sleep, stress and smoking
Poor sleep and high stress amplify pain, and smoking works against joint and tissue health. They are rarely talked about with arthritis, but tidying them up makes everything else work better.
What the guidelines actually say
The evidence here is unusually clear and consistent. The 2022 NICE guideline (NG226) puts therapeutic exercise, weight management and education at the core of treatment for everyone with OA — offered first, to all, whatever the X-ray shows. Medication and injections are add-ons around that core, not replacements for it (NICE, 2022).
Our approach at The Treatment Table
We build the plan around that evidence — then make it specific to you, your knee and your goals.
Assess properly, then strengthen
A full assessment of the joint, your strength, movement and what you want to get back to — then a progressive, tailored strengthening and activity plan that is the real engine of improvement. Where it will change the plan, we can arrange diagnostic ultrasound in-house.
Treat the whole picture
We coach the load management, lifestyle and — for those who want it — the metabolic side that the research shows matters, not just the sore joint. And we’re honest about when an injection or an onward referral is the right next step.
Different routes, matched to where you are
Not everyone needs the same thing. Depending on how your knee responds, we step through the options in a sensible order — always keeping exercise as the foundation.
Foundation — rehab & lifestyle
Education, a tailored strengthening and activity plan, and the weight, load and lifestyle changes that matter. This is the core for everyone and resolves or controls most knee OA.
Add support for pain
If pain is limiting your rehab, we add targeted help — pain management, load tweaks and, where appropriate, an injection — to create a window to keep progressing.
Injection options
Discussed as an addition, not a replacement, for exercise — see below.
Onward referral
For advanced OA no longer helped by the above, we refer at the right time for a surgical opinion, and keep supporting your rehab around it.
Options alongside — not instead of — rehab
When pain is limiting despite good rehab, injections can be discussed as an addition to exercise, not a substitute for it:
Corticosteroid
A steroid injection can settle a painful flare for the short term, creating a window to get moving (NICE, 2022).
Hyaluronic acid
A single hyaluronic acid injection that aims to lubricate and cushion the joint. The evidence is mixed and it is not a substitute for exercise, but some people find it helps — we’ll give you an honest view.
Durolane injections →
Hydrogel
A newer, single-injection polyacrylamide hydrogel that cushions the joint. Studies report pain relief lasting up to three years; the evidence base is promising but still developing (Bliddal et al.; Henriksen et al.).
Arthrosamid injections →Sources & further reading
National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NICE guideline [NG226]. 2022. nice.org.uk/guidance/ng226
Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2015;(1):CD004376. cochranelibrary.com
Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013;310(12):1263–1273. jamanetwork.com
Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA:D): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC Musculoskelet Disord 2017;18:72. biomedcentral.com
Berenbaum F. Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Osteoarthritis Cartilage 2013;21(1):16–21. oarsijournal.com
Alentorn-Geli E, Samuelsson K, Musahl V, et al. The association of recreational and competitive running with hip and knee osteoarthritis: a systematic review and meta-analysis. J Orthop Sports Phys Ther 2017;47(6):373–390. jospt.org
Bliddal H, et al.; Henriksen M, et al. Polyacrylamide hydrogel (iPAAG / Arthrosamid) for knee osteoarthritis — prospective and randomised data, including 3-year follow-up presented at OARSI 2023. pubmed.ncbi.nlm.nih.gov
Physiotherapy assessment for knee osteoarthritis
Your first appointment is a proper assessment, in two parts:
Subjective assessment
A detailed discussion about how it started, what makes it better or worse, how it is affecting your work, training and daily life, and your goals — including any event you are building towards.
Objective assessment
A hands-on examination — strength, movement, loading and specific tests — to pin down the diagnosis and what is driving it. Where it will change your plan, we can arrange diagnostic ultrasound scanning in-house.
Book your knee assessment
Get a clear picture of your knee, a strengthening plan that genuinely works for OA, and an honest discussion of whether an injection — and which one — is worth it for you.