The short answer. No treatment can promise that you will never need a knee replacement. The approaches with the strongest guideline support are exercise, often guided by a physical therapist, and weight loss for people who are overweight1,2. In a randomized trial of people who already qualified for a knee replacement, two out of three who were given a 12-week nonsurgical program instead had not had the operation two years later3.
Some people can, at least for years. The most direct evidence comes from a randomized trial of 100 people with moderate to severe knee osteoarthritis who were all eligible for a total knee replacement4. Half were assigned to surgery followed by 12 weeks of nonsurgical care, and half to the 12 weeks of nonsurgical care alone: exercise, education, dietary advice, insoles and pain medication, delivered by physiotherapists and dietitians4.
The results cut both ways:
So the honest answer is that a structured program let many people put surgery off, while surgery gave more relief on average to those assigned to it. Which way to go is a decision to make with your surgeon, based on how much the knee limits your life.
For people who are overweight, it is strongly recommended. The American College of Rheumatology strongly recommends weight loss for knee and hip osteoarthritis in people who are overweight or obese. A loss of 5% of body weight can make a measurable difference, and the benefits keep increasing with larger losses1. The AAOS guideline also recommends sustained weight loss to improve pain and function2.
The knee feels the change. In one study, each pound of weight lost was linked with a fourfold reduction in the load on the knee with every step5. In the IDEA trial, 454 overweight and obese adults with knee osteoarthritis were assigned to diet, exercise, or both. After 18 months, the diet-plus-exercise group had lost an average of 10.6 kg (about 23 pounds, 11.4% of body weight) and had less pain and better function than either the diet group or the exercise group6.
Exercise is strongly recommended by both the American College of Rheumatology1 and the American Academy of Orthopaedic Surgeons (AAOS)2. Programs tend to work better when they are supervised, often by a physical therapist, than when done alone at home1.
A 2024 Cochrane review of 139 trials and 12,468 people found that exercise probably improves pain, function and quality of life in the short term7. Physical therapy has also been compared directly with a cortisone shot. In a trial of 156 people, those assigned to physical therapy had less pain and disability at one year than those given a glucocorticoid (cortisone) injection8.
For daily life, the AAOS suggests swapping high-impact activities such as jogging or tennis for lower-impact ones such as swimming or cycling, and limiting activities that aggravate the knee, such as climbing stairs9. See physical therapy at our practice.
They can, for the right person. The table below summarizes common nonsurgical options that the two main US guidelines recommend, from the American College of Rheumatology in 20191 and the AAOS in 20212.
| Treatment | American College of Rheumatology (2019) | AAOS (2021) |
|---|---|---|
| Exercise | Strongly recommended | Recommended (strong) |
| Weight loss, if overweight | Strongly recommended | Recommended (moderate) |
| Knee brace | Strongly recommended (tibiofemoral brace) | Could be used (moderate) |
| Cane | Strongly recommended | Could be used (moderate) |
| Oral anti-inflammatory drugs (NSAIDs) | Strongly recommended | Recommended (strong) |
| Cortisone injection | Strongly recommended | Could provide short-term relief (moderate) |
The ACR's brace and cane recommendations apply when arthritis is affecting walking, stability or pain enough to warrant a device, and for braces, when the person can tolerate wearing one1. An "unloader" brace shifts weight away from the affected part of the knee9. The AAOS cautions that anti-inflammatory drugs should be used carefully, or avoided, by people with conditions such as heart disease, heart failure or chronic kidney disease9.
Cortisone. Cortisone shots can provide short-term relief2. As a safety point, the AAOS notes that doctors may limit injections to three or four per year in each joint because of possible side effects, and that with frequent repeated injections, or injections over a long period, joint damage can increase9.
Hyaluronic acid (viscosupplementation). Hyaluronic acid is injected directly into the knee joint. The AAOS knee arthritis guideline describes viscosupplementation as a viable option for some patients who have not done well with other treatments, when appropriately indicated2. In the guideline's analysis of trials that compared it with PRP, patients in both groups improved at six months2. It has also been studied for delaying surgery: a 2022 review of observational studies found that people who had hyaluronic acid injections went 9.8 months longer between diagnosis and knee replacement than people who did not10. At this practice, viscosupplementation and physical therapy come first in the order of care.
Orthobiologics (PRP and BMAC). These injections are prepared from your own body. PRP uses platelets separated from your blood, concentrated and injected into the knee; the platelets contain growth factors thought to help reduce the symptoms of inflammation9. Stem cells can also be taken from your own body and injected into the knee, where they may have the potential to grow into new tissue9. The AAOS says both treatments show promise9, and its knee arthritis guideline states that PRP may reduce pain and improve function2. In the guideline's pooled analysis of four trials, PRP showed a clinically significant advantage over hyaluronic acid on a standard arthritis score at 9 to 12 months, and a course of three PRP injections appeared to give more favorable results2. We cover PRP and bone marrow concentrate in more depth in a separate article: Can you avoid knee replacement surgery? What orthobiologics offer.
According to the AAOS, people who benefit from a total knee replacement often have11:
The recommendation is based on pain and disability, not age11. Data pooled from 14 national joint registries suggest that about 82% of total knee replacements last 25 years12.
An orthopedic evaluation usually includes your medical history, a physical exam of the knee's motion, stability, strength and alignment, and X-rays to see how much damage there is11. At this practice, physical therapy and viscosupplementation come first; PRP, BMAC or the two combined may be considered when those have not worked. Not every patient is a candidate, and candidacy is decided at a consultation before any financial commitment. Patients outside the area can have the first consultation by telemedicine, with imaging sent by email. More on this in joint preservation.
If you are in the Santa Barbara area, Dr. Scheinberg can examine the knee, review any imaging and talk through the options. See knee conditions or call (805) 682-1394.
Related reading: non-surgical treatment for knee arthritis and knee arthritis treatment options and cost.
Short answers to the questions patients ask most.
Have a question about your own situation?
Call (805) 682-1394Nobody can promise that. In a trial of people who already qualified for surgery, 32% of those given a 12-week nonsurgical program had a replacement within two years, and the rest had not3.
Pooled registry data suggest about 82% of total knee replacements last 25 years12.
Reviewed by Dr. Richard Scheinberg, MD, a board-certified orthopedic surgeon in Santa Barbara with 40 years of surgical experience.
