A diagnosis of a degenerated knee joint does not mean that joint replacement surgery is needed immediately. Many people begin with care that is not surgery, in order to manage the symptoms, increase strength and function, and support the activities that matter. These treatments help manage the disease, but do not make the knee joint as good as new or guarantee that surgery will not be needed in the future.
The important question is not merely "can surgery be avoided", but whether the current plan helps control the pain and maintain function well enough, whether the burden and the risks are still suitable, and whether an assessment for joint replacement might give a better balance of benefit against risk.
Degeneration affects both the joint and the person
A degenerated knee joint involves the cartilage, the bone, the lining of the joint, the meniscus, the ligaments, the muscles, and the system that processes pain. The severity of the symptoms does not always match the radiographic image. Weakness, reduced activity, sleep, mood, body weight, accompanying diseases, and confidence in movement can all have an effect on the impairment.
The words "putting weight down wrongly" or "the alignment of the joint is wrong" should not be used to blame the patient or to claim that one pattern of movement causes the disease. The assessment should look for factors that can be adjusted, such as strength, tolerance in walking, the amount of activity, or a suitable walking aid, without promising that the mechanics can be put right permanently.
The assessment before choosing treatment
The clinical assessment should review:
- The pattern of the pain, joint stiffness, swelling, instability, locking, and the duration of the symptoms
- Walking, stairs, standing up and sitting down, work, sleep, exercise, and the goals for participation
- Strength, the range of movement, walking, balance, and the results of neurological or vascular examination
- Medicines, previous treatment, accompanying diseases, and the patient's wishes
- Danger signals or features that indicate another diagnosis
NICE advises that in general degeneration is diagnosed clinically and does not require imaging as a routine. Imaging suits cases where the symptoms are abnormal, where another disease is suspected, or where structural information is needed in order to plan surgery. Doing an ultrasound to "map the joint", or repeated MRI as a routine, does not predict who will respond to treatment that is not surgery (NICE (opens in a new tab))
The main care without surgery
Knowledge, activity, and therapeutic exercise
Therapeutic exercise adjusted to the individual is the main treatment. The plan may consist of increasing the strength of the muscles of the thigh and the hip, aerobic work, balance, walking, and activities that are really used. There may be discomfort in the initial period, so the load should be adjusted according to the response, rather than avoided automatically.
The training may be supervised or done by yourself, and done on land or in water. Hydrotherapy or an underwater treadmill may be a choice when training with full weight-bearing is difficult to do, but it is not superior to, or necessary for, everyone.
Managing weight where relevant
For those who are overweight or obese, losing weight with support may reduce pain and increase function. It should be discussed without stigma, and should not be used as an obstacle to suitable treatment or to referral for surgery.
Walking aids and certain devices
A walking stick or another aid may increase confidence and reduce the load in some activities. A brace to support the joint, or an insole, is not routinely of benefit for everyone, but may be considered when the joint is unstable or there are abnormal mechanical forces, and devices that help movement or participation in exercise.
Medicines
Medicines should be chosen according to the individual and used together with care that does not use medicine. A non-steroidal anti-inflammatory medicine of the applied kind is usually considered for a degenerated knee joint. For oral medicines, the risks to the stomach, the kidneys, the heart and blood vessels, bleeding, and interactions between medicines must be reviewed. Strong opioid medicines do not give a suitable long-term balance of benefit against risk for the routine care of degeneration.
What should be known about injection
The advice on injection differs according to the guidelines, the health system, and the group of patients. A systematic review of 27 clinical practice guidelines found an overall opinion that corticosteroids may relieve the symptoms fairly quickly but for a short period, while the advice on hyaluronic acid differs, and the advice on plasma with a high concentration of platelets (PRP) is usually not clear-cut (PubMed (opens in a new tab))
Corticosteroids
NICE states that injecting corticosteroid into the joint may be a choice when other medicines have not worked or are not suitable, or in order to help participation in therapeutic exercise. The effect expected is short-term, about 2–10 weeks. It does not create new cartilage, and repeated injection requires discussion of the benefit against the risk in each individual case.
Hyaluronic acid
Hyaluronic acid is sometimes advertised as a "joint lubricant", but the evidence and the advice are not consistent. NICE does not recommend injecting hyaluronan into the joint to treat degeneration, while some guidelines allow it to be chosen in some cases. If it is considered, the uncertainty, the costs, the alternatives, and the fact that it does not create new cartilage should be explained.
PRP and "growth factor" products
PRP differs in the concentration of platelets, the white blood cells, the activation, the method of preparation, the dose, and the number of sessions. This difference makes it difficult to compare products and the results of trials. "Superdose Growth Factor" is not a standard scientific category, and should not be presented as more concentrated or as able to restore tissue without a clearly documented formula and evidence specific to the product.
PRP has not been proved to create new cartilage or to prevent joint replacement consistently. The regulatory status, the evidence, the costs, the risks, and the alternatives should be explained before it is used.
The use of ultrasound guidance
Ultrasound helps an expert see the needle, the fluid, and some structures during the procedure, but does not guarantee a correct diagnosis, an injection free of risk, or a better long-term result. It should be used when it adds value to the aim and the procedure, not as a mark that the injection is "advanced" in itself.
Procedures that are not a standard choice for a degenerated knee joint
Hydrodissection (separating the layers of tissue with fluid) uses fluid to separate the layers of tissue or to create a space around selected nerves. It is not a standard treatment for the changes in the cartilage, the bone, or the lining of the joint in a degenerated knee joint. It may be considered only when there is a separate diagnosis of a nerve or of soft tissue.
Focused shockwave therapy (focused shockwave therapy) is not a treatment inside the knee joint for degeneration as a routine. It may be considered in indications for tendons or tissue outside the joint that have separate evidence, but it should not be described as maintaining a degenerated knee joint.
Washing out the joint or trimming the joint with an arthroscope is not recommended as a routine in degeneration that has no other accompanying state. True acute locking or suspicion of another state must be assessed separately, rather than concluding that arthroscopy or injection is needed.
Rehabilitation after the symptoms improve
Relieving pain may open the opportunity to move, but injections and procedures in which the patient exerts no effort do not take the place of rehabilitation. Progress should be measured with relevant outcomes, such as tolerance in walking, the use of stairs, standing up and sitting down, strength, sleep, and participation.
Rehabilitation may consist of increasing strength and aerobic work, pacing activity, balance or gait training, adjusting activity, and gradually returning to work or activity. NMES or other devices may be a supplement for a defined impairment, but no technology is necessary for everyone.
When should there be a referral for joint replacement?
Joint replacement is not a failure of conservative treatment, and postponing it is not always safer. NICE advises considering a referral when pain, joint stiffness, reduced function, or a joint deformity that is progressing affects the quality of life greatly, and suitable care without surgery has not worked or is not suitable.
The decision should be made from the clinical assessment and shared decision-making, not from the grade on a radiographic image, age, the body mass index, or a numerical score alone. NICE also advises not to deny the right to a referral because of age, sex or gender, smoking, accompanying diseases, or being overweight/obese alone. Improving health and discussing the risks are still important.
A referral does not compel surgery, but opens the opportunity to discuss the benefit expected, the kind of artificial joint, anaesthesia, complications, rehabilitation, and the effects of postponing surgery.
When should a knee be assessed urgently?
There should be an early assessment after a severe accident, being unable to bear weight, a hot red swollen joint, fever, swelling increasing quickly, true acute locking, a new neurological abnormality, or a swollen calf together with difficulty breathing.
Continuous pain that disturbs sleep or daily life, repeated instability of the joint, great deformity of the joint, or reduced function despite a suitable plan, should also be reviewed. Continuous procedures should not be received merely in order to postpone asking for a surgeon's opinion
Frequently asked questions
Can a degenerated knee joint be managed without joint replacement?
It often can, particularly when the symptoms and the function are still at a level that is acceptable with exercise, adjusting activity, managing weight where relevant, medicines, and selected devices. Care without surgery does not guarantee that surgery can be avoided permanently.
Is injection enough?
In general it is not enough. It may relieve the symptoms temporarily in some people, but it does not take the place of exercise, restoring function, or managing the other factors that have an effect on the impairment.
Does "bone on bone" mean that surgery is needed?
Not necessarily. The severity in the image is only one factor. The symptoms, the function, the needs, health, and the response to suitable care are also important. If the quality of life is greatly affected despite suitable care without surgery, a referral should be discussed.
Is ultrasound guidance always better?
It may help in seeing and placing the needle in some procedures, but it does not make every kind of injection necessary, effective, or free of risk.
What is the goal of care without surgery?
It is to be able to control pain, function, and take part in activities in a way that is meaningful and sustainable, with a burden and risks that are acceptable, not to guarantee the creation of cartilage or the avoidance of surgery in every case.