A severely degenerative knee joint may make walking, going up stairs, getting up and sitting down, sleeping, working, and doing meaningful activities difficult. Knee replacement may be considered when the symptoms greatly affect the quality of life and suitable care without surgery has not worked or is not suitable. Some people must improve their health condition or wait for a time before surgery, while some decide not to have surgery after receiving complete information.
Age, body weight, smoking, or accompanying diseases should not automatically deny the right to a referral for a surgical assessment. The risks, the benefit expected, the rehabilitation needs, and the wishes of the patient should be discussed individually with the orthopaedic team (NICE (opens in a new tab))
What care without surgery can and cannot do
Care without surgery may help reduce pain, increase strength and confidence, make walking and transferring safer, and support independence, but it cannot create cartilage that has been lost, reverse great deformity, or guarantee that joint replacement will not be needed in the future.
The care should be based on the symptoms and the function, not on the description of an X-ray image alone. An image of severe degeneration does not by itself determine the level of pain, the capability, or the treatment. The goals may be getting up from a chair, walking to the toilet safely, walking a useful distance, going up the stairs that are necessary, sleeping better, or taking part in family and community activities.
The main care: knowledge, exercise, and managing weight where suitable
NICE states that therapeutic exercise adjusted to suit the individual, the giving of information and support, and managing weight where suitable, are the core of the care for degeneration. The period of beginning exercise may bring added discomfort, but the kind, the amount, the supervision, and the progression should be adjusted, rather than stopping altogether (NICE (opens in a new tab))
The plan may consist of:
- Training the strength of the knee and the hip, training getting up and sitting down, and aerobic activity according to tolerance
- Gradually increasing walking, cycling, or other activities according to the symptoms and the health
- Training balance and transferring when there is concern about instability or falling
- Pacing activity and planning for flare-ups, distinguishing expected fluctuation from a new problem
- Supporting the management of weight for those who are overweight or obese and want to do it, without using it as a condition for access to other care
The goal is not to put right the whole "chain of movement" of the body or to force perfect alignment, but to increase the ability to do the activities that matter, while following the pain, the swelling, the fatigue, and any adverse effects.
Exercise in water when activity on land is difficult
The supporting force of water may make walking and strength training more tolerable in some people who cannot yet do the same activity on land. Exercise in water or an underwater treadmill is an environment for exercising, not a cure or a technology that everyone must use.
The goals should still connect with life outside the pool, with the result measured from tolerance in walking, getting up and sitting down, balance, strength, confidence, and participation, and with training on land added when it can be done. Care in the pool may not be suitable when there is an open wound, an infection, unstable heart or respiratory disease, being unable to control continence, or another safety concern.
Relieving pain should support function
Reducing pain may help the patient exercise and do daily routines. The choices may include heat or cold, applied medicine, oral medicine, or injection in some cases. The risks to the kidneys, the digestive tract, the heart and blood vessels, bleeding, the sugar level, and interactions between medicines must be considered.
Injection may relieve the symptoms for a limited period in some patients, but it does not create a new joint and does not take the place of joint replacement. The response, the adverse effects, and the benefit to function should be reviewed, rather than repeating it automatically.
Walking aids, supportive devices, walking, and preventing falls
A walking stick, a walking frame, grab rails, a higher chair, suitable footwear, or certain supportive devices may reduce the load or increase safety. They should be chosen to suit the individual, adjusted to size, and trained in. Gait training aims to find a way that is safe and effective, not a form that looks perfect.
The assessment of falls may review the eyesight, the blood pressure, medicines, problems of the feet, hazards in the home, balance, and strength. Instability that has just arisen or that gets worse rapidly should be assessed anew, and should not be generally attributed to degeneration.
Review and the long-term plan
Progress should be reviewed with meaningful outcomes, such as walking distance, the ability to get up and sit down, confidence on stairs, sleep, falls, independence, and participation. Continue, adjust, or stop each part according to the benefit that can be measured, the burden, and any adverse effects.
The decision about surgery can change. Rehabilitation is still of benefit before surgery, after surgery, or when surgery is not chosen. Care without surgery and an orthopaedic assessment are paths that support each other, not that compete.
When should a surgeon's opinion be sought again?
The choice of joint replacement should be reviewed when pain, joint stiffness, reduced function, or increasing deformity greatly affects the quality of life, despite suitable care without surgery. The surgeon helps explain the benefits and the risks for the individual. Chronological age alone cannot answer whether surgery is suitable (The rationale accompanying the NICE guideline (opens in a new tab))
There should be an urgent assessment when the knee becomes hot and very swollen suddenly together with fever, when weight cannot be borne after an accident, when the knee locks, when the foot becomes newly cold or pale, or when there is a swollen calf together with chest pain or difficulty breathing.
Frequently asked questions
Can a severely degenerative knee joint be cared for without surgery?
In some cases the symptoms may be reduced and the function increased, or the surgery postponed. The plan should not promise to reverse advanced degeneration or to avoid joint replacement permanently.
What should be done if the risk from surgery is high?
The risk should be assessed individually and the problems that can be put right improved. When surgery is not yet suitable, a systematic plan can still care for the pain, the strength, the movement, falls, equipment, and the goals of daily life.
Can injection replace joint replacement?
No injection can replace it with a guarantee. Selected injections may relieve the symptoms temporarily, and their value should be assessed from meaningfully better function together with the pain.
Is exercise in water of benefit?
It may be of benefit when exercise on land is not well tolerated and entering the pool is safe. It should connect with functional goals and be reviewed like any other exercise programme