What Should You Do if You Have Osteoarthritis?
Start with regular low-impact exercise such as walking, swimming, or cycling for at least 150 minutes per week. Strengthen the muscles around affected joints, particularly the quadriceps for knee OA. If overweight, aim for 10% weight loss. Use topical NSAIDs like diclofenac gel for pain relief. These first-line approaches are strongly recommended by the ACR.
The American College of Rheumatology (ACR) and Arthritis Foundation published updated guidelines in 2019 that strongly recommend exercise as the foundation of osteoarthritis management. This includes aerobic exercise such as walking 30 minutes most days of the week, strengthening exercises targeting the muscles around affected joints 2 to 3 times per week, and flexibility exercises to maintain range of motion. The guidelines emphasize that exercise should be performed consistently, not just during flare-ups, and that some discomfort during exercise is acceptable as long as it resolves within 2 hours.
Weight management is the second pillar of OA treatment. For individuals with knee osteoarthritis who are overweight or obese, losing 10% of body weight reduces knee pain scores by approximately 50% according to the Intensive Diet and Exercise for Arthritis (IDEA) trial published in JAMA. Each pound of weight loss reduces the compressive force on the knee joint by 4 pounds during walking. The ACR strongly recommends weight loss for overweight patients with knee or hip OA through a combination of dietary modification and physical activity.
Topical NSAIDs, specifically diclofenac sodium gel (Voltaren), are strongly recommended as first-line pharmacologic therapy for knee and hand osteoarthritis. They provide local anti-inflammatory and analgesic effects with minimal systemic absorption, reducing the gastrointestinal and cardiovascular risks associated with oral NSAIDs. Apply the gel to the affected joint 4 times daily as directed. For patients who need additional relief, oral NSAIDs such as naproxen, ibuprofen, or celecoxib may be used at the lowest effective dose for the shortest necessary duration.
The ACR and Arthritis Foundation published updated guidelines in 2019 strongly recommending exercise
Losing 10% of body weight reduces knee pain scores by approximately 50%
What Are the Symptoms of Osteoarthritis?
The hallmark symptoms of osteoarthritis include joint pain that worsens with activity and improves with rest, morning stiffness lasting less than 30 minutes, joint stiffness after prolonged sitting, crepitus (a grinding or crackling sensation), and gradual loss of range of motion. Symptoms develop gradually over months to years and typically affect the knees, hips, hands, and spine.
Joint pain is the primary symptom of osteoarthritis and follows a characteristic pattern. Unlike inflammatory arthritis, OA pain is typically worse with weight-bearing activity and improves with rest, described as a mechanical or use-related pattern. Pain may be localized to the affected joint or referred to adjacent areas. Knee OA pain is often felt in the medial (inner) compartment, while hip OA pain frequently radiates to the groin, anterior thigh, or buttock. As the disease progresses, pain may occur at rest or even during sleep, indicating more advanced joint damage.
Morning stiffness in osteoarthritis typically lasts less than 30 minutes, an important distinguishing feature from rheumatoid arthritis where stiffness persists for over 1 hour. Patients also experience gelling, a stiffness that occurs after prolonged sitting or inactivity and resolves within minutes of movement. Crepitus, a grinding, crackling, or popping sensation during joint movement, is common and results from roughened cartilage surfaces and loose debris within the joint. While often concerning to patients, crepitus alone is not necessarily indicative of severe disease.
Joint swelling in OA may occur from excess synovial fluid production (effusion) or bony enlargement from osteophyte formation. In the hands, characteristic bony nodules develop at the distal interphalangeal joints (Heberden nodes) and proximal interphalangeal joints (Bouchard nodes). Progressive loss of range of motion affects daily activities such as walking, climbing stairs, gripping objects, and bending. Muscle weakness, particularly quadriceps atrophy in knee OA, develops from pain-related disuse and contributes to functional decline and joint instability.
Morning stiffness typically lasts less than 30 minutes, distinguishing OA from rheumatoid arthritis
What Causes Osteoarthritis to Develop?
Osteoarthritis develops from a combination of mechanical stress, biological factors, and genetic predisposition. It is no longer considered simple wear and tear but rather a complex whole-joint disease involving cartilage degradation, subchondral bone remodeling, synovial inflammation, and changes in periarticular muscles and ligaments. Major risk factors include aging, obesity, joint injury, and genetics.
The traditional view of osteoarthritis as inevitable cartilage wearing has been replaced by a more nuanced understanding of OA as an active disease process involving the entire joint. Articular cartilage, which normally provides a near-frictionless surface for joint movement, breaks down through an imbalance between repair and degradation processes. Matrix metalloproteinases (MMPs) and aggrecanases released by chondrocytes break down the collagen and proteoglycan matrix faster than it can be repaired. Inflammatory mediators including interleukin-1 beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) drive this catabolic process.
Aging is the strongest risk factor for osteoarthritis, with prevalence increasing sharply after age 50. However, aging alone does not cause OA. Age-related changes in cartilage include decreased water content, reduced proteoglycan concentration, and impaired chondrocyte repair capacity. These changes make the cartilage more vulnerable to mechanical injury. Obesity is the second most important modifiable risk factor, acting through both increased mechanical loading and systemic inflammatory effects of adipose tissue. The Framingham Study demonstrated that women who lost approximately 11 pounds over 10 years reduced their risk of symptomatic knee OA by more than 50%.
Prior joint injury is a major risk factor for post-traumatic osteoarthritis, which accounts for approximately 12% of all OA cases. ACL tears increase the risk of knee OA by 3 to 5 times within 10 to 15 years, even after surgical reconstruction. Meniscus tears, intra-articular fractures, and joint dislocations similarly accelerate OA development. Genetic factors contribute an estimated 40% to 65% of OA risk, with multiple genes involved in cartilage maintenance, inflammation, and bone metabolism. Female sex is an independent risk factor, with women having a significantly higher risk of knee and hand OA after menopause.
Women who lost approximately 11 pounds over 10 years reduced their risk of symptomatic knee OA by more than 50%
What Are the Best Exercises for Osteoarthritis?
The best exercises for osteoarthritis include low-impact aerobic activities such as walking, swimming, and cycling, combined with strengthening exercises for the muscles surrounding affected joints. Water-based exercise (aquatic therapy) is particularly beneficial because buoyancy reduces joint loading by up to 50%. The ACSM and ACR recommend exercising most days of the week.
Strengthening exercises are the most important component of an exercise program for osteoarthritis. For knee OA, quadriceps strengthening reduces pain and improves function as effectively as NSAIDs in some studies. Key exercises include straight leg raises, mini squats (0 to 45 degrees), leg presses with light resistance, and terminal knee extensions with a resistance band. For hip OA, focus on strengthening the gluteus medius, gluteus maximus, and hip flexors with exercises such as clamshells, side-lying hip abduction, bridging, and seated hip flexion. The ACSM recommends 2 to 3 sessions per week with 2 to 3 sets of 10 to 15 repetitions per exercise.
Aquatic exercise (water-based therapy) is highly recommended for individuals with osteoarthritis who find land-based exercise too painful. Water buoyancy reduces body weight loading on joints by 50% to 90% depending on immersion depth, while water resistance provides a strengthening stimulus. A Cochrane review found that aquatic exercise produced clinically meaningful improvements in pain, physical function, and quality of life for people with knee and hip osteoarthritis. Water temperature of 83 to 88 degrees Fahrenheit (28 to 31 degrees Celsius) is ideal for therapeutic exercise.
Flexibility and range of motion exercises help maintain joint mobility and reduce stiffness in osteoarthritis. Gentle stretching of the muscles around affected joints should be performed daily, holding each stretch for 15 to 30 seconds without bouncing. For knee OA, focus on quadriceps, hamstring, calf, and hip flexor stretches. Tai chi has shown particular benefit for knee OA, with a randomized trial published in Annals of Internal Medicine finding that 12 weeks of tai chi was as effective as physical therapy for knee OA symptoms.
Balance and proprioception exercises are important additions for individuals with lower extremity OA, as joint pain and muscle weakness increase fall risk. Single-leg standing (with support nearby), tandem walking, and step-overs challenge balance while strengthening stabilizing muscles. The CDC reports that adults with arthritis have a 2.5 times higher risk of falling compared to those without arthritis, making balance training a critical safety component of the exercise program.
Aquatic exercise produced clinically meaningful improvements in pain, function, and quality of life
Tai chi was as effective as physical therapy for knee OA symptoms
- Walking: 30 minutes most days, starting with 10 minutes and progressing gradually
- Swimming or water aerobics: 20 to 30 minutes, 2 to 3 times per week
- Stationary cycling: 15 to 30 minutes at low resistance, 3 to 5 times per week
- Quadriceps sets and straight leg raises: 3 sets of 10 to 15 reps daily
- Hip strengthening (clamshells, bridges): 2 to 3 sets of 12 to 15 reps, 3 times per week
- Tai chi: 60-minute sessions, 2 times per week
- Daily stretching: Hold each stretch 15 to 30 seconds, repeat 2 to 3 times
What Medications Are Used to Treat Osteoarthritis?
First-line medications include topical NSAIDs (diclofenac gel) for knee and hand OA, and oral NSAIDs (ibuprofen, naproxen, celecoxib) at the lowest effective dose. Acetaminophen has limited evidence for OA pain. Intra-articular corticosteroid injections provide short-term relief for acute flares. Duloxetine is conditionally recommended for patients with persistent pain despite other treatments.
The ACR 2019 guidelines established a clear pharmacologic hierarchy for osteoarthritis. Topical NSAIDs are strongly recommended for knee and hand OA as the preferred initial medication due to their effectiveness with minimal systemic side effects. Diclofenac sodium gel (Voltaren, now available over the counter) is the most studied topical NSAID, with efficacy comparable to oral NSAIDs for knee OA in clinical trials. Topical capsaicin is conditionally recommended for knee OA as an alternative for patients who cannot tolerate NSAIDs.
Oral NSAIDs remain the most effective oral medications for OA pain and are conditionally recommended when topical treatments are insufficient. Options include ibuprofen (200 to 800 mg three times daily), naproxen (250 to 500 mg twice daily), and celecoxib (200 mg daily). Celecoxib, a selective COX-2 inhibitor, carries a lower gastrointestinal bleeding risk than non-selective NSAIDs. The PRECISION trial published in the New England Journal of Medicine found that celecoxib was non-inferior to ibuprofen and naproxen for cardiovascular safety. All oral NSAIDs should be used at the lowest effective dose for the shortest duration needed.
Intra-articular corticosteroid injections are conditionally recommended for acute OA flares, providing rapid anti-inflammatory relief lasting 4 to 12 weeks. However, the frequency should be limited to 3 to 4 injections per year per joint due to concerns about accelerated cartilage loss with frequent injections. Duloxetine (Cymbalta), an SNRI antidepressant, is conditionally recommended by the ACR for patients with persistent knee OA pain, working through central pain modulation. The ACR conditionally recommends against acetaminophen for OA due to limited efficacy evidence and liver toxicity risk.
Celecoxib was non-inferior to ibuprofen and naproxen for cardiovascular safety
How Does Weight Affect Osteoarthritis?
Excess body weight is the most important modifiable risk factor for knee osteoarthritis. Each pound of body weight adds 4 pounds of compressive force to the knee during walking. The IDEA trial demonstrated that losing 10% or more of body weight reduces knee pain by approximately 50%. Obesity also promotes OA through systemic inflammation independent of mechanical loading.
The mechanical impact of excess weight on weight-bearing joints is substantial. During walking, the knee experiences forces of 2 to 3 times body weight with each step. During stair climbing, this increases to 3 to 5 times body weight. For an individual weighing 200 pounds, the knee absorbs 600 to 1,000 pounds of force with every step. This excessive loading accelerates cartilage breakdown and drives the progression of osteoarthritis. The Framingham Osteoarthritis Study, one of the largest longitudinal OA studies, demonstrated a clear dose-response relationship between body mass index and knee OA incidence.
Beyond mechanical loading, obesity promotes osteoarthritis through metabolic and inflammatory pathways. Adipose tissue, particularly visceral fat, produces inflammatory adipokines including leptin, adiponectin, and resistin that directly affect cartilage metabolism. Leptin receptors are present on chondrocytes, and elevated leptin levels in obese individuals stimulate the production of cartilage-degrading enzymes. This metabolic component explains why obesity also increases the risk of hand osteoarthritis, where mechanical loading from body weight is not a factor. Research published in Arthritis & Rheumatology has confirmed that systemic inflammation mediates part of the obesity-OA relationship.
Weight management through combined dietary modification and exercise is strongly recommended by both the ACR and AAOS. The Intensive Diet and Exercise for Arthritis (IDEA) trial, a landmark randomized controlled trial published in JAMA, assigned 454 overweight adults with knee OA to diet only, exercise only, or combined diet and exercise. The combined group lost an average of 11.4% body weight and experienced the greatest improvements in pain, function, and inflammatory biomarkers. These results demonstrate that weight loss in the range of 10% is achievable and produces clinically meaningful benefits for OA symptoms.
The IDEA trial assigned 454 overweight adults with knee OA to diet, exercise, or combined groups
What Surgical Options Exist for Osteoarthritis?
Total joint replacement (arthroplasty) is the most effective surgical treatment for end-stage osteoarthritis, with over 90% of patients reporting significant pain relief and improved function. Other options include arthroscopic debridement, osteotomy to realign the joint, and partial joint replacement. Surgery is only recommended after comprehensive conservative treatment has been exhausted.
Total knee arthroplasty (TKA) is one of the most successful procedures in modern medicine, with over 750,000 performed annually in the United States. The AAOS reports that 90% to 95% of patients experience significant pain relief and improved quality of life after TKA. Modern implants have survivorship rates exceeding 95% at 15 years and 82% at 25 years. The procedure involves replacing the damaged cartilage and bone surfaces with metal and polyethylene components. Post-operative rehabilitation is critical, beginning on the day of surgery with range of motion exercises and progressive weight bearing.
Total hip arthroplasty (THA) is equally successful, with even higher patient satisfaction rates than knee replacement in some studies. The procedure replaces the damaged femoral head and acetabulum with prosthetic components, most commonly using an anterior or posterior surgical approach. Recovery from hip replacement is typically faster than knee replacement, with most patients walking independently within 2 to 4 weeks. Modern techniques including minimally invasive approaches and rapid recovery protocols have reduced hospital stays to 1 to 2 days for many patients.
Arthroscopic surgery for osteoarthritis (lavage and debridement) is no longer recommended by the AAOS or ACR. A landmark randomized trial by Moseley et al. published in the New England Journal of Medicine demonstrated that arthroscopic lavage and debridement was no more effective than sham surgery for knee osteoarthritis. Osteotomy, which involves cutting and realigning bone to shift load from the damaged compartment, may be appropriate for younger patients with unicompartmental knee OA and malalignment. Partial knee replacement (unicompartmental arthroplasty) is an option for patients with disease limited to one compartment of the knee.
Arthroscopic lavage and debridement was no more effective than sham surgery for knee osteoarthritis
How Can You Protect Your Joints With Osteoarthritis?
Joint protection strategies include using assistive devices like a cane in the opposite hand to reduce joint loading by 25%, wearing supportive footwear with shock-absorbing insoles, pacing activities to avoid overexertion, and modifying your environment to reduce joint stress. These strategies complement exercise and medical treatment to preserve joint function and reduce pain.
Assistive devices can significantly reduce the mechanical stress on arthritic joints. Using a cane in the hand opposite to the affected knee or hip reduces joint loading by approximately 25%. The cane should be sized so that the handle is at the level of your wrist crease when standing upright. For hand osteoarthritis, ergonomic tools with larger grips, jar openers, and built-up utensils reduce stress on finger and thumb joints. The Arthritis Foundation and occupational therapy organizations provide extensive resources for adaptive equipment selection.
Footwear selection impacts lower extremity joint loading. Flat, flexible shoes with good arch support and shock-absorbing soles are recommended over high heels or rigid-soled shoes for individuals with knee or hip OA. Lateral wedge insoles were previously recommended for medial compartment knee OA but have been found ineffective in recent large randomized trials. Motion control shoes may benefit individuals with excessive foot pronation. The AAOS recommends against high-impact activities and suggests substituting swimming, cycling, or elliptical training for running and jumping sports.
Activity pacing and energy conservation are practical daily strategies for managing OA. Alternate periods of activity with rest, break large tasks into smaller segments, and plan demanding activities for times of day when pain is lowest. Applying heat to stiff joints before activity and ice after activity can help manage symptoms. Maintaining a comfortable room temperature and using ergonomic workstation setups that minimize sustained joint positions also reduce symptom burden. Occupational therapy consultations can provide individualized joint protection strategies for home and workplace.
What Emerging Treatments Show Promise for Osteoarthritis?
Emerging treatments for osteoarthritis include platelet-rich plasma (PRP) injections, mesenchymal stem cell therapies, nerve growth factor (NGF) inhibitors such as tanezumab, and disease-modifying osteoarthritis drugs (DMOADs). While several show promise in early trials, none are yet established as standard treatments, and more rigorous clinical evidence is needed.
Platelet-rich plasma (PRP) therapy involves concentrating growth factors from the patient's own blood and injecting them into the affected joint. A 2021 meta-analysis in the American Journal of Sports Medicine found that PRP provided superior pain relief compared to hyaluronic acid at 12 months for knee OA. However, significant variability in PRP preparation methods, concentration protocols, and injection regimens across studies limits the strength of current recommendations. PRP is not yet covered by most insurance plans and remains an out-of-pocket expense typically ranging from $500 to $1,500 per injection.
Mesenchymal stem cell (MSC) therapy aims to regenerate damaged cartilage by injecting cells harvested from bone marrow or adipose tissue into the joint. Early-phase clinical trials have shown some cartilage repair and symptom improvement, but large randomized controlled trials are lacking. The FDA has cautioned against unproven stem cell treatments marketed by clinics outside of clinical trials. Disease-modifying osteoarthritis drugs (DMOADs) that could slow or halt cartilage destruction remain an active area of pharmaceutical research. Sprifermin, a recombinant human fibroblast growth factor 18, has shown dose-dependent cartilage thickness increases in the FORWARD trial but has not yet received regulatory approval.
Nerve growth factor (NGF) inhibitors represent a new analgesic approach for OA pain. Tanezumab, a monoclonal antibody that blocks NGF signaling, has demonstrated efficacy for knee and hip OA pain in phase 3 trials. However, an increased rate of rapidly progressive osteoarthritis (RPOA) and joint replacements in the tanezumab group has raised safety concerns with the FDA. Wearable technology and digital therapeutics are emerging as tools for OA management, with smartphone apps providing guided exercise programs, activity tracking, and symptom monitoring to improve adherence to evidence-based self-management strategies.
PRP provided superior pain relief compared to hyaluronic acid at 12 months for knee OA
