Here, HSS surgeons Edwin P. Su, MD, and Brian Chalmers, MD, both specialists in hip and knee replacement surgery, discuss knee replacement alternatives that can relieve pain, restore mobility, and improve your overall quality of life. As with any medical decisions involving modifying your routine, it’s best to check with your doctor before trying anything new. 

Weight Loss and Activity Modification

When you’re experiencing knee pain, one of the first suggestions you’ll likely be told is to lose weight if you’re overweight. While shedding excess weight in general is better for the joints, the knees in particular feel the strain when weight is on them. Trying to lose weight while dealing with knee pain might seem daunting, but every little bit helps: For every pound lost, there is a four-pound reduction in knee stress. “Losing 10 pounds would reduce the stress on the knee by approximately 40 pounds with each step the person takes,” says Dr. Su.

If you’re a fan of high-impact sports like running or basketball, it’s also a good idea to scale down to lower-impact activities, which shouldn’t cause as much pain. These exercises are good for maintaining muscle mass, suggests Dr. Chalmers. He recommends bicycling, level-ground walking, swimming, elliptical workouts, and low-weight, high-repetition weight training to strengthen while improving stability. “While some patients are able to return to higher-impact activities after periodic rest and breaks, as the arthritis process and pain worsens over time, many patients are unable to return to these at all,” says Dr. Chalmers.

Over-the-Counter Pain Relief Medications

You might already be experiencing buckling (when your knee suddenly gives way), instability, locking or catching of the knee that’s interfering with your ability to move normally. Over-the-counter medications for pain, inflammation and swelling can help, says Dr. Chalmers.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (Aleve) offer a safe and effective way to reduce inflammation associated with arthritic pain. Topical creams like Voltaren arthritis pain relief gel or lidocaine patches can help with pain and stiffness as well as general mobility improvements, he adds. 

Though they can help in the short term, you should avoid long-term use of NSAIDs due to potential gastrointestinal and cardiovascular side effects, says Dr. Su. These medications should be used on an as-needed basis to manage pain and discomfort. There are also oral steroids and prescription pain medications available, but those are best discussed with your doctor.

Bracing 

Wearing a brace can help redistribute forces within the knee joint. “That can help unload the part of the knee that's arthritic, decrease swelling, provide some additional support and stability for the knee and make people feel fewer symptoms,” says Dr. Chalmers.

Here are some types of braces for knee pain that Dr. Chalmers suggests:

• Compression neoprene sleeves (soft braces) with a hole cut out may help keep the knee warm, decrease swelling and help with clicking or noises from the knee, but they don’t really reduce the forces upon the knee. They’re affordable and not very cumbersome. 
• Medial unloader braces are for people who have more arthritis in the side of the knee that’s closest to the other knee. There is also a version of this brace for people who have more lateral arthritis, which is on the opposite side. “They're bigger, they go up and down the leg more and have a hinge,” says Dr. Chalmers. “The hinge takes some of the load from the knee when you're walking. The problem is that they’re quite bulky and cumbersome to put on.”
• Hinge knee braces, with hinges on one or both sides, can provide more stability to the knee. They’re typically unpopular because they are bulky.

Physical Therapy

Strengthening the muscles around the knee to better stabilize it can help decrease the forces going through the front of the knee and help people feel stronger, with fewer symptoms, Dr. Chalmers says.

“I think there's a role for physical therapy, especially in people with a lot of anterior [front] knee pain or patellofemoral arthritis, or just anterior knee pain in general,” he adds.

The muscles around the knee act as “shock absorbers” for the stress the knee is required to absorb, says Dr. Su. “There are limits to what physical therapy can accomplish, but it is an excellent first step.”

Injections 

Injections for knee pain can provide temporary relief by reducing inflammation and lubricating the joint. They can be effective for managing the early symptoms of arthritis, says Dr. Su. However, their effects are short-term.

Three types of injections for knee arthritis pain:

• “Cortisone is the gold standard of injections,” says Dr. Su. You can get one every three to four months. “It can reduce inflammation associated with arthritic pain and relieve symptoms. It may reduce pain, swelling, and allow a person to increase activity for a few months. But because it doesn’t do anything for the already damaged cartilage, the relief will be temporary,” he adds. The goal with cortisone steroid injections is to reduce the pain, swelling and inflammation by locally concentrating a large dose of anti-inflammatory medication in the knee, says Dr. Chalmers. “I tell patients the efficacy of these varies but on average, they last for a few months.”

  Cortisone injections are often recommended because they have the overall best combination of cost effectiveness and efficacy. The American Academy of Orthopedic Surgeons (AAOS) clinical practice guidelines on treatment of knee arthritis has a moderate to strong recommendation for cortisone injections and does not recommend hyaluronic acid injections due to these factors, says Dr. Chalmers.​​​​​

• Viscosupplementation injections, otherwise known as gel shots or gel injections, are thick liquids comprised of hyaluronic acid (HA), which naturally occurs in joint fluid. They’re intended to lubricate the existing cartilage and reduce arthritis symptoms. “It’s common that patients try this before seeing an orthopedic surgeon about knee replacement surgery,” says Dr. Chalmers.  

  “These [gel shots] may work a bit longer than cortisone, but they don’t replenish cartilage, so their effect is also temporary,” says Dr. Su. The shots are generally given as one injection per week over a three-week period. 

  As some cartilage is necessary for viscosupplementation to work, they tend to be more effective in less-severe cases of cartilage loss. 

  “I've found with my patients and most studies support that there's not as much efficacy as with cortisone injections,” says Dr. Chalmers. 

  Some patients get an HA shot and then a cortisone shot three months later, and an HA shot three months after that, followed by cortisone three months later. This could be their schedule for a couple of years.  “While every doctor is different, most would continue these injections while they are still effective,” says Dr. Chalmers. “However, typically the injections wane in efficacy over time and would typically not be as effective after a year or two of this type of schedule.”

• Regenerative medicine methods include injections of platelet-rich plasma or stem cells from different sources. The goal is to aid the body’s ability to heal damaged tissue. However, scientific studies have not shown that any cartilage within the joint or meniscus can be regrown with these injections, our experts say. “They’re less-commonly utilized since they’re not typically covered by insurance,” says Dr. Chalmers.

If you’re considering knee replacement surgery, it’s recommended you wait at least three months after your last injection before having surgery, says Dr. Chalmers.

Alternative Therapies for Knee Arthritis

“There is little downside to acupuncture, so if it can help reduce inflammation or pain, I am in favor of it,” says Dr. Su. 

The same goes with chiropractic options, topical creams that contain CBD, or massage, he says. Talk to your healthcare team to see if any alternative therapies might be a good fit for you.

Surgical Options for Knee Arthritis

There are less-invasive types of surgeries that people might explore before resorting to total knee replacement surgery.

Knee arthroscopy is typically reserved for people who have specific movement-related symptoms—like the knee getting stuck or locked—or meniscus tears, says Dr. Su.  Because arthroscopic surgery doesn’t replace cartilage, the arthritic symptoms such as pain and stiffness will continue afterward if that was an initial problem. 

“Osteotomy, a major surgical procedure, redirects forces within the knee to healthy cartilage and is suitable for select patients, particularly younger people with good bone quality,” explains Dr. Su. In older patients, a total knee replacement will generally give a faster and more predictable recovery than an osteotomy, he says.

Total Knee Replacement Surgery 

Total knee replacement surgery is the best option when nonsurgical treatments don’t relieve symptoms and arthritis limits daily activities. Dr. Su stresses the importance of individualized treatment plans based on results from imaging like X-rays as well as how a person’s disease is progressing.

“If the knee is becoming more bowlegged or knock-kneed, or becoming stiff due to the arthritis, then knee replacement surgery may be suggested at an earlier stage so that results can be better,” Dr Su says.

Published 10/17/2024

About the Expert

John S. Blanco, MD
Emily R. Dodwell, MD, MPH, FRCSC