In brief

Knee osteoarthritis affects the whole joint, not just the cartilage. International guidelines put tailored exercise, with weight loss if needed, at the core of managing it. A physical therapist (a physiotherapist, in UK terms) adjusts the load and builds it up gradually. Diagnosis, medication, injections and surgery are a doctor's call — and so is a hot, swollen knee or a fever.

A diagnosis of knee osteoarthritis often sounds like a verdict: the cartilage has "worn away", and all that is left is to spare the leg. International guidelines say the opposite — do not hide the knee from movement, load it regularly and in measured doses. You will not find a ready-made set of exercises here: a programme is put together after an examination, because the same words on two people's reports often call for quite different work.

The information in this article does not replace a doctor's consultation. A physical therapist does not diagnose and does not prescribe treatment. Diagnosis, medication, joint injections and decisions about surgery are a doctor's responsibility.

Osteoarthritis (gonarthrosis): what happens in the joint, and why "salt deposits" are a myth

Arthrosis, osteoarthrosis, osteoarthritis, gonarthrosis — medical reports use different words, but they all describe the same thing: a long-term condition of a joint that develops gradually. "Gonarthrosis" means osteoarthritis of the knee specifically. Reports written in Ukraine often say "arthrosis" or "gonarthrosis"; English-language guidelines use "osteoarthritis".

For a long time osteoarthritis was thought of simply as cartilage wearing away. Today it is seen as a condition of the whole joint and the tissues around it. The cartilage covering the ends of the bones becomes thinner. The bone underneath grows denser, and bony outgrowths — osteophytes — form at the edges of the joint. The joint's inner lining becomes inflamed from time to time, and then the knee swells. The surrounding muscles weaken.

The typical picture is pain with activity: on stairs, when getting up from a chair, after a long walk. In the morning or after sitting, the knee may feel stiff, but the stiffness is usually short-lived and eases once you get moving. The condition tends to come in waves: calm spells alternate with flare-ups, and a flare-up on its own does not mean things have got permanently worse.

The X-ray and how the knee feels do not always match. Some people have marked changes on the image and hardly any trouble, and the reverse happens too. That is why the UK's National Institute for Health and Care Excellence (NICE) advises diagnosing osteoarthritis clinically, without imaging, in people aged 45 or over with typical symptoms, and guiding management by symptoms and what the person can do rather than by the "grade" on the image.

Now to "salt deposits". On an X-ray, osteophytes look like growths, and in Ukraine and neighbouring countries they are often called "salt deposits" in everyday speech. In fact they are bone tissue — the bone's response to changes in the joint, not salt from food. So neither a salt-free diet nor products that promise to "flush out salts" have any effect on osteoarthritis.

Conditions in which crystals really do collect in a joint do exist — gout and pseudogout. But these are separate diagnoses made by a doctor, and they usually come as attacks: the joint suddenly becomes hot, red and very swollen.

Why guidelines put movement at the core of managing osteoarthritis

In its 2022 guideline NG226, NICE names the core treatments for osteoarthritis: therapeutic exercise and weight management where appropriate, along with information and support. Exercise is recommended for everyone with osteoarthritis, but tailored to the individual: strengthening the muscles around the joint and building general aerobic fitness.

The Osteoarthritis Research Society International (OARSI), in its 2019 guidelines for knee osteoarthritis, lists the same foundations: education, structured exercise programmes and, where needed, weight management.

Why movement in particular:

Cartilage has no blood vessels of its own. It is nourished by the joint fluid, and that exchange is kept going by the alternation of loading and unloading as you move.
The thigh muscles take on part of the load and control how the knee bends and straightens. When they weaken, the joint has a harder time.
Avoiding movement sets up a vicious circle: the knee hurts, so you move less; the muscles weaken; ordinary activity becomes harder; and the pain comes on even sooner.

A common fear is "wearing out" the joint with exercise. The guidelines do not support it: NICE advises explaining to people that regular, consistent exercise will benefit their joints even if it causes some pain or discomfort at first, and that sticking with it over the long term increases the benefit.

To be honest about the limits: exercise does not "regrow cartilage" and does not remove the changes seen on an X-ray. Its aims are stronger muscles, steadier walking and less pain in everyday activities. Nobody can tell you in advance how much your own condition will change.

What a physical therapist does: thigh strength, range of motion, walking, stairs

Work begins with an assessment. At the first meeting we ask what exactly gets in the way: stairs, long walks, getting up from a low armchair, crouching down to a bottom shelf. Then we look at movement: how far the knee bends and straightens, the strength of the thigh and hip muscles, how you get up from a chair, walk and manage a step, and how well you keep your balance.

The programme is then built around several strands:

Strength. Above all the muscles at the front of the thigh and the gluteal muscles: they stabilise the knee when you walk and climb stairs.
Range of motion. Especially full straightening: a knee that does not straighten all the way makes you walk on a slightly bent leg, and the load on the joint goes up.
Walking and stamina. We advise on general aerobic activity to do outside sessions — walking, an exercise bike, a pool — and how to dose it so that the knee tolerates it.
Stairs and everyday movements. Standing up, sitting down, going up and down — the things all of this is for.
Balance. Unsteadiness on uneven ground is often linked not only to pain but also to the fear that the knee will "give way".

We adjust the load to how you respond and increase it gradually. NICE also advises considering supervised exercise sessions, and that is how sessions run here: one to one, so technique is visible straight away and the programme changes as your condition does. The home part is essential: short, regular repetitions at home achieve more than occasional long efforts. The session format is described on the physical therapy (exercise therapy) page, and the other joint complaints we work with are on the back, neck and joint pain page.

Hands-on work — gentle mobilisation within the range the joint already has, work on tight muscles — can be part of a session, but only alongside exercise. NICE takes the same view of manual therapy: it should only be considered alongside therapeutic exercise, because there is not enough evidence to support its use on its own. More on the manual techniques page.

What a physical therapist does not do: diagnose, interpret imaging in place of a doctor, prescribe medication or injections, or promise to "restore cartilage" or to have the pain gone by a particular date.

Pain during sessions: what is acceptable and what is a signal to stop

With osteoarthritis, completely pain-free sessions are often not realistic, and NICE says so plainly: joint pain may increase when you start therapeutic exercise. That does not mean putting up with anything at all. A simple framework helps draw the line.

Usually acceptable:

moderate discomfort or familiar pain during an exercise that does not build from one set to the next;
pain that settles back to its usual level within a few hours of the session;
a knee that is no worse than usual the next morning.

A signal to stop and tell your therapist:

sharp or stabbing pain that makes you hold your breath or change the movement;
pain that gets worse with every repetition;
new swelling that leaves the knee feeling tight;
pain and stiffness the next morning that are noticeably worse than before the session;
a feeling that the knee has "locked" or is giving way.

If your response goes beyond what is acceptable, that is not a reason to give up the sessions but a reason to change the dose: fewer repetitions, a smaller range, a different exercise. The exception is a knee that has locked, has suddenly swollen and become hot, or will no longer take your weight: then the session stops and you see a doctor first (see the section on seeing an orthopaedic trauma surgeon).

Weight, shoes, a walking stick: everyday decisions

Weight. If you are carrying extra weight, losing some of it sits alongside exercise in both the NICE and the OARSI recommendations. NICE stresses that any amount of weight loss is likely to be beneficial. How to go about it is worth discussing with your family doctor: we do not prescribe diets, but movement is part of that work.

Shoes. Comfortable and stable, with a closed heel and a sole that cushions each step; high heels are best put aside during a flare-up. Special insoles are not routinely needed: NICE advises against offering them to everyone and limits them to specific situations — and that is a doctor's decision.

Walking stick. NICE recommends considering walking aids, such as a stick, for osteoarthritis in the legs. A stick is not a defeat but a way to take load off the knee and walk further. It is usually held in the hand on the side of the unaffected leg; the height and technique are best chosen with a specialist.

Around the home. A higher chair with armrests instead of a low sofa, a handrail on the stairs, breaks during long periods of sitting — small things that take some of the load off the knee every day.

When to see an orthopaedic trauma surgeon

Osteoarthritis is diagnosed and managed by a doctor: you usually start with a family doctor, then, if needed, see an orthopaedic trauma surgeon — or a rheumatologist if several joints are swollen (especially the small joints of the hands or feet) or morning stiffness lasts longer than half an hour. If your knee started hurting recently and no doctor has examined it yet, start with a doctor.

Do not wait for your next session — see a doctor if:

the knee has suddenly got stuck in one position and will not straighten fully — this is what a locked joint looks like;
the joint has suddenly become swollen, red and hot to the touch, especially with a fever or chills, or after a recent injection into the joint — see a doctor the same day;
the pain started after an injury: a fall, a blow, a sudden twist of the leg; if you then cannot stand on the leg, or the knee swells markedly within hours or changes shape, go to an emergency trauma unit the same day;
things have got sharply worse: the pain is much stronger than usual, you cannot stand on the leg, or the knee has started giving way;
pain wakes you at night, does not depend on your position and does not ease with rest, especially together with unexplained weight loss, general weakness or a current or past cancer;
pain, swelling, a firm area or a feeling of warmth has appeared in the calf — possible signs of a deep vein thrombosis, which a doctor needs to assess the same day;
sudden shortness of breath, chest pain, coughing up blood or sudden severe weakness — call emergency medical services on 103 immediately; do not wait until morning and do not drive yourself.

It is not urgent, but do talk to a doctor if, despite regular exercise and changes to daily life, pain and limitation keep getting in the way of sleep, walking and ordinary life. The doctor then weighs up other options — medication, injections and, if needed, surgery. NICE advises considering referral for joint replacement when symptoms substantially affect quality of life and non-surgical management is ineffective or unsuitable.

If surgery is already planned

The decision about a joint replacement is made by the orthopaedic trauma surgeon and the patient together. If it has already been made, a few things are worth finding out in advance.

Ask your surgeon:

whether anything needs to change before the operation — activity, weight, medication — and if so, what exactly;
when you will be able to put weight on the leg after the operation, and with what support — crutches or a walking frame;
what restrictions will apply after discharge, and when the follow-up appointment will be;
when and where rehabilitation begins.

Prepare your home in advance: a higher chair with armrests, a handrail on the stairs, a non-slip mat in the bathroom, walkways clear of rugs and cables, and a light along the route to the toilet at night. Find out which walking aids you will need, get them beforehand, and arrange who will help at home during the first weeks after discharge.

The operation replaces the worn joint surfaces, but muscle strength, an even gait and confidence on stairs have to be rebuilt afterwards. Rehabilitation is a stage of its own, and its order is set by the operating surgeon. How it works and who is responsible for what is covered in our article on rehabilitation after joint replacement.

Questions and answers

Can I exercise if my knee hurts?

In most cases, yes: with osteoarthritis, measured movement is part of dealing with the pain and does not harm the joint, although pain may increase for a while when you start. A rule of thumb: the pain does not build during the session and settles back to its usual level within a few hours. The exceptions are a hot, swollen joint, a fever, a locked knee or a fresh injury — in those cases, see a doctor first. If pain gets in the way of exercising, talk to your doctor: medication for osteoarthritis is used alongside exercise, including to support it, and it is prescribed by a doctor.

Are squats and stairs bad for the knee?

Not in themselves. The knee is built to bend under load, and getting up from a chair and climbing stairs are part of every day. What matters is depth, technique and dose: squats can be kept shallow and done with support, and during a flare-up you can take the stairs one step at a time — leading with the stronger leg on the way up and with the painful leg on the way down. Whether deep weighted squats, jumping or running suit you is decided individually after an examination.

Does massage help with osteoarthritis?

Guidelines do not support it as a stand-alone method: NICE considers manual therapy only alongside exercise, because there is not enough evidence for using it on its own. Massage can ease tension in the thigh and calf muscles and make sessions more comfortable, but it does not change the joint and does not replace exercise. So therapeutic massage can only be considered with osteoarthritis as an addition to an exercise programme, not instead of one. At the practice it is given by massage therapist Alona Kaliuzhna.

Do I need a knee brace?

Not routinely. NICE advises against routinely offering braces, supports or insoles to people with osteoarthritis. The exceptions are joint instability or abnormal loading of the joint, when exercise is ineffective or unsuitable without such an aid and adding one is likely to improve movement and function. Whether that applies to you, and which brace you would need, is for a doctor to decide. If you already have a knee support and feel more comfortable in it, mention it at the consultation.

Sources

Osteoarthritis in over 16s: diagnosis and management — NICE guideline NG226. National Institute for Health and Care Excellence, UK, 2022.
OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis — Bannuru R. R. et al. Osteoarthritis and Cartilage, 2019, 27(11): 1578–1589.
Osteoarthritis — fact sheet, World Health Organization, 2023.

If you are in Zaporizhzhia

Rehab Place is an outpatient physical therapy practice, and sessions are one to one. They are run by Oleksandr Kaliuzhnyi, physical therapist, in practice since 2012. Sessions are conducted in Ukrainian and Russian; you can write to us in English to arrange the details.

A first consultation takes about 60 minutes — conversation, examination, testing and a plan of work — and costs UAH 300. Service members and veterans get 30% off the consultation and sessions: the consultation costs UAH 210 instead of UAH 300. The discount applies on presentation of a combat participant certificate (UBD).

Bring your doctor's report, any X-rays you have had, a list of the medication you take regularly, and shorts so the knee is easy to examine. If you use a walking stick, bring that too.

Accessibility: the practice is on the ground floor with no stairs inside, there is a ramp at the building entrance, and parking nearby. One thing to know in advance: the toilet in the building is not adapted for visitors with reduced mobility — please take this into account when planning your visit.

Address: 28 Pavlokichkaska St., Zavodskyi Palace of Culture building, Zavodskyi district, Zaporizhzhia — address and how to get here. Opening hours: Mon–Fri 09:00–19:00, Saturday by prior appointment, Sunday closed.

To book or ask a question: +380 97 824 48 01 — by phone, or in English by message on Telegram or Viber at the same number. If you are not sure whether your situation is one for a physical therapist, describe it to us: if we hear signs that call for a doctor first, we will tell you so plainly.

The information in this article does not replace a doctor's consultation. Questions of diagnosis, medication, injections, safe loading and surgery are decided by a doctor.

Knee Osteoarthritis: What Exercise and Physical Therapy Can Do