Managing Existing Joint Disease
Physiotherapy and specific exercises are the first-line treatment for OA recommended by every major orthopedic and rheumatology guideline — yet are dramatically underutilized compared to pharmacological treatment. The Cochrane review of exercise for hip OA found significant reductions in pain (effect size 0.38) and functional limitation (0.35) that were maintained at 6-month follow-up without ongoing supervised exercise. The key elements of effective OA exercise: aerobic exercise 150 minutes/week (land or water-based), resistance training for periarticular muscles 2-3x/week, range-of-motion and flexibility work daily. Physiotherapist guidance is valuable for learning joint-protective movement patterns that avoid aggravating positions while maintaining mobility and strength.
Pharmacological options for OA: topical NSAIDs (diclofenac gel) provide local pain relief with minimal systemic absorption — recommended as first-line pharmacological treatment by OARSI (Osteoarthritis Research Society International) guidelines due to excellent efficacy-to-risk profile. Oral NSAIDs are effective but carry gastrointestinal, renal, and cardiovascular risks with chronic use. Acetaminophen provides minimal benefit for OA pain in recent meta-analyses and its traditional first-line status has been downgraded in current guidelines. Intra-articular corticosteroid injections provide 4-8 weeks of significant pain relief in flares but may paradoxically accelerate cartilage loss with repeated use (quarterly) — use sparingly. Hyaluronic acid injections have mixed evidence across trials; PRP (platelet-rich plasma) injections show moderate evidence for symptom improvement with an excellent safety profile.
Glucosamine and chondroitin: these supplements have generated considerable research interest and controversy. The large GAIT trial found that glucosamine + chondroitin sulfate combined was significantly more effective than placebo in people with moderate-to-severe knee OA symptoms (64% vs 54% responder rate) but not in mild OA. The MOVES trial found similar results with chondroitin sulfate alone — comparable to celecoxib for pain and function in knee OA. The CONCEPT trial found no benefit. The overall picture: there may be a subgroup of moderate-to-severe OA patients who respond meaningfully; there is no disease-modifying effect on radiological progression; and safety is excellent. A 3-month trial of glucosamine (1500mg) + chondroitin (1200mg) daily in those with significant knee OA symptoms is reasonable given the safety profile.
When to consider surgery: total joint replacement (arthroplasty) for hip and knee OA is one of the most cost-effective surgical procedures in medicine, producing dramatic reductions in pain and improvements in function in appropriately selected patients. Indications: severe OA with significant pain that substantially limits daily activities and doesn’t respond to conservative management (exercise, physiotherapy, weight loss, appropriate analgesics). The optimal timing of surgery is controversial — earlier surgery may provide better functional outcomes but exposes patients to surgical risks; later surgery may allow conservative management time to work but may reduce surgical outcomes due to muscle atrophy and reduced activity. Physiotherapy-optimized fitness before surgery (“prehabilitation”) significantly improves post-surgical recovery outcomes.