Knee osteoarthritis: what can be done before surgery

Knee osteoarthritis, technically gonarthrosis, is the progressive wearing down of the articular cartilage that covers the bones of the knee. It is a very common degenerative condition, especially after age 50, and it affects women more than men. The typical picture combines pain with activity, stiffness when getting up from a chair or starting to walk, cracking or grinding sounds, and growing difficulty with everyday activities like climbing stairs or crouching down.

In my daily practice I see many patients with knee osteoarthritis who arrive convinced that "that's it, I need surgery," or with the opposite idea that "there's nothing to be done until it's time for a knee replacement." Both positions are extreme and, in general, wrong. Between the first episode of pain and joint replacement surgery there is a long road, spanning many years, in which a great deal can be done to preserve function, slow the progression of symptoms and significantly improve quality of life. Thinking of knee osteoarthritis as a disease with stages, rather than a sentence, changes the entire approach.

What many patients don't know is that between a diagnosis of osteoarthritis and a knee replacement there is a whole universe of options, and most people with mild to moderate osteoarthritis can keep their symptoms well controlled for many years without going to the operating room.

How it is diagnosed

The diagnosis of knee osteoarthritis is fundamentally clinical and is confirmed with plain X-rays. MRI can add information about the state of the cartilage, the menisci and the ligaments, but it is not essential in most cases.

It is important to know that the severity of osteoarthritis on an X-ray does not always correlate with the pain. There are patients with significant arthritic changes and little pain, and patients with mild changes and significant pain. That is why treatment is tailored to the symptoms and the functional limitation, not just to the imaging.

An important technical nuance: X-rays and MRI often do not correlate with the intensity of the pain. I see patients with radiographically very worn knees who function reasonably well, and patients with mild to moderate osteoarthritis who have a great deal of pain and limitation. That is why the grade of osteoarthritis on the image is not what determines the treatment approach: what determines it is the symptoms, the functional impact and the response to previous treatments. Treating images instead of patients is one of the reasons some people end up having surgery too soon while others go on suffering when there was still much that could be done.

The stages of treatment

Stage 1 — General measures and education

It sounds basic, but this is what makes the biggest difference over the long term:

• Weight management: every extra kilo of body weight puts three to four extra kilos of load on the knee when walking. Losing 5 kilos can transform the pain for many patients.
• Appropriate physical activity: inactivity makes osteoarthritis worse. Walking, swimming, cycling or using an elliptical strengthens the muscles without overloading the joint.
• Footwear and support: comfortable shoes with good cushioning, and insoles if there are alignment problems.

Stage 2 — Medication

For the pain:

• Paracetamol (acetaminophen) or dipyrone as first-line options for mild pain.
• Anti-inflammatories in short courses during flare-ups (not for chronic use).
• Topical anti-inflammatories (gel or cream) are an excellent alternative because they provide a local effect with far fewer systemic side effects.
• Supplements such as chondroitin and glucosamine: the evidence is controversial, but some patients report benefit.

Stage 3 — Physical therapy and strengthening

The quadriceps is the most important muscle for stabilizing the knee. A strengthening program for the quadriceps, hamstrings and glutes, combined with proprioception work, can reduce pain significantly. Physical therapy needs to be sustained over time, not a treatment lasting just a few weeks.

Stage 4 — Joint injections

When the previous steps are not enough, intra-articular knee injections are very useful. The most commonly used options:

• Intra-articular corticosteroids: provide rapid relief of pain and inflammation, particularly useful during flare-ups. The effect lasts weeks to months. It is recommended not to exceed three injections per year in the same knee.
• Hyaluronic acid (viscosupplementation): acts as a joint lubricant. The effect builds up gradually and lasts between 6 and 12 months depending on the preparation. It can be repeated periodically.
• Regenerative medicine with platelet-rich plasma (PRP): uses growth factors from the patient's own blood to stimulate tissue repair. The evidence suggests benefit in mild to moderate osteoarthritis, especially in patients under 65.

The choice between these options depends on the grade of osteoarthritis, the patient's profile, the response to previous treatment and the clinical situation of each case.

Stage 5 — Advanced interventional procedures

When pain persists despite injections and surgery is not yet an option (because of age, other health conditions or patient preference), there are techniques such as genicular nerve radiofrequency ablation: a minimally invasive technique that targets the nerves that carry pain signals from the knee. The effect lasts 6 to 12 months or longer, and it can be repeated.

Stage 6 — Surgery

Knee replacement is a very effective treatment when the osteoarthritis is severe, the pain is disabling and conservative treatments have been exhausted. It is a major operation that requires rehabilitation afterward. The decision is individual and should be made when the risk-benefit balance is favorable.

My criteria for recommending an intra-articular injection — with corticosteroids, hyaluronic acid or, in selected cases, platelet-rich plasma — depend on the patient's clinical stage, not on a rigid rule. I reserve corticosteroids for flare-ups with a clear inflammatory component, hyaluronic acid for mild to moderate osteoarthritis in active patients who want to gain quality time, and I always combine them with active quadriceps strengthening, weight management where appropriate, and adjustments to physical activity. An injection on its own, without the rest of the plan, delivers far less than it could.

An honest conversation about expectations

Osteoarthritis is a degenerative condition. It cannot be "cured" with any of the treatments available today — not even with surgery (which replaces the joint, it does not regenerate it). What can be done is:

• Control the pain for extended periods.
• Improve function and quality of life.
• Delay or avoid surgery when possible.
• Keep the patient active and independent.

And for someone living with osteoarthritis, that is a lot.

For me, the goal in treating knee osteoarthritis is not to eliminate the pain completely — that is often not realistic — but for the patient to keep doing the things that matter to them: walking, traveling, playing with their grandchildren, staying active. When a patient understands that muscle is the best shock absorber the knee has, and commits to a strengthening program over time, the results last far longer than with any procedure on its own. Surgery remains an option when the time comes, but that time comes considerably later than patients believe at the start.

Dr. Mauricio Casarsa

Anesthesiologist, specialist in Pain Medicine and Interventional Pain Management. Postgraduate training at UBA (Fundación Dolor) and UNLP (CAIDBA). Staff physician at Hospital Alemán in Buenos Aires.

MN 137756 · San Isidro · Villa Urquiza