Non-operative Measures

Not all cases of hip or knee osteoarthritis require surgery

There are numerous non-operative measures available that can effectively improve your pain, function, and overall management of arthritis without the need for surgery.

By utilizing these non-operative measures, you can find relief and improve your quality of life while managing your arthritis. Surgical intervention is not be an absolute necessity for most cases of osteoarthritis, as it is a highly manageable condition that can be treated safely without surgery. However, in certain situations, earlier surgery may be recommended, and if applicable, Mr Costin-Brown will discuss this with you.

These non-operative treatments can make your arthritis symptoms more manageable and tolerable, although they cannot reverse the presence of arthritis in your joints. There are well-established non-operative approaches, emerging treatments, anecdotal remedies, and alternative therapies that can be explored. Some of these options include:

Pain killers, Topical gels or rubs, Physiotherapy, Activity modification, Weight loss, Walking aids,
Knee braces, Injections, Dietary supplements, Diet, Alternative treatments.

Pain killers

Painkillers play a significant role in managing arthritis symptoms. Non-steroidal anti-inflammatories (NSAIDs) like ibuprofen or diclofenac are highly effective in improving arthritis pain. However, it’s important to note that certain patients, such as those with kidney, heart, gastrointestinal, or lung issues, should avoid NSAIDs. Before starting any medication, you should consult with your GP to ensure there are no contraindications. If you anticipate using anti-inflammatories for an extended period or have stomach issues, your GP may recommend taking an additional stomach-protecting tablet, such as omeprazole.

Paracetamol is another option, although it is not as effective for arthritis pain. While there is no strong evidence supporting its effectiveness specifically for osteoarthritis, paracetamol is considered a safe alternative when anti-inflammatories are not suitable for you.

It is generally advised to avoid stronger painkillers containing opioids, such as codeine, tramadol, or morphine, if possible. Pre-operative use of opioids has been associated with poorer outcomes following joint replacement surgery and carries a risk of addiction and withdrawal. The risks associated with strong opioids often outweigh their benefits. If you reach a point where you require opioid-based painkillers, it may be advisable to explore other non-operative measures or consider surgical intervention as an option.

Topical gels or rubs

Topical gels or rubs are valuable options for delivering medication directly to the affected joint, providing localised relief without the potential side effects associated with oral medications. There are two main types of topical gels/rubs commonly used: anti-inflammatory gels (such as Ibulieve or Volarol) and capsaicin-based products.

Anti-inflammatory gels function similarly to oral tablets by reducing inflammation within the joint and alleviating pain.

Capsaicin-based rubs, on the other hand, contain chili extract and produce a warming sensation when applied to the skin. Regular application of capsaicin aims to desensitize the nerves surrounding the joint, potentially reducing the perception of pain associated with arthritis. It is important to note that consistent and proper usage is necessary for optimal results, and it can take up to 6 weeks to see the full benefit.

Physiotherapy

Physiotherapy plays a crucial role in managing arthritis by maintaining joint mobility and strengthening the surrounding muscles. Arthritis often leads to joint stiffness, which can hinder daily activities and increase pain during extreme movements. By keeping the joint supple through physiotherapy, stiffness can be prevented. Additionally, arthritis causes muscle loss around the affected joint as movement becomes painful and limited. This creates a cycle of pain, reduced movement, muscle wasting, and joint weakness. Physiotherapy helps break this cycle by progressively building muscle strength, despite potential initial discomfort. It is essential not only to target the muscles around the joint but also to strengthen the core and hip muscles for a solid foundation. Incorporating exercises like Pilates can be beneficial. While results may take 6-8 weeks to manifest, it is important to persevere even if immediate improvements are not seen.

There are some excellent group classes that are run through national bodies.
For example, https://escape-pain.org is a group rehabilitation programme for people with chronic joint pain that integrates educational self-management and coping strategies with an exercise regimen individualised for each participant. They run local classes which you can register for online. Similarly, Nuffield Health run a Joint Pain Programme (https://www.nuffieldhealth.com/about-us/our-impact/healthy-life/joint-pain-programme) with local group sessions available.

Activity modification

Engaging in regular and consistent exercise is beneficial for managing arthritis, particularly weightbearing exercises that are generally well tolerated. However, it is important to modify activities that may aggravate your arthritis, such as high impact exercises like running or jumping. Exploring alternative hobbies or exercises that are gentler on the joints can be appropriate. Lifestyle modification involves adapting to living with arthritis while continuing to enjoy activities. For example, if walking around a full 18 holes of golf becomes challenging, utilising a buggy can make it more manageable and allow you to continue to pursue your hobby. Similarly, if you enjoy skiing but struggle with off piste or moguls, focusing on easier slopes and making the most of après ski activities can still provide enjoyment.

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Weight loss

Weight loss can be challenging when managing arthritis, as the pain in the joint often makes exercise difficult. However, it is important to recognise that the majority of weight loss is attributed to diet rather than exercise. Therefore, focusing on reducing calorie intake and making healthy dietary choices is crucial (see below for food advice). Putting excessive force through an arthritic joint increases pain. For instance, when going up and down stairs, approximately 5 times the body weight is exerted on the kneecap joint, which can be problematic for individuals with knee arthritis. By losing just 5 kg, you can reduce the load on the joint by 25 kg, significantly impacting pain levels. Professional weight loss services are available through your GP and seeking professional assistance can provide valuable support in your weight loss journey.

Walking aids

Walking aids, such as walking sticks, crutches, walking frames, and rollators, offer dual benefits. Firstly, they help reduce the amount of force exerted on your arthritic joint, similar to the impact of weight loss. Secondly, they provide balance support, preventing trips and jolts that can worsen pain and reduce the risk of falls and potential injuries.

It is advisable to seek professional assistance when selecting and fitting a walking aid, as improperly fitted sticks or crutches can potentially increase your discomfort. For hip arthritis, it is recommended to hold the stick or crutch in the opposite hand, while for knee arthritis, holding it on the same side is often more beneficial (though not always).

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Knee braces

Knee braces or sleeves can provide benefits for knee osteoarthritis. Over-the-counter braces or sleeves have limited effectiveness and likely work by keeping the joint warm and enhancing joint position sense. In cases of knee arthritis where the joint is worn on a specific side (such as the inside or outside), an “offloader” brace can be helpful. These specialised braces, which have to be prescribed by a healthcare professional and fitted by an Orthotist, apply a constant force across the joint to redistribute the forces across the knee and offload the arthritic part of the joint.

Injections

There are various substances that can be injected into joints, including local anaesthetic, steroids, and hyaluronic acid. Joint injections serve two main purposes: diagnostic and therapeutic. In the diagnostic context, injecting local anaesthetic into the joint numbs it from within, allowing us to determine if the joint is the source of your pain. This is particularly useful in cases of hip arthritis with associated back pain, as it helps distinguish between the contributions of the hip and the back. On the other hand, therapeutic injections aim to provide longer-lasting pain relief by targeting the joint directly. For further details on joint injections, please refer to the dedicated “Joint injections” page.

Dietary supplements

There are a huge number of dietary supplements on the market that advertise to help relieve arthritis pain. In reality, the vast majority of these claims are not backed up by high quality research.

The most commonly used supplement in osteoarthritis is glucosamine and chondroitin, which aims to protect the remaining cartilage in the joint, although the exact mechanism is unclear. Recent evidence suggests that there is no strong evidence of benefit for glucosamine. However, these supplements generally have few side effects, so there is little harm in trying them except for the potential cost. If considering glucosamine and chondroitin, it is recommended to look for formulations containing “glucosamine sulfate” rather than “hydrochloride,” with or without chondroitin sulfate. It’s important to note that it may take several weeks for these supplements to fully take effect.

Turmeric has gained attention for its purported anti-inflammatory properties. Despite lacking strong evidence to support its use, it is generally considered safe. Studies have examined doses of approximately 1-1.5 grams per day, which cannot be achieved through turmeric powder used in cooking and would require a supplement. Taking turmeric with black pepper, which is believed to enhance absorption, is often recommended (some supplement formulations already include black pepper in the tablet).

Diet

There is increasing evidence that diet can impact inflammation levels in the body and influence the gut microbiome. However, at present, there is limited strong evidence linking diet and gut microbiome to symptom management in established arthritis. Nonetheless, maintaining a healthy diet has many benefits, including potential weight loss, blood pressure control, and reducing the risks of certain types of cancers. Foods associated with high inflammation should be avoided, such as seed oils (rapeseed, canola, vegetable oils), red meat, and highly processed foods (e.g. cereals, ready meals). Conversely, foods with anti-inflammatory properties are recommended, such as fresh fruits and vegetables, legumes (e.g. beans), fermented foods (e.g. sauerkraut, kimchi), and specific oils (e.g. olive, coconut, avacado).

Recent research suggests a shift from the traditional “5 a day” guideline to aiming for 30 different fruits and vegetables over a week, ensuring a diverse intake of vitamins and nutrients. Mr Costin-Brown recommends exploring the works of Tim Spector, particularly his publication found at https://joinzoe.com/post/tim-spector-gut-tips., which offers valuable insights into gut health.

The Mediterranean diet is widely regarded as highly beneficial as it aligns with the aforementioned principles—low in inflammatory foods, abundant in anti-inflammatory foods, and rich in a wide variety of fresh fruits and vegetables.

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Alternative treatments

CBD, or cannabidiol, has been advertised to manage arthritis symptoms. CBD is a compound found in cannabis. It doesn’t cause a high but may make some people feel drowsy. While animal studies suggest CBD may have pain-relieving and anti-inflammatory properties, there’s limited high-quality research in humans. Some arthritis patients report pain relief, better sleep, and reduced anxiety with CBD, but results vary. CBD’s safety is still being studied, and it may interact with certain medications. You should discuss with your GP before trying CBD, especially if taking specific medications. In the UK, it is legal to buy and sell CBD products, as long as they meet strict regulations set by government authorities. When shopping for CBD, be cautious due to lack of regulation.

Websites

Mr Costin-Brown recommends the following websites as reliable sources of information:

https://www.arthritis.org
https://www.versusarthritis.org
https://www.nhs.uk/conditions/osteoarthritis/