For patients needing knee replacement surgery, the NHS waiting lists are getting longer. We now have over 5 million patients waiting for treatments on the NHS, with over 500,000 patients waiting specifically for orthopaedic surgery alone: of these, 67,000 have already waited for more than 1 year!
So, what alternative options are actually available for patients whilst they wait for knee replacement surgery? In this article, I’ve outlined 5 specific treatments that may potentially buy a patient extra time if they’re heading towards or waiting for knee replacement surgery. I’ve also provided an estimate of how much each treatment might cost using private healthcare. Importantly, I’ve also highlighted the treatments to avoid: in particular, ‘stem cell’ injections!
1. Painkillers and anti-inflammatories
Painkillers / anti-inflammatories can help significantly, in terms of helping patients continue to cope with their daily activities and to keep fit (with light non-impact cardio work). They can also help stop a painful knee from waking them up at night.
Occasional painkillers / anti-inflammatories are fine; however, if a patient is ‘popping pills’ regularly, then there is the risk they might be taking too many and that they should seek the advice of their GP or Consultant.
2. The role of intra-articular steroid injections
I do sometimes recommend that patients have a steroid injection into their knee to help ease the pain of osteoarthritis, but this comes with a number of important caveats…
Steroid (corticosteroid) acts as a very powerful anti-inflammatory. It’s not like ‘being on steroids’: the injection does not affect the rest of the body to any significant degree – it’s simply like having a massive dose of Nurofen all in one spot, inside the knee joint, exactly where it’s needed.
The likelihood of a steroid injection working is highly variable, and it depends very much on what is actually damaged in the knee and/or how severe that damage might be. In addition, the effects can vary considerably between individuals. Basically, the more inflamed the joint is (warm, tender and swollen), then the more likely it is that a steroid injection will work. Broadly speaking, a steroid injection might work in maybe 75% or so of people with knee arthritis, although the percentage pain relief varies considerably. The injection may last just a few weeks or could last as long as 6 months; again, however, this is highly variable.
The advantages of steroid injections:
- they are quick,
- they are easy to give,
- they’re very low risk and
- they’re relatively cheap.
The disadvantages of steroid injections into the knee are that:
- the injection might not work,
- any relief might only be partial,
- the benefits are only ever temporary, and
- there is evidence that in the longer-term they can actually make a joint worse, increasing the likelihood that the individual will actually end up needing knee replacement surgery.
Steroid injections can sometimes be an appropriate option if a patient needs help to get through a particular period or event, such as a family wedding or a big and important family holiday. However, we normally tend to wait at least 3 months after someone has had their knee injected with steroid before then potentially going ahead with any knee replacement surgery, as there is a small fear that steroids may inhibit the immune response and potentially increase the risk of post-operative joint infection if given too close to the time of surgery.
Intra-articular steroid can be particularly useful in disorders where there is severe inflammation within a joint (an inflammatory arthropathy), such as rheumatoid arthritis or gout. However, intra-articular steroid injections are rarely, if ever, a good idea in younger patients with traumatic damage in their knee, such as a meniscal tear or an area of traumatic articular cartilage damage. In these cases, steroids can mask a patient’s symptoms but without addressing the actual underlying cause of the symptoms, which breaks the biofeedback loop, thus ‘fooling’ the patient into thinking that their knee is better (when it is not), and thus potentially encouraging them to do more on their knee, which can then simply end up making the joint damage even worse.
Other things that people sometimes inject into people’s knee include things like hyaluronic acid or PRP (platelet-rich plasma). These are a lot more expensive than steroid, and their use is somewhat contentious, as there is only limited and conflicting evidence as to whether or not they actually work, and whether they are actually any better than just simply injecting a placebo!
Importantly, steroid joint injections should not be confused with ‘stem cell’ injections!
Beware the dodgy ‘stem cell’ salesmen!
There is currently a lot of hype and some deeply misleading and disingenuous marketing out there by some ‘rogue stem cell clinics’ luring patients with the promise of ‘stem cell’ injections as a treatment for arthritis, and charging several thousand pounds per injection! This is absolutely nothing more than just a simple con! These injections are not actual ‘stem cells’, and there is no proper scientific evidence to justify their use.
The BBC has already investigated and exposed some of these rogue stem cell clinics, which should be avoided at all costs!
– https://www.bbc.co.uk/news/health-51006333
– https://www.bbc.co.uk/programmes/m000cz1l
– https://www.bbc.co.uk/sounds/play/m000cz1l
Please also read this specific article too:
And you can find out more in this short video:
– ‘Beware the dangers of ‘the stem cell salesmen’! – YouTube’
3. Physiotherapy
Physiotherapy is specifically recommended by NICE as part of the treatment pathway for knee arthritis [CLICK HERE for further information]. Appropriate physiotherapy prior to surgery (so-called ‘pre-hab’) can improve a patient’s mobility and build strength and fitness levels, helping them to cope better with any subsequent surgery and with the extensive post-op rehab that’s required after knee replacement surgery – and, importantly, this then increases the likelihood of a better long-term outcome from the surgery itself. Therefore, either way, whether a patient is trying avoid or delay surgery, or whether they’re already booked in and waiting for surgery, physiotherapy is an invaluable and essential part of the overall management of knee arthritis. If a patient doesn’t already have a physiotherapist, then their knee surgeon should be able to recommend one nearby.
At London Sports Orthopaedics we work closely with many expert therapists within the London area who specialise in treating musculoskeletal conditions, including knee arthritis. Click here for further information about LSO’s partnered therapists.
4. Non-impact cardio fitness exercise
Slightly separately from, but in addition to the role of physiotherapy, is the importance of regular light non-impact cardio fitness exercise.
Manual therapy with a physical therapist can be very helpful. Specific advice about what exercises to do and hands-on supervised guidance about how best to do them, safely, is also invaluable. However, when it comes to getting cardiovascularly fit, there’s just no real alternative to ‘JUST DO IT!‘…
It’s worth listing ‘cardio fitness exercise’ as a separate category because this is something that every patient needs to do themselves, in addition to and outside of whatever time might be spent with an actual physiotherapist.
If you’re doing ‘proper’ cardio fitness exercise, then your pulse should be racing, you should be out of breath and you should be sweating. If you can hold a conversation whilst you’re ‘exercising’, then you’re not doing proper cardio! Walking is good for you on many levels, including just ‘getting out’, getting fresh air, getting Vitamin D and keeping your joints moving. However, when you’re doing ‘proper’ cardio exercise (pulse racing, short of breath, sweating), then your body is pumping out Endorphins. Endorphins are one of the best anti-depressants known to man, they are addictive (so that the more you do, the more you want to do) and they raise your natural pain threshold, so that you feel less pain. Endorphins don’t actually reverse knee arthritis or make joints physically better, but they do make your knees feel better, and the fitter you are, the longer you’ll be able to keep going and cope before you do eventually end up having to resort to knee replacement surgery. In addition, being fit also reduces one’s risk of heart attack, stroke, hypertension and diabetes, and it even boosts your immune system, and fitter people tend to live longer.
You don’t have to ‘pound’ your knees to do exercise, and you don’t need to worry about heavy weights and ‘bulking up’ your muscles. The best exercises for patients with arthritic knees are those that are light and gentle on the joints, such as walking, cycling / the exercise bike, the crosstrainer and swimming. Just 20 to 30 minutes x 2 or 3 a week, taking things really gently and easily to start with, and just slowly and gradually building up with time, will make a world of difference to many patients.
So, regular light cardio exercise really ought to be considered ‘mandatory’!
5. Off-loader knee braces
The use of knee braces has become more common in recent years, as bracing technology has progressed.
If a patient has osteoarthritis affecting just one side of their knee (the inner/medial side or the outer/lateral side), then an off-loader knee brace can transfer some of the load going through the joint from the affected side/compartment to the un- or less-affected side. Reducing the load passing through the affected compartment can reduce pain, which, in turn, can lead to an increase in activity levels and quality of life. Off-loader braces may also slow down the rate of wear and tear in the affected side of a knee, and this can help delay (or potentially even negate completely) the need for knee replacement surgery.
My personal opinion is that the Össur Unloader One X brace is probably the best off-loader brace on the market. These braces are robust and hard-wearing, and they are designed to exert significant offloading forces on the knee and also to last for years. Therefore, they are not cheap – and a proper off-loader knee brace will normally cost somewhere in the region of £600.
For an off-loader knee brace to actually work and be effective, and for it to be comfortable and to fit properly, it is essential that the brace is sized and fitted properly, specifically to the individual patient’s knee. This means using a specialist brace-fitting service, with experts who can advise exactly what type of brace might be needed, who can size and fit the brace for the patient, and who can show the patient exactly how best to put the brace on and use it. In addition, it’s also important to have a specific named person who you can approach with any queries or concerns about your brace.
In my practice in Central London, I am very lucky to have access to an expert brace-fitting service from Mr Mike Aunger, Physiotherapist and the team at Technique Health & Fitness, and I can strongly recommend their services:
– Knee brace fitting service in London
How much will non-surgical knee treatments cost?
The costs in the table below give just a broad indication of the range of costs associated with the treatments outlined above, if accessing via healthcare privately. However, these costs can vary considerably, so it’s important that you receive a quotation before undergoing any treatment.
| Treatment | Cost range |
| Private Physiotherapy | £50 – £120 per session |
| Private Consultation with a Consultant Knee Surgeon. | £200 – £300 per ½-hour appointment |
| Steroid Knee Joint Injection | £100 |
| Knee Brace | £600 |
In summary
With NHS waiting times for knee replacement surgery getting longer, there will be a greater need for patients to consider alternative treatment options: A) to try and delay the need for surgery, B) to help them cope whilst they are waiting for surgery, and C) to ensure that they are in the best possible shape for when their knee replacement surgery does actually go ahead.
Some of the main options to help achieve this are:
- Managing pain with appropriate painkillers / anti-inflammatories, with the guidance of a GP or a Consultant Pain Specialist, where necessary.
- For some people, steroid injections into the knee joint (if/when appropriate), to provide short-term pain relief.
- Physiotherapy assessment and treatments / advice.
- Regular light non-impact cardio fitness exercises.
- Off-loader knee braces for some patients where their arthritis is only affecting one side of the joint.
For further information about the various non-surgical treatment options for managing the symptoms of knee arthritis, CLICK HERE
For information about what’s actually involved with undergoing knee replacement surgery, CLICK HERE
For advice about when to actually go ahead with knee replacement surgery, CLICK HERE
For information about top-of-the-range custom-made knee replacements, for the best possible outcomes, CLICK HERE
For more information visit https://sportsortho.co.uk/specialist/mr-ian-mcdermott/
Mr Ian McDermott, Consultant Knee Surgeon