Knee Osteoarthritis: What To Do When Knee Pain Gets Worse?

Knee pain from osteoarthritis can start gradually. Perhaps your knees ache after a long walk, feel stiff after sitting for some time, or climbing stairs feels more uncomfortable than before. But what happens when the pain becomes more frequent or begins interfering with your everyday activities?

Knee osteoarthritis treatment is not one-size-fits-all. Depending on the severity of your condition, your symptoms, lifestyle and treatment goals, options can range from physiotherapy and pain management, to knee preservation procedures or knee replacement surgery.

In this special feature, our orthopaedic surgeon Dr Kelvin Tan from Gleneagles Hospital and pain management specialist Dr Yoong Chee Seng from Mount Elizabeth Novena Hospital team up to explain the different treatment options for knee osteoarthritis, and how specialists determine which may be suitable for you.

What is knee osteoarthritis?

Knee osteoarthritis occurs when the tissues within the knee joint undergo degenerative changes over time. Cartilage, which helps the bones of the knee move smoothly against each other, can become thinner and damaged, while other structures within the joint may also change.

This can result in symptoms such as:

• Knee pain during or after activity
• Stiffness, particularly after periods of inactivity
• Swelling around the knee
• Reduced range of movement
• Difficulty walking, climbing stairs or getting up from a chair
• Grinding, clicking or other sensations when moving the knee

Symptoms do not always correspond directly with the extent of changes seen on an X-ray. Doctors therefore consider how much pain and loss of function you are experiencing, not just what appears on a scan when recommending treatment.

Does knee osteoarthritis always get worse?

Not necessarily.

Osteoarthritis is often described as a progressive condition, but symptoms can fluctuate. Some people experience relatively stable symptoms for long periods, while others may notice their pain and mobility gradually worsening.

This is also why a diagnosis of knee osteoarthritis does not automatically mean that you need knee replacement surgery.

Treatment is generally tailored according to factors such as your pain, mobility, how the condition affects your daily activities and quality of life, your overall health and how you have responded to previous treatments.

How is knee osteoarthritis treated?

Treatment can broadly be thought of as a spectrum:

• Exercise, lifestyle changes and physiotherapy
• Medication and pain management
• Intra articular knee injections
• Advanced pain interventions
• Knee preservation surgery
• Partial or total knee replacement

However, not everyone progresses through these treatments in this order.

Your specialist will recommend an approach based on your individual condition rather than simply moving you from one treatment to the next.

Can knee osteoarthritis be treated without surgery?

For many people, particularly when symptoms are manageable, treatment begins without surgery.

Exercise and physiotherapy

It can be tempting to exercise less when your knee hurts, but appropriate movement remains an important part of knee osteoarthritis management.

A physiotherapist may recommend exercises to strengthen the muscles supporting your knee, improve mobility and help you remain physically active.

The type and intensity of exercise should be tailored to your symptoms and physical ability. Activities such as walking, cycling, swimming or other lower-impact exercises may be suitable for some people.

Weight management

For people who are overweight, reducing excess body weight can reduce the load placed on the knee and may improve pain and physical function.

Rather than treating weight loss as a stand-alone solution, it is generally considered alongside exercise and other approaches as part of an overall knee osteoarthritis management plan.

Medication for knee osteoarthritis pain

Medication may be used to help control pain so that you can continue with daily activities and participate in rehabilitation.

Depending on your health and symptoms, a doctor may consider treatments such as topical or oral non-steroidal anti-inflammatory drugs (NSAIDs).

These medicines are not appropriate for everyone. Your doctor will consider factors such as your age, other medications and medical conditions before recommending them.

What can a pain management specialist do for knee osteoarthritis?

Persistent knee osteoarthritis pain does not necessarily mean that surgery is the immediate next step.

A pain management specialist can assess the characteristics and possible sources of the pain, its severity, and how it affects movement, sleep and everyday activities.

This assessment may include reviewing the patient's symptoms, medical history, physical examination findings and imaging results. Because the severity of pain does not always correspond directly with the changes seen on an X-ray, clinical assessment remains an important part of determining the appropriate treatment.

Depending on the patient, treatment may include medication, injections and selected interventional pain procedures. For patients with persistent pain that has not responded adequately to conservative treatment, a pain specialist may consider nerve-targeting procedures targeting the nerves that carry pain signals from the knee.

What injections can be used for knee osteoarthritis?

When pain persists despite initial treatment, injections may sometimes be considered.

One option is an intra-articular corticosteroid injection, in which medication is delivered directly into the knee joint to help provide short-term relief of pain and inflammation. Others include hyaluronic based injections which serve to lubricate the knee as well as to reduce inflammation.

However, injections do not reverse the underlying osteoarthritis. Their role should therefore be considered as part of a broader treatment plan rather than as a cure for the condition.

What is radiofrequency treatment for knee osteoarthritis?

One such treatment is radiofrequency ablation of the genicular nerves. Genicular nerves are sensory nerves around the knee that carry pain signals from the joint. During radiofrequency treatment, targeted energy is applied to selected genicular nerves with the aim of reducing the transmission of pain signals.

Radiofrequency treatment does not repair damaged cartilage or reverse osteoarthritis. Its purpose is to reduce pain and improve function.

It may therefore be considered for selected patients with chronic knee osteoarthritis pain whose symptoms have not responded adequately to more conservative treatments. It may also be an option for some patients for whom surgery is not currently appropriate or who prefer to continue with non-surgical treatment after discussing the available options with their doctors.

Can pain management delay knee replacement surgery?

For selected patients, effective pain management may reduce symptoms and support mobility without the immediate need for knee replacement. By helping patients remain active and participate in physiotherapy, treatment may also support muscle strength, weight management and overall physical function.

These measures remain valuable if surgery is eventually required, as maintaining strength and general health may support postoperative rehabilitation and recovery.

However, reducing pain does not mean that the structural changes caused by osteoarthritis have been reversed. The goal of pain management is to provide appropriate symptom relief and help the patient maintain function and quality of life, rather than to postpone necessary surgery for as long as possible.

Treatment should therefore be reviewed over time. If pain and loss of function continue to significantly affect everyday life despite appropriate non-surgical treatment, it may be appropriate to discuss surgical options with an orthopaedic surgeon.

When might surgery be considered for knee osteoarthritis?

There is no single level of pain or X-ray finding that determines when someone should undergo knee surgery.

An orthopaedic surgeon may consider factors including:

• How severe and persistent your pain is
• Whether pain affects sleep or everyday activities
• How far you can comfortably walk
• Whether you have difficulty using stairs or getting up from a chair
• The location and extent of damage within your knee
• Whether the knee has become misaligned or unstable
• Your age and activity level
• Your overall health
• Whether appropriate non-surgical treatments are still helping
• Your personal goals and expectations

Surgery also does not necessarily mean replacing the entire knee.

For selected patients, there may be opportunities to preserve more of the natural knee joint.

What is knee preservation surgery?

Knee preservation refers to treatments intended to preserve the patient's natural knee joint for as long as appropriately possible.

Rather than replacing the entire joint, the surgeon identifies the particular problem contributing to symptoms and determines whether it can be addressed while retaining the existing knee.

Depending on the patient's condition, knee preservation approaches may include procedures that address cartilage damage, meniscus problems, ligament instability or abnormal alignment of the knee.

Who may be suitable for knee preservation surgery?

Knee preservation is generally more relevant when damage is localised and there are parts of the knee joint that remain suitable for preservation.

For example, a relatively active patient with arthritis concentrated in one part of the knee and an underlying alignment problem may have very different treatment options from someone with advanced osteoarthritis affecting several areas of the joint.

Procedures such as an osteotomy can, in selected patients, change the alignment of the leg so that load is redistributed away from the more damaged part of the knee.

Other joint-preserving procedures may be considered where cartilage, meniscal or ligament problems are contributing to symptoms, in the form of cartilage repair procedures, meniscus repair and/or ligament reconstructive procedures.

However, knee preservation is not suitable for every person with osteoarthritis. Where joint damage is extensive, knee replacement may provide a more appropriate option.

When is knee replacement recommended for osteoarthritis?

Knee replacement may be considered when osteoarthritis causes persistent pain, stiffness and loss of function that substantially affect quality of life and appropriate non-surgical treatments are no longer providing sufficient relief.

During knee replacement surgery, damaged joint surfaces are replaced with artificial components designed to restore a smoother moving joint.

The goal is not simply to treat what appears on an X-ray. It is to reduce pain and improve function in appropriately selected patients whose symptoms are significantly affecting their lives.

Depending on where the arthritis is located, your surgeon may discuss either a partial or total knee replacement.

Partial knee replacement

The knee can broadly be divided into different compartments. If osteoarthritis is confined to one compartment and the remaining parts of the knee are suitable, some patients may be candidates for partial knee replacement.

Only the affected portion of the joint is replaced, preserving all the native ligaments and other unaffected compartments, therefore allowing more of the patient's natural knee structures to be retained.

Total knee replacement

When osteoarthritis is more extensive and affects multiple areas of the knee, total knee replacement may be considered.

During the procedure, damaged joint surfaces at the ends of the thigh bone and shin bone are replaced with prosthetic components, with treatment of the kneecap considered where appropriate.

Knee preservation or knee replacement: how do doctors decide?

There is no universal "best" operation for knee osteoarthritis.

The appropriate treatment depends on what is happening inside your knee and how it is affecting you.

A younger or active patient with localised disease and correctable alignment may potentially be considered for a joint-preserving procedure.

Someone with advanced osteoarthritis across several parts of the knee, persistent pain and significant difficulty with everyday activities may be better suited to knee replacement.

And another person with similar X-rays but manageable symptoms may not need surgery at all.

This is why treatment decisions are based on the individual rather than an X-ray alone.

What can help with recovery after knee replacement?

An Enhanced Recovery After Surgery (ERAS) approach may be used to support recovery after knee replacement. It combines measures such as pain management, early mobilisation and physiotherapy to help patients regain movement and function safely after surgery.

Learn more about Enhanced Recovery After Surgery (ERAS) for knee replacement here.

When should you see a specialist about knee osteoarthritis?

Consider seeking an orthopaedic surgeon's advice if knee pain:

• Persists or repeatedly returns
• Is becoming progressively worse
• Causes significant swelling or stiffness
• Makes walking or climbing stairs increasingly difficult
• Affects sleep
• Limits work, exercise or activities you enjoy
• Is no longer adequately controlled by your existing treatment

You do not have to wait until your knee pain becomes unbearable before having it assessed.

Understanding the cause and severity of your symptoms earlier can help you discuss the range of appropriate options, whether that means exercise and pain management, a knee-preserving approach or, when appropriate, knee replacement surgery.