Non-Surgical Arthritis Treatment: Physio, Drugs, Injections

Non-surgical treatment of arthritis rests on four tools: weight loss and diet, physiotherapy to strengthen the muscles around the joint, walking aids to unload it, and medicines or joint injections to control pain. These measures relieve symptoms, but they do not restore lost cartilage. Joint injections in particular work best while the joint space on X-ray is still preserved, which is why early diagnosis matters.

Dr. Mannu Bhatia, Associate Director - Centre for Orthopaedics, BLK-Max Super Speciality Hospital, New Delhi, India, structured this part of his masterclass as a sequence rather than a menu, with surgery reserved for patients in whom conservative care has failed, and he stressed that its success depends on the patient following the plan. How arthritis is recognised and diagnosed, and how the X-ray guides this choice, is set out in the complete guide to joint arthritis diagnosis and management.

Treatment without medication comes first

Dr. Bhatia begins with what can be done without giving the patient any medicine at all. Three measures make up this first rung: weight loss with a better diet, physical therapy, and unloading the joint with a walking aid.

Weight loss and diet

People who are obese have a higher tendency to develop arthritis, and every kilogram the knee or hip carries is loaded through damaged cartilage with each step. Dr. Bhatia's first recommendation is therefore always weight loss.

His dietary advice is specific. He recommends a balanced diet that is higher in protein and lower in fat and carbohydrates, and he advises patients to avoid carbohydrate-heavy foods, confectionery and pastries. He also advises them to avoid dairy products. International osteoarthritis guidelines centre their dietary advice on weight loss itself rather than on excluding particular food groups; the American College of Rheumatology's 2019 guideline recommends weight loss for overweight patients with knee or hip osteoarthritis, with greater benefit as the loss reaches 5 per cent of body weight or more.

Physiotherapy and strengthening

The second measure is physical therapy. Its purpose is to strengthen the muscles around the joint, particularly through knee exercises, so that strong muscles share the load and balance the problem the damaged joint creates. Exercise is one of the most strongly supported treatments for osteoarthritis in every major guideline, and it costs the patient little beyond time and discipline.

Physiotherapy also has a defined role in Dr. Bhatia's injection strategy, described below: the aim of an injection is to let the patient stop daily painkillers and continue with exercises alone.

Walking aids to unload the joint

The third measure is mechanical. A patient with an arthritic joint who cannot walk comfortably should use a walker, a walking stick, a cane or crutches. The aim is to take load off the joint so that the inflammation settles down.

Dr. Bhatia applies the same logic to people who have fallen and are limping without having arthritis. They are told to rest, but rest in real life still means getting to the washroom and managing daily routines. A walker or cane lets them do that without loading the painful joint. The American College of Rheumatology strongly recommends a cane for patients with knee or hip osteoarthritis whose disease affects their ability to walk.

Arthritis medicines: what they can and cannot do

The second rung is pharmacological. Dr. Bhatia lists the main options:

• Painkillers, such as paracetamol.
• Non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac.
• Steroids, used in some cases.
• Disease-modifying anti-rheumatic drugs (DMARDs), for rheumatoid arthritis.
• Topical preparations: gels, ointments and sprays applied over the joint.

His summary of the whole group is direct. These medicines reduce or remove the symptoms. They do not cure the disease. A patient who takes painkillers for years without addressing weight, muscle strength and the stage of the joint will be treated for pain while the arthritis continues to progress.

Why NSAIDs should not be taken continuously

Asked during the session which NSAID is best for osteoarthritis, Dr. Bhatia answered that he would not advise taking NSAIDs continuously, because they have a harmful effect on the kidneys. They have a place for short periods.

The established guidance is consistent with that caution. Oral NSAIDs carry risks to the kidneys, the stomach and the cardiovascular system, which rise with dose and duration, so they are used at the lowest effective dose for the shortest necessary time. For knee osteoarthritis, topical NSAIDs are recommended before oral ones because far less of the drug reaches the bloodstream.

Rheumatoid arthritis is different

The DMARDs on his list mark an important distinction. Osteoarthritis medicines treat symptoms; in rheumatoid arthritis, disease-modifying drugs act on the immune process that destroys the joint, and they need to be continued. Dr. Bhatia was emphatic that a patient who has been prescribed treatment for rheumatoid arthritis should take it and should not stop it. Stopping treatment for an autoimmune arthritis does not simply bring the pain back; it allows joint damage to continue.

Joint injections: steroids, hyaluronic acid and PRP

The third rung is injection into the joint (intra-articular injection). Three types were discussed: corticosteroids, hyaluronic acid and platelet-rich plasma (PRP).

Steroid and hyaluronic acid injections

Hyaluronic acid is a natural component of joint fluid, injected to supplement the joint's lubrication; corticosteroids are injected to suppress inflammation inside the joint.

Dr. Bhatia reports good results from both, with one condition that he repeated for emphasis: the joint space must still be maintained. The ideal candidate is a patient whose X-ray shows a preserved joint space but who still has pain. The objective of the injection is specific. Dr. Bhatia wants the patient off oral medicines and managing with exercises alone, and injections of steroid or hyaluronic acid are the bridge that allows the patient to stop daily painkillers.

Guideline bodies weigh the two injections differently. The American College of Rheumatology's 2019 guideline recommends intra-articular corticosteroid injection for knee and hip osteoarthritis, and conditionally recommends against hyaluronic acid injection for the knee, so practice on hyaluronic acid varies between specialists.

Both remain, in his words, ways of treating the symptoms. Neither changes the underlying cartilage loss.

Does PRP work for arthritis?

Dr. Bhatia is not an advocate of PRP. His reasoning is mechanical: when the joint surface and the cartilage are already gone, PRP cannot regenerate them. He is explicit that this is his personal view, and that he believes in treatments whose result he can deliver. A patient should leave treatment able to do something he could not do before, not with a promise that may not materialise.

One question during the session illustrated the point. A participant described a patient with intermittent elbow pain who had been treated with oral and topical NSAIDs and then PRP injections, and asked what outcome to expect from the PRP. Dr. Bhatia's answer was that he would want to see the patient's X-rays, and an MRI if needed, before deciding what should actually be done. The imaging, not the injection, should drive the decision.

His position is consistent with the major guideline: the American College of Rheumatology's 2019 osteoarthritis guideline strongly recommends against PRP injections.

Stem cell therapy and other emerging options

Stem cell therapy, which is said to regenerate cartilage, is not supported by current guidelines: the American College of Rheumatology's 2019 guideline strongly recommends against stem cell injections for osteoarthritis, citing a lack of standardised preparations and evidence. Dr. Bhatia closed his treatment section with stem cells and one other area still developing.

That second area, customised 3D-printed implants, belongs to the surgical end of the ladder and is covered in joint replacement of the hip, knee, shoulder and elbow.

When non-surgical arthritis treatment has run its course

The non-surgical ladder has a clear endpoint. In Dr. Bhatia's framework, the definitive treatment is considered when the patient has failed conservative management, whether medicines, injections or physiotherapy, and his life is being affected.

Three signals point to that stage:

1. Rest pain. Pain that continues when the patient is lying down or not walking means the disease has moved beyond the activity-related pain of early arthritis, and the patient needs a specialist.
2. Loss of joint space on X-ray. Dr. Bhatia reports good results from injections where the joint space is maintained. Once the cartilage is gone and bone is rubbing on bone, they have little left to work with.
3. Loss of daily function. Difficulty standing up from a chair, walking, standing for long or managing basic self-care despite treatment.

The X-ray, again, is the deciding test. In Dr. Bhatia's practice it is the X-ray that tells the surgeon whether a patient needs surgery or can continue to be managed with medicines and physiotherapy.

The patient's role in conservative care

Every tool on this ladder depends on the patient. Weight loss, diet and exercise are the patient's work, and medicines prescribed for rheumatoid arthritis only help if they are taken without interruption. The patient Dr. Bhatia described as progressing to osteoarthritis and eventually needing a replacement is one who was advised an investigation, a treatment or an operation at the right time and did not follow through.

His message to patients is therefore not to sit at home with a painful joint, to see a doctor at an early stage, to change the lifestyle, and not to lose heart: with the right treatment protocol, even a patient who is severely limited can regain function.

For a different emphasis on conservative care before surgery, including the grading of osteoarthritis, see Dr. Ramkinkar Jha's article on osteoarthritis diagnosis and treatment before replacement. The physiotherapy costs that international patients can expect are summarised on the physiotherapy and rehabilitation cost page, and more orthopaedic content is collected on the orthopaedics specialty page.