Bone on bone, can exercise still help a hip or knee?
Being told your knee or hip is “bone on bone” can be frightening. Many people go home thinking any movement will grind the joint down faster. So they stop walking, stop going to the gym and wait for surgery.
The research points the other way. For most people with hip or knee arthritis, the right kind of exercise is safe, and it is the first treatment that international guidelines recommend.
What does “bone on bone” mean?
Inside a healthy joint, the ends of the bones are covered with smooth cartilage. In osteoarthritis, this cartilage slowly thins. On an X-ray, the gap between the bones looks smaller. When the gap looks very small, people often call it bone on bone.
The phrase describes a picture. It does not tell you how much pain you will have or what you can still do.
Why the X-ray does not tell the whole story
Studies that compare X-rays with symptoms find only a loose link between the two. Some people with badly worn joints on X-ray have little pain. Others with mild changes have a lot of pain.1
Pain in arthritis depends on many things. These include how strong the muscles around the joint are, how you move, your weight, your sleep, your mood and how confident you feel using the joint. Many of these can change, even when the X-ray does not.
Will exercise wear out my joint faster?
Joints are made to move and take load. Cartilage has no blood supply of its own. It gets its nourishment from the fluid in the joint, and movement helps that fluid flow.
The two main international guidelines for arthritis, from OARSI and EULAR, list education and exercise as core treatment for everyone with hip or knee arthritis, at every stage.2,3 In research trials, serious harm from exercise is rare.4 A day or two of extra soreness after a new exercise is common and usually settles. A good program is adjusted so these flare-ups stay mild.
What exercise can and cannot do
Exercise will not regrow cartilage or change your X-ray. On average, large reviews show that exercise improves pain and day to day function by a small to moderate amount.4,5 Some people improve a great deal and others less. The newest review on hip arthritis found the average gains were small, which is why a program should be tailored, progressed and given a fair trial.5
Stronger muscles help in other ways too. Weak thigh muscles are linked with a higher chance of knee arthritis developing in the first place.6 Strength also helps with stairs, getting out of a chair and balance.
A well known trial from Denmark looked at people who were already eligible for a knee replacement.7 One group had surgery followed by a 12 week program. The other group had only the 12 week program of exercise, education, diet advice, insoles and pain medicine. People who had surgery improved more, but they also had more serious complications. Most people in the program-only group improved and had not needed surgery by the end of the first year.
So exercise is worth a proper try, even when the X-ray looks bad. If it does not give enough relief, joint replacement remains a very good option. Read about anterior hip replacement or subvastus knee replacement with Prof Phong Tran.
What a good exercise program looks like
- It starts with an assessment. Your physiotherapist checks your strength, movement and balance, and asks what you want to get back to.
- It is made for you. Exercises are chosen for your joint, your fitness and your goals, not copied from a sheet.
- It gets harder over time. Muscles only get stronger when the work slowly increases.
- It mixes strength and fitness. Leg and hip strengthening sits alongside walking, cycling or swimming.
- It runs long enough. Most programs in the research run for around 12 weeks, and the habits need to continue after that.
- It includes learning about pain. Knowing that soreness does not mean damage makes it easier to keep going.
- It looks at weight where it helps. For knee arthritis in particular, losing some weight can ease the load on the joint.
How SOS Clinic can help
The physiotherapists at SOS Clinic in East Melbourne see people with hip and knee arthritis every day. Your first visit includes a full assessment and a plan you can start straight away.
For a clearer picture, a biomechanical profile assessment measures your strength and movement with VALD force plates, a strength testing frame and a 3D motion camera. The results show how each leg is working, and repeat tests show your progress in numbers rather than guesswork.
Myotherapy can work alongside your exercise program to ease tight, sore muscles around the joint.
If exercise stops helping, the clinic team can arrange a review with Prof Phong Tran, an orthopaedic surgeon who works from the same clinic, to talk about other options.
When to get help sooner
See a doctor promptly if your joint becomes hot, red and swollen, especially with a fever. The same applies if you suddenly cannot put weight on your leg, your knee keeps locking, or pain wakes you every night and does not settle. During opening hours, contact the clinic. After hours and on weekends, go to your nearest emergency department.
Book a physiotherapy assessment at SOS Clinic
Frequently asked questions
Should I rest when my knee or hip flares up?
A short break from the activity that set it off can help. Total rest usually makes things worse, because muscles weaken quickly. Keep moving gently, then build back up with your physiotherapist’s guidance.
Is walking good for hip or knee arthritis?
Yes, for most people. Walking keeps the joint moving and helps your general health. Start with a distance that feels comfortable and add a little each week.
Can I still exercise while I wait for a joint replacement?
Yes. Getting stronger before surgery can make recovery after surgery easier. Your physiotherapist can set up a program that suits your joint.
Do I need a referral to see a physiotherapist?
No. You can book directly. If you have a GP management plan, Medicare may cover part of the cost of a limited number of visits.
Will I definitely need a joint replacement one day?
Not always. Arthritis changes slowly in many people, and plenty manage well for years with exercise, weight care and other simple treatments. If pain and loss of function become too much, surgery is worth discussing.
References
- Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008;9:116.
- Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-89.
- Moseng T, Vliet Vlieland TPM, Battista S, Beckwée D, Boyadzhieva V, Conaghan PG, Costa D, Doherty M, Finney AG, Georgiev T, Gobbo M, Kennedy N, Kjeken I, Kroon FPB, Lohmander LS, Lund H, Mallen CD, Pavelka K, Pitsillidou IA, Rayman MP, Tveter AT, Vriezekolk JE, Wiek D, Zanoli G, Østerås N. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update. Ann Rheum Dis. 2024;83(6):730-40.
- Lawford BJ, Hall M, Hinman RS, Van der Esch M, Harmer AR, Spiers L, Kimp A, Dell’Isola A, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2024;12(12):CD004376.
- Hall M, Lawford BJ, Hinman RS, Dobson F, Spiers L, Kimp A, French HP, Reichenbach S, Hernandez-Molina G, Bennell KL. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2026;7(7):CD007912.
- Øiestad BE, Juhl CB, Eitzen I, Thorlund JB. Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis. Osteoarthritis Cartilage. 2015;23(2):171-7.
- Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-606.
