What is the best treatment for osteoarthritis?

If you've ever had a patient come in after being told their knee is "bone on bone," you know the look. They're worries. They've already decided there's nothing that can be done. They're just waiting to hear when they need a replacement.

In this episode of the Rehab and Performance Lab podcast, I sat down with Dr. Christopher Bise, PT, DPT, PhD, Associate Professor at the University of Pittsburgh, to talk about what the research actually says about osteoarthritis – and why the conversation we're having with patients may be doing more harm than the diagnosis itself. 

OA Is Not Wear and Tear – This Matters More Than You Think     

For years, osteoarthritis has been discussed as a wear-and-tear phenomenon – the idea that the more you use your joints, the more they break down. This is wrong, and the research is pretty clear on this. The evidence points to low-grade chronic synovial inflammation as the primary driver of OA – not the progressive cartilage breakdown we've been blaming.

Dr. Bise used a phrase I love for this: the inflammatory reframe. OA isn't a structural failure that snowballs from overuse. It's more of a metabolic cascade – one that's influenced by inflammation, inactivity, weight, and yes, the language we use with patients.

OA is a sign of aging, not damage. And unlike gray hair, we can actually do something about it.

Why does this matter clinically? Because pain does not correlate with structural severity. One patient with bone-on-bone contact on imaging might report a 2 out of 10 pain level. Another with the same X-ray might be at an 8. The structural findings do not dictate the experience. If we treat the image rather than the patient, we are going to miss the mark every time.

 

 

 

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The Real Problem with "Bone on Bone"

The phrase "bone on bone" doesn't just describe a finding – it starts a cascade. And I don't mean a biological one.

When patients hear that language, they begin to believe their joints are a finite resource. They think: If I'm already wearing them out, I need to use them less. Save what I have. So they stop walking. They stop going to the gym. They back off activities they love. And with every step down in activity, the OA cycle gets worse – not better.

Less movement → muscle weakness → gait changes → more inflammation → more pain → even less movement.

Dr. Bise described this as a biopsychosocial cascade. The fearful language we use – wear and tear, bone on bone – doesn't just misinform patients. It initiates kinesiophobia, a fear of movement that becomes one of the biggest barriers to recovery.

As rehab professionals, we are positioned to stop that cycle before it solidifies. But only if we're intentional about the language we choose.

Interventions That Work – and Those That Don't

Here is what the research says about the most common OA interventions:

Weight Loss                    

The ACR guidelines give weight loss a strong recommendation, and for good reason. There is clear dose-response data: meaningful benefits begin at 5% body weight loss, increase at 10%, and continue beyond that. If we're not having the weight conversation, we're leaving a significant intervention on the table.

Exercise

This is non-negotiable. Exercise is the most strongly supported intervention we have for OA at every joint. Every major guideline, every joint, supports exercise as a first-line intervention – not as an adjunct, but as the primary treatment. Progressive strengthening, aerobic conditioning, Tai Chi, yoga, walking – all have strong or conditional recommendations. Build your session structure, your home program, and your patient communication around this. Everything else is secondary.

I also want to be clear about a myth: heavy, high-intensity exercise has not been shown to accelerate OA progression. Exercise is better than no exercise. The goal isn't to coddle the joint. It's to progressively load it, restore strength, and rebuild confidence in movement.

Manual Therapy                    

The 2019 ACR guideline moved manual therapy from a conditional recommendation for to a conditional recommendation against – a reversal from 2012. Manual therapy is not harmful. The safety data is very reassuring. But the efficacy evidence at the population level was judged to be insufficient.

That said, this does not mean throwing out the baby with the bathwater. The research suggests there are subgroups who respond well to manual therapy. And what makes the biggest difference is where you apply it. A landmark study took a pragmatic approach – identifying range of motion deficits at the hip, knee, foot, ankle, and even low back, then intervening at whatever level the impairment was found. That approach was substantially more effective than simply applying manual therapy to the knee. Having a systematic approach the identify impairments that are increasing the stress on the knee is essential.

The takeaway: manual therapy to the OA joint may not be helpful. Manual therapy to address biomechanical deficits contributing to abnormal joint loading – that's a different conversation entirely.

Glucosamine, Chondroitin, and Hyaluronic Acid                    

Strong recommendations against. The research base supporting these supplements largely consists of poorly designed studies with small sample sizes and flawed methodology. They are not harmful – but they are most likely not doing what patients (and clinicians) think they are. 

TENS

Same category. The evidence does not support it for OA management. If you're spending treatment time on TENS, you're spending time that could go toward exercise.

If you want the full clinical detail and the case-by-case breakdowns, listen to the complete episode on the Rehab and Performance Lab Podcast.

You can listen to the episode at the links below. If you'd like CEUs, make sure to use the MedBridge link.