The right treatment depends on your stage

"You may need a knee replacement" is a frightening phrase, but replacement is rarely the first answer. Which alternative will work depends mainly on how advanced your arthritis is, along with your age, alignment and activity level.

Knee osteoarthritis is very common in India: about 28.7% of adults in a five-site community study (Pal et al., 2016), and nearly half of people over 60 in a 2025 meta-analysis (Daniel et al., 2025). Women, people who are overweight and those with sedentary work are at higher risk. Deep squatting, floor sitting and squatting toilets add extra load.

The four stages of knee arthritis

Surgeons grade arthritis on X-ray using the Kellgren–Lawrence (KL) scale, combined with your symptoms:

Stage	X-ray findings	Typical symptoms
KL 1: Doubtful	Possible small bone spurs; joint space normal	Occasional ache after heavy activity
KL 2: Mild	Definite bone spurs; joint space possibly narrowed	Pain after activity, mild stiffness
KL 3: Moderate	Several bone spurs; definite narrowing; some bone hardening	Regular pain, stiffness, reduced walking distance
KL 4: Severe	Large spurs; marked narrowing or bone-on-bone; deformity	Constant pain, night pain, deformity, difficulty with daily tasks

X-ray stage and pain do not always match, so your symptoms and examination matter as much as the image. It also matters where the wear is: whether it is in one part of the knee (one compartment) or throughout, and whether the leg is bowed.

Which treatment for which stage

✔ = appropriate · ○ = selected cases · ✖ = not appropriate or not effective

Treatment	KL 1–2 (doubtful–mild)	KL 3 (moderate)	KL 4 (severe)	Evidence strength
Exercise and physiotherapy	✔	✔	✔ (for symptoms and before surgery)	Strong
Weight loss (if overweight)	✔	✔	✔	Strong
Activity changes (chairs, western toilet, low-impact exercise)	✔	✔	✔	Common sense, low risk
Pain medicines (topical or oral NSAIDs, paracetamol)	✔	✔	✔ (short term)	Strong for NSAIDs
Unloader brace or insoles	○	○ (one-sided arthritis)	○	Limited
Steroid injection	○ (flare-ups)	✔ (flare-ups)	○ (short-term relief)	Short-term benefit
PRP injection	○	○	✖	Limited; best in early stages
Hyaluronic acid injection	○	○	✖	Not recommended for routine use
Glucosamine, chondroitin	✖	✖	✖	No proven benefit
Stem cell injections	Experimental	Experimental	✖	Insufficient
Genicular nerve radiofrequency ablation	○	○	○ (unfit for surgery)	Limited
Genicular artery embolization	○ (trials)	○ (trials)	✖	Conflicting
Arthroscopic clean-out (lavage, debridement)	✖	✖	✖	Not recommended
Arthroscopy for a true mechanical block (displaced tear)	○	○	✖	For specific problems only
High tibial osteotomy (bowed leg, inner-side arthritis)	○	✔	○ (selected younger patients)	Good in selected patients
Partial (unicompartmental) replacement	✖	✔ (one compartment)	✔ (one compartment)	Strong (TOPKAT trial)
Total knee replacement	✖	○	✔	Strong

The sections below explain each option and the evidence behind it.

Non-surgical treatment: the foundation at every stage

The 2021 American Academy of Orthopaedic Surgeons (AAOS) guideline is the main evidence reference for non-surgical knee arthritis care (AAOS, 2021).

Proven and recommended

Exercise and physiotherapy: strengthening the thigh and hip muscles and improving balance reduces pain and improves function at every stage. It is the cornerstone of all treatment.
Weight loss: for overweight patients, losing weight is one of the most effective treatments and costs nothing.
Anti-inflammatory medicines: topical gels are recommended and are safer than tablets; oral NSAIDs help flare-ups but need medical supervision, especially with kidney, stomach or heart problems.
Lifestyle changes: chairs instead of floor sitting, a western toilet, handrails on stairs, and swimming, cycling or walking instead of running or jumping.

Not proven

Glucosamine and chondroitin: the AAOS has long recommended against them, and the 2021 guideline found that more evidence is needed for any supplement, including turmeric and ginger.

Injections: what each can and cannot do

Injection	Best stage	What to expect	Evidence
Corticosteroid	Any stage, for flare-ups	Quick relief lasting weeks to a few months	Short-term benefit; not for repeated long-term use
Platelet-rich plasma (PRP)	Early to moderate (KL 1–3)	Some patients get relief for several months	The AAOS says PRP may reduce pain and improve function (limited evidence)
Hyaluronic acid	Early to moderate	Variable	The AAOS does not recommend it for routine use
Stem cells and other "regenerative" injections	Experimental	Not proven to regrow cartilage	Insufficient evidence; be wary of clinics promising cartilage regrowth or guaranteed results

No injection rebuilds lost cartilage. Injections are best used to control pain so that you can exercise and stay active.

Newer procedures: promising but not yet proven

Genicular artery embolization (GAE)

A radiologist passes a fine catheter through a blood vessel and blocks the small, abnormal arteries that feed the inflamed knee lining. It is aimed at mild to moderate arthritis that has not responded to conservative care.

What the trials show: results are conflicting. A small US trial found more pain relief than a sham procedure (J Vasc Interv Radiol, 2022). However, two larger sham-controlled trials found that GAE gave similar pain relief to the sham, with both groups improving (van Zadelhoff et al., 2024; Landers et al., 2023). Until larger trials report, GAE is best considered within research settings or for carefully selected patients.

Genicular nerve block and radiofrequency ablation (RFA)

The small sensory nerves around the knee are numbed (block) or heated (ablation) to interrupt pain signals. The AAOS says denervation therapy may reduce pain and improve function (limited evidence) (AAOS, 2021). Relief is temporary because nerves regrow, so it suits patients who cannot have, or want to delay, surgery.

Joint-preserving surgery

Knee arthroscopy: only for specific problems

Keyhole "clean-out" (lavage and debridement) for arthritis does not help, and the AAOS recommends against it (AAOS, 2021). Trimming degenerative meniscus tears also works no better than physiotherapy in arthritic knees. Arthroscopy is useful only for a true mechanical problem, such as a displaced tear locking the knee or a loose body, or for focal cartilage repair in younger patients.

High tibial osteotomy (HTO): realigning a bowed leg

In bow-legged knees with arthritis mainly on the inner side, the shin bone is cut and realigned to shift weight onto the healthier outer side.

Best for: active patients, typically under about 55, with arthritis mainly on the inner (medial) side, a bowed leg, stable ligaments and a healthy weight
How long it lasts: in a 20-year study, HTO survived (no conversion to replacement) in 77% of patients at 10 years and 44% at 20 years; in ideal candidates (under 55, BMI under 30), 97% survived at 10 years (Sundaraj et al., AAOS 2024). Results are less durable in older patients, women and those with advanced arthritis (Clement et al., 2018).
Value: keeps your own knee and can delay a replacement by a decade or more.

Partial (unicompartmental) knee replacement

When arthritis is advanced but limited to one compartment, only that part is resurfaced, keeping the ligaments and healthy parts of the knee.

What the evidence shows: the TOPKAT trial randomised 528 patients to partial or total replacement. At 5 years, outcomes, re-operations and complications were similar, and partial replacement was cheaper and more cost-effective (Beard et al., 2019). At 10 years, results remained similar, with partial replacement slightly ahead on complications and quality of life (TOPKAT 10-year).
Best for: advanced arthritis in one compartment with intact ligaments; the surgeon's experience with the procedure matters.

Cartilage repair and meniscus procedures

Cartilage repair techniques and meniscus transplantation suit younger patients with a focal cartilage defect or a missing meniscus in an otherwise healthy, well-aligned knee. They are not treatments for widespread arthritis.

When total knee replacement is the right choice

Chasing alternatives for too long can mean years of avoidable pain and loss of fitness. A total knee replacement is usually the right decision when:

Arthritis is severe (KL 4) or affects the whole joint, not just one compartment
Pain is constant, disturbs sleep and limits daily life despite several months of proper non-surgical treatment
There is significant deformity or instability
Your independence and quality of life are clearly suffering

At this stage, injections and newer procedures give only short-lived relief, while a well-timed replacement reliably relieves pain and restores function. Our article on when to have a knee replacement explains how to judge the timing.

Frequently asked questions

Can I avoid knee replacement completely? Many people with mild to moderate arthritis (KL 1–3) can delay or avoid it with exercise, weight loss, medicines and, in selected cases, osteotomy or partial replacement. In severe, whole-knee arthritis, total replacement usually gives the best long-term result.

Is PRP effective for knee arthritis? PRP may reduce pain in early to moderate arthritis, but the evidence is limited and it does not regrow cartilage. It is not useful in severe, bone-on-bone arthritis.

Are stem cell injections proven? No. They remain experimental, and there is no reliable evidence that they regrow cartilage. Be cautious of clinics that promise guaranteed results.

Does genicular artery embolization work? The evidence is conflicting: some trials found benefit, while two sham-controlled trials found no difference from a placebo procedure. It is not yet a standard treatment.

Will a keyhole "wash-out" help my arthritis? No. Arthroscopic lavage or debridement for arthritis is not recommended, because trials show it does not help.

Do glucosamine supplements help? They have not been shown to help, and guidelines do not recommend them.

Who is suited to high tibial osteotomy? Active patients, usually under about 55, with arthritis mainly on the inner side of a bow-legged knee and stable ligaments.

Partial or total knee replacement? If advanced arthritis affects only one compartment and the ligaments are healthy, a partial replacement gives results similar to a total replacement, with a quicker recovery and a more natural-feeling knee.

The bottom line

In early and moderate arthritis, exercise, weight loss and sensible use of medicines are the proven foundations; steroid and PRP injections can help control pain. Hyaluronic acid, glucosamine and arthroscopic wash-outs are not recommended, and stem cells and embolization remain unproven. For arthritis in one part of the knee, osteotomy or partial replacement can preserve much of your own joint. In severe, whole-knee arthritis, a total knee replacement is often the most reliable way back to a pain-free life.

For an honest assessment of which option suits your knee, book a consultation with Dr Naveen Kumar L V and the team at Sports Orthopedics Institute, HSR Layout, Bengaluru.

This article is for general information and does not replace a personal consultation with a qualified orthopedic surgeon.

References

Pal CP, et al. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop. 2016;50(5):518–522.
Daniel RA, et al. Prevalence of knee osteoarthritis among elderly persons in India: a systematic review and meta-analysis. J Family Med Prim Care. 2025.
American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty): Clinical Practice Guideline, 3rd edition. 2021.
AAOS knee osteoarthritis guideline summary, 2nd edition. Am Fam Physician. 2014.
Multicenter randomized sham-controlled study of genicular artery embolization for knee pain secondary to osteoarthritis. J Vasc Interv Radiol. 2022;33(1):2–10.
van Zadelhoff TA, et al. Genicular artery embolisation versus sham embolisation for symptomatic osteoarthritis of the knee: a randomised controlled trial. BMJ Open. 2024;14(10):e087047.
Landers S, et al. Genicular artery embolization for early-stage knee osteoarthritis: results from a triple-blind randomized controlled trial. Bone Jt Open. 2023;4(3):158–167.
Sundaraj K, et al. High tibial osteotomy delays progression to knee replacement by 10 years: a prospective 20-year outcome study. AAOS 2024.
Clement ND, et al. Survival and functional outcome of high tibial osteotomy for medial knee osteoarthritis: a 10–20-year cohort study. Eur J Orthop Surg Traumatol. 2018;28:1381–1389.
Beard DJ, et al. The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes. Lancet. 2019;394:746–756.
Beard DJ, et al. TOPKAT: 10-year follow-up. Lancet Rheumatol. 2025.

Not Ready for a Knee Replacement? Evidence-Based Alternatives Matched to Your Stage of Arthritis