Exercise for knee and hip OA: what the evidence says

If you've been told your knee or hip pain is just "wear and tear" and there's nothing to do but wait for a replacement – that advice is outdated. And the research has been saying so for years.

Exercise-based therapy is the single most consistently recommended treatment for knee and hip osteoarthritis across every major clinical guideline in the world. Not as a last resort. Not as a nice-to-have alongside medication. As a first-line treatment – ahead of painkillers, injections, and surgery.

So why are so few Australians actually receiving it?

Every major guideline agrees: exercise comes first

It's rare to find universal agreement in healthcare. But when it comes to osteoarthritis management, the world's leading clinical bodies are remarkably aligned.

The Osteoarthritis Research Society International (OARSI), the American College of Rheumatology (ACR), the UK's National Institute for Health and Care Excellence (NICE), the European League Against Rheumatism (EULAR), and Australia's own Royal Australian College of General Practitioners (RACGP) all strongly recommend exercise as a core treatment for knee and hip OA.

A 2023 systematic review of clinical practice guidelines found that exercise was considered first-line care in every guideline that specified an order of treatment. All six guidelines that assessed exercise therapy strongly recommended it for both knee and hip OA (Osteoarthritis and Cartilage, 2023).

The OARSI guidelines specifically classify structured land-based exercise programs as a "core treatment" – meaning they're appropriate for nearly all patients, regardless of comorbidities, and safe to use alongside other interventions (Bannuru et al., Osteoarthritis Cartilage, 2019).

This isn't a niche position held by physio advocates. It's the global clinical consensus.

What the research actually shows

The evidence base behind exercise for OA is substantial. Decades of randomised controlled trials and systematic reviews have established that structured exercise programs reduce pain, improve physical function, and enhance quality of life for people with knee and hip osteoarthritis.

A 2025 overview of systematic reviews published in BMJ Open examined the breadth of evidence for exercise therapy in knee OA. The study analysed multiple systematic reviews of RCTs and confirmed that exercise therapy consistently improved knee joint function and quality of life outcomes (Kitagawa et al., BMJ Open, 2025).

A landmark individual participant data meta-analysis published in The Lancet Rheumatology in 2023 – pooling data from thousands of participants across multiple RCTs – found that therapeutic exercise improved both pain and physical function in people with knee and hip OA. Importantly, patients with worse baseline symptoms tended to benefit more, suggesting exercise is especially valuable for those who need it most (Holden et al., Lancet Rheumatology, 2023).

And here's one finding that should change how we talk about treatment: a 2024 systematic review and network meta-analysis found that exercise had comparable effects on pain and function to non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol – without the associated adverse effects. Given the well-documented gastrointestinal and cardiovascular risks of long-term NSAID use, this positions exercise as the safer, more sustainable option (OARSI Year in Review: Rehabilitation, 2024).

Why it matters for health insurers

For Australian private health funds, MSK conditions represent the largest and fastest-growing claims category. Musculoskeletal conditions cost the Australian economy over $53 billion annually (AIHW), and joint replacements have increased 132% since 1990 (GBD 2019 data).

A single knee replacement in a private hospital costs roughly $23,000. Hip replacements sit around $25,600. These procedures are often clinically necessary – but a significant proportion of patients reaching the surgical pathway have never received adequate conservative care first.

An estimated 70% of patients on surgical waiting lists have not received adequate non-surgical treatment (Wallis et al., Osteoarthritis and Cartilage Open, 2020). That's a system failure, not a patient failure.

The financial case is straightforward. If a structured exercise-based program costing a fraction of a joint replacement can delay or prevent even a small percentage of surgical claims, the return on investment is significant. But it's not just about cost avoidance. It's about giving members access to the treatment that every clinical guideline says they should be receiving first.

Digital delivery makes exercise programs scalable

One of the historical barriers to exercise-based OA care has been access. Traditional physiotherapy requires in-person appointments – often multiple times per week, over several weeks. For people in regional areas, those with mobility limitations, or anyone juggling work and family, that model doesn't always work.

This is where digital health is starting to close the gap. Two systematic reviews published in 2024 found that digitally-delivered rehabilitation – including exercise and cognitive behavioural therapy delivered via apps, websites, or telehealth – was more effective than usual care or education alone for hip and knee OA (OARSI Year in Review: Rehabilitation, 2024).

Non-inferiority trials have also begun comparing telehealth physiotherapy to in-person consultations for exercise delivery. Early results suggest that virtual delivery can achieve comparable outcomes when it's structured, clinician-led, and supported by the right technology.

That's the model Beyond The Clinic was built around. JointFit combines motion-tracked home exercise programs with telehealth support from AHPRA-registered physiotherapists – delivering the structured, evidence-based exercise therapy that guidelines recommend, in a format patients can actually stick with.

Early pilot data from Project Mobilise supports this approach: 70% of participants saw improvement in knee function, 60% reported reduced pain, and the program achieved an 87.7% opt-in rate from screening to program enrolment (BTC pilot data, 2025). These are early results, but they're consistent with the broader evidence for structured exercise programs.

Adherence is the real challenge – and it's solvable

The evidence for exercise is strong. So why don't outcomes always match what the research promises?

Adherence. Most exercise interventions work well when people do them. The challenge has always been getting patients to start and keep going.

Data from the Swedish OA Register (SOAR), which tracked nearly 20,000 people with knee or hip OA in education and exercise programs, found that only older age and higher self-efficacy were meaningfully associated with better exercise adherence – and even those factors explained just 1% of the variability (OARSI Year in Review: Rehabilitation, 2024). In other words, we can't reliably predict who will stick with a program based on demographics alone.

What we can do is design programs that make adherence easier. That means structured programs with clear milestones, real-time feedback on exercise form, clinician check-ins that keep patients accountable, and technology that meets people where they are – at home, on their schedule.

Beyond The Clinic's real-time analytics surface patient progress data directly to clinicians, flagging when someone is falling behind before they drop out entirely. It's the kind of proactive support that the research says matters most.

What this means for the MSK care pathway

The evidence isn't new. Exercise has been the recommended first-line treatment for OA for over a decade. What's new is that we finally have the technology to deliver it at scale – with the clinical oversight, outcome tracking, and accessibility that the traditional model couldn't offer.

For health insurers, that means a real opportunity to intervene upstream. Screen members for MSK risk before they need a $25,000 procedure. Offer them structured, guideline-aligned conservative care. Track outcomes in real time. And fund a pathway that the evidence already supports.

For surgeons and clinics, it means having a trusted referral pathway for the patients who aren't yet appropriate for surgery – and knowing those patients are receiving quality care in the interim.

The gap between what the guidelines recommend and what patients actually receive is one of the most expensive problems in Australian healthcare. Closing it starts with exercise. The evidence says so.

Where to from here?

• Book a demo: Talk to the BTC team – we'll walk you through the platform in 20 minutes.
• See the evidence: Clinical outcomes and pilot results

Frequently asked questions

Is exercise really better than medication for osteoarthritis?

Research suggests exercise has comparable effects on pain and function to common pain medications like NSAIDs and paracetamol, without the associated side effects. Every major OA clinical guideline recommends exercise as a first-line treatment, ahead of pharmacological options.

What type of exercise is best for knee and hip OA?

Clinical guidelines strongly recommend structured land-based exercise, including strengthening, aerobic, and flexibility training. Aquatic exercise is also recommended. The most important factor is that the program is structured, progressive, and ideally supervised by a qualified physiotherapist.

Can exercise make osteoarthritis worse?

Research consistently shows that appropriate exercise does not accelerate joint damage. In fact, movement is protective – strengthening the muscles around the joint, improving joint stability, and reducing pain. The key is that the program is tailored to the individual and supervised by a qualified health professional.

Does virtual physiotherapy work as well as in-person treatment?

Emerging evidence from non-inferiority trials suggests that telehealth-delivered exercise programs can achieve comparable outcomes to in-person physiotherapy for people with knee OA, provided the program is structured and clinician-led. Digital delivery also improves access for people in regional areas or with mobility limitations.

How long does it take to see results from an exercise program for OA?

Most clinical trials demonstrate meaningful improvements in pain and function within 6 to 12 weeks of a structured exercise program. Patients with more severe baseline symptoms tend to see greater improvements. Continued exercise is important for maintaining long-term benefits.

References

1. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27:1578–1589.
2. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72:220–233.
3. Kitagawa T, Isaji Y, Sasaki D, et al. Effectiveness of exercise therapy in patients with knee osteoarthritis: an overview of systematic reviews. BMJ Open. 2025;15(7):e093163.
4. Holden MA, Hattle M, Runhaar J, et al. Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis. Lancet Rheumatol. 2023;5:e386–e400.
5. Wallis JA, Ackerman IN, Brusco NK, et al. Barriers and enablers to uptake of a contemporary guideline-based management program for hip and knee osteoarthritis. Osteoarthr Cartil Open. 2020;2(4):100089.
6. Osteoarthritis Year in Review 2024: Rehabilitation and outcomes. Osteoarthritis and Cartilage. 2024.
7. Cross M, Smith E, Hoy DG, et al. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:1323–1330.
8. Australian Institute of Health and Welfare (AIHW). Musculoskeletal conditions and comorbidities. Canberra: AIHW.
9. Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis and Cartilage. 2023.
10. Australian Commission on Safety and Quality in Health Care. Osteoarthritis of the Knee Clinical Care Standard. 2024.