Update: Recommendations for hip and knee osteoarthritis

This is the lay version of the EULAR recommendations for managing osteoarthritis in the hip or knee using  non-drug management options. The original publication can be downloaded from the EULAR website:  www.eular.org. 

Moseng T, Vliet Vlieland TPM, Battista S, et alEULAR recommendations for the non-pharmacological core  management of hip and knee osteoarthritis: 2023 updateAnnals of the Rheumatic Diseases Published  Online First: 11 January 2024. doi: 10.1136/ard-2023-225041 

EULAR – the European Alliance of Associations for Rheumatology – gives advice to health professionals  such as doctors, nurses, physiotherapists, occupational therapists, and patients about the best way to treat  and manage diseases. In 2023, EULAR produced new recommendations focused on non-drug approaches  to help people with osteoarthritis in their hips or knees.  

Doctors, nurses, other health professionals, and patients worked together to develop this new advice. The  patients in the team ensured that the patient point of view was included.  

What do we already know?
Osteoarthritis is very common. Around 11% of adults have osteoarthritis in their hips, and 24% have it in their  knees. Osteoarthritis is age related, and usually starts to affect people in middle age. Osteoarthritis is the  most common cause of disability for elderly people, resulting in pain and limited mobility and participation.  

Recommendations for managing osteoarthritis are divided into those looking at drug therapies, non-drug  treatments, and surgery. Since there is no cure for osteoarthritis, non-drug management options are a core  treatment. These approaches aim to relieve symptoms and improve or maintain physical function. 

EULAR first wrote recommendations focusing on non-drug options for people with osteoarthritis in their hips  or knees in 2013. This new update takes into account new evidence that has been collected since then.  

What do the recommendations say?
In total, there are two overarching principles and eight recommendations. The principles say that in people  with osteoarthritis in their hips or knees, the initial assessment should use a biopsychosocial approach to  consider physical and psychological status, activities of daily living, participation including work, social  determinants and environmental factors. They also stress that treatment should be based on shared  decision-making considering the needs, preferences, and capabilities of each individual person. 

Each recommendation is based on the best current knowledge from studies of scientific evidence or expert  opinion. The more stars a recommendation has the stronger the evidence is. However, recommendations  with limited scientific evidence may be important, because the experts can have a strong opinion even when  the published evidence may be lacking. 

One star (*) means it is a recommendation with limited scientific evidence.  

Two stars (**) means it is a recommendation with some scientific evidence. 

Three stars (***) means it is a recommendation with quite a lot of scientific evidence. Four stars (****) means  it is a recommendation supported with a lot of scientific evidence.


  • If you have hip or knee osteoarthritis you should be offered a multicomponent management plan  including recommended non-drug approaches that are tailored to you. **** Evidence shows that combining different non-drug approaches has a larger effect on pain and function  compared with providing each separately. This means it is a good idea to combine different approaches,  such as education, exercise, and lifestyle changes. The exact plan should be tailored to you and your  personal needs, but it will likely include more than one component.

  • People should be offered information, education, and advice on self-management strategies. ****
    Self-management is a way of helping you to cope with the everyday effects of your disease. The advice  you are given should consider only strategies which are available to you, and appropriate for your own  personal circumstances. This information should be reinforced at subsequent clinical appointments, so  you may find that your healthcare team repeats some advice to you.

  • Everyone with hip or knee osteoarthritis should be offered an adequate exercise programme,  tailored to their physical function, preferences, and available services. ****
    The right programme for you might include exercises focused on building strength, aerobic capacity,  flexibility, or maintaining neuromotor function. This will depend on how your osteoarthritis affects you,  and what your personal preferences and goals are – as well as what services are available where you  live.

  • How exercise programmes are delivered will depend on local availability and your personal preferences, but they should be embedded in an individual plan for physical activity. ****
    Exercises could include individual or group sessions. These might be supervised or unsupervised, face to-face, or by using digital technology. Some people might do well with land-based programmes, whilst  others prefer water-based exercise. This will depend on your personal preferences and goals, as well as  what services are available where you live. But this should form part of a personalised plan to help you  maintain the right level of physical activity.

  • You should be offered education on the importance of maintaining a healthy weight. ****
    Your weight has an impact on your joints. If you have overweight or obesity you should be offered  support to help you achieve and maintain weight loss.

  • Some people might need to consider walking aids, appropriate footwear, assistive devices, and  adaptations at home and at work to reduce pain and increase participation. ****
    You might find it useful to use some assistive devices. This will vary from person to person, but some  individuals find the right devices can help reduce pain and improve participation at home and at work.  These might be ways to help you get dressed, height-adjustable chair, raised toilet seats, handrails in  staircases, or the use of appropriate walking aids. Other people get benefits from special insoles in their  shoes. There is no one-size-fits- all approach, so work with your healthcare team to find the most  suitable solutions for you.

  • People with or at risk of work disability should be offered timely advice on modifiable work related factors and, where appropriate, referral for expert advice. *
    Osteoarthritis is one of the leading causes of reduced work participation. You might find your disease  results in sick days, and it might affect your career progression. Your healthcare team should assess  your work situation and make recommendations for how you can adapt your workplace to better suit  your abilities. This might mean working from home, using a height-adjustable desk or chairs, and/or using assistive technology for your tasks.

  • When lifestyle changes are recommended, your healthcare team might consider using behaviour  change techniques. ****
    It can be hard to make lifestyle changes, such as taking regular physical activity and losing weight. To  help support you in making these changes, your healthcare team might use some techniques to help  you identify and change certain behaviours. This might include ways to cope with and manage pain, or  counselling to support exercise and weight-loss efforts.

Overall, these recommendations give guidance to health professionals and patients about managing hip and  knee osteoarthritis with non-drug management approaches. You should work with your healthcare team to  make informed decisions about your disease and its non-drug management, and you will need to be an  active part of the solution to help relieve symptoms and improve or maintain your physical function.  

Recommendations with just one or two stars are based mainly on expert opinion and not backed up by  studies, but these may be as important as those with three or four stars. 

If you have any questions or concerns about your disease or your medication, you should speak to a health  professional involved in your care.