EULAR refreshes the core non-drug playbook for hip and knee osteoarthritis
Hip and knee osteoarthritis remains one of the most common sources of chronic pain, mobility loss, and downstream disability in adults, and the 2023 EULAR update puts non-pharmacological care back at the center of management. The new recommendations do not treat exercise, education, weight control, and assistive devices as optional add-ons. They define them as core treatment elements that should shape routine care for people living with symptomatic disease in the hip or knee.
The update arrives after a long interval. EULAR’s prior recommendations for the non-pharmacological core management of hip and knee OA were published in 2013, and the evidence base expanded enough over the following decade to justify a full reassessment. A multidisciplinary Task Force of 25 members from 14 European countries reviewed the evidence, revisited the clinical questions, and translated the literature into updated guidance for everyday practice.
One sentence captures the clinical shift: OA care is no longer framed around passive advice and isolated interventions.
The updated framework centers the person, not just the joint
The revised guidance is built around two overarching principles and eight evidence-based recommendations. The first principle is an individualized, multicomponent management plan. In practical terms, that means treatment should be assembled around the patient’s symptoms, functional limits, goals, comorbidities, and daily context rather than offered as a one-size-fits-all checklist.
The second principle emphasizes that non-pharmacological care is not a temporary bridge to something more definitive. It is foundational management. For a condition driven by mechanical loading, pain sensitization, deconditioning, and weight-related joint stress, that approach is biologically coherent. The hip and knee are load-bearing joints; if the load is maladaptive, the intervention has to be too.
The evidence review covered studies published from 1 January 2012 through 27 May 2022. Investigators used EULAR’s standard operating procedures, formulated an updated search strategy around 11 research questions, and then used the retrieved evidence to refine the recommendations and build a research and education agenda. The resulting statements were not presented as abstract theory. They were intended to guide how clinicians structure care in routine musculoskeletal practice.
Exercise, education, and weight loss remain the strongest practical pillars
Three of the recommendations map directly onto the most familiar conservative tools in osteoarthritis care: information and self-management, exercise, and weight management. Education and self-management sit at the front of the pathway because patients need more than a diagnosis label. They need a clear explanation of pain mechanisms, realistic expectations, and a workable plan they can follow over months, not days.
Exercise remains central, but the wording matters. The Task Force emphasized adequate tailoring of dosage and progression. In OA, that is not a minor detail. Exercise that is too aggressive can worsen symptoms and sabotage adherence; exercise that is too timid can fail to restore function. The therapeutic target is a sustainable dose that improves strength, balance, mobility, and confidence while respecting pain and joint tolerance.
Weight management was retained as a core recommendation because excess body mass increases mechanical burden across the hip and knee while also feeding metabolic inflammation that may amplify symptoms. Even modest weight reduction can lower joint load and improve the day-to-day experience of walking, standing, and rising from a chair. For many patients, weight loss is not a cosmetic intervention. It is an analgesic and functional strategy.
Delivery, devices, and behavior change determine whether the plan works
The updated recommendations also address how care is delivered. Mode of exercise delivery matters because access, preference, severity, and available support all shape adherence. Some patients will respond best to supervised rehabilitation; others will do better with home-based programs, digital support, or a hybrid model. The recommendation reflects a basic clinical reality: an intervention that cannot be maintained will not deliver durable benefit.
Footwear, walking aids, and assistive devices also remain part of the core management toolkit. These devices can redistribute load, stabilize gait, and reduce pain during activity. In hip and knee OA, a properly fitted walking aid may be the difference between staying active and withdrawing from movement altogether. Small biomechanical changes can have a large effect on function when pain has already narrowed a patient’s mobility envelope.
Work-related advice was included as a separate recommendation, which makes sense in a condition that often affects people while they are still employed. OA symptoms can interfere with standing, lifting, walking, kneeling, climbing, and sustained sitting. Advice on pacing, task modification, and workplace adjustments can help people keep working while reducing flare burden and functional decline.
Behavior change techniques round out the list. Those techniques matter because the best recommendation in the world still fails if it never changes daily behavior. Exercise initiation, weight loss, and self-management all require sustained adherence, and adherence depends on more than information alone. Motivation, goal setting, feedback, and problem-solving all influence whether a patient actually follows the plan.
The mean level of agreement for the recommendations ranged from 9.2 to 9.8 on a 0-to-10 scale, with 10 representing total agreement. That degree of consensus suggests broad confidence across the Task Force in the clinical direction of the update.
Research gaps now sit in plain view
The research agenda is as important as the recommendations themselves because it identifies what remains uncertain in daily care. The agenda focused on adherence, uptake, and impact on work, all of which are central to whether non-pharmacological treatment succeeds outside a trial setting. Clinical efficacy is only part of the story. Real-world implementation determines whether patients benefit at scale.
Future studies will need to answer how best to increase uptake of exercise and self-management, which delivery models sustain engagement over time, and how these interventions affect employment and work capacity. Those are not side questions. They are the difference between a recommendation that exists on paper and one that changes the trajectory of chronic osteoarthritis.
For clinicians, the message is straightforward. Hip and knee OA management should begin with an individualized non-pharmacological plan that combines education, exercise, weight management when relevant, and practical supports such as assistive devices and behavior change strategies. The 2023 update strengthens the case for making those interventions routine rather than discretionary, while leaving the implementation burden squarely where it belongs: in the hands of systems that must make conservative care accessible, tailored, and sustainable.