If you take up exercise later in life, as a treatment for joint or hip pain, you should expect a small, temporary increase in pain. But if you proceed sensibly, you will be rewarded with pain relief similar to that of a non-steroidal anti-inflammatory drug, such as ibuprofen, and twice that of a non-prescription painkiller, such as paracetamol. In fact, the pain relief from taking up exercise is large enough that many people put their knee or hip surgery on hold.

Physical activity is important for good health and is prescribed by doctors to treat a range of diseases, including diabetes and cardiovascular disease. But many people don’t follow this advice because of aching joints and the fear that exercise may harm these joints.

Paradoxically, the last 20 years of research has found that exercise is a good pain reliever. Today, exercise is recommended worldwide as a treatment for painful joints in middle-aged and older people. However, recommending is one thing. Putting this recommendation into practice is something else altogether.

Most people experience a 10% pain increase when they start to exercise – some experience more, others less. This is not a warning sign but the body signalling that you are doing something you are not used to. Our bodies, including bone, muscle and cartilage are great at adapting and their quality improves when we exercise.

How much pain relief you will get depends on how much exercise you do. In our study of 10,000 people with knee and hip osteoarthritis, we found that people who exercised twice a week for six weeks experienced 25% pain relief, on average.

Earlier research also shows that people who exercise in groups, supervised by a physiotherapist, experience greater pain relief than those who exercise at home, unsupervised. Reasons for this difference may be that we work harder and dare to do more when guided by a physiotherapist with specialist knowledge.

To get the most from exercise, you should feel short of breath, or sweat a little, and increase the level of difficulty of the exercises as your body gets stronger.

Participants in the Danish GLAD study. Author provided

Two simple rules

You can exercise safely by following two simple pain rules. One, the pain you experience after exercise should be at a level that is tolerable. And, two, you shouldn’t experience any increase in pain from day to day.

Pain should be assessed daily after exercise on a zero-to-ten scale. On this scale, zero to two is considered “safe”, two to five “acceptable”, and five to ten “avoid”.

Let’s say your usual pain is three, and after exercising you rate it five. That’s fine. If your usual pain is three and after exercising you rate it a seven, you have done too much and should cut back the next time.

If your pain goes up to five after exercising, but the next morning is back at three – your usual morning pain – that’s fine. If your pain goes up to five after exercising, and is still at four or five the next morning (that is, more than your usual morning pain), you have done too much and should cut back. Keep at it, but at a lower level.

Exercising with arthritis

Interestingly, our research shows that it is safe to exercise with severe arthritis. When people with severe or bone-on-bone arthritis followed these two simple pain rules, 95% of all exercise sessions were performed with acceptable pain, and pain was relieved after a few weeks.

In a recent study, we enrolled people with mostly severe arthritis who fulfilled all the criteria to have a knee replacement op. All the participants received information on arthritis and its treatments, including self-help advice. They also took part in supervised exercise sessions twice weekly for eight weeks, and saw a dietitian if they were overweight.

Half of the participants were randomised to have their knee replaced. Among those not having their joint replaced immediately, only a quarter chose to have their joint replaced within a year. In other words, the pain relief that people experienced as a result of the exercise was enough for three-quarters of the participants to delay surgery for at least a year.

Exercise, especially when supervised, provides effective pain relief, but requires physical effort and sweat. Passive treatments, such as manual therapy, deep tissue massage and muscle stretches, given by a physiotherapist, doesn’t seem to work for people with hip or knee pain.

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The myth that running causes osteoarthritis and ruins your knees has long been debunked. But what if your joints are already ruined?

Before we get to the new stuff, let’s just make sure we’re on the same page with regard to the old “running will ruin your knees” thing. It won’t. Numerous studies have compared groups of runners and non-runners over the course of many decades, and found no evidence that runners are more likely to develop knee osteoarthritis or need knee replacements. In fact, in many studies runners seem to be less likely to develop knee problems, perhaps due to their lower weight, reduced systemic inflammation, and the ability of cartilage to adapt and get stronger in response to regular exercise.
That’s all great, but it doesn’t answer another important question. What if you already have knee osteoarthritis, meaning that your cartilage—the shock absorber between the bones of your upper and lower legs—has started to degenerate? After all, just because running doesn’t cause osteoarthritis, that doesn’t mean it makes you immune. At this point, your knee joint is no longer working the way it’s supposed to. If you keep running, will you hasten the progression of the disease?
Given that over 30 million Americans have osteoarthritis, this is a big question. And the answer, from a scientific perspective, is that we don’t know for sure. Logic suggests that if the joint is already compromised, the high stresses that result from running could worsen the wear-and-tear on the cartilage. But so far there has been very little evidence on which to base any conclusions.
That’s why a new study in the journal Clinical Rheumatology, from a group led by Grace Lo of Baylor College of Medicine, is worth digging into. It draws on a big multicenter study called the Osteoarthritis Initiative, which followed nearly 5,000 people in Pawtucket, Columbus, Pittsburgh, and Baltimore for about a decade. In that group, there were 1,203 people over the age of 50 who had osteoarthritis in at least one knee, of whom 138 happened to be runners throughout the study period.
The subjects underwent a bunch of diagnostic tests, including X-rays, to determine how severe their knee osteoarthritis was. These tests were repeated four years later. So the question is: did those who ran during that period of time have a faster progression of their symptoms than those who didn’t run? No, they didn’t. Here’s what the researchers wrote:

Contrary to what we expected, we found little evidence to suggest that running is harmful in this cohort... Among individuals at least 50 years of age with knee OA [i.e osteoarthritis], running was not associated with longitudinal worsening knee pain or radiographically defined structural progression. Additionally, runners also had more improvement in knee pain compared to non-runners, suggesting that there may be a benefit to running from a knee health perspective in people who have knee OA. 

If you look at a measure called “joint space narrowing,” which indicates that the bones are getting closer together because the cartilage is disappearing, 23.6 percent of the non-runners got worse during the study period, while just 19.5 percent of the runners got worse. Similarly, 29.0 percent of the non-runners reported new frequent knee pain, compared to just 26.8 percent of the runners. Conversely, 39.1 percent of the non-runners reported improvements in their knee pain, compared to 50 percent of the runners. When you adjust for other characteristics like age and BMI, it turns out that the runners were about 70 percent more likely to see improvements in their symptoms.
All this is great, but let’s not get carried away. We have very little information about how much mileage the runners logging, or what other differences there may have been between the runners and non-runners. Clearly it’s possible that those who were able to keep running were healthier in some way—although the researchers did look for this possibility, and found that at baseline the runners and non-runners had very similar levels of disease progression and similar BMIs.
One thing that’s very important to emphasize is that these runners weren’t instructed to go forth and run as much as they wanted. They were given no specific instructions at all about running, so they were presumably following their own common sense and the advice of their doctors. Were they running shorter distances, or less frequently, than they used to? Were they stopping and walking home if their knees started bothering them more than usual during a run? Maybe, but we don’t know.
Getting a knee replacement, or living with the pain and compromised mobility of a severely arthritic knee, is no joke, so I’m really hesitant to make any suggestions that might hasten the progression of anyone’s condition. On the other hand, one of the serious consequences of osteoarthritis is that it generally leads to a reduction in physical activity, which in turn leads to elevated risk down the road of other chronic conditions like heart disease and diabetes. For example, one recent study found that osteoarthritis-induced difficulty in walking was associated with a 30-percent increase in the risk of heart attacks, strokes, and other cardiovascular events.
You might argue that if your knees go bad, you should err on the side of caution and take up “joint-friendly” aerobic exercise options like cycling or swimming. That’s eminently reasonable, but not everyone has easy access to a pool or lives in a climate where you can conveniently cycle all year. You can overcome all these objections with sufficient motivation, but in practice, the fact remains that if you take away a popular and convenient exercise option, some people are going to exercise less, with predictable health consequences. So we don’t want to forbid running without considering all the options.
This new study doesn’t tell us that you can run through osteoarthritis with impunity. But I think it does offer some tentative support for the sort of advice I’ve heard from a number of “running-friendly” doctors who I’ve asked about this. They suggest, in essence, letting your symptoms be your guide. That will probably mean modifying how long, how often, and perhaps how fast you run. It may mean trying different shoes or a different running surface, or strengthening your hips and quads, to see if that affects the load on your knee. But it doesn’t mean simply quitting cold-turkey. If you’re able to find a running routine that’s compatible with your osteoarthritis symptoms, these results offer some reassurance that even if your knees are already giving you trouble, you’re still not ruining them by running.

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