 For anyone with a creaky, painful knee, the advice from doctors and physiotherapists has always been simple and unshakeable: "Just exercise." It's the first-line treatment recommended in every clinical guideline for knee osteoarthritis. But what if the reason it helps has almost nothing to do with the exercise itself? A wave of high-quality research from the last five years is revealing a more complex and surprising picture, challenging some of the most fundamental beliefs about how, why, and how much exercise helps. These findings don't suggest exercise is a bad idea, but they are radically shifting our understanding of what’s really happening. The new science suggests the benefits of exercise are less about the physical changes in the joint and more about the psychological and contextual experience of care. Drawing on a major 2025 narrative review in the Journal of Physiotherapy, here are five of the most impactful takeaways that are changing how experts think about exercise for knee osteoarthritis. 1. The benefits of exercise might be smaller—and more mysterious—than we thought. The conventional wisdom has long been that exercise is a highly effective treatment. A landmark 2015 Cochrane Review was so confident in its findings that its authors concluded further evidence was unlikely to change their conclusion. But recent, more sophisticated analyses are painting a different picture. Two major reviews—an individual participant data (IPD) meta-analysis and an updated 2024 Cochrane Review—found that while exercise does help, the effects on pain and function are small. What does "small" mean? On a 100-point pain scale, the updated Cochrane Review found exercise improved pain by about 13 points. However, the minimum improvement researchers believe patients would actually notice is around 12 points, putting the benefit right on the edge of being meaningful. What’s more, we don't really know how exercise achieves its benefits. One study set out to see if changes in factors like knee strength could explain the improvements. Surprisingly, it found that changes in knee extension strength explained only 2% of the positive effects, leaving the other 98% of the mechanism a complete "black box." This has led some researchers to question the source of the benefits. According to an editorial in Osteoarthritis and Cartilage, any observed clinical benefits of exercise may be attributed more to contextual effects (like the patient-therapist relationship) and regression to the mean (a statistical phenomenon where people who seek help when their pain is at its worst will naturally tend to feel a bit better over time, regardless of treatment) than to specific physiological effects of the exercise itself. This "black box" may help explain another surprising finding: when it comes to exercise for knee pain, more isn’t necessarily better. 2. The 'more is better' approach to exercise is likely a myth. Many patients and clinicians operate on a logical assumption: if some exercise is good, then a higher "dose"—more intensity, more frequency, or more volume—must be better. However, recent research has consistently failed to support this dose-response relationship. A systematic review investigating the link between exercise volume and its effects on pain and function found no association. This means that, on the whole, doing more did not lead to better results. This finding is backed by several high-quality randomized controlled trials (RCTs):
The takeaway for patients is liberating: the pressure to grind through high-intensity or high-volume workouts is likely unnecessary. And if a higher physical dose doesn't improve outcomes, it starts to make sense why perfect adherence to that dose might not be the magic bullet we once thought. 3. Improving exercise adherence might not actually improve outcomes. This next finding may be the most challenging for clinicians and patients to accept. Another deeply ingrained belief is that for an exercise program to work, you have to stick with it. Clinicians often focus on improving a patient's adherence, assuming that better adherence will directly translate to better results. Remarkably, new research directly challenges this assumption. A large systematic review found no association between how well patients adhered to their prescribed exercise programs and their ultimate improvements in pain or function. This counter-intuitive finding has been tested in recent RCTs with consistent results:
As the authors of that study concluded, the findings questioned the long-held assumptions "that doing more lower limb exercise, with greater individualisation, exercise progression and supervision, leads to better pain and function." So, if the physical dose doesn't matter and adherence to that dose doesn't matter, what does? The emerging evidence points to the power of the therapeutic experience itself. 4. Remote and digital care can be just as good as in-person therapy. Many people assume that telehealth or digital programs are a lesser substitute for traditional, in-person physiotherapy. But here’s where the story takes a truly remarkable turn. Strong new evidence shows this is not the case. A large, high-quality RCT compared a physiotherapy program delivered via videoconferencing to the exact same program delivered in person. The results showed that the remote option was "non-inferior"—meaning it was not unacceptably worse—for improving pain and function. In fact, patients reported higher satisfaction with the telehealth care. This finding reinforces the idea that the "contextual" part of care—feeling supported, heard, and guided—may be more important than the physical location where care happens. The evidence extends to fully digital, largely unsupervised programs as well. RCTs have shown that exercise programs delivered via websites or mobile apps, supported by automated text messages or minimal clinician contact, can be both effective and safe. This has led to "stepped care" models, where research suggests about one-third of patients can successfully manage their knee OA with digital tools alone, avoiding more intensive and costly in-person care. 5. How we talk about arthritis can directly impact recovery. The public narrative around OA is often filled with negative language. Phrases like "wear and tear," "degenerative," or "bone-on-bone" create a powerful impression that the joint is fragile and that exercise could cause further damage. If contextual effects are what truly drive improvement, then the language used to create that context isn't a soft skill—it's a primary component of the therapy itself. Recent RCTs have provided causal evidence that language has a direct and powerful impact on patient beliefs and confidence:
This research demonstrates that changing the conversation around OA—from one of damage to one of empowerment—is a crucial, evidence-based component of effective treatment. A New Chapter for Knee Pain Management The core recommendation for exercise in knee OA isn't being overturned, but our understanding is becoming far more nuanced. The simple rules we thought we knew—that the benefits are large, more is better, and perfect adherence is critical—are being challenged by high-quality evidence. It's not that exercise doesn't work, but our understanding of whyit works is shifting from a story about physiology to a more powerful story about psychology, confidence, and the therapeutic experience. As this new science unfolds, it prompts a critical question for both patients and clinicians: How can we shift our focus from simply prescribing exercises to creating empowering experiences that truly help people live well with osteoarthritis? Comments are closed.
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