Knee Osteoarthritis: Does Hands-On Physio Add to Exercise?
5 Oct 2026
A review of 29 trials published in October 2026 found that adding hands-on manual therapy to an exercise programme reduced knee osteoarthritis pain and improved function in the short and medium term, but not in the long term [1]. The certainty of that evidence was mostly very low, so treat it as a possible helper for getting started. Exercise itself remains the foundation of knee arthritis care [2].
Knee Osteoarthritis at a glance
- New review: 29 randomised trials of manual therapy plus exercise versus exercise alone [1].
- Result: less pain and better function over weeks to months, with no clear benefit later on [1].
- Certainty: very low for most results, moderate for medium-term pain [1].
- Foundation of care: land-based exercise, backed by a Cochrane review of 139 trials [2].
What did the new review find?
Researchers in Brazil and Australia pooled 29 randomised trials in people with knee osteoarthritis. Every trial compared exercise plus manual therapy, meaning hands-on techniques such as joint mobilisation, with exercise alone. The review was registered in advance and graded the certainty of its evidence [1].
People who had both treatments had less pain than people who exercised alone, straight after a session, in the short term and in the medium term. Function, meaning things like walking and climbing stairs, was also better in the short and medium term. There was no clear difference in pain or function over the long term [1].
How big is the benefit, and how sure can we be?
The medium-term gain in pain was about one point on a pain scale (mean difference -0.98), and the reviewers rated the evidence for this as moderate certainty. Most of the other results were rated very low certainty [1]. Put simply, the effect looks real but modest, and the studies are not strong enough to be confident about its size.
The authors' conclusion is that manual therapy can be an add-on at the start of rehabilitation, helping a person get going with exercise. It was not shown to replace exercise or to change the outcome years later [1].
Is exercise still the main treatment?
Yes. A 2024 Cochrane review of 139 trials with 12,468 people found that, compared with placebo or attention control, exercise probably improves physical function and may slightly improve pain. The review's authors note that all current international guidelines recommend exercise for knee osteoarthritis [2]. They also warn that most trials had a risk of bias, so the certainty of the pain results was low [2].
A separate review of resistance exercise in knee and hip osteoarthritis looked at how much exercise you need. Programmes lasting 3 to 6 months gave a moderate benefit for pain and function. The amount of exercise and how closely people stuck to the plan did not predict the size of the benefit, which suggests you don't need a rigid dose to gain something [3].
| Question | Answer from the evidence | Strength of evidence |
|---|---|---|
| Does manual therapy add to exercise? | Short and medium-term pain and function gains; none long term | Very low to moderate |
| Does exercise help? | Probably improves function; may slightly reduce pain | Low to moderate |
| How long should a programme run? | Moderate benefit at 3 to 6 months | Based on 280 studies |
What the three reviews tell you about knee osteoarthritis [1,2,3].
Who is this relevant to?
It applies to adults with knee osteoarthritis, the "wear and tear" arthritis that causes pain on stairs, stiffness after sitting and sometimes swelling. It does not cover people with a recent injury, a locked knee, fever with a hot swollen joint, or night pain that doesn't ease, who need a doctor's review first.
It is common to put off exercise because the knee hurts, and wait for an injection or surgery instead. The evidence says movement is part of the treatment, not something you do after it. A short course of hands-on therapy may make the first weeks easier, but the exercise is what you keep doing.
What are the limits?
Manual therapy techniques differed a lot between the 29 trials, and the reviewers could not find any trials that measured pressure pain threshold. Long-term results were no better with manual therapy [1]. Exercise reviews also found mostly unclear or high risk of bias [2]. None of this tells you which technique suits your knee. That needs an examination.
Getting help in Delhi
At Brain Bridge Clinic in Safdarjung Enclave, New Delhi, a knee pain assessment begins with your history, a physical examination of the joint and, where it helps, imaging to look at the structure. Our team can then discuss a graded exercise plan with physiotherapy and decide whether hands-on techniques or other options are worth adding. If your knee pain is limiting stairs, walking or sleep, you are welcome to book an assessment.
Related pages: Chronic Pain, Physiotherapy For Pain, Physical Therapy.
Frequently asked questions
Does manual therapy help knee osteoarthritis?
When added to exercise, it reduced pain and improved function in the short and medium term in a 2026 meta-analysis of 29 trials. The certainty was mostly very low, and there was no long-term benefit [1].
Is exercise good for knee arthritis even if it hurts?
A 2024 Cochrane review of 139 trials found exercise probably improves physical function in people with knee osteoarthritis, and guidelines recommend it. Your clinician can help you set a level that your knee tolerates [2].
How long should I exercise for knee osteoarthritis?
A large review found moderate benefits for programmes lasting 3 to 6 months, and it found no strong link between the total amount of exercise and the benefit [3].
Can I avoid knee surgery with physiotherapy?
The reviews here looked at pain and function, not whether surgery was avoided, so they can't answer this. Surgeons usually consider surgery when other options haven't given enough relief.
When should I see a doctor urgently about knee pain?
See a doctor soon if the knee is hot, red and swollen, you have a fever, or the joint locks or gives way after an injury.
References
- da Silva VR, Ramalho RB, de Noronha M, et al. Additional Effects of Manual Therapy to Exercise on Pain and Function in Individuals With Knee Osteoarthritis: A Systematic Review and Meta-Analysis. European journal of pain (London, England). 2026;30(9):e70397. doi:10.1002/ejp.70397. PMID 42885413.
- Lawford BJ, Hall M, Hinman RS, et al. Exercise for osteoarthritis of the knee. The Cochrane database of systematic reviews. 2024;12(12):CD004376. doi:10.1002/14651858.CD004376.pub4. PMID 39625083.
- Marriott KA, Hall M, Maciukiewicz JM, et al. Are the Effects of Resistance Exercise on Pain and Function in Knee and Hip Osteoarthritis Dependent on Exercise Volume, Duration, and Adherence? A Systematic Review and Meta-Analysis. Arthritis care & research. 2024;76(6):821-830. doi:10.1002/acr.25313. PMID 38317328.