What to Try Before Knee Replacement: A Complete Checklist

Key Takeaways

Knee replacement is major surgery with 3-6 months of recovery. Trying conservative treatments first is both medically sound and often required by insurers.
Research shows a systematic approach to conservative care can delay or even eliminate the need for surgery in many patients.
Each tier of treatment builds on the previous one. Skipping steps often means missing opportunities for relief.
Gel injections (viscosupplementation) are a proven option that many patients never hear about despite being FDA-approved for 27+ years.
Documenting your treatment history is essential for both medical decision-making and insurance approval.

The Pre-Surgery Checklist Philosophy

If your doctor has mentioned knee replacement, you might feel like surgery is inevitable. But here is something important: most orthopedic surgeons actually want you to try other options first.

This is not about delaying necessary care or making you jump through hoops. There are genuine medical reasons to approach knee replacement as a last resort rather than a first response:

Artificial knees have a lifespan. Most last 15-20 years. If you can delay surgery by even 3-5 years, you may avoid needing a more complex revision surgery later in life.

Recovery is significant. Plan for 3-6 months before you are back to normal activities. That is time away from work, grandchildren, and the activities you love.

Conservative treatments genuinely work for many people. Studies show that 30-40% of patients who try a comprehensive conservative approach find enough relief to delay or avoid surgery entirely.

Surgery outcomes are better when you are stronger. Patients who build muscle and lose weight before surgery have faster recoveries and better long-term results.

Think of this checklist as a roadmap. You may find relief at an early tier, or you may work through everything and ultimately decide surgery is right for you. Either way, you will make that decision with confidence, knowing you have truly explored your options.

Tier 1: Foundational Treatments (Start Here)

These are the building blocks of knee osteoarthritis management. They cost little to nothing, have no side effects, and create the foundation for everything else to work better.

Weight Management

Understand the math: Every pound of body weight creates 4 pounds of pressure on your knees. Losing just 10 pounds removes 40 pounds of stress per step.
Set a realistic target: Losing 10-15 pounds can reduce knee pain by 50% for many people. You do not need to reach an “ideal” weight to see benefits.
Choose joint-friendly approaches: Swimming, water aerobics, and stationary cycling burn calories without stressing your knees. Many people find that as pain decreases, activity naturally increases.
Track your progress: Keep a simple log. Weight management takes time, and seeing gradual progress keeps you motivated.

Why this matters: The ADAPT study found that weight loss combined with exercise reduced knee pain and improved function more than either approach alone. Research published in Arthritis & Rheumatism showed that even modest weight loss of 5-10% of body weight significantly reduced pain scores.

Related reading: Weight and Joint Pain: What Research Says

Physical Therapy (6+ Weeks)

Get a referral: Ask your doctor for a physical therapy prescription. Medicare Part B covers PT when medically necessary.
Commit to the full program: Most PT programs run 6-12 weeks with 2-3 sessions per week. Stopping early means missing the full benefit.
Do your home exercises: What you do between sessions matters more than the sessions themselves. Set a daily reminder.
Focus on quadriceps strength: Strong thigh muscles absorb shock that would otherwise go through your knee joint. Research shows quadriceps weakness is a major predictor of knee pain progression.
Document your experience: Keep notes on pain levels before and after the program. This documentation matters for insurance and for deciding next steps.

Why this matters: The American Academy of Orthopaedic Surgeons strongly recommends physical therapy as first-line treatment for knee osteoarthritis. Studies show that structured PT programs reduce pain by 40-50% for many patients.

Related reading: Physical Therapy for Knee Osteoarthritis

Activity Modification

Identify your triggers: Track which activities cause the most pain. Common culprits include stairs, prolonged standing, and high-impact exercise.
Swap high-impact for low-impact: Trade running for swimming, jogging for cycling, tennis for golf. You stay active without pounding your joints.
Use assistive devices when needed: A cane, walker, or knee brace is not a sign of failure. It is a tool that reduces joint stress and keeps you moving.
Modify your environment: Handrails on stairs, raised toilet seats, and shower chairs reduce strain on arthritic knees.

Minimum time at Tier 1: 6-8 weeks of consistent effort before moving to Tier 2. If you see significant improvement, stay here as long as it is working.

Tier 2: Medication Options

When foundational treatments alone are not enough, medications can provide additional relief to keep you active and engaged in physical therapy.

Over-the-Counter Anti-Inflammatories

Try acetaminophen first: Tylenol is gentler on your stomach and kidneys than NSAIDs. Take it consistently for 2-4 weeks to assess effectiveness.
Consider NSAIDs if needed: Ibuprofen (Advil, Motrin) or naproxen (Aleve) reduce inflammation. They work better for arthritis than acetaminophen alone for many people.
Use the lowest effective dose: More is not better. Follow package directions and talk to your doctor about long-term use.
Know the risks: NSAIDs can affect your stomach, kidneys, and heart with long-term use. Regular blood pressure and kidney function checks are smart if you use them frequently.
Time them strategically: Take anti-inflammatories 30-60 minutes before activities that typically cause pain.

Related reading: NSAID Risks and Alternatives

Topical Treatments

Try topical NSAIDs: Voltaren Gel (diclofenac) delivers anti-inflammatory medication directly to the joint with fewer systemic side effects. Now available over the counter.
Consider capsaicin cream: Derived from hot peppers, it depletes pain signals over time. Give it 2-4 weeks of consistent use before judging effectiveness.
Use proper technique: Apply to clean, dry skin. Wash hands thoroughly afterward. Avoid contact with eyes and mucous membranes.

Minimum time at Tier 2: 4-6 weeks of consistent medication use combined with Tier 1 treatments. Document what you tried and how it worked.

Tier 3: Injection Therapies

When oral medications and foundational treatments are not providing enough relief, injections deliver treatment directly where you need it most.

Cortisone Injections (Short-Term Relief)

Understand the purpose: Cortisone provides powerful anti-inflammatory relief that can last weeks to months. It is excellent for flare-ups or breaking a pain cycle.
Know the limits: Most doctors recommend no more than 3-4 cortisone injections per joint per year. Research suggests repeated cortisone may accelerate cartilage loss over time.
Use the window wisely: When cortisone reduces your pain, use that relief to engage more fully in physical therapy and exercise.
Document the duration: Track how long relief lasts. This information helps guide decisions about gel injections and surgery timing.

Related reading: Cortisone Injection Risks

Gel Injections / Hyaluronic Acid (6-12 Months Relief, Repeatable)

Understand what they are: Hyaluronic acid (HA) injections, also called viscosupplementation or gel shots, restore the natural lubricating and cushioning properties of joint fluid.
Know the evidence: FDA-approved for 27+ years. Clinical studies show 51% average pain reduction. Real-world data shows HA users delay knee replacement by 1-3+ years compared to non-users.
Check your eligibility: Medicare covers gel injections for knee osteoarthritis when medical necessity criteria are met. Most private insurers cover them with prior authorization.
Try at least one series: A single series (1-5 injections depending on brand) is needed to assess if you are a responder. About 70% of appropriately selected patients get meaningful relief.
Repeat if effective: If gel injections work for you, they can be repeated every 6-12 months as needed. Each course may extend your time before surgery.

Why Gel Injections Deserve Special Attention

Of all the treatments on this checklist, gel injections may be the most overlooked. Despite being FDA-approved since 1997 and covered by Medicare, studies suggest that 80% of patients with knee arthritis have never heard of them.

The Case for Trying Gel Injections Before Surgery

Research on Surgery Delay:

A study of 182,000+ patients found that those who received hyaluronic acid injections delayed knee replacement by an average of:

HA Treatment History	Time Before Surgery
No HA injections	0.7 years
1+ HA series	1.4 years
3+ HA courses	2.3 years
5+ HA courses	3.6 years

Each additional course of treatment extended the time before surgery became necessary.

What Makes Gel Injections Different from Cortisone

Factor	Cortisone	Gel Injections
How it works	Reduces inflammation	Restores joint lubrication
Duration of relief	Weeks to months	6-12 months
Repeatability	Limited (3-4x/year)	Can repeat as needed
Effect on cartilage	May accelerate breakdown	May protect cartilage
Medicare coverage	Yes	Yes

Who Responds Best to Gel Injections

Mild to moderate osteoarthritis (Stages 2-3 on X-ray)

Patients who want to delay surgery for personal, medical, or practical reasons

Those under 65 who face higher revision surgery risk if they operate young

Patients with medical conditions that make surgery risky

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How to Know You Have “Really Tried”

Surgeons and insurance companies look for evidence that you have given conservative treatment a genuine effort. Here is what that typically means:

Minimum Treatment Durations

Treatment	Minimum Duration	Documentation Needed
Physical therapy	6-12 weeks	PT notes, attendance record
Weight management	Ongoing effort	Weight log, provider notes
NSAIDs/medications	4-6 weeks	Prescription records
Cortisone injection	At least 1	Injection records, response duration
Gel injections	1 full series	Injection records, response assessment

What “Failure” Actually Means

A treatment has not “failed” just because you still have some pain. Failure means:

Pain remains severe enough to significantly limit daily activities
Function has not improved despite consistent treatment
Side effects prevent continued use
Relief does not last long enough to be practical

Partial improvement is still improvement. Many people achieve their best results by combining multiple treatments (for example, gel injections plus physical therapy plus weight management).

The Insurance Angle: Why This Matters for Approval

Here is a practical reality: many insurance plans, including Medicare Advantage plans, require documentation of conservative treatment before approving knee replacement surgery.

What Insurers Typically Require

3-6 months of documented conservative treatment

Physical therapy records showing attendance and progress

Medication history documenting what you have tried

Injection records if applicable

Imaging confirming moderate to severe arthritis

How to Protect Yourself

Keep your own records. Do not rely solely on medical records. Maintain a treatment journal with dates, providers, and your assessment of each treatment.
Request documentation. After completing physical therapy or receiving injections, ask for a summary letter noting the treatment provided and your response.
Follow through completely. Insurers may deny coverage if you started but did not complete a recommended treatment course.
Ask about requirements upfront. Before scheduling surgery, ask your surgeon’s office what documentation the insurance company will need.

When You Have Exhausted Your Options

After working through this checklist, you will be in one of three positions:

Scenario 1: Conservative Treatment Is Working

You have found a combination of treatments that manages your pain well enough to maintain your quality of life. This is success. Continue your current approach, reassessing periodically. Many people manage knee arthritis for years or even decades without surgery.

Scenario 2: You Are Managing But Declining

Conservative treatments help, but you are noticing gradual decline. Pain is creeping up, activities are becoming harder. This is a reasonable time to have a serious surgery conversation. You have bought yourself time, strengthened your body for recovery, and gathered the documentation needed for insurance approval.

Scenario 3: Conservative Treatment Has Failed

Despite genuinely trying each tier of treatment, your pain remains severe and your function is significantly limited. Surgery may be the right choice. You can move forward knowing you have explored your options and that you are making an informed decision.

Signs That Surgery May Be the Right Next Step

Pain is constant, including at rest and at night

You cannot do basic daily activities (walking, climbing stairs, grocery shopping)

You have tried and documented all appropriate conservative treatments

Your imaging shows significant structural damage (bone-on-bone arthritis)

Your quality of life is significantly diminished

Related reading: When Is Knee Replacement Necessary?

Your Complete Pre-Surgery Checklist

Print this checklist and bring it to your next doctor visit:

Frequently Asked Questions

How long should I try conservative treatment before considering surgery?

Most experts recommend at least 3-6 months of consistent conservative treatment. However, this depends on your arthritis severity and how much your quality of life is affected. If you have bone-on-bone arthritis and severe limitations, the timeline may be shorter. If you have mild to moderate arthritis, you may manage for years with conservative care.

Will trying gel injections delay my surgery approval?

No. In fact, documenting that you tried gel injections and other conservative treatments typically strengthens your case for surgery approval. Insurers want to see that you gave non-surgical options a fair chance.

What if I have already had cortisone injections but never heard of gel injections?

You are not alone. Many patients receive multiple cortisone injections without ever being offered gel injections. It is worth asking your doctor specifically about hyaluronic acid viscosupplementation, which works differently and can be repeated more safely over time.

Are gel injections covered by insurance?

Medicare Part B covers gel injections for knee osteoarthritis when medical necessity criteria are met. Most private insurance plans also cover them, often requiring prior authorization. Your doctor’s office can verify your specific coverage.

What if conservative treatment is not working at all?

If you have genuinely tried the treatments in this checklist without meaningful improvement, that is important information. Not everyone responds to conservative care, and for some patients, surgery is the right answer. The goal is to make an informed decision, not to suffer unnecessarily.

Can I do these treatments in a different order?

The tiers are guidelines, not rigid rules. Your doctor may recommend starting with injections if your pain is too severe for effective physical therapy. The key is trying a comprehensive approach rather than jumping straight to surgery.

This article is for informational purposes only and does not replace medical advice. Consult with your healthcare provider about the treatment plan that is right for your individual situation.

Last reviewed: January 2026