What are the best exercises for an older patient with knee osteoarthritis?

Best Exercises for Knee Osteoarthritis

For older patients with knee osteoarthritis, prescribe a combination of quadriceps strengthening exercises and low-impact aerobic activity (walking, cycling, swimming, or aquatic exercise), performed at moderate intensity for 30-60 minutes most days of the week, with at least 12 supervised sessions initially to maximize pain relief and functional improvement. 1, 2

Core Exercise Components

Strengthening Exercises (Primary Focus)

Quadriceps strengthening is the most critical exercise intervention for knee OA. 1, 2 Both specific quadriceps exercises and general lower limb strength training effectively reduce pain (effect sizes 0.29-0.53) and improve function (effect sizes 0.24-0.58). 1

Home-based quadriceps exercises to prescribe: 1

• Quad sets (lying): Squeeze thigh muscles, hold 6-7 seconds, perform 5-7 repetitions, 3-5 times daily
• Short-arc quad sets (sitting): Place pillow under knee, straighten leg, hold 6-7 seconds
• Long-arc quad sets (sitting): Lift foot until leg straight, hold 6-7 seconds
• Gluteal squeezes: Tighten buttocks, hold 6-7 seconds
• Closed-chain knee extension (standing): Bend knees to 30 degrees, slowly extend

Progressive strength training protocol: 1

• Frequency: At least 2 days per week
• Intensity: Moderate to vigorous (60-80% of one repetition maximum)
• Repetitions: 8-12 per set
• Progression: Increase intensity and duration over time with dynamic exercises

Aerobic Exercise (Essential Component)

Low-impact aerobic activities demonstrate substantial effects with effect sizes of 0.52 for pain relief and 0.46 for disability reduction. 2, 3 The American College of Rheumatology recommends 30-60 minutes of moderate-intensity aerobic activity most days of the week. 2, 3

Recommended aerobic options: 1

• Walking (most studied, highly effective)
• Cycling (stationary bike preferred)
• Swimming or aquatic exercise (excellent choice, reduces joint loading in warm water at 86°F)
• Low-impact aerobics (including Tai Chi or dance)
• Utilitarian activities (walking the dog, mowing lawn, golfing)

Aquatic exercise deserves special emphasis as it provides analgesia through warm water, reduces joint loading through buoyancy, and enhances pain-free motion. 1

Critical Implementation Details

Supervision Requirements

Initial supervision is essential for optimal outcomes. Twelve or more directly supervised sessions produce significantly better results than fewer sessions: 1

• Pain reduction: Effect size 0.46 (≥12 sessions) vs 0.28 (<12 sessions), p=0.03
• Function improvement: Effect size 0.45 (≥12 sessions) vs 0.23 (<12 sessions), p=0.02

After initial supervised sessions, patients should integrate exercise into daily life. 1

Exercise Dosing Specifications

For aerobic training: 1

• Moderate intensity (70% of maximal heart rate)
• 30 minutes minimum daily, up to 60 minutes for greater benefit
• 45 minutes per day, 3 days per week produces significant aerobic gains

For strength training: 1

• Dynamic exercises with progression over time (not isometric)
• Major muscle groups targeted
• Progressive overload principle applied

Neuromuscular Training

Neuromuscular exercises address muscle weakness, reduced sensorimotor control, and functional instability specific to knee OA. 1 These involve dynamic maneuvers of increased complexity and should be incorporated alongside strengthening and aerobic components. 1

Common Pitfalls and Practical Considerations

Pain During Exercise

Patients experiencing pain should not avoid exercise—clinical trials demonstrate improvements in pain and function even in symptomatic patients. 1 Use shared decision-making to determine when to initiate exercise, but recognize that pain presence is not a contraindication. 1

Patient Preferences Matter

While no specific exercise hierarchy exists, patients benefit more from specific advice than generic encouragement to exercise. 1 Individual preferences, access, and affordability influence adherence and outcomes. 1

Combining with Other Interventions

Exercise programs are more effective when combined with: 1

• Self-efficacy and self-management interventions
• Weight loss programs (if BMI ≥25 kg/m²)
• Education programs (individualized packages, phone calls, group education, coping skills training)

Long-term Maintenance

Re-evaluate at 4 weeks, monitor at 4-6 months, and encourage increasing physical activity into recreational or utilitarian activities. 1 The goal is lifelong integration of exercise, not just a temporary intervention. 1

Special Populations

For medically stable/robust older adults: Use the home-based quadriceps program outlined above. 1

For patients with multiple medical problems: Consider referral to an experienced physical therapist for individualized program development. 1

For patients who cannot reach recommended levels: Encourage being as physically active as abilities and condition allow—some exercise is better than none. 1