Back and knee pain: what actually helps, and what makes it worse

Two things patients ask me for on the first visit are a scan and a period of complete rest. For most back and knee pain, both requests point in the wrong direction — and explaining why is usually more valuable than anything I could prescribe on that visit.

Low back pain: the evidence, briefly

The overwhelming majority of low back pain is mechanical: muscles, ligaments and joints, with no nerve involvement and no serious underlying disease. It hurts a great deal and it is not dangerous. Around nine in ten cases settle substantially within six weeks.

What helps

• Staying active. Keep doing your ordinary activities within the limits of the pain. More than a day or two of bed rest measurably delays recovery and weakens the muscles supporting the spine.
• Walking, and gentle progressive movement. Start short and increase gradually rather than waiting to be pain-free.
• Heat for the first days, for muscle spasm. Ice suits some people better; use whichever helps you.
• Simple analgesia for a short period, so you can move — the painkiller is there to enable activity, not to replace it.
• Physiotherapy and a specific exercise programme for pain that persists beyond a few weeks. This is the treatment with the best long-term evidence, and it is the one most often skipped.

What does not help, or actively harms

• Prolonged bed rest
• An MRI in the first six weeks, absent red flags. Scans of pain-free adults routinely show disc bulges and degenerative change; finding one in a person with back pain proves nothing and makes many people move less because they now believe their spine is damaged.
• Long courses of anti-inflammatory painkillers, which carry stomach, kidney and blood pressure costs
• Traction, and passive treatments that require you to lie still and have something done to you
• Untrained manipulation. A forceful manoeuvre from someone without training can cause real injury, particularly where there is nerve involvement or osteoporosis.

Knee osteoarthritis

Knee pain that is worse after activity, stiff for a short time in the morning, and slowly progressive over years is usually osteoarthritis. The cartilage has thinned. The two treatments with the strongest evidence are also the two least popular in clinic, because neither of them comes in a box.

1. Weight loss. Each kilogram lost removes roughly four kilograms of load from the knee with every step. For someone carrying an extra ten kilos this is the largest single intervention available.
2. Strengthening the quadriceps. A strong thigh muscle takes load off the joint surface. Straight-leg raises, sit-to-stand repetitions from a chair, and stationary cycling all work and can all be done at home.

Beyond those: activity modification rather than activity avoidance, a walking stick held in the opposite hand when needed, appropriate footwear, and short courses of painkillers for flares. Steroid injections can give real relief for a bad flare, but repeated injections into the same knee are not a long-term strategy. Glucosamine and similar supplements have not performed well in good trials.

“A knee that hurts needs a stronger thigh far more than it needs a scan of its cartilage.”

When surgery is the answer

Knee replacement is an excellent operation for the right patient: severe pain that limits daily life and sleep, with radiographic changes that match, after non-surgical treatment has been given a genuine trial. It is the wrong operation for moderate pain, and arthroscopy for straightforward degenerative knee arthritis has repeatedly failed to outperform physiotherapy in trials.

For the back, surgery is indicated for cauda equina, for progressive neurological weakness, and for nerve root pain that has failed several months of proper conservative management — not for back pain alone.

Bring any previous X-rays and MRIs to your visit, along with an honest account of what you have already tried and for how long. That history determines the plan far more than the images do.