Pilates guide
Pilates is a good way to do the exercise that is the first treatment for knee arthritis (osteoarthritis). It strengthens the thigh and hip muscles that support the knee, mostly lying down or on your side, so the knee isn't carrying your weight. In small trials it eased knee pain more than doing nothing and about as much as other exercise, and the NHS has a free Pilates class for knee problems. It won't cure arthritis or rebuild cartilage, but it won't wear your knee out either.
Pilates sits beside your care, not in place of it: a physiotherapist's programme, your GP's advice and, if it comes to it, a surgeon's advice come first.
This guide covers what the trials found, how much pain is all right, kneeling and deep bends, the reformer, what to do in a flare and the warning signs that need help the same day, with the moves to start with and our 25-minute no-kneeling class. Our knee arthritis guide has the full exercise plan, and our Pilates for arthritis guide covers other joints.
NICE says to offer exercise, tailored to the person, to everyone with osteoarthritis, and names no type. The NHS lists Pilates among the low-impact activities that suit arthritis and has a free 33-minute Pilates class for knee problems. Pilates isn't a treatment of its own.
In a 2025 review of 11 small trials (476 people), Pilates eased pain more than no exercise (3 trials, 66 people, low certainty) and no differently from other exercise (5 trials, 210 people, very low certainty). A second review of 8 trials found the same.
In the 2024 Cochrane review (139 trials, 12,468 people), exercise improved pain by about 9 to 13 points out of 100 and function by about 11 to 13, amounts its authors call of uncertain clinical importance. No type of exercise beat another.
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Mat Pilates works the thigh and hip muscles without your weight on the knee. Add chair and standing moves, such as sit-to-stands, step-ups and balance: programmes aimed at the thigh muscles did more in one analysis of 48 trials, and NICE asks for muscle strengthening and general fitness.
Pain up to 5 out of 10 during and after exercise is acceptable if it's back to usual by the next day, the rule in a programme for severe hip and knee arthritis, and NICE says pain may rise when you start. No guideline bans kneeling or deep bends: pad them, swap them or keep them short.
In one diary study, 30 of 67 people with knee pain had flares, lasting a median of 8 days, and heavy days of kneeling, squatting or stairs made them more likely. Do less, not nothing, and build back.
Osteoarthritis is the most common type of arthritis in the UK. The cartilage on the ends of the bones breaks down, bony growths can form and the joint can swell. In the knee, the NHS says it's often most painful when you walk, particularly up or down hills or stairs, and the knee may give way or be hard to straighten. Symptoms can come and go, it doesn't necessarily get worse over time, and it can sometimes improve.
NICE says osteoarthritis can be diagnosed without imaging in people aged 45 or over who have activity-related joint pain and no morning stiffness, or stiffness lasting 30 minutes or less, and that care should be guided by symptoms and physical function. So let how your knee responds, not an X-ray report, set what you do (our reading).
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Arthritis can affect the main knee joint, the joint behind the kneecap, or both. Lifelong daily squatting was linked more with the main joint in one study, and long daily kneeling with worsening kneecap cartilage in another. If your pain is at the front of the knee, keep deep bends and kneeling small at first (our suggestion); the seated knee extension's page says to work from 90° to about 45° if the full range hurts.
Exercise strengthens the muscles round the knee, and eases pain and stiffness for many people by a modest amount on average. It doesn't rebuild cartilage, and it doesn't wear the joint out: loading exercise didn't harm cartilage in 9 trials (low-quality evidence), and long-term exercise was safe for most older adults with knee pain across 48 trials. NICE wanted to reassure people that exercise isn't harmful to arthritic joints.
Mat Pilates is done mostly lying, on your side and sitting, so the thigh and hip muscles work without your weight on the knee. In 32 healthy older women, 12 weeks of Pilates made the muscles that straighten and bend the knee stronger than stretching did. The knee trials' classes ran 2 or 3 times a week for 6 to 10 weeks, using moves such as the hundred, the leg stretches, clams, side kicks, leg circles, bridges and squats.
What mat Pilates usually lacks is load and standing work, so add sit-to-stands, step-ups and balance (our reading of NICE's call for muscle strengthening and of the GLA:D programme's standing exercises).
After a knee replacement, the NHS says not to kneel on the new knee until your doctor says you can, and not to sit with your legs crossed for the first 6 weeks: our Pilates after a knee replacement guide covers it. If you're living with overweight or obesity, NICE says any weight loss is likely to help; Pilates isn't a weight-loss tool, and our Pilates for plus-size bodies guide has chair-to-mat options. Rheumatoid arthritis, gout, or a hot, swollen knee without an injury are different problems (see the warning signs).
Small, short Pilates trials, mostly at high risk of bias; the evidence for exercise in general is much larger.
In the 2024 Cochrane review (139 trials, 12,468 people), exercise improved pain by 8.7 points out of 100 against placebo or attention control and by 13.1 against usual care or no treatment (both low certainty), and function by about 11 to 13 points (moderate certainty). The authors took 12 points for pain and 13 for function as a noticeable change, so they called the benefits of uncertain clinical importance. They found no differences between types of exercise, and side effects were more common than with usual care (low certainty). The 2015 version, with 44 trials, had rated its evidence higher.
In the 2025 review of 11 trials (476 people aged 43 to 68, from Iran, India, Brazil, Pakistan, Nigeria, Egypt and Turkey), Pilates eased pain more than no exercise by a large but uncertain amount (3 trials, 66 people, low certainty). A second 2025 review of 8 trials (322 people) agreed, with signs that small trials with negative results may be missing.
Against conventional exercise, there was no clear difference in pain or function (5 trials, 210 people, very low certainty). A 2022 review of 7 studies in older adults with joint and muscle conditions found Pilates as effective as other exercise, with good attendance at group classes and poorer practice at home.
Two network meta-analyses ranked Pilates top for pain or for function, but each rested on a couple of small Pilates trials and indirect comparisons, and one of them warned that its rankings should be read cautiously. The largest, in the BMJ (217 trials), found aerobic exercise likely the most helpful overall, with mind-body exercise such as tai chi, yoga and Pilates giving a large short-term gain in function. Rankings like these don't show that Pilates is the best exercise.
All are small, short and from single centres. In older women in Brazil, knee scores improved with mat Pilates twice a week but not without exercise (the abstract gives no test between the groups). In 40 women in Pakistan, Pilates beat isometric exercise with heat and TENS (a kind of electrical pain relief); in 41 people in Iran, it beat conventional exercise; in 30 Iranian women, suspension training beat Pilates. Adding pain education before Pilates eased fear of movement but not pain (54 adults). In 20 Italian women, in a study that wasn't randomised, pain fell 33% with Pilates and 83% with Gyrokinesis. Only 2 of the 11 trials in the 2025 review reported side effects.
In one analysis of 48 trials, programmes aimed at the thigh muscles (quadriceps), and supervised exercise 3 times a week, reduced pain more, though the 2024 Cochrane review found no link with the number of sessions. In Denmark, the GLA:D programme (education plus 12 supervised exercise sessions over 6 weeks) went with pain about 12 to 14 points lower at 3 and 12 months in 9,825 people, without a comparison group, and the UK's ESCAPE-knee pain programme improved function more than usual care in 418 people.
In 100 people eligible for a knee replacement, about three-quarters of those given 12 weeks of exercise and other non-surgical care hadn't had a replacement a year later. Surgery improved symptoms more but brought more serious complications. NICE puts exercise first and suggests referral for a replacement when symptoms substantially affect quality of life and non-surgical care hasn't worked.
NICE, OARSI, the American College of Rheumatology and EULAR all make exercise a core treatment for knee osteoarthritis, and none names Pilates. The American College of Rheumatology found too little evidence to recommend one form of exercise over another; it strongly recommends tai chi and conditionally recommends yoga for the knee. In 204 people, tai chi twice a week did as well as physical therapy. No trial has compared Pilates with yoga or tai chi.
The Pilates trials used 2 or 3 sessions a week for 6 to 10 weeks, and GLA:D twice a week for 6 weeks. Keep going after that: in pooled trials the benefit was smaller by 6 and 12 months, and NICE says sticking with exercise brings more benefit. Our editorial starting point: the 25-minute no-kneeling class 2 or 3 times a week, with walking or cycling on other days.
In a programme for 76 people with severe hip or knee osteoarthritis, pain up to 5 out of 10 was allowed during and after training, as long as it was back to usual by the next day; if it wasn't, the training was eased. Pain after sessions stayed low, fell over the weeks, and no one dropped out with joint problems. Across chronic muscle and joint pain, exercise that hurt a little worked slightly better in the short term than pain-free exercise. NICE says joint pain may rise when you start, and exercise still helps.
Rate your knee from 0 to 10 during and after a class. If it goes above 5, or is still worse the next morning, do less next time, with fewer repetitions or a smaller bend, not nothing (our suggestion, from the programme above).
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Across 80 observational studies, lifting, kneeling, climbing, squatting and standing at work were all linked with knee arthritis, and in another analysis the odds rose by about a quarter for every 5,000 hours of kneeling or squatting at work (about two and a half years of full-time work, our arithmetic). In Beijing, squatting for hours a day as a young adult went with more arthritis of the main knee joint in later life. None of this is about a weekly class.
In 600 people at risk of knee arthritis, kneeling for 30 minutes or more on 6 or more days a week went with worsening kneecap cartilage on MRI scans over 2 years, but the link weakened when the kneecap's position was taken into account, and the analysis was exploratory. Long kneeling and squatting can also bring on a flare.
None of the guidelines we read tells people with knee arthritis to avoid kneeling or deep bends, and NICE says exercise isn't harmful to arthritic joints.
Pad kneeling moves with a folded mat and keep them short, or swap them for lying or standing versions. Keep deep bends small while the knee is sore and bring them back as the pain rule allows, and avoid long spells of kneeling (our suggestion, from the studies above).
A reformer is a sliding carriage on springs. A classical beginner session starts with footwork on 4 springs, then moves such as the hundred, feet in straps, the elephant and the knee stretches, which are done kneeling on the carriage.
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Footwork is a lying leg press: the knee bends and straightens against the springs without your body weight (our reading of the method). In lab studies in healthy people, the direction you push on the footbar changed which muscles worked, and spring settings didn't predict the force precisely, so a lighter spring isn't a precise lighter load.
Our searches found no reformer trial in knee or hip arthritis. Set the footbar so the knee bend is comfortable, and leave the kneeling knee stretches and the jump board until your knee allows (our suggestion).
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2 or 3 times a week. Lateral breathing: the move page's dose, "5 to 8 breaths at the start of every session". Heel slides: the move page's dose, "10 slow repetitions each side, once or twice a day". Hundred: the move page's dose, "50 beats to start, building to 100 (the classical count)", head down with your knees bent. Single-leg stretch: the move page's dose, "6 to 10 each side", hands behind the thigh, not on the shin. Leg circles: the move page's dose, "5 circles each direction, each leg (the classical sequence uses 5)". Side kick: the move page's dose, "8 to 10 each side". Quad sets, 5 holds of 5 seconds each leg; straight-leg raises and side-lying leg raises, 8 each; bridges, 8 slow; clams, 10 each side (our Pilates for knee pain class). Skip the clam if the outside of your hip is sore.
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoQuad set (static quads)Beginner · No equipment
3D demoStraight-leg raiseBeginner · No equipment
3D demoSupine heel slideBeginner · No equipment
3D demoPelvic tilt into bridgeBeginner · No equipment
3D demoHundred (Pilates)Intermediate · No equipment
3D demoSingle-leg stretch (Pilates one leg stretch)Intermediate · No equipment
3D demoSingle-leg circle (Pilates one leg circle)Beginner · No equipment
3D demoSide kick (Pilates side kick series)Beginner · No equipment
3D demoSide-lying leg raiseBeginner · No equipment
3D demoClamshellBeginner · No equipmentSeated knee extension: the move page's dose, "3 sets of 10 to 15 each leg, 2 to 3 days a week"; if the full range hurts, work from 90° to about 45°, as its page says. Sit to stand, 3 sets of 8 from a high seat, using your arms if needed; step-ups, 3 sets of 8 to 10 each leg on a low step with a rail; wall sits, 3 to 4 holds of 20 to 40 seconds, only as deep as the pain rule allows, breathing throughout; heel-to-toe stance, 3 holds of 30 seconds (our knee arthritis guide's plan). Sit squats to about 45°, 8 slow; calf raises, 10 slow; single-leg stands, 2 holds of 20 seconds each leg, fingertips on a counter (our Pilates for knee pain class). Side-stepping: the move page's dose, "10 steps each way, next to a counter (the NHS balance exercises)".
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight
3D demoSit to stand from a chairBeginner · A bench or box
3D demoSit squat (partial squat)Beginner · No equipment
3D demoStep-upBeginner · A step
3D demoSlow calf raiseBeginner · A wall
3D demoWall sitBeginner · A wall
3D demoSingle-leg standBeginner · A wall
3D demoSide-stepping (sideways walking)Beginner · A wall
3D demoTandem stance and heel-to-toe walkBeginner · A wallA flare is a temporary worsening of pain, swelling and stiffness, worse than your normal, that can disturb sleep and activity. The NHS says flares can last several days.
In a UK diary study of 67 people aged 45 and over with knee pain or osteoarthritis, followed for up to 3 months, 30 had 54 flares between them, lasting a median of 8 days (2 to 30). A day of heavy loading in the previous 48 hours, such as long kneeling, squatting, stairs, ladders or heavy lifting, about doubled the odds.
No flare treatment has been proven in trials; the only two studies favoured carrying on with a modified exercise programme. So do less, not nothing: keep to gentle range and easy strength, take a shorter walk, and build back over a few days (our suggestion, from that review).
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5 to 10 slow repetitions of each, within a comfortable range and never forced into pain (our editorial starting point, as our exercise for arthritis guide gives it). Do the seated knee extension in the bent-knee half.
3D demoLateral breathing (Pilates breathing)Beginner · No equipment3D demoSupine heel slideBeginner · No equipment3D demoQuad set (static quads)Beginner · No equipment3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight
3D demoAnkle CARs (controlled articular rotations)Beginner · No equipment
3D demoSeated marchBeginner · A bench or boxWith painful knees, pad or skip kneeling moves such as the knee hover, bird dog and kneeling side kick, and sit on a chair for the mermaid. After a knee replacement, the NHS says not to kneel on the new knee until your doctor says you can, and not to sit with your legs crossed for the first 6 weeks.
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Rocking, the single-leg kick, child's pose, a deep squat hold and hugging the knee in during the single-leg stretch: keep the bend small, hold behind the thigh, or leave them out while the knee is sore. The rocking page says to avoid it with knee injuries, and the single-leg kick's says to kick through a smaller range if deep bending hurts the kneecap. For the mermaid, sit cross-legged, on a block or on a chair.
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Leave the reformer's jump board and jumping jacks until the knee is settled and strong (our suggestion; no study has tested jumping in knee arthritis).
Modify or avoid exercises that round your back deeply or repeatedly, especially with a weight: sit-ups, toe touches, Pilates roll-downs and curl-ups, and extreme yoga forward folds. Bend from the hips instead. You do not need to avoid bending, twisting or lifting altogether: move smoothly and keep your upper back straight.
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Our Pilates for knee pain class is the main class: no kneeling, built from the moves in the knee arthritis trials, with a flare-day stop point. Its structure is our own and untested. The arthritis class suits knees plus other sore joints; the chair classes suit days when getting down to the floor is hard; the knee strengthening workout is the next step once the class feels easy (its full-range block is for knees that tolerate deep bending); the arthritis routine is a circuit for a non-Pilates day; and the balance class suits anyone who feels unsteady. If you'd rather do yoga, try the yoga for knee pain class.
A 25-minute Pilates class for sore knees and knee arthritis: lying and side-lying leg work, shallow squats and balance, with no kneeling at all.
25 minBeginner15 movesBench or box, something with weightA gentle 25-minute Pilates class for arthritis: lying, side-lying, chair and standing moves, with no kneeling or weight on your hands, and flare-day options.
25 minBeginner16 movesBench or box, something with weightA 20-minute chair Pilates workout for beginners and older adults: breathing, sitting tall, gentle spine and leg moves, and a standing finish at the chair.
20 minBeginner14 movesBench or box, something with weightA 15-minute chair Pilates class done entirely sitting down, in a chair or wheelchair: breathing, spine moves, and leg and arm strength with water bottles.
15 minBeginner13 movesBench or box, something with weightA 25-minute session for knees that don't currently hurt: thigh and hamstring strength, single-leg control, then an optional full-range block with knees over toes.
25 minBeginner14 movesBench or box, wallA 30-minute joint-friendly circuit built like the GLA:D and ESCAPE-pain programmes: a gentle warm-up, chair, step and band strength moves, balance, then stretches.
30 minBeginner14 movesBench or box, stepA 25-minute Pilates class for steadier balance: standing balance and leg strength at a kitchen counter, then mat work for your trunk and hips.
25 minBeginner17 movesWall, bench or boxA 25-minute knee-friendly yoga practice with no kneeling and no deep bends: shallow standing poses, hip and thigh strength on the floor, and supported stretches.
25 minBeginner15 movesFirm cushionThe beginner plan builds a Pilates habit over 4 weeks (swap its kneeling moves as above); the seniors plan adds walking and strength.
A free 4-week, 3-day Pilates plan for complete beginners. Two mat days and one wall day, with clear rules for when to move each exercise to its harder version.
3 training days25 minBeginner3 days a weekA 12-week exercise plan for over-65s: strength and balance three times a week, short balance sessions and daily walks, based on falls-prevention trials.
3 training days40 minBeginnerThis is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Call 999 or go to A&E if breathing suddenly becomes difficult, if pain in your chest or upper back comes on suddenly with breathlessness or a very fast heartbeat, or if someone passes out. Do not drive yourself. It can be a blood clot that has reached the lungs.
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Same day (urgent GP appointment or NHS 111): throbbing pain in one leg (rarely both), usually the calf or thigh; swelling in one leg (rarely both); red, blue or darkened skin around the painful area, which may be harder to see on brown or black skin; or swollen veins. It could be a blood clot (deep vein thrombosis, DVT), which is more likely while you're moving about much less than usual or after a hospital stay.
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Ask for an urgent GP appointment or get help from NHS 111. In the US, use your doctor's urgent line or urgent care.
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Stop a move that makes the knee lock, give way or swell, and get it checked as above. An ache within the pain rule that has settled by the next morning is expected, especially in the first weeks (our suggestion, from the NHS knee pain advice and NICE).
Call 999 if:
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
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You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
Loading exercise didn't harm knee cartilage in 9 trials (low-quality evidence), long-term exercise was safe for most older adults with knee pain across 48 trials, and NICE says exercise isn't harmful to arthritic joints. Recreational runners had less hip and knee arthritis than people who didn't run (3.5% against 10.2%), though that kind of study can't prove cause.
There's no cure for osteoarthritis, and no trial shows exercise rebuilds cartilage. Pilates eased pain in small trials by about as much as other exercise.
It wasn't better than conventional exercise in either 2025 review, the rankings that put it first rest on a couple of small trials, and guidelines don't rank one type above another. The best exercise is the one you'll keep doing.
Pain up to 5 out of 10 that settles by the next day was the rule in a programme for severe hip and knee arthritis, and pain fell over the weeks. NICE says pain may rise at first and exercise still helps. A hot, swollen knee with a high temperature is different (see the warning signs).
Without movement, the muscles that support the knee weaken. In a flare, do less, not nothing; flare treatments haven't been tested in trials, and the advice to keep gently active is expert advice.
No guideline bans it. Padding, short spells and swapping for lying or standing versions are sensible; what studies link with cartilage change and arthritis is long daily kneeling, and years of it at work.
The knee trials used mat Pilates or mat-based programmes, and no trial has tested the reformer in knee arthritis.
In a trial of people eligible for a replacement, about three-quarters of those given exercise and other non-surgical care hadn't had one a year later, and NICE puts exercise first.
Yes, as one way to do the exercise that's the first treatment for knee arthritis. In small trials it eased pain more than doing nothing and about as much as other exercise, and the NHS has a free Pilates class for knee problems. Pair it with walking or cycling and some standing strength work.
No better and no worse, as far as the small trials can tell, and guidelines don't rank one type of exercise above another. The best exercise is the one you'll keep doing.
Exercise isn't harmful to arthritic joints, NICE says, and loading exercise didn't harm cartilage in trials. Some ache is normal; if pain goes above 5 out of 10, lasts into the next day or the knee swells, do less next time. A hot, swollen knee with a high temperature needs NHS 111 straight away.
You can if it's comfortable: pad your knees with a folded mat and keep it short, or use a lying or standing version of the move. What studies link with cartilage changes is long daily kneeling, far more than a class.
It can be: footwork is a lying leg press against springs, so you can strengthen your legs without your weight on the knee. No trial has tested the reformer in knee arthritis, so set the footbar for a comfortable bend and leave the kneeling moves and the jump board until your knee allows.
Moves that strengthen the thigh and hip: quad sets, straight-leg raises, the bridge, side kicks and side-lying leg raises, leg circles and the head-down hundred, then chair and standing work such as sit-to-stands and the seated knee extension. Programmes aimed at the thigh muscles did more in one analysis of trials.
The trials used 2 or 3 sessions a week for 6 to 10 weeks. Keep going after that: in pooled trials the benefit shrank over the following months, and NICE says sticking with exercise brings more benefit.
Do less, not nothing: gentle movement such as heel slides and quad sets, a shorter walk and lighter strengthening, then build back over a few days. In one study flares lasted about a week, and days with a lot of kneeling, squatting or stairs made them more likely.
No trial has tested Pilates for this. Exercise in general comes first, and in one trial about three-quarters of people eligible for a replacement who had exercise and other non-surgical care hadn't had one a year later. If your knee still stops you living your life, talk to your GP about a referral.
No trial has compared them. Tai chi and yoga are recommended for the knee by the American College of Rheumatology, which doesn't rate Pilates, and all three are reasonable. Our yoga for knee arthritis guide covers the yoga trials and a class.
Yes, once your team agrees, but don't kneel on the new knee until your doctor says you can. Our Pilates after a knee replacement guide covers the stages.
Get advice from NHS 111 now for a hot, red or swollen knee with a high temperature, a knee you can't move or put weight on, or one that locks or gives way. See a GP or physiotherapist if knee pain hasn't improved within a few weeks.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
