The Benefits of Electrical Stimulation after Knee Replacement

The success of your knee replacement surgery depends on several different factors.  One of the most important of these is how you progress during your rehabilitation.  In particular, the first few weeks of physical therapy are essential for your long-term success.  This is because the function of your quadriceps muscle on the front of your thigh is one of the biggest predictors of long-term success.  Neuromuscular electrical stimulation to your quadriceps is a proven way to speed up your recovery after knee replacement surgery.

Quadriceps Muscle Loss after Knee Replacement

Knee replacement

Weakness and atrophy of your quadriceps is common after knee replacement surgery.  Pain and swelling in your knee results in your quadriceps muscle shutting down. Your brain is responsible for this reflex.  However, the longer you allow this, the longer and harder your recovery will be.  Research is now showing that early restoration of quadriceps muscle strength is crucial if you want to have a successful outcome one year after your surgery.  Using neuromuscular electrical stimulation alongside your strength training exercises results in the best outcomes.

What is Neuromuscular Electrical Stimulation? 

Neuromuscular electrical stimulation (NMES) uses electrical current to facilitate muscle contraction.  Your physical therapists places pads (also known as electrodes) on the skin over your quadriceps muscle.  Placement of the pads is important to activate certain portions of your muscle.  The pads connect to an electrical stimulation unit.  Some units are small, portable, and battery powered.  Other larger units in a physical therapy clinic require power from an electrical outlet.  Larger units produce electrical currents at greater intensities.

total knee replacement

Your physical therapist will adjust the intensity of your treatment.  In general, the higher the intensity the more effective the electrical stimulation is.  Expect some discomfort.  You will be asked to perform an isometric muscle contraction while the stimulation is on.  This means your muscle will contract but no movement will occur at your knee.  The contraction lasts for 5 to 10 seconds.  Then, you rest for period of 15 to 50 seconds.  You will perform a total of 10 to 15 maximum intensity contractions each session.

Ideally, NMES is administered daily.  On the days you attend physical therapy you will receive treatments as part of your exercise program.  Also, if a portable unit is available, you will be asked to complete the same protocol at home during the other days.  With each treatment, you want to be increasing the intensity of the electrical stimulation.  This will recruit a greater number of muscle fibers.

3 Benefits to Using Neuromuscular Electrical Stimulation

Knee electrical stimulation

Neuromuscular electrical stimulation restores quadriceps muscle function quicker after your surgery.  This is also associated with greater strength 1 year after surgery compared to people who do not receive the treatment.  These improvements in strength are linked to improvements in your functional abilities such as walking and climbing stairs.

  1. Improved Walking Speed. A 2003 study from the United Kingdom looked at walking speed over 3 minutes in patients who received NMES after surgery.  They compared these results to patients who did not receive the NEMS treatments.  Patients who received NMES resulted in 3 times the improvement in walking speed compared to patients who did not.  This was evident 6 weeks and 12 weeks after surgery.
  1. Improved Walking Distances. A 2012 study from the University of Colorado looked at walking endurance over a 6-minute period.  Sixty patients recovering from knee replacement surgery completed an intensive strengthening program immediately after surgery. Half of the patients also received daily NMES to their quadriceps.  One year after surgery, patients who received NMES were walking about 10% further than those who did not receive NMES.
  1. Improved Stair Climbing. The same study also looked at the patient’s ability to climb a flight of stairs. One year after surgery, patients who received NMES were climbing stairs 20% faster than those who did not receive NMES.  Climbing stairs, along with many other functional tasks, is highly dependent on the strength of your quadriceps muscle.

Closing Thoughts on Electrical Stimulation after Knee Replacement

Recovering from your knee replacement is not easy.  This is especially true during the first 2 to 4 weeks.  However, this is the most important time of your recovery.  Your priorities are to minimize pain and swelling, restore range of motion, and get your quadriceps muscle firing.  Our experience, and the research evidence, suggests regaining function and strength of your quadriceps muscle is the most important.  Incorporating neuromuscular electrical stimulation into your rehabilitation will expedite your early recovery.  It will also help you achieve a better long-term outcome.  Contact us if you have questions about rehabilitating from your knee replacement surgery.

Prevent Stiffness after Your Knee Replacement Surgery

Knee replacement surgeries are helping hundreds of thousands of people each year.  Most studies show 1-year patient satisfaction rates at 80% to 90%.  However, some people do develop complications.  Approximately 5% of people undergoing knee replacement surgery develop a stiff and painful knee.  Knee stiffness after surgery is associated with worse results.  People with increased stiffness after their knee replacement have more pain, worse functional outcomes, and lower satisfaction rates.  Thankfully, there are steps you can take to prevent knee stiffness from negatively impacting your recovery.

Who is Susceptible for Developing Stiffness after Knee Replacement Surgery?

Research suggests there are several factors linked to knee stiffness after surgery.  These include the presence of back pain, lung disease, or diabetes.  Some studies suggest males are more susceptible to developing stiffness.  Other studies show females are more susceptible.  Multiple studies show people who are overweight are at a greater risk. Surprisingly, younger people undergoing knee replacement are at risk.  Not surprisingly, having a stiff knee prior to surgery places you at greater risk for stiffness after your surgery.  If any of these factors sound like you, it is important for you to read on.

The Importance of Exercise before Your Knee Replacement

Your knee range of motion before your surgery is closely associated with how much you will achieve after surgery.  If you cannot straighten your knee fully before surgery, it is unlikely you will ever fully straighten it after surgery. This becomes a big problem!  At least 3 months before your surgery you should start performing range of motion exercises. This will improve your chances of a smooth recovery and rehabilitation after surgery.  Losing weight before surgery will also help.  Don’t forget about aerobic exercise and your diet.

Exercises to Improve Knee Extension

Knee stiffness is defined as a range of motion loss of 5 degrees or more of straightening, or extension, 12 weeks after surgery.  We believe full knee extension is absolutely necessary to achieve the best possible outcome after surgery.  When this is not achieved early (within 6 weeks of surgery) you will develop problems with your gait pattern.  This leads to persistent hip and back pain.   Also, if you lack knee extension you will be very uncomfortable sleeping at night.

Exercises to restore your knee extension should begin immediately after surgery.  This means as soon as you are alert and oriented during your recovery.  Begin by performing isometric quadriceps exercises with your knee fully straight.  Begin the heel prop exercise a few days later.  Start with one minute twice per day.  Work up to 5 minutes several times per day until your physical therapist advises you to stop. There is one last important point to keep in mind.  Please do not develop the bad habit of resting with a pillow under your knee.  This makes it almost impossible for you to regain your range of motion.

Exercises to Improve Knee Flexion

Knee stiffness is defined as a range of motion of less than 90 degrees of bending, or flexion, 12 weeks after surgery.  People with less than 90 degrees 6 weeks after surgery require an additional procedure to restore their range of motion.  In these cases, your surgeon will manipulate your knee while you are under anesthesia.  Loss of knee flexion will result in difficulties sitting, climbing stairs, and with sleeping.

Start the heel slide exercise immediately after surgery.  Research shows performing active knee exercise (on your own) is better than depending on a continuous passive motion (CPM) machine.  These CPM machines often do not fit properly and lead to unnecessary pain and aggravation.  You are better off lying in your bed and repeatedly sliding your heel up towards your hip on your own. After a week or so you can begin using a belt or a strap to assist. Riding a stationary bike for 5 to 10 minutes daily begins around 2 weeks after surgery. Don’t worry if you cannot perform complete revolutions.  Try rocking back and forth to start.  In a few more weeks, start stretching your knee from the prone lying position.

Final Thoughts on Preventing Stiffness after Your Knee Replacement 

Recovering from your knee replacement surgery is no easy task.  Set yourself up for success. Start early.  Ideally begin exercising several months in advance of your surgery.  Be consistent with your exercises each day and don’t push too hard.  Creating unnecessary pain is unhelpful and can set you back in your recovery.  Most importantly, work closely with your physical therapist.  Your physical therapist will be your guide. It is rarely, if ever, necessary for your physical therapist to be forceful with bending or straightening your knee.  If you have questions or would like some help, give us a call.

6 Strength Training Exercises for Hip and Knee Arthritis

If you are one of millions of Americans bothered by hip or knee arthritis, this post is for you.  And if you would prefer not to rush into popping pills, having injections, or pursuing surgery, this post is really for you.  The following paragraphs are for people who want to take back control of their health and quality of life.  You may be thinking, “But there is no cure for arthritis.”  We disagree.  The Cambridge dictionary defines a cure as something that makes someone who is sick healthy again.  A cure refers to making you, a whole person, healthy again not correcting or reversing some change in your joint.  With this definition in mind, there is no better cure for your hip and knee arthritis than exercise.

There are many different types of exercise which have been proven to be helpful for arthritis.  Aerobic exercise, stretching, yoga, tai chi, aquatics, and balance training are all proven forms of exercise.  This post goes into detail about one of the most effective forms of exercise for people with hip and knee arthritis: strength training.

You may be thinking, “But my knee [or hip] hurts too much to exercise.”  Or someone may have even told you,” Exercise will make your arthritis worse.”  These claims are flat out wrong!  If you accept them as true, you are playing the victim.  Victims wait around for their lives to change.  Successful people create the changes they want in their life.  If you don’t to be a prisoner to your arthritis pain, now is the time do get moving with an exercise program.

A Proven Approach: Strength Training for Arthritis

When we look at the entire body of research done on arthritis it is clear that strength training is beneficial.  A 2019 review of 103 different clinical trials found 4 different types of exercise to be beneficial for people with hip and knee arthritis.  These were aerobics, mind-body exercise (yoga or tai chi), strength training, and stretching.  A regular strength training routine was proven to be beneficial for decreasing pain, improving function, and restoring quality of life.

In 2016, a panel of medical experts across the world reviewed the best evidence looking at exercise for people with hip arthritis. Compared to all other forms of exercise, these experts found strength training to be the best for decreasing pain, improving function, and regaining mobility.  Recommendations include performing one to three 45-minute sessions each week.  You can use exercise equipment at a local gym or fitness center.  For most people, it is more practical to start strength training at home without all the fancy equipment.  The 6 home exercises that follow focus on strengthening your core, hips, and thigh muscles.  They are a great starting point for you.

Band Knee Extension

The quadriceps muscle or “quads” on the front of your upper thigh is crucial for walking, climbing stairs, and standing up from a chair.  The quads of people with hip and knee arthritis are weaker and smaller than people without arthritis.  Weakness places additional stress through your arthritic joints.  Stronger quads reduce joint stress and decrease your pain.  Band knee extension is a great exercise to start working your quads.

Loop a resistance band around your lower leg.  Attach the other end to the leg of a chair or your bed.  Sit up nice and tall with good posture.  Extend your leg straight to activate your quads.  Do this quickly.  Once you have your knee fully extended pause 2 to 3 seconds.  Then slowly lower your leg over a 5 second period.  To review, raise the leg fast, hold 2 to 3 seconds, and then lower it back really slow.  This will give you the best results.  Perform 10 to 15 repetitions for 2 to 3 sets.

Band Knee Flexion

The hamstrings in the back of your thigh are also critical for balance and walking.  Stand to perform this exercise.  Loop a resistance band around your lower leg.  Attach the other end to the leg of a chair or your bed.  Keep a nice tall posture.  Bend your leg behind you but keep your knee directly under your hip.  All movement occurs at your knee.  No movement occurs at your hip.  Bend the leg fast, hold 2 to 3 seconds at the top, and then lower it back really slow.  Perform 10 to 15 repetitions for 2 to 3 sets.

Partial Wall Squats

Many people cringe at the word “squat”.  In fact, you may have even had another healthcare professional tell you to never squat.  Unfortunately, it is impossible to go through life without squatting.  Every time you sit down or get into your car you are squatting.   You might as well get better at it and learn to do it in a way that minimizes stress to your joints.

Stand with your back against a wall.  Place your feet 12 to 18 inches out from the wall.  With your arms crossed over your chest, slowly squat to a depth you are comfortable with.  Start small and as you get strong you will be able to go a little deeper.  Be sure your knees stay in line with your hips and ankles.  Don’t allow your knees to cave in.  Hold the down position for 2 to 3 seconds, and then push up fast back to a standing position.  Perform 8 to 12 repetitions for 2 to 3 sets.


Your glutes are the key muscles that extend your hips to stand up or climb a flight of stairs. The bridge is a great glute exercise to start with.  Begin by lying on your back with the hips bent and your feet lined up with your shoulders.  Perform the bridge by lifting both your hips from the floor.  A common mistake is to excessively arch your low back.  Hold the bridge position for 2 to 3 seconds then return to the starting position slowly over 5 seconds. Perform the lift fast but lower your body back down in a slow and controlled manner.  Perform 10 to 15 repetitions for 2 to 3 sets.

Clam Shell

Your abductor muscles on the outside of your hip are important for stability when you walk, run, or climb stairs.  When these muscles are not working properly, you will walk with a side to side lean or lurch.   This will increase joint stress and increase your risk for falls.

Lie on your side with your hips and knees slightly bent.  Keep your feet together.  Pace a resistance band around your thighs just above your knees. Start the exercise by rotating the top hip to bring the knees apart. Hold this position for 2 to 3 seconds and then return to the starting position slowly over 5 seconds. Be sure to remain completely on your side with one hip stacked on top of the other.  Allowing the pelvis to roll back during the movement is the most common mistake with this exercise. Perform 10 to 15 repetitions for 2 to 3 sets.

Hip Abduction

Lie on your side with the bottom hip and knee bent.  Keep your top knee straight.  Your top hip is maintained in neutral or slight hip extension with the toes pointed forward.  Point your toes forward to orient your hip properly. Initiate the movement by lifting your top leg about 30 degrees.  Hold this position for a count of 2 to 3 seconds and then slowly lower the leg to the start position over 5 seconds.  Perform 10 to 15 repetitions for 2 to 3 sets.  For those who struggle with this exercise, try doing it standing instead of lying down.

This exercise activates the gluteus medius to a greater level than the clam shell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on your side with one hip stacked on top of the other.  Allowing the pelvis to roll back during the movement is the most common mistake.   Also, as your muscle tires, your leg will drift forward into hip flexion.  It is important to maintain your leg lined up or slightly behind your upper body.

Hip and Knee Arthritis: Get Started with Strength Training

The hardest part to any exercise program is getting started.  Commit to performing these exercises a few times each week.  You will see small changes after a few weeks.  Expect to see the best results after consistently exercising for 6 to 12 weeks.  If you don’t feel like you can do it alone, give your physical therapist a call.  The physical therapists at BSR are committed to helping you move without pain.  Exercise is the first treatment for arthritis before resorting to drugs, injections, or surgery.  We want to help you take back control of your health and quality of life.





Knee Replacement and Early Physical Therapy

Nearly 5 million people are living in the United States with a total knee replacement.  This number is rapidly growing.  Knee replacement surgery is helping many people lead happy and active lives for many years.  However, 1 year after surgery only 1/3 are completely satisfied.  Even worse, 30% are dissatisfied.  This is because of knee pain, weakness, difficulty climbing stairs, poor balance, and problems walking.  The truth is that a successful outcome is equally due to the surgery itself and from your rehabilitation.

Physical therapy after knee replacement surgery requires patience and commitment.  There will always be ups and downs.  The recovery process is not smooth.  Your physical therapist is your guide.  He or she assesses your progress along the way and determines the best program for you.  Factors that are important include minimizing your pain, decreasing your swelling, restoring your knee range motion, improving your strength, and correcting your walking pattern.

Health Physical Therapy

Quadriceps Muscle Strength after Knee Replacement

Many research studies prove the importance of quadriceps muscle strength after knee replacement surgery.  Your quadriceps is the large muscle on the front of your thigh.  A 2009 study from the University of Delaware showed superior results 1 year after surgery in people who performed progressive quadriceps exercise compared to those who received standard physical therapy.  Other research shows patients who undergo knee replacement surgery move differently than those who do not.  This occurs when getting out of a chair, climbing stairs, and when walking.  If you develop these compensations you often develop pain in your other knee, low back, or hip.

Performing quadriceps exercise before surgery and soon after surgery is important to achieve the best outcome after your knee replacement.  Early on perform your exercises within your pain tolerance.  You do not want to over stress your knee joint.  By controlling your pain and swelling you will be able to better exercise your quadriceps.  You can perform the 5 exercises in this article within the first few days after surgery.  Progress them based on your ability levels and goals.

Quadriceps Isometric Set

This exercise minimizes quadriceps muscle loss following surgery.   It also helps restore full knee straightening which is important for you to walk without a limp.  Begin with your knee extended and a small towel roll placed under your heel.  Push the back of your knee down towards the floor while simultaneously tightening the front of your thigh.  Hold the contraction for 10 seconds and perform 10 repetitions.  Perform this exercise multiple times per day.

Short-Arc Quadriceps

Lie on your back with a foam roll, pillow, or towel roll under your knee.  Fully extend your knee by kicking the foot up.  Hold this position for 3 to 5 seconds and lower back to the starting position.  Achieving a fully straight knee is very important during this exercise.  Perform 10 to 20 repetitions for 2 to 3 sets each day.  Weights can be added to your ankle as your strength improves.

Terminal Knee Extension in Prone

Lie on your stomach with your ankle bent so you are supported on your toes.  Fully straighten your knee to contract the quadriceps.  Hold this position for 3 to 5 seconds and lower back to the starting position.  Achieving a fully straight knee is very important during this exercise.  Perform 10 to 20 repetitions for 2 to 3 sets each day.  Weights can be added above your thigh as your strength improves.

Terminal Knee Extension with Band

Stand with a resistance band looped around your leg just above your knee.  Begin with your knee slightly bent.  Pull your knee straight by contracting the quadriceps on the front of your thigh.  Hold this position for 3 to 5 seconds then return to the starting position.  Again, achieving a fully straight knee is very important during any quadriceps exercise.  Perform 10 to 20 repetitions for 2 to 3 sets each day.

Sit to Stand

Many people struggle with rising from a chair after knee replacement surgery.  The movement is often painful and limited by weakness.  Start with a higher chair or a chair with several pillows stacked on top.  Be sure to distribute weight equally between legs so you don’t develop compensations.  Perform 5 to 10 repetitions several times per day.

Final Thoughts on Physical Therapy after Knee Replacement 

Many people are plagued by persistent pain and limited walking ability long after knee replacement surgery.  However, progressive strengthening exercise targeting your quadriceps is a proven treatment approach.  These 5 exercises are only a small sample of an early and effective physical therapy program.  Your physical therapist will perform an individual assessment and design an exercise program based on your abilities and goals.  Contact us today if you have questions about which exercises are right for you.

Knee Pain in Women: 5 Exercises for Less Pain

Approximately 1 in 5 women over the age of 18 experience knee pain.  This prevalence of knee pain in women is even higher in those older than 60.  The reasons women are more susceptible to knee pain and injury are based on anatomical, biomechanical, and hormonal factors.  The wider shape and structure of the female pelvis and hips may predispose women to knee injuries.  Women also tend to run, walk and jump with different mechanics than males.  Finally, the female hormones, such as estrogen, make their joints and ligaments are looser and susceptible to injury.

Some of the contributing factors to knee pain in women (pelvis structure, etc.) are not changeable.  However, other factors are under your control.  Several studies have linked problems in muscle strength and coordination to knee injuries and pain in women of all ages.  In particular, deficits of the hip, pelvis, and core muscles are more common in females than males with knee pain.  Thankfully, studies prove these deficits can be improved with exercise and the right exercise programs significantly reduce knee pain.

Proven Exercises for Knee Pain in Women

A 2014 study conducted in Brazil investigated the effects of two different types of exercise programs in women with knee pain.  One group of women performed 8 weeks of traditional thigh muscle strengthening exercises such as the leg extension, leg press, and squats.  The other group of women performed 8 weeks of core, pelvis, and hip muscle strengthening exercises.  These exercises focused on strengthening the hip muscles and improving control of the pelvis and trunk.  Control of the pelvis and spine has been linked to knee injuries in females but these factors are often overlooked in traditional physical therapy programs.

Three months after the study began, the group of women doing the hip, pelvis, and core exercises outperformed those doing the traditional exercises.  Women who performed the hip and core exercises were experiencing less knee pain.  These women also were more satisfied with their overall improvement and functioning at a higher level than those who performed the traditional strengthening exercises.  It is also important to note the women who improved the most demonstrated larger improvements in the lower limb, pelvis, and trunk control during a single leg squat.   This proves the benefits of this type of exercise program.  The following 5 videos are a few examples of the types of exercises that are most helpful for women with knee pain.

90/90 March

Training begins with developing an awareness and control of the pelvis and trunk in supported positions.  The 90/90 March begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 to 20 slow repetitions on each side.  To learn about other progressions of these types of exercise go here.

Hip Extension in Plank Position

Exercises targeting the gluteus medius and gluteus maximus are very important for those with knee pain.  Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.  To learn about other progressions of these types of exercises go here and here.

Sitting 1-Leg Balance

Once exercises are mastered in non-weight bearing positions they are progressed to weight-bearing on 2- and then 1-leg.  Single leg balance on a stability ball is a great place to start this transition.  Begin sitting upright on a ball with your hands on both sides of the pelvis.  Maintain upright and tall throughout the exercise.  Slowly extend 1 leg and hold this position for 10 seconds.  Try alternating sides with each repetition.  Pay special attention to minimizing any lean of the trunk as you transition between legs.

Standing Lateral Rotation

The deep rotator muscles of the hip are important because they assist with controlling rotation (twisting) of the thigh and knee.  This exercise can be challenging at first.  With practice, balance and control will improve.  Start by grasping a resistance band in both hands.  Hold the hands close to the body.  Stand on 1-leg and slowly rotate the body to the opposite side.  Pause 1 second then slowly return to the starting position.  This exercise is typically performed for 10 to 15 repetitions with multiple sets.

Pelvic Drop Exercise

With 1 leg, stand on a small step.  Place the hands on the sides of the pelvis.  The knee remains straight throughout the exercise.  Slowly lower the pelvis and leg down towards the floor.  Lightly tap the floor and return to the starting position.  This exercise targets the gluteus medius muscle and trains control of the pelvis.  Most women struggle in these areas.  This can be a challenging exercise because it requires adequate balance and strength of the glute muscles.

Closing Thoughts about Knee Pain in Women

 Many women are plagued by persistent and nagging knee pain.  However, exercise targeting the hips, pelvis, and core is a proven treatment approach.  These 5 exercises are only a small sample of an effective physical therapy program for knee pain.   Performing thigh muscle strengthening exercises alone is not enough.  Your physical therapist can perform an individual assessment and design an exercise program based on your deficiencies and goals.   Contact us today if you questions about which exercises are right for you.

Meniscus Tears: Exercises to Help You Manage

The meniscus is two curved-shaped pieces of cartilage in your knee. They act as shock-absorbing pads between the bones and cartilage of your thigh and lower leg.  With age, these pads begin to wear away or tear over time. This is a degenerative meniscus tear. Meniscus tears may be painful, but many times are not.  Thankfully, exercise is an effective way for you to treat your meniscus injury.Meniscus of knee

Hundreds of thousands of people undergo surgery for meniscus tears each year. Arthroscopic partial meniscectomy is the most common.  A small incision is made in your knee.  The damaged meniscus is cut away. However, many doctors are now recommending you should not have surgery to remove the damaged meniscus. Instead, exercise, weight management, and education is prescribed as the first course of treatment.

Exercise is Effective for Meniscus Tears

A 2018 study conducted in Europe compared arthroscopic surgery and exercise to a placebo surgery and exercise.  People receiving placebo surgery have a small camera inserted into their knee.  However, the meniscus is left untouched. The camera is removed and the incision closed up.  These research participants were then prescribed an exercise program by their physical therapist. Two years after the surgeries, there were no differences in pain or functional abilities between those who received arthroscopic surgery and the placebo surgery.

Other studies from The Netherlands and Norway have shown equal effectiveness between surgery and physical therapy for treating meniscus tears. These studies were also long-term studies following patients for 2 years. Of course, there are some people with meniscus tears who benefit greatly from surgery. These are typically younger people with acute injuries and complaints of knee locking. However, for the large majority of people with meniscus tears, exercise is the first course of treatment. The following 5 exercises are examples of what might be included in a rehabilitation program at our clinics.

Quadriceps Isometric Set

This exercise minimizes quadriceps muscle loss. The quadriceps muscle is important for everyday activities such as standing up from a chair and climbing steps. The quadriceps set also restores full knee straightening.  Normal walking requires a fully straight knee. To perform the quadriceps set, begin with the knee straight using a small towel roll placed under your heel. Push the back of your knee down towards the floor while simultaneously tightening the front of your thigh.  Hold the contraction for 10 seconds and perform 10 repetitions.

Heel Slides

The heel slide helps restore full knee bending which is important to sit comfortably and climb stairs. Begin with your knee extended and a long towel, belt, or stretch-out strap around your foot. Next, gently slide your heel towards your hip until you feel a mild stretch in your knee. Hold the stretch for 10 seconds and perform 10 repetitions.

Bridge + Hamstring Curl

This exercise strengthens the hamstring muscle on the back of your thigh and knee.  Some of the muscle fibers of the hamstrings attach to the meniscus. Begin lying on your back with an exercise ball under your lower legs. Perform a bridge by pushing your buttocks up from the floor.  Hold the bridge position and curl your feet towards your hips. Pause 2 seconds. Maintain the bridge as you return your legs to the extended position. Finally, lower your buttocks down to the floor.  This completes one repetition. Perform 8 to 10 repetitions for multiple sets each day.

1-Leg Band Kicks

Stability on 1-leg is important for anyone with a meniscus injury. The band kicks train balance and stability on 1-leg. This involves the co-contraction of the quadriceps, hamstrings, and glutes. Begin with a resistance band loop around your ankles. Stand on the injured leg.  Your other leg performs repeated band kicks to the front, side, and back without touching your foot down. It is important to maintain an upright vertical trunk as you perform the kicks. As your balance and stability improve, increase the speed of each kick.

Step Up

Difficulty climbing stairs is a common complaint for people with injuries to the meniscus. It is important to retrain muscular control of stepping up and down on the injured leg.  Begin by stepping with your injured leg up onto a 6 to 8-inch step.  Flex your uninjured leg and bear full weight on your injured leg.  Pause 2 seconds at the top. Return your uninjured leg to the floor followed by your injured leg. Perform 8 to 12 repetitions for multiple sets.

Exercising with a Meniscus Tear

Meniscus tears of the knee can be painful and annoying. Not everyone has to suffer. These 5 exercises are only a small sample of the types of exercises that can help you.  Start on your road to recovery today.  Meet with your physical therapist. Your physical therapist will continually assess your injury and progress your exercise program based on your goals. The objective is to decrease pain and restore function as quickly and safely as possible. Contact us today if you have questions about which treatments are right for you.

Hamstring Strains: 5 Important Exercises for Recovery

Hamstring strains occur at high rates in sports that require running and sprinting. One of every 3 injuries in soccer are hamstring strains.  Other sports with high injury rates include baseball, football, and track and field. These injuries can be very frustrating for athletes.  This is because of the long rehabilitation time. Return to sport may take several weeks or 2 to 3 months based on the severity of the injury. Also, nearly 1 in 3 hamstring injuries will recur and many of these happen within the first 2 weeks of returning to sport.  Thankfully, rehabilitation exercises can help get you back in the game and avoid re-injury.

Your hamstrings consist of three muscles: the semitendinosus, semimembranosus, and the biceps femoris. These 3 muscles start from a common tendon on your pelvis. The hamstrings cross your hip and knee joints attaching just below the back of your knee. Hamstring injuries commonly occur during high speed running.  This occurs as your leg is swinging from a bent to an extended position in preparation for landing. During this phase of running, hamstring muscle activity is extremely high to control the length of the muscle.

Hamstring Injury

The Most Effective Approach to Rehabilitating Hamstring Strains

There are 3 types of rehabilitation exercises which assist in recovery from hamstring strains. Agility exercises involve changes of direction simulating sport movements.  These exercises reduce re-injury rates.  Always initiate these exercises early after your injury. Trunk or core stabilization exercises are also effective at reducing your risk of re-injury.  Finally, exercises that lengthen your injured hamstring can speed up your return to play.

The remainder of this article highlights 5 rehabilitation exercises for hamstring strains.  Three of the exercises progressively lengthen your hamstrings.  These are the active hamstring stretch, the “diver”, and the “glider”.  Perform lengthening exercises slowly and through pain-free ranges at first. Aggressive stretching delays recovery. As you improve, gradually increase the speed and range of movement.

Trunk stabilization exercises target your spine, hip, and pelvic muscles.  To reduce your risk of re-injury, it is important to strengthen your hamstrings and all surrounding muscles. Keep in mind, your hamstring muscle group originates from your pelvis. The position of your pelvis during running can influence the length and activity of your hamstring muscles. Increasing the strength of your injured hamstring itself builds resilience and promotes a safe return to sport.

Active Hamstring Stretch

Lie on your back holding your thigh. Your opposite leg remains straight. With your upper thigh in a vertical position, slowly extend your knee.  At the point where a mild stretch is felt pause and hold. The stretch should not be painful. Gentle stretching of your hamstring is helpful for recovery. Aggressive stretching of your hamstring will delay your recovery. Hold this position for 3 to 5 seconds, and then lower your leg back down.  Perform 3 sets of 12 repetitions once per day.

Cook Hip Lift

Begin lying on your back with your hips bent and feet lined up with your shoulders.   Pull your knee of the uninjured leg up to your chest. It is helpful to place a small towel roll or ball in the crease of your hip. Lift your toes off the floor and perform a bridge from your other leg. Be sure to achieve the bridge position by extending through your hips, not your low back. Hold this position for 2 to 3 seconds then return to the starting position. Typically, 2 to 3 sets of 10 to 15 repetitions are performed on each side once per day.

Bridge Walk-Out

Begin lying on your back with your hips bent and the feet lined up with your shoulders.  Perform the bridge by lifting both hips from the floor.  Hold the bridge position and alternately walk your feet out away from your body.  It is important to maintain a level pelvis throughout the exercise.  After 2 to 3 steps walk your feet back to the starting position.   Lower your body back down in a slow and controlled manner between each repetition.  Typically, 3 sets of 6 to 8 repetitions are performed once per day.

Hamstring “Diver”

This exercise resembles a simulated dive. Stand on your injured leg with your knee slightly bent. Bend forward at the hip and simultaneously stretch your arms forward. Your back should remain flat.  Your opposite knee remains bent as your hip extends.  Perform this exercise very slowly in the beginning. As a progression, you can increase the speed and range of motion. Typically, 3 sets of 6 to 8 repetitions are performed every other day.

Hamstring “Glider”

Begin in a standing position with one hand holding on to a support. Your legs are slightly split. All your body weight is on the heel of your injured (front) leg with your knee slightly bent. The motion is started by gliding backward on your other leg (wearing only a sock).  As always, stop just before pain is felt. The movement back to the starting position is performed with the help of your arms, not using your injured leg. Begin slowly in a pain-free range of motion. Progression is achieved by increasing the gliding distance and performing the exercise faster. This exercise requires slightly more recovery between each session. Typically, this exercise is performed 3 times per week for 3 sets of 6 receptions.

Get Started Soon

Your rehabilitation after a hamstring injury should begin as soon as possible. Initiate pain-free agility and trunk stabilization exercises immediately.  Also perform lengthening exercise soon after your injury, but be gentle.  It is best to perform these under the supervised of a licensed physical therapist. The progression of an athlete’s rehabilitation program is based on specific criteria. Your physical therapist will continually assess your injury and progress your program.  Our goal is to get you back as quickly and safely as possible. Contact us today if you have had a hamstring strain or simply have questions about which treatments are right for you.

Knee Replacement: Pre Surgery Physical Therapy

In the United States, more than 600,000 people undergo total knee replacement surgery each year. This number is expected to rise to over 1 million by the year 2025.  Success rates for knee replacement surgery are high.  Almost 90% of people report less pain and improved function.  Post surgical rehabilitation is considered an integral part of the recovery process.

Rehabilitation following surgery can make or break your long-term outcome.  With proper physical therapy, you can expect to perform most activities of daily living within 6 weeks.   You can expect to begin driving within 3 to 6 weeks depending on which leg is operated on.  Most people take 6 months to a year to fully recover.   However, new research is suggesting pre surgical physical therapy can expedite your recovery.

Preoperative Exercise for Knee Replacement

In 2017, researchers in Spain investigated the effects of intensive strength training prior to knee replacement surgery.  One group of patients performed the exercise program and another group did not.   The exercise program was performed 3 days per week for 8 weeks and supervised by a physical therapist.  Outcome following surgery favored the group of patients who performed the exercise program.   Hospital stay was significantly shorter in those who performed preoperative exercise.  Pain levels were less in those who exercised.  Also, these patients recovered greater strength, range of motion, and function 3 months after surgery.

Prior to knee replacement surgery, you should focus on 3 goals.  The first goal is to restore as much knee range of motion as possible.  It is especially important to have a fully straight knee in order to walk with normally.  The second goal is to maximize strength of your quadriceps muscle.  This muscle is responsible for walking, climbing stairs, and getting you up from a chair.  Your quadriceps muscle becomes very weak immediately after surgery.  The third goal is to normalize your walking pattern.  The following 5 videos include exercises that we commonly prescribe prior to knee replacement surgery.

Quadriceps Isometrics

This exercise can minimize quadriceps muscle loss following your surgery.   It also helps restore full knee straightening.  Begin with your knee extended with a small towel roll placed under your heel.  Push the back of your knee down towards the floor while simultaneously tightening the front of your thigh.  Hold the contraction for 10 seconds and perform 10 repetitions.

Knee Extension Stretch

This exercise also helps restore full knee straightening.  Again, this is imperative to walk normally.  Begin with your knee extended with a small towel roll placed under your heel.  Place a long towel, belt, or stretch-out strap around your foot.  Gently pull your toes towards your shin while keeping your knee straight.  Hold the stretch for 10 seconds and perform 10 repetitions.

Heel Slides

The heel slide helps restore full knee bending.  This is important to sit comfortably and climb stairs.  Begin with your knee extended with a long towel, belt, or stretch-out strap around your foot.  Gently slide your heel towards your hip until a mild stretch is felt in your knee.  Hold the stretch for 10 seconds and perform 10 repetitions.   The more your knee bends prior to surgery, the easier it will be to regain range of motion after surgery.

Sit to Stand

This exercise involves an activity that older adults perform frequently in their daily lives.  The ability to transfer from a chair without the assistance of your hands has been linked to fall risk in older adults.  It can be easily performed in the physical therapy clinic, any community exercise studio, or in your home.  The exercise is progressed by lowering the height of the chair or by holding weighted objects such as a medicine ball or kettle bell.

Single Leg Balance

The ability to balance on one leg is important to walk normally and negotiate a step or curb.  Use the assistance of a chair or a counter if needed.  As you improve, progress away from using assistance.  Aim for at least 10 seconds on each side.  Start with 5 to 10 repetitions each day.

Pre Surgery Physical Therapy Before Knee Replacement: Closing Thoughts

Preoperative physical therapy reduces your pain and results in a faster recovery from total knee replacement surgery.  The preoperative exercise program should be individualized based on your needs and goals.  Meet with your physical therapist to determine the exercises that are best for you to perform prior to your surgery.  Call us if you have questions about getting started.

Patellofemoral Pain Syndrome:  How a Physical Therapist Can Help

Patellofemoral pain syndrome refers to pain in the front of the knee or around the kneecap (patella).  It is the most common form of knee pain.  Patellofemoral pain syndrome is sometimes referred to as runner’s knee.  However, anyone can get it.  It commonly affects runners, cyclists, and office workers or anyone else who sits for a long periods.  Patellofemoral pain syndrome is also very common in teens, particularly girls.

Pain often occurs when friction is created between the undersurface of the kneecap and the thigh bone (femur).  Tenderness can be found along the edges of the kneecap.  The ligaments and soft tissues surrounding the knee cap can also become sensitive.  Changes within the nervous system may lead to the area of pain spreading to other areas of the knee.

Pain is often experienced with the following activities:

  • Walking up or down stairs
  • Walking on uneven surfaces
  • Squatting or standing up from a chair
  • Pain that increases with activity and improves with rest
  • After sitting for long periods of time with the knee bent
  • A “crack” or “pop” when bending or straightening the knee

Tracking of the Kneecap

Knee cap tracking

Anatomy allows the kneecap to slide smoothly on the femur in a groove (situated along the thigh bone) during movement.   Excessive friction between the undersurface of the kneecap and the femur can occur when the knee cap moves slightly out of this groove.   This is similar to a train sliding slightly off its track.

The kneecap may fail to track properly in its groove when the quadriceps muscle on the inside front of the thigh is weak.   Weakness of the hip muscles may also cause the track (femur) to move underneath the train (kneecap).   Also, the kneecap is pulled in the direction of any tight muscles or ligaments.  Any of these factors can cause the kneecap to track or tilt to the side, which irritates the tissues around the kneecap.

Physical Therapy for Patellofemoral Pain Syndrome

Manual therapy performed by a licensed physical therapist alleviates pain from patellofemoral pain syndrome.  Joint mobilization involves stretching the ligaments which attach to the kneecap.  This improves mobility of the kneecap allowing it to remain situated in its normal groove.  Soft tissue techniques to the surrounding muscles also alleviate pain and improve mobility of the kneecap.  Common muscles treated include the hamstrings, quadriceps, and iliotibial band.

manual therapy

Strengthening exercise is the foundation of any rehabilitation program for patellofemoral pain syndrome.  Research indicates strengthening exercise for the quadriceps and hip muscles is the most effective intervention for this condition.  Initial exercises should be pain free.  Exercise is started in non-weight bearing or lying positions.  Examples include the clam shell or bridge.  Once a baseline level of strength has been established, standing or weight bearing exercises are performed.

Rehabilitation involves improving poor movement patterns.  In order to uncover the cause of pain or poor movement, whole movement patterns must be assessed and treated.  For individuals with pain in the front of their knee, isolated treatments to the knee rarely provide complete relief.  The brain stores patterns of movement and then signals muscles to execute what is believed to be the most efficient pattern. With repeated performance of compensatory movement patterns, the abnormal becomes the new normal.  These patterns can be reprogrammed and corrected with appropriate movement training by physical therapists.

Closing Thoughts

Exercise is the most effective treatment for people with patellofemoral pain syndrome.  Less than 5% of people with this problem will undergo surgery.  The long-term success of these surgeries is questionable at best.  Physical therapists prescribe individualized exercise programs which are unique to each person’s needs and goals.  Of course, the long-term success of any exercise program is dependent on consistency and discipline.

Knee Arthritis:  How Physical Therapy Can Help

Osteoarthritis is a condition where the protective cartilage of the joint surfaces breaks down.  The cartilage serves as a pad or cushion to the bone beneath it.  The knee, hip, and spine are the most joints where osteoarthritis develops.  In the knee, this can occur on the end of the thigh bone (femur), the lower leg bone (tibia), or both.   Arthritis can also be present underneath the knee cap.   When the cartilage wears away, the body responds by laying down additional bone.  This results in spurs and narrowing of the joint space.

knee arthritis

Knee arthritis is not always associated with pain.  Also, “severe” arthritis viewed on x-rays may result in only mild pain.  Likewise, mild arthritis may result in higher levels of pain.  The experience of pain is complex.  Joint inflammation, joint stiffness, muscle weakness, muscle tightness, and changes within the nervous system can all contribute to pain experienced from arthritis.

Symptoms of Knee Arthritis

Knee arthritis typically affects people over 50 years of age, although it can be present in younger people.  It is more common in females.   Common symptoms include stiffness early in the morning or when initiating walking after prolonged sitting.  Pain, stiffness, weakness, and cracking or popping sounds are hallmark signs.  The pain is generally worse with weight-bearing activities (e.g., walking, standing, or twisting).  Most people experience “flare-ups” of increased pain and stiffness interspersed with periods of little or no pain.

Physical Therapy for Knee Arthritis

Recent research shows several types of exercise are effective for improving pain and function in people with knee arthritis.  This includes aerobic exercise, strengthening exercise and stretching.

knee arthritis

Aerobic exercise for people with arthritis is backed bys solid research. Regular walking for 30 minutes five days per week is recommended.  Continuous walking is preferred but if a person is unable to perform one 30-minute walk, multiple shorter walks totaling 30 minutes can be employed.  Physical therapists help patients begin and progress an individualized walking program.  Cycling, swimming, and other forms of aerobic exercise can also be incorporated.  However, walking programs show the greatest improvements.

An individualized muscle strengthening program is prescribed for patients with knee arthritis.  The quadriceps and hip muscles are targeted.  These muscles are important for walking, climbing stairs, and transferring from sitting to standing.  Weakness of the quadriceps muscle on the front of the thigh is common in people with knee arthritis.  Strengthening both the quadriceps and hip muscles has been shown to produce the greatest improvements in walking ability.   Sit to stand training is an excellent way to incorporate both of these muscle groups.

Knee arthritis results in stiffness of the joint capsule and ligaments.  The surrounding muscles shorten further limiting range of motion.  Stretching exercises to improve knee straightening (extension) range of motion is important to restore normal walking patterns.  Manual therapy performed by a physical therapist is often needed to achieve sufficient improvements in people with longstanding stiffness.  Manual therapy may be incorporated at the knee, hip, ankle, or spine joints.  This is because problems at the knee are often associated with problems at neighboring joints.

Closing Thoughts

Knee arthritis does not have to be a disabling condition.  Exercise can be very effective for improving pain, function, and quality of life.  Many people are unsure how to start and what type of exercise is best for their goals.  Meet with your physical therapist to develop an individualized exercise program that meets your needs.


  1. Goh SL, Persson MSM, Stocks J, et al. Relative efficacy of different exercises for pain, function, performance and quality of life in knee and hip osteoarthritis: Systematic review and network meta ‑analysis. Sport Med. 2019;49(5):743-761.
  2. Hislop AC, Collins NJ, Semciw AI, Tucker K, Deasy M. Does adding hip exercises to quadriceps exercises result in superior outcomes in pain, function and quality of life for people with knee osteoarthritis? A systematic review and meta-analysis. Br J Sports Med. 2019;0:1-10.