Knee Replacement: Quadriceps Weakness Slowing You Down?

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 active lives for many years.  However, only 1/3 are completely satisfied with their function 1 year after surgery.  Even worse, 30% are dissatisfied because of knee pain, weakness, difficulty climbing stairs, poor balance, and poor walking ability.  Many within the medical community believe a successful outcome is equally due to the surgery itself and from the rehabilitation process.

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

Quadriceps Muscle Strength after Knee Replacement

Growing evidence from research studies are showing the importance of restoring quadriceps muscle strength after knee replacement surgery.  A 2009 study from the University of Delaware showed superior outcomes 1 year after surgery in patients who performed progressive quadriceps exercise compared to those who received standard physical therapy.   Other research shows patients who undergo knee replacement surgery move with different strategies when getting out of a chair, climbing stairs, and when walking.  Patients who develop these compensations often develop pain in the other knee, low back pain, or hip pain.

Performing quadriceps exercise before surgery and soon after surgery is important to achieve the best long-term outcome after knee replacement surgery.  Early exercises are performed within the patient’s pain tolerance and should not overstress the knee joint.  Controlling pain and swelling will assist with the return of the quadriceps muscle.  The following 5 exercises are performed within the first few days after surgery and are progressed based on the patient’s 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 to walk without a limp.  Begin with the knee extended and a small towel roll placed under the heel.  Push the back of the knee down towards the floor while simultaneously tightening the front of the thigh.  Hold the contraction for 10 seconds and perform 10 repetitions.  This can be performed multiple times per day.

Short-Arc Quadriceps

Lie on your back with a foam roll, pillow, or towel roll under your knee.  Fully extend the 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 the ankle as your strength improves.

Terminal Knee Extension in Prone

Lie on your stomach with the ankle bent so you are supported on your toes.  Fully straighten the 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 the thigh as your strength improves.

Terminal Knee Extension with Band

Stand with a resistance band looped around your leg just above the knee.  Begin with the knee slightly bent.  Pull the knee straight by contracting the quadriceps on the front of the thigh.  Hold this position for 3 to 5 seconds then return 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.

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.

Get Started Today

Many people are plagued by persistent pain and limited walking ability long after knee replacement surgery.  However, progressive strengthening exercise targeting the quadriceps is a proven treatment approach.  These 5 exercises are only a small sample of an effective physical therapy program.  Your physical therapist will perform an individual assessment and design an exercise program based on your deficiencies 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 layers of cartilage in your knee joint. They act as shock-absorbing pads between the bones and cartilage of your thigh and lower leg. As people age, these pads may begin to wear away or tear over time. These changes are typically called degenerative meniscus tears. Meniscus tears can be painful, but not always, and can limit mobility. Thankfully, exercise is an effective treatment option for people with meniscus injuries.

Meniscus of knee

Hundreds of thousands of people undergo surgery for meniscus tears each year. A type of surgery called arthroscopic partial meniscectomy is the most common. With this surgery, a small incision is made in the knee and the damaged pieces of the meniscus are cut away. However, based on the latest research studies, many doctors are recommending you should not have surgery to remove the damaged meniscus. Instead, exercise, weight management, and education are being prescribed as the first course of treatment.

Research Shows Exercise is Effective for Meniscus Tears

A 2018 study conducted in Finland compared arthroscopic surgery and exercise to a placebo surgery and exercise. Those patients receiving placebo surgery had a small camera inserted into the knee joint but the meniscus was left untouched. The camera was removed and the patients were then prescribed an exercise program by a physical therapist. Two years after the surgeries, there were no differences in pain or functional abilities between those who received arthroscopic surgery and 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 individuals 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 can minimize quadriceps muscle loss. The quadriceps muscle is important for everyday activities such as standing up from a chair and climbing steps. This exercise also helps restore full knee straightening which is imperative for a normal walking pattern. To perform the quadriceps set, begin with the knee extended using a small towel roll placed under the heel. Push the back of the knee down towards the floor while simultaneously tightening the front of the 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 the knee extended with a long towel, belt, or strap around the foot. Gently slide the heel towards the hip until a mild stretch is felt in the knee. Hold the stretch for 10 seconds and perform 10 repetitions.

Bridge + Hamstring Curl

This exercise strengthens the hamstring muscle group on the back of the 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 the lower legs. Perform a bridge by pushing the 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 the buttocks down to this floor.  This completes one repetition. Typically 8 to 12 repetitions are performed for multiple sets each day.

1-Leg Band Kicks

Stability one 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 looped around the ankles. Stand on the injured leg. The other leg performs repeated band kicks to the front, side, and back without touching the 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 the injured leg up onto a 6 to 8-inch step. The uninjured leg is flexed as you bear full weight on to the injured leg.  Pause 2 seconds at the top. Return the uninjured leg to the floor followed by the injured leg. Perform 8 to 12 repetitions for multiple sets.

Final Thoughts on Meniscus Tears

Meniscus tears of the knee can be painful and debilitating. Not everyone has to suffer. These 5 exercises are only a small sample of the types of exercises that can help. Meet with your physical therapist and get started on the road to recovery. 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 knee pain or simply have questions about which treatments are right for you.

Hamstring Strains: 5 Exercises for Recovery

Hamstring strains occur at high rates in sports which require running and sprinting.One of every 3 injuries in soccer is hamstring strains.  Other sports with high injury rates include baseball, football, and track and field. These injuries can be very frustrating for athletes 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 athletes can back in the game and avoid re-injury.

The hamstrings consist of three muscles: the semitendinosus, semimembranosus, and the biceps femoris. The three muscles originate from a common tendon on the pelvis. The hamstrings cross the hip and knee joints attaching just below the back of the knee. During high-speed running the hamstring muscle is commonly injured as the 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

Research indicates there are 3 types of rehabilitation exercises which assist in recovery from hamstring strains. Agility exercises which involve changes of direction simulating sport movements reduce re-injury rates. These exercises can be initiated early after the acute injury. Trunk or core stabilization exercises are also effective at reducing risk of re-injury.  And exercises which lengthen the injured hamstring can speed up an athlete’s return to play.

The remainder of this article highlights 5 rehabilitation exercises for hamstring strains.  Three of these exercises are intended to progressively lengthen the injured hamstrings.  These are the active hamstring stretch, the “diver”, and the “glider”. Lengthening exercises are performed slowly and through pain-free ranges at first. Aggressive stretching can delay recovery. As the athlete improves, the speed and range of motion of these exercises are gradually increased.

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

Active Hamstring Stretch

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

Cook Hip Lift

Begin by lying on your back with your hips flexed and feet lined up with the shoulders.   Pull the knee of the uninjured leg up to the 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 the other leg. Be sure to achieve the bridge position by extending through the hips, not the 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 by lying on your back with your hips flexed and the feet lined up with the shoulders.  Perform the bridge by lifting both hips from the floor.  Hold the bridge position and alternately walk the feet out away from the body.  It is important to maintain a level pelvis throughout the exercise.  After 2 to 3 steps walk the feet back to the starting position.   Lower the 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 the injured leg with the knee slightly bent. Bend forward at the hip while simultaneously stretching the arms forward. The back should remain flat. The opposite knee remains bent as the hip extends. This exercise should be performed very slowly in the beginning. As a progression, the speed and range of motion can be increased. Typically, 3 sets of 6 to 8 repetitions are performed every other day.

Hamstring “Glider”

Begin from a standing position with one hand holding on to a support. The legs are slightly split. All the body weight is on the heel of the injured (front) leg with the knee slightly bent. The motion is started by gliding backward on the other leg (wearing only a sock) and stopped before pain is reached. The movement back to the starting position is performed with the help of the arms, not using the 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.

Getting Started with Exercise After a Hamstring Strain

Rehabilitation for hamstring strains should begin early after injury. Pain-free agility and trunk stabilization exercise are initiated immediately. Lengthening exercise can be safely performed soon after injury when supervised by 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. The goal is to return the injured athlete 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.

Physical Therapy before Knee Replacement

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 performmost 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 rehabilitation 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 a normal pattern.  The second goal is to maximize strength of the quadriceps muscle.  This muscle is responsible for walking, climbing stairs, and getting up from a chair.  The quadriceps muscle becomes very weak immediately after surgery.  The third goal is to normalize your walking pattern.  The following 5 videos include exercises which physical therapists commonly prescribe prior to knee replacement surgery.

Quadriceps Isometrics

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

Knee Extension Stretch

This exercise also helps restore full knee straightening which is imperative to walk normally.  Begin with the knee extended with a small towel roll placed under the heel.  Place a long towel, belt, or strap around the foot.  Gently pull the toes towards the shin while maintaining the knee straight.  Hold the stretch 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 the knee extended with a long towel, belt, or strap around the foot.  Gently slide the heel towards the hip until a mild stretch is felt in the knee.  Hold the stretch for 10 seconds and perform 10 repetitions.   The more the 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 which older adults perform frequently in their daily lives.  The ability to transfer from a chair without the assistance of the 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 the 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.

Closing Thoughts

Preoperative physical therapy reduces pain and results in faster recovery of function following total knee replacement surgery.  The preoperative exercise program should be individualized based on your needs and goals.  Meet with your physical therapist to determine which exercises are best for you to perform prior to your surgery.

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.


Total Knee Arthroplasty (Replacement)

Total Knee Replacement (TKR), also known as a Total Knee Arthroplasty (TKA), is a surgical procedure commonly used to relieve knee pain due to arthritis or in some cases trauma-related injury. TKR is a viable option when the individual’s function is extremely limited due to pain and when conservative care, an exercise program, and weight loss was not substantially effective in relieving symptoms. Greater than 600,000 TKR are performed each year with approximately 90% of individuals experiencing significant symptom reduction.

Knee Replacement Surgery

There are multiple surgical approaches with Total Knee Replacement with most common types being Traditional and Minimally Invasive Surgery (MIS). In both approaches, the damaged cartilage and bone surfaces are removed and replaced with prosthetic implants. The Traditional approach will typically result in an 8-12 inch scar, whereas the MIS results in a 3-4 inch incision. Research suggests outcomes for both procedures are similar over the long term, with fewer complications experienced with the Traditional approach.

The Role of Physical Therapy

Following TKR most individuals are fully weighted bearing on the involved lower extremity, but will likely have to use an assistive device for a short period (walker, crutches, cane). Best evidence supports that patients receive outpatient orthopedic physical therapy where the focus is on restoring normal knee motion, strength training, normalizing walking patterns and restoration of prior functional/recreational activities. Your physical therapist will work with you targeting your greatest impairments and develop a plan of care to help you achieve your goals. The entire surgery and rehabilitation process is typically 12 weeks in length with continued functional gains made after 12 weeks by the performance of a home exercise program.

A recent study suggests that approximately 98% of individuals who undergo TKR will be able to return work, including heavy work activities. Depending on the type of work patients with sedentary jobs can return to their work tasks as early as 1 month after surgery, whereas more strenuous jobs may take up to 3 months. Patients can expect to realistically return to walking without an assistive device, swimming, golfing, driving, light hiking, biking, dancing, and other low-impact sports. However, outcomes are specific to each patient and is based on prior levels of function.

Closing Thoughts

Physical therapy following knee replacement surgery requires a team approach between the patient, surgeon, and physical therapist.  If you are considering undergoing a knee replacement, or have recently undergone this procedure, please call one of our physical therapists to learn more about your recovery and return to function.


-Dr. Jermemy Boyd, PT, DPT, OCS