Science Behind Our WHY

Our experience in treating people with symptomatic knees has been closely mirrored by what the studies show us about knee pain. Whether you have knee pain that comes and goes, or severe arthritis that is worsening with time, therapy exercises can and do offer a proven way to improve your symptoms. Below is a brief review of the various diagnoses and studies that support our therapeutic intervention and exercise system.

Knee Pain

Knee Arthritis

This 2019 study demonstrates that having and maintaining hip abduction strength helps maintain function and decrease symptoms

Hip Muscle Strength and Protection Against Structural Worsening and Poor Function and Disability Outcomes in Knee Osteoarthritis.

 

This 2018 article describes how it does not matter if you run long distances or not – long distance running does not increase your chance of developing osteoarthritis.

The next three articles demonstrate that exercises do improve the symptoms associated with knee arthritis; there is no down side to range of motion and strengthening. In fact, these exercises will make your knee feel better.

Is there an association between a history of running and symptomatic knee osteoarthritis? A cross-sectional study from the osteoarthritis initiative.

 

 

The next 4 articles review the benefits and value of a home based exercise program.

Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial.

Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial.

Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.

The contribution of home based exercise programme in case of osteoarthritis of the knee.

 

 

The 2013 review article states that resistance training (ie strengthening) has been shown to be effective at decreasing pain and improving physical function.

Resistance Exercise for Knee Osteoarthritis

 

This 2013 review article states that “current evidence strongly supports exercise as a pain-relieving option in patients with knee OA.”

The pain-relieving qualities of exercise in knee osteoarthritis

 

This review article for 2011 states that “muscle strengthening and aerobic exercise are effective in reducing pain and improving physical function in patients with mild to moderate OA of the knee”.

Effectiveness of exercise for osteoarthritis of the knee: A review of the literature

 

The American Academy of Orthopaedic Surgeons state that there is strong evidence for self management programs such as this one for symptomatic knee arthritis.  They state that the strength of their recommendation is strong. 

 

Patellofemoral Pain

This 2018 article explains to us that improving knee function is more than just working on the quads, but it is a balance of many muscles – the quads, hamstrings, hips, and core.  To optimize knee function means to strengthen core and leg muscles.

Added value of isolated core postural control training on knee pain and function in women with patellofemoral pain syndrome: a randomized controlled trial.

 

This 2017 review states “There is consistent evidence that exercise therapy for PFP may result in clinically important reduction of pain in the short, medium and long terms; improvement in functional ability in the medium and long terms, as well as enhancing long-term recovery.”

Patellofemoral pain in athletes: clinical perspectives

 

 

This 2015 review reports that balance, stretching, and strengthening are the programs that are most effective in relieving patellofemoral pain and improving function.

Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: a systematic review

 

 

The 2017 review stated hip and knee strengthening is effective in decreasing pain and improving activity in people with patellofemoral pain.

Hip and Knee Strengthening Is More Effective Than Knee Strengthening Alone for Reducing Pain and Improving Activity in Individuals With Patellofemoral Pain: A Systematic Review With Meta-analysis.

 

This review of 31 studies from 2015 found that there is consistent evidence that exercise therapy for patellofemoral pain reduces pain and improves function in the long term. 

Exercise for treating patellofemoral pain syndrome

 

This 2016 consensus statement has the top 2 recommendations as: 1) exercise-therapy is recommended to reduce pain in the short, medium and long term, and improve function in the medium and long term, and 2) Combining hip and knee exercises is recommended to reduce pain and improve function in the short, medium and long term, and this combination should be used in preference to knee exercises alone.

2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures

 

Research published in the Journal of the American Medical Association in 2013 shows weight loss also lowers levels of the bodywide inflammation that contributes to joint damage in OA and related conditions.

 

This study from American Journal of Sports Medicine showed that a 6 week PT program will cause a significantly greater decrease of average pain, worst pain, and disability when compared to non PT program-  also states the common nature of pfp, occurring in 7-15 % of population

Physical Therapy for Patellofemoral Pain: A Randomized, Double-Blinded, Placebo-Controlled Trial

 
 

Meniscus Tear

This review study from 2019 indicates no added benefit for knee arthroscopy over exercise/therapy with underlying knee arthritis.

Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis.

 

This 2014 review states that most meniscus tears in adults can be treated with a physical therapy program, but even if they do require surgery at some point they have the same outcomes as though they were treated with surgery initially. In other words, physical therapy alone may resolve the symptoms – or if surgery is performed, there is no detriment in having waited.

Treatment of meniscal tears: An evidence based approach

 

A 2016 study found “Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.”

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up.

 

A 2015 consensus statement concerning ACL tears states “in the absence of reliable evidence, it is the recommendation of APTA that a patient with an ACL tear who is not having ACL reconstruction undergo rehabilitation with goals of (1) full and pain free knee joint ROM is restored (equal to that of the contralateral limb), (2) thigh muscle strength and single hop test indexes are at least 90% (ratio of involved to uninvolved limb performance), and (3) self-reported knee function on reliable, valid, and responsive questionnaires is at least 90%.

This study from May 2013 demonstrates that patients with a meniscus tear do about the same at 6 months if they’ve had either an arthroscopy or just physical therapy.  The interesting thing is that 30 % of the patients enrolled in the physical therapy arm ended up crossing over to arthroscopy arm.

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

 

This 2016 study looked at why people who are initially assigned to PT end up under going an arthroscopy for a MMT, finding that shorter duration of pain and increased pain score (meaning their knees seemed to hurt more)- they stated “PT pre-op did not compromise the surgical outcome”

Predictors and Outcomes of Crossover to Surgery From Physical Therapy for Meniscal Tear and Osteoarthritis: A Randomized Trial Comparing Physical Therapy and Surgery

 

This 2018 article in JAMA stated that at 2 years their study patients that had PT did the same as though that had arthroscopic surgery- although 29 % of patients assigned to PT crossed over to have surgery and 5 % of surgery patients never had surgery.

Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears

 

This 2002 study from New England Journal of Medicine found that arthroscopy when used for knee arthritis offered no additional benefit compared to doing nothing at multiple time points up to 2 years

A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

ACL Tear

This 2019 review demonstrated that the 3 types of autografts (bone-patellar tendon-bone, hamstring, quadriceps tendon) all had relatively similar outcomes, but allografts had a higher failure rate in younger people that seemed to equalize to autografts at age 35-40

Outcomes Following ACL Reconstruction Based on Graft Type: Are all Grafts Equivalent?

 

This 2010 study shows that a primarily home-based PT program for an ACL reconstruction does as well, if not better, than a therapy program performed at a physical therapy clinic.

Two- to 4-Year Follow-up to a Comparison of Home Versus Physical Therapy-Supervised Rehabilitation Programs After Anterior Cruciate Ligament Reconstruction

 

This 2005 study reports that the number of physical therapy visits did have an effect on outcome. In fact, the patients that went to only 4 physical therapy sessions instead of 17 did better. They all did home exercises during the course of the study.

Comparison of Home versus Physical Therapy-Supervised Rehabilitation Programs after Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial

 

This 2012 review stated how range of motion after ACL reconstruction is vital to long term outcomes.  Patients who did not return their knees to their full range of motion had higher rates of arthritis and lower subjective scores.

Osteoarthritis after anterior cruciate ligament reconstruction: the importance of regaining and maintaining full range of motion.

 

This 2012 article states that the chance of getting arthritis after ACL surgery is lower in patients who achieve full range of motion afterwards.

Loss of Normal Knee Motion After Anterior Cruciate Ligament Reconstruction Is Associated With Radiographic Arthritic Changes After Surgery  

 

This 2014 review states that there is no consensus as to optimal timing of ACL reconstruction, but waiting at least 3 weeks lowers risk of arthrofibrosis (knee stiffness due to scarring after surgery).

ACL RECONSTRUCTION ‐ it is ALL ABOUT TIMING

 

This 2018 article states that people who delay having ACL reconstruction may be at higher risk for developing medial meniscus tears. 

Relationship Between Time to ACL Reconstruction and Presence of Adverse Changes in the Knee at the Time of Reconstruction

 

This 2016 study suggests that performing knee rehab extensively prior to ACL reconstruction results in better 2-year post-op outcomes. 

Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction?: A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts

 

This 2005 study reports that the number of physical therapy visits had an inverse effect on outcome. There were two group tested, one that did 4 visits and one that did 17 visits.  Both groups did home exercises during the course of treatment.  The ones that visited physical therapy only 4 times did better than those that visited physical therapy 17 times.  

Comparison of Home versus Physical Therapy-Supervised Rehabilitation Programs after Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial

Total/Partial Knee Replacement

These three articles debate how much activity can be performed after a total knee replacement. A total knee replacement is designed to allow patients to return to activity without the pain they had previously. However, no one is certain whether high impact exercises wear the knee components down versus low impact exercises. These articles state no difference in survival rates to total knee replacements with high vs low impact exercise.

Recommendations for patient activity after knee replacement vary among surgeons.

Sports participation does not affect TKA durability.

Physical activity after total joint arthroplasty.

 

These two studies compared the use of cryotherapy, the first from the Journal of Arthroplasty in 2002 found that continual cold therapy after total knee replacement offered improvement in range of motion, pain control, and bleeding compared to no cold.  The other study was a review published in the Journal of Orthopaedic Surgery in 2019 found that there was benefit to cryotherapy but limited high level evidence

Continuous-flow Cold Therapy After Total Knee Arthroplasty

Cryotherapy Following Total Knee Arthroplasty: What Is the Evidence?

Knee Injections

This 2020 publication from Emedicine reviewed the current evidence for intraarticular knee injections for arthritis stating that all 3 types of injections (cortisone, hyaluronic acid, and prp) provide pain relief with different advantages and disadvantages.

Knee Injection