Physical Therapy Management of Knee Osteoarthritis

in the Middle-aged Athlete

Thomas Adams, PT, DPT, CSCS,* Debra Band-Entrup, PT, BS,*w Scott Kuhn, PT, MS, ATC,*
Lucas Legere, PT, MS,w Kimberly Mace, PT, MS, CSCS,w Adam Paggi, PT, DPT,w and
Matthew Penney, PT, DPT, SCS, ATC*
Abstract: Osteoarthritis (OA) is prevalent in todays population,
including the athletic and recreationally active middle-aged
population. OA is a degenerative condition of the articular/hyaline
cartilage of synovial joints and commonly aects the knee joint. In
general, athletic participation does not specically inuence a
higher incidence of knee OA in this population; however, traumatic
injury to the knee joint poses a denitive risk in developing early-
onset OA. The purpose of this article is to review evidence-based
nonpharmacological interventions for the conservative manage-
ment of knee OA. Manual therapy, therapeutic exercise, patient
education, and weight management are strongly supported in the
literature for conservative treatment of knee OA. Modalities
[thermal, electrical stimulation (ES), and low-level laser therapy
(LLLT)] and orthotic intervention are moderately supported in the
literature as indicated management strategies for knee OA. While
many strongly supported conservative interventions have been
published, additional research is needed to determine the most
eective approach in treating knee OA.
Key Words: osteoarthritis, knee, athlete, physical therapy, reha-
bilitation, intervention, manual therapy, therapeutic exercise,
modalities
(Sports Med Arthrosc Rev 2013;21:210)
A
rthritis is the most common cause of disability among
US adults
1
with costs attributable to arthritis and other
rheumatic conditions estimated at $128 billion in 2003.
2
In
2005, approximately 27 million US adults were diagnosed
with clinical osteoarthritis (OA) aecting quality of life
through pain and functional limitations.
3
The number of
US adults with arthritis is projected to rise to 67 million by
2030.
4
Recent research reports increased prevalence of knee
OA among middle-aged athletes and former professional
athletes. In a New Zealand study of 22 male ex-table tennis
players, 78% of the players displayed radiologic evidence of
knee OA as compared with 36% in age-matched and sex-
matched controls.
5
In a 2012 systematic review out of the
Netherlands, between 60% and 80% of former elite soccer
players developed radiologic evidence of knee OA.
6
In
addition, a study in the United Kingdom in 1996 suggested
higher incidence of OA in female, ex-athletes (tennis players
and middle- distance, long-distance runners) aged 40 to 65
compared with age-matched controls.
7
The Osteoarthritis Systematic International Review
and Synthesis Organization (OASIS) in 2006 presented
recommendations for patients with knee OA regarding
appropriate physical activity participation. They concluded
the 3 highly modiable risk factors for symptomatic knee
OA are obesity, injury, and occupations involving excessive
mechanical stress.
8
For sports and recreational activity, OASIS suggests a
correlation between activities representing risk factors for
knee OA and intensity and duration of exposure. The group
also states that risk of OA is associated more with history of
trauma and obesity than with sport participation in general.
The group recommends athletes to be informed that joint
trauma is a greater risk factor than mere activity or sport
participation. Additional evidence concludes that OA risk
is associated with duration and intensity of exposure in
higher level activities. The clinical consensus of OASIS
stated patients with OA participate regularly in recreational
sports as long as the activity does not cause pain, but
should be encouraged to change sports that involve activ-
ities at risk for joint trauma.
8
Other research groups have studied OA to compile
treatment protocols and interventions for conservative
management of the disease. For example, the American
College of Rheumatology in 2010 to 2011, convened a
Technical Expert Panel to update recommended guidelines
for nonpharmacological and pharmacological management
of OA of the hand, hip, and knee. The Technical Expert
Panel performed extensive literature reviews and evaluated
the best available evidence for specic interventions for the
conservative management of hand, hip, and knee OA
9
(Table 1).
Another scientic study group, the Osteoarthritis
Research Society International (OARSI), developed
guidelines for conservative management of hip and knee
OA. The OARSI group rst released their guidelines in
2007 with updated recommendations in 2008. Overall, they
presented 23 recommended interventions for the treatment
of hip and/or knee OA, based on opinion alone, research
evidence or both. However, despite the groups high ratings
for a core set of pharmacologic and nonpharmacologic
recommendations, OARSI admits that the consensus rec-
ommendations are not always supported by the best
available evidence.
10
Other recommended interventions
include patient education regarding lifestyle modication,
activity pacing, exercise, weight reduction, knee bracing,
and appropriate footwear/orthoses/wedging devices.
11
MANUAL THERAPY
Symptoms associated with knee OA may result from
restricted soft-tissue mobility and adhesions as a result of
From the *Advanced Sports Therapy, Wellesley; and wOrthopedic and
Sports Physical Therapy, Boston, MA.
Disclosure: The authors declare no conict of interest.
Reprints: Matthew Penney, PT, DPT, SCS, ATC, Advanced Sports
Therapy, 62 Walnut Street, Wellesley, MA 02481.
Copyright
r
2013 by Lippincott Williams & Wilkins
REVIEW ARTICLE
2
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Volume 21, Number 1, March 2013
recurrent inammation of both intra-articular and peri-
articular tissue. Resultant adhesions may alter bio-
mechanical forces on articular surfaces by restricting joint
movement therefore creating additional symptoms. Manual
therapy has been hypothesized to counteract some of these
physiological changes through reduction of adhesions and
improved range of motion (ROM), therefore breaking the
inammatory cycle associated with progressive OA.
12
Benets of manual therapy include improved joint
mobility and ROM, reduced soft-tissue contracture and
brosis, decreased pain, and improved function. Although
some might propose that knee OA symptom relief may
occur with rest or knee joint unloading, research by
Mangione and Axen
13
has shown that unweighting of the
knee through deweighted treadmill training has not relieved
pain in patients with knee OA. Deyle and colleagues have
reported 20% to 40% pain relief from patients in 2 to 3
clinical treatments of manual therapy and exercise. This
rapid reduction in symptoms implies the structures
responsible for at least a portion of patients pain are not
uncontrollable aspects of OA pathology; therefore peri-
articular connective or muscular tissue could potentially
generate symptoms.
14
Repeated tension challenges to these
tissues with manual therapy techniques such as end-range
passive stretching and active ROM provide a strong stim-
ulus for pain relief.
Other proposed benets of manual therapy include
mechanical alteration of tissue, neurophysiological eects,
and psychological inuence. Joint mobilization has been
shown to induce immediate hypoalgesia in individuals with
knee OA with a concurrent improvement in function.
15
Moss and colleagues demonstrated immediate reduction in
pain pressure threshold after joint mobilization in patients
with knee OA, further supporting hypoalgesic eects found
in other studies. The positive hypoalgesic aects are
believed to occur through stimulation of mechanorecep-
tors and activation of pain inhibitory cortical systems.
16
Sambajon and colleagues has demonstrated nearly 70%
decreased concentration of prostaglandin PGE2 24 hours
after repetitive mobilization in a healthy in vitro animal
study. As an inammatory mediator, prostaglandin PGE2
is implicated in arthritic hyperalgesia, which may sensitize
peripheral nociceptors.
17
The authors of this study have
found that the hypoalgesic eects of manual therapy often
improve patients participation in therapeutic exercise in
those who are limited by pain.
Knee joint mobilization techniques focus on accessory
movement of both the tibiofemoral joint and the patello-
femoral joint as both articulations have been shown to be
aected by soft-tissue restrictions associated with knee
OA.
18
Benets have been reported for various amplitudes
of joint mobilization. Moss and colleagues concluded that
large amplitude (Maitland Grade III
19
) anterior-posterior
glide of the tibia on femur (supine, slight knee exion)
combined with pain-free oscillatory glides (Maitland Grade
I, II
19
) of the tibia improved pain levels 3 to 4 times greater
than a control group not receiving joint mobilization.
Performance during Sit-To-Stand and Timed Up and Go
testing also showed signicant improvement in the joint
mobilization group.
15
Pollard and colleagues demonstrated that a combina-
tion of knee joint mobilization techniques decreased
patients pain and crepitus, while also improving patients
satisfaction, general function, and joint mobility. The rst
technique in the study was active knee ROM from 90
degrees of exion (Fig. 1) through as much pain-free
extension possible while a sustained inferior patella glide
was applied to the superior pole of the patella (Fig. 2). The
technique was performed to minimize the natural superior
glide of the patella and to decrease compressive forces of
the patella into the femoral trochlea. The second technique
consisted of a grade IV posterior tibial mobilization while
applying a tibial traction force near full knee extension
20
(Fig. 3) (Table 2).
Connective tissue is known to lose extensibility related
to the physiological aging process and is believed to occur
secondary to collagen adaptation. The diminished extensi-
bility combined with joint degeneration in patients with
knee OA may cause loss of terminal knee extension and
exion ROM.
21
Loss of full knee extension ROM has been
shown to result in abnormal joint arthrokinematics with
subsequent increases in patellofemoral and tibiofemoral
joint contact pressure.
22
Weng and colleagues has demon-
strated ROM of the arthritic knee joint as the main factor
resulting in muscular weakness during isokinetic exercise.
Therefore, when developing a program for an athletic or
recreationally active patient with knee OA, improving knee
joint ROM is a vital consideration.
20
The authors of this study include static and proprio-
ceptive neuromuscular facilitation (PNF) stretching to
restore muscle length of the lower extremity. In athletes
TABLE 1. Nonpharmacologic Recommendations for the
Management of Knee Osteoarthritis
We strongly recommend that patients with knee osteoarthritis
(OA) should do the following
Participate in cardiovascular (aerobic) and/or resistance land-
based exercise
Participate in aquatic exercise
Lose weight (for persons who are overweight)
We conditionally recommend that patients with knee OA should
do the following
Participate in self-management programs
Receive manual therapy in combination with supervised exercise
Receive psychosocial interventions
Use medially directed patellar taping
Wear medially wedged insoles if they have lateral
compartment OA
Wear laterally wedged subtalar strapped insoles if they have
medial compartment OA
Be instructed in the use of thermal agents
Receive walking aids, as needed
Participate in tai chi programs
Be treated with traditional Chinese acupuncture*
Be instructed in the use of transcutaneous electrical stimulation*
We have no recommendations regarding the following
Participation in balance exercises, either alone or in combination
with strengthening exercises
Wearing laterally wedged insoles
Receiving manual therapy alone
Wearing knee braces
Using laterally directed patellar taping
*These modalities are conditionally recommended only when the patient
with knee OA has chronic moderate to severe pain and is a candidate for
total knee replacement but either is unwilling to undergo the procedure, has
comorbid medical conditions, or is taking concomitant medications that lead
to a relative or absolute contraindication to surgery or a decision by the
surgeon no to recommend the procedure.
Reprinted from Hochberg et al
9
with permission from publisher John
Wiley & Sons Inc. This material is copyrighted and any further reproduction
or distribution requires written permission from John Wiley & Sons Inc.
Sports Med Arthrosc Rev

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3
with knee OA, joint capsule extensibility and quadricep,
hamstring, hip exor, gastrocnemius, and soleus muscle
length must be assessed because of their impact on knee
function and their function when participating in athletics.
Reid and McNair demonstrated a signicant increase in
knee extension ROM (mean, 7.7 degrees) after a 6-week
stretching program focusing on the above-mentioned
lower-extremity muscle groups. The stretching intervention
utilized supervised and independent stretching sessions. The
relevance of the study demonstrates the importance of
independent stretching exercises as an eective piece of
long-term knee OA management.
21
Weng and colleagues compared isokinetic muscular
strengthening exercise (group I), isokinetic exercise with
static stretching (group II), and isokinetic exercise with
PNF stretching (group III) in patients with knee OA. All
groups demonstrated a signicant reduction in knee pain
and disability with increased peak muscle torques after
treatment and at follow-up. However, only groups II and
III had signicant improvements in knee extension and
exion ROM, with group III demonstrating the greatest
increase in ROM. Group III also demonstrated the greatest
increase in muscle strength gain during 180 degrees/second
angular velocity peak torque testing.
20
The study results
provide evidence that PNF stretching may be more eective
than static stretching in the treatment of knee OA.
THERAPEUTIC EXERCISE
Research has reported a correlation between increased
physical activity and decreased pain levels, improved
function, and delayed disability. At least 30 minutes of
moderate physical activity over a minimum of 5 d/wk is
recommended by the Centers for Disease Control in specic
regards to OA.
23
Participation in regular physical activity
has been shown to provide signicant benets in the
treatment of knee OA, whereas failure to remain active may
exacerbate impaired joint mechanics and potentially result
in articular cartilage softening and matrix dysfunction,
leading to accelerated cartilage degeneration.
24
Also, indi-
viduals without knee OA who opt to exercise will not have
increased progression of joint degeneration as a result of
their increased physical activity; indeed, they can poten-
tially expect reductions in knee pain and disability as the
years progress.
25
Repetitive loading of the arthritic knee joint can force
compensatory movement and muscular recruitment
FIGURE 1. Sustained inferior patella glide in 90-degree knee
flexion.
FIGURE 2. Sustained inferior patella glide nearing terminal knee
extension.
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patterns of the lower extremity. Liikavaino studied gait and
muscle activation changes in subjects with knee OA to
examine both level and stair walking biomechanics. The
authors observed minor dierences in gait kinetics during
level-walking at each predetermined gait speed in patients
(mean age 59 y) with knee OA as compared with healthy
age-matched and sex-matched control subjects. However,
patients with knee OA exhibited approximately 18% to
26% lower maximal loading rate, indicative of lighter
loading of their lower extremities. The dierences in force
loading parameters were magnied during more demanding
motor tasks such as stair descension at higher speeds.
Patients with knee OA demonstrated signicantly higher
initial peak and maximal horizontal acceleration and
decreased attenuation of the shock wave. Furthermore,
these ndings were supported by changes in muscular
recruitment during all activity. The authors hypothesized
that an overall decrease in muscle strength and power in
subjects with knee OA was secondary to both vastus
medialis and biceps femoris infrequent muscle activation
while using dierent strategies to execute the same tasks.
26
Lower-extremity strength disparities also were high-
lighted by Costa who studied 25 patients with unilateral
knee OA,
25
with bilateral knee OA (both with mean age
56 y) and 50 matched controls by using a Visual Analog
Scale (VAS), Knee Lequesne Index, Western Ontario and
McMaster University Arthritis Index (WOMAC) ques-
tionnaire, and a Cybex (Chattanooga, TN) isokinetic
assessment. For the unilateral and bilateral knee OA
groups, signicantly lower peak torque was found for hip
exion, extension, abduction, adduction, medial rotation,
and lateral rotation at all velocities on the ipsilateral side.
Even in patients with unilateral knee OA, a similar decrease
in peak torque was found on the contralateral hip when
compared with controls, potentially suggesting why
patients with knee OA have both impaired lower-extremity
muscular strength and biomechanics.
27
Traditionally, exercise programs for knee OA have
focused on impairments associated with lower-extremity
FIGURE 3. Caudal tibial traction coupled with posterior tibial
glide.
TABLE 2. Common Knee Impairments Addressed by Manual Therapy
Impairments Manual Intervention Typical Delivery
Loss of knee
extension
Manual mobilization through range of motion
(ROM) and knee extension at end range
Knee extension
Knee extension with valgus or abduction
Knee extension with varus or adduction
Mobilizations grades III and IV to III ++ and IV++ 2-6 bouts of
30 s/manual technique
Clinical observation: this manual intervention may provide near-immediate
decrease of symptoms and may be approached with relatively more vigor
than knee exion
Loss of knee
exion
Manual mobilization through ROM and knee
exion at end range
Knee exion
Knee exion plus medial (internal) rotation
Mobilization grades of III and IV to III + and IV 2-6 bouts of
30 s/manual technique
Clinical observation: pain with end-range knee exion may be due to
degenerative meniscal tears: end-range techniques should be utilized with
caution
Loss of
patellar
glides
Manual mobilization of the patella in 5-10
degrees of knee exion
Medial
Lateral
Caudal
Cephalad
Mobilization grades of IV to IV++ 2-6 bouts of 30 s/manual technique
Clinical observation: some patients may be intolerant of even slight
compressive forces over the patella; therapist hand placement is
important
Muscle
tightness
Manual stretches at end length of muscle
Quadriceps femoris
Hamstrings
Gastrocnemius
Adductors
Iliopsoas
Tensor fascia latae and iliotibial band
Sustained manual stretches of 12-30 s duration repeated 1-3 times per
manual technique
Clinical observation: the lumbar spine should be manually stabilized and
protected during all extremity stretches; particularly hip exor stretches;
many of these patients also will have arthritic changes in the spine, and
symptoms can be increased without care in positioning
Soft-tissue
tightness
Soft-tissue mobilization
Suprapatellar and peripatellar regions
Medial and lateral joint capsule
Popliteal fossa
Circular ngertip and palm pressure mobilization at the depth of the
capsule or retinaculum for 1-3 bouts of 30 s/area
Clinical observation: the soft-tissue work in the popliteal fossa seems to
work best when performed slowly with occasional sustained positions of
10-12 s, this technique works well when combined with the manual
mobilizations into knee extension
Reprinted from Deyle et al
12
with permission from the American Physical Therapy Association. This material is copyrighted and any further reproduction
or distribution requires written permission from APTA.
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5
joint motion decits, muscle weakness, and reduced aerobic
capacity.
28
Although these impairments are associated with
the majority of patients with knee OA, many exercise
programs inadequately focus on other aspects of ambula-
tion and higher level activity such as turning, quick stop-
ping, negotiating obstacles, or change in surface con-
sistency. Fitzgerald et al
29
reports that a range of 11% to
44% of patients with knee OA will experience mechanical
symptoms of giving way or buckling during activities of
daily living.
Similar mechanical symptoms are reported in patients
with a decient anterior cruciate ligament (ACL). Extensive
research supports the application of perturbation training
with nonoperative, ACL-decient patients. The study
results by Axe and Snyder-Mackler
30
demonstrate a more
eective return to high-level physical activity than an
impairment-based standard program by exposing individ-
uals to activities that challenge the knee to potentially
destabilizing loads during therapy. Although there appears
to be a correlation between the ACL-decient knee and
knee OA symptomology, there is limited research measur-
ing the proprioceptive decline in patients with knee OA and
its subsequent eect on agility (Table 3).
Exercise prescription for individuals with knee OA has
been studied regarding the frequency, intensity, and mode
of resistance and strength training has been found to be
benecial for patients with knee OA. A study by Farr and
colleagues looked at resistance training on overall moderate
and vigorous physical activity in 171 patients with early
knee OA. Patients (mean age, 55 y) participated in a
resistance-training program, a self-management program,
and a combined program. The resistance-training group
participated in 1-hour exercise sessions that included leg
press, leg curl, hip abduction and adduction, straight leg
lift, incline dumbbell press, seated row, and calf raise. The
self-management group was given educational classes. The
groups were tested at baseline, 3 months, and 9 months and
both the self-management and resistance-training groups
were eective in raising moderate to vigorous physical
activity levels in the short term. However, the resistance-
training group proved signicantly more eective in main-
taining these results long term. The results by Farr and
colleagues suggest that functional exercises targeting per-
formance can be useful in managing knee OA.
32
Sayers and colleagues conducted a study comparing
high-speed versus slow-speed power training in 33
TABLE 3. Evidence-based Clinical Practice Guidelines
Strengthening exercises
Lower-extremity strengthening vs. control, level 1 (RCT, n_345): grade A for pain getting up from oor and functional status (clinically
important benet); grade C for pain during walking, pain while climbing stairs, functional tasks, and quadriceps femoris muscle peak
torque (clinical benet); grade C for stiness, mobility, quadriceps femoris muscle force, muscle activation, and quality of life (no
benet). Patients with a diagnosis of osteoarthritis (OA) of the knee
Lower-extremity isometric strengthening vs. control, level 1 (RCT, n_102): grade A for pain getting down to and up from oor (clinically
important benet); grade C for pain getting down and up stairs and timed functional tasks (clinical benet); grade C for stiness and
functional status (no benet). Patients with a diagnosis of OA of the knee
Isotonic resistance training vs. isotonic combined with isokinetic (Kinetron) resistance training for knee, level 1 (RCT, n_32): grade C for
quadriceps femoris muscle peak torque (no benet). Patients with a primary diagnosis of OA of the knee
Isotonic combined with isokinetic (Kinetron) resistance training for knee vs. control, level 1 (RCT, n_32): grade C for muscle force (no
benet). Patients with primary diagnosis of OA of the knee
Eccentric resistance training (Cybex) for knee vs. control, level 1 (RCT, n_32): grade C for muscle force (no benet). Patients with primary
diagnosis of OA of the knee
Concentric resistance training for knee vs. control, level 1 (RCT, n_23): grade A for pain at rest and during activities (clinically important
benet); grade C for global functional status (no benet). Patients with knee OA bilaterally and grade II or III OA
Concentric-eccentric resistance training for knee vs. control, level 1 (RCT, n_23): grade A for pain at rest and during specic functional
activities: 15-m walk and stair climbing/descending time (clinically important benet). Patients with knee OA bilaterally and grade II or
III OA
Home program strengthening for knee vs. control, level 1 (RCT, n_81): grade A for pain, functional status, energy level, and ROM in exion
(clinically important benet); grade C for physical mobility, muscle force, swelling, and exercise (no benet). Patients with knee OA
General lower-extremity exercise program (including muscle force, exibility, and mobility/coordination) vs. control, level 1 (RCT,
n_490): grade A for pain at night and ability on stairs (clinically important benet); grade C for knee exion range of motion (ROM),
muscle force, knee joint position, gait, functional status, quality of life, muscle activation, stiness, and physical activity (no benet).
Patients with OA
Progression vs. no-progression lower-extremity strengthening exercises, level 1 (RCT, n_179): grade A for pain at rest and ROM
(clinically important benet); grade C for stiness and functional status (no benet). Patients with radiographic evidence of OA in the
tibiofemoral compartment
General physical activity, including tness and aerobic exercises
Whole-body functional exercise vs. control, level 1 [RCT, n_864): grade A for pain and functional status (mobility, walking, work,
disability in activities of daily living (ADL)] (clinically important benet); grade C for knee exor ROM, quadriceps femoris muscle
force, hamstring muscle force, gait, and quality of life (no benet). Patients with OA of the knee
Walking program vs. control, level 1 (RCT, n_1,089): grade A for pain, functional status, stride length, disability transferring from bed,
disability bathing, aerobic capacity, energy level, and medication use (clinically important benet); grade C for disability in ADL
(clinical benet); grade C for walking speed, disability toileting, disability dressing, blood pressure, morning stiness, and quality of life
(no benet). Patients with OA
Jogging in water vs. control, level 1 (RCT, n_115): grade A for physical activity and aerobic capacity (clinically important benet); grade
C for morning stiness, pain, grip force, trunk ROM, functional status, and exercise endurance (no benet). Patients with current
symptoms of chronic pain and stiness in involved weight-bearing joints
Reprinted from Brosseau et al
31
with permission from the American Physical Therapy Association. This material is copyrighted and any further repro-
duction or distribution requires written permission from APTA.
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participants with mean age of 67 years with knee OA. The
high-speed group performed a greater number of repeti-
tions at 40% of 1 repetition maximum on a leg press as
fast as able, whereas the slow-speed group performed
fewer repetitions at 80% of 1 repetition maximum slowly.
The high-speed group improved muscle strength, power,
and speed over the 12-week period. These ndings are
particularly relevant in eectively treating a recreationally
active population performing high-speed movements.
33
High-resistance training is shown to be equally eec-
tive as low-resistance training in people with knee OA. Jan
et al
34
looked at the eects of pain, function, muscle torque,
and walk time in high-resistance versus low-resistance
training over an 8-week period. The 2 groups performed
isokinetic knee exion and extension training at high-
resistance (mean age, 63 y) and low-resistance (mean age,
63 y) session over 3 episode/wk. Both groups improved in
all categories compared with the control group (mean age,
62 y). In another study regarding resistance training, Gur
and colleagues looked at the eects of concentric versus
concentric-eccentric quadricep and hamstring strengthening
on functional capacity and pain levels in patients aged 41 to
75 years old with knee OA. They determined an 8-week
program of isokinetic quadriceps and hamstring strength-
ening performed 3 times/wk resulted in the concentric-
eccentric group displaying a greater eect on functional
activities, including stair ascension and descension while
concentric training exhibited improvements in overall pain
rating. The results of the study show that extensive training
involving high number of repetitions and eccentric con-
tractions are safe, eective, and productive in patients with
knee OA.
35
Isokinetic versus progressive resistance exercise (PRE)
of the quadriceps and hamstrings was studied by Eiygor.
Knee exion and extension strengthening was assessed
3 times/wk in the isokinetic group (mean age, 53 y) and
5 times/wk in the PRE group (mean age, 51 y) over a 6-week
period. Both modes of strengthening were found to be
eective in achieving strength gains and subjective
decreases in pain and function. There was no signicant
dierence found between the 2 groups in overall reports of
pain, function, or peak torque of the tested muscles.
36
Consideration of the surrounding musculature of the
hip and ankle joints when prescribing exercise for the
patient with knee OA is also important. Both dynamic and
isometric training of the entire lower extremity represent
eective modes of resistance strengthening in people with
knee OA. Topp and colleagues conducted a 16-week study
comparing dynamic and isometric training, specic to
eects on pain level and physical function. Two groups
trained the same 6 lower-extremity muscle groups: ankle
plantar and dorsiexors, knee extensors and exors, and
hip extensors and exors. The isometric group (mean age,
64 y) used maximum resistance Thera-band (The Hygienic
Corporation, Akron, OH), whereas the dynamic group
(mean age, 66 y) used appropriate-level resistance Thera-
band to achieve the desired muscle activation. Both resist-
ance-training groups exhibited similar, signicant declines
in reported knee pain and decrease in time to perform
functional tasks, whereas the control group remained
unchanged over the duration of the study. Only the
dynamic training reduced perceived functional limitations,
and the control group (mean age, 61 y) did not change their
measures on any of the outcome variables over the duration
of the study.
37
MODALITIES
The trend of increased incidence of knee OA in a
younger, more active population has developed a role for
therapeutic modalities in the conservative management of
functionally limiting impairments associated with knee OA.
ES, therapeutic ultrasound (US), LLLT, and thermo-
therapeutic agents such as heat and ice packs represent
common noninvasive, nonpharmacological treatment app-
roaches often coupled with therapeutic exercise to treat
patients with articular degradation and other joint changes
associated with knee OA.
ES is a commonly used treatment option to relieve pain
and improve function in patients with knee OA. Three pri-
mary forms of ES were identied during this articles liter-
ature review: interferential current (IFC), neuromuscular
electrical stimulation (NMES), and transcutaneous electrical
nerve stimulation (TENS).
The eectiveness of IFC treatment in patients with knee
OA has been researched extensively with variable results
suggesting short-term improvement in pain and function.
However, as Adedoyin and colleagues comment in their
paper, studies have largely failed to show benet over con-
trolled groups receiving an exercise program or sham treat-
ment. In a randomized control trial (RCT) of 46 subjects
with mean age of 55 years, subjects in 3 groups receiving
IFC, TENS, or exercise program alone all reported improved
levels of pain and function as dened by the WOMAC.
38
To further highlight inconsistencies in this eld of study,
consider a recent RCT by Gundog and Atamaz of 60 patients
with median age of 60 years and mild to moderate knee OA.
Patients were treated 5 times/wk for 3 weeks consecutively
with IFC treatment and compared with a sham-controlled
group. The authors concluded that IFC treatment was an
eective intervention in the management of knee OA, while
also noting both IFC and controlled groups demonstrated
signicant improvements in pain and function as dened by
the WOMAC.
39
Related systematic reviews conducted by
Hawker and Mian
40
and Jamtvedt and Dahm
41
support these
ndings, concluding that results in patients with knee OA are
unclear because of low quality of evidence and a general
heterogeneity of study parameters.
Less empirical data exist to support NMES as an
eective therapeutic agent to improve pain or function
scores in patients with knee OA. In a RCT conducted by
Palmieri-Smith and Thomas, 30 women with mean age of
57 years and radiographic evidence of knee OA were pro-
vided either NMES treatment 3 times/wk for 4 weeks or no
treatment over the same time period. The authors
hypothesized that the group receiving NMES would dem-
onstrate improved quadriceps activation and strength when
compared with the controlled group. After a priori power
analysis, the research group determined no statistically
signicant increase in quadriceps activation or strength in
the intervention group of patients receiving NMES.
42
Although patients in this study, and the IFC trials men-
tioned above, are slightly older than middle-aged athletes,
principles of ecacy with respect to individuals with mild to
moderate knee OA are expected to remain constant.
TENS represents another commonly used modality in
treatment of knee OA, although ecacy with respect to
functional mobility and joint stiness is generally incon-
clusive. In a meta-analysis by Brosseau and Yonge, the
reviewers reported a statistically signicant reduction in
pain levels in the treatment of patients with knee OA. As
such, the authors recommended TENS as an adjunct
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therapy for the treatment of knee OA.
43
Similarly, a sys-
tematic review by Jamtvedt and Dahm concluded that there
is moderate evidence that TENS reduces pain when com-
pared with a placebo intervention in treatment of knee
OA.
41
However, in contrast, a 2010 Cochrane review by
Rutjes and Nu esch concluded that the current level of
evidence to support the ecacy of TENS treatment in
patients with knee OA with respect to pain and function is
inadequate because of inclusion of small trials with uncer-
tain methodology.
44
The ecacy of therapeutic US treatment in patients with
knee OA has been sharply contended over the past several
decades. Both nonthermal and thermal eects on localized
pain, inammation, and tissue repair remain in question. In a
randomized, placebo-controlled, double blind study by
Tascioglu and Kuzgun, the short-term eectiveness of ther-
apeutic US was tested in 90 patients with moderate knee OA.
The patients with a mean age of 62 were treated with either
continuous, pulsed, or sham US for a duration of 5 min/
session, 5 d/wk for 2 weeks. The authors reported signicant
improvements in pain levels, via the VAS, and functional
status, via the WOMAC, across all the 3 groups. When
compared with the placebo group, patients receiving pulsed
US reported signicantly improved scores on the VAS and
WOMAC. Thus, Tascioglu and Kuzgun
45
determined that
pulsed US represents an eective short-term treatment
approach for decreasing pain and improving function in
patients with moderate knee OA.
In another Cochrane review by Rutjes and Nu esch and
a systematic review of RCTs with meta-analysis by Loyola-
Sanchez and colleagues therapeutic US in patients with
knee OA was investigated. Both reviews report that ther-
apeutic US may represent an ecacious treatment modality
in the management of patients with knee OA.
46,47
Speci-
cally, Loyola-Sanchez et al
47
concluded that pulsed US at
low intensities has a signicant eect on pain reduction in
patients with knee OA when compared with continuous US
and sham. Despite the ndings, both authors acknowledge
a low quality of evidence and a large degree of hetero-
geneity in study parameters, ultimately conceding to the
need for additional study in this eld.
45,47
Several studies have reported positive eects from
LLLT including inuences on broblast propagation,
osteoblast production, and collagen synthesis as well as
revascularization in wound healing. In a double blind,
randomized, placebo-controlled trial by Hegedu s and
Viharos, 27 patients with mean age of 42 years and mild to
moderate knee OA received either LLLT or placebo LLLT.
Patients received treatment twice a week over a 4-week
period at a continuous wave form and dose of 6 J/point.
Hegedu s and Viharos found patients treated with the active
laser diode demonstrated a signicant improvement in pain,
knee circumference, point pressure sensitivity, and knee
exion compared with the control group. Still more
impressive is that the authors report patients in the active
LLLT group continued to present with improved test var-
iables 2 months after treatment.
48
Further, Jamtvedt and
colleagues discussed similar ndings in their systematic
review, concluding that moderate-quality evidence supports
the positive anti-inammatory eects of LLLT on pain and
function in patients with knee OA.
41,48
Thermotherapy produces localized thermal eects on
supercial target areas, depending on clinical indications
and desired therapeutic outcomes. In a Cochrane review by
Brosseau and Yonge, thermotherapeutic treatment of knee
OA was discussed with respect to knee ROM, pain,
strength, edema, and function. Brosseau and Yonge deter-
mined that ice massage, compared with control, had a
statistically signicant eect on knee ROM and function.
The authors concluded that ice massage (20 min/session,
5 sessions/wk for 2 wk) represents an eective adjunct
treatment in patients with knee OA demonstrating decits
associated with knee ROM and function. However, the
authors do acknowledge a general heterogeneity in study
parameters, citing variable methodology with respect to
outcome results and test administration.
43
Discrepancy in
research standards is echoed in a systematic review by
Jamtvedt and Dahm,
41
who concluded due to small sample
sizes and low quality of studies, the ecacy of thermo-
therapeutic agents on pain and function in patients with
knee OA is inconsistent and therefore unclear.
Ultimately, there is low-quality evidence to support the
use of IFC, NMES, and thermotherapy
3844
; variable low-
quality to moderate-quality evidence to support therapeutic
US and TENS
38,41,4448
; and, moderate-quality evidence to
support LLLT in the treatment of patients with knee OA.
41,48
Currently, therapeutic exercise and weight reduction possess
the highest quality of evidence with respect to eects on pain,
inammation, and stiness in patients with knee OA.
41
In
light of these ndings, further studies are needed to
unequivocally substantiate the use of therapeutic modalities
in treating middle-aged athletes with knee OA.
PATIENT EDUCATION, WEIGHT MANAGEMENT,
ORTHOTICS
OARSI recommends patients with knee OA to be
provided with information pertaining to treatment options
and lifestyle modications related to functional impair-
ments and excessive joint loading.
11
Arguably, the most
inuential risk factor associated with increased internal
knee adductor moments (KAM), a clinically accepted
identier of moderate to advanced medial joint knee OA, is
increased body mass. Research consistently substantiates
obesity correlating signicantly with both the incidence and
progression of knee OA. Weight management, and ulti-
mately weight loss, therefore represents the treatment
option of choice in patients presenting with knee OA. In a
study by Aaboe and Blidda, the authors found a signicant
reduction in knee joint loads during walking among sub-
jects with an average body weight reduction of 13.7 kg
(13.5% decrease relative to baseline) after a 16-week dietary
intervention course. Aaboe and Blidda
49
conclude that
weight loss represents an excellent short-term approach to
decreasing functional limitations associated with increased
joint loading in patients with knee OA.
Alternative approaches to decrease joint loading forces
in patients with knee OA include utilization of shoe wedges,
knee braces, and assistive devices. Although the level of evi-
dence supporting these intervention strategies remains vari-
able, the biomechanical advantage gained by redistributing
ground reaction forces (GRFs) during contact phase of gait is
supported by experts in their respective elds.
11
This bio-
mechanical understanding of GRFs during gait reveals
another rehabilitation trend found in literature; namely, that
all patients with knee OA be educated on appropriate foot-
wear as pertains to specic activity demands and impairments
associated with articular changes found in with knee
OA.
11,5052
Although authors agree that footwear recom-
mendations should be provided to all patients with knee OA,
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the most eective type of shoe (ie, stability, cushioned, min-
imalist) remains in question.
5052
An individualized inter-
vention approach is required when assessing middle-aged
patients with knee OA, specic to activity demands, pro-
gression of disease, body composition, work/sport environ-
ment, and foot strike pattern.
A shock-absorbing insole may represent the ideal foot-
wear choice for an obese, heel-striking patient with increased
internal KAM and moderate medial tibiofemoral joint
compartment narrowing, while a shoe designed to simulate
barefoot mechanics may represent the desired footwear
approach in a midfoot-strike athletic population presenting
with early evidence of knee OA. The latter example describ-
ing innovative footwear is more specic to this paper and has
recently been reported to signicantly reduce dynamic knee
loads during gait through proposed increased sensorimotor
input and neuromuscular communication.
50,51
In addition to KAM-modifying and GRF-reducing
wedges and supports, the importance of activity modication
represents an essential educational component when treating
middle-aged athletes with knee OA. As Vignon and his col-
leagues reported in their 2006 international systematic review,
athletes should be made aware that the risk of knee OA is
associated with duration and intensity of joint exposure;
however, this risk is considerably less than being overweight
or having a history of joint trauma. Further, middle-aged
athletes with knee OA should be encouraged to engage reg-
ularly in recreational sport, provided the activity does not
cause pain. No specic sport (long-distance running, tennis,
soccer, eld hockey, basketball, track and eld, cross-country
skiing, and hockey) demonstrated a signicantly increased
risk of knee OA when compared with others, but patients
should be encouraged to change sport involving high risk of
joint trauma.
8
Middle-aged athletes are encouraged to continue rec-
reational sport as no correlation exists between practice of a
regular sport and clinical or radiographic progression of
knee OA.
13
In adddition, as highlighted earlier in this
paper, the role of exercise in treating impairments asso-
ciated with knee OA has been well established and coincides
with improved functional outcomes. Therefore, as a pre-
ventative measure and rehabilitation staple, we recommend
that the middle-aged athlete continue recreational sportin
a pain-free contextas research substantiates the associa-
tion between increased physical activity and improved
reports of pain, physical function, physical performance,
and perceived eect in patients with knee OA.
53
CONCLUSIONS
In summary, knee OA is a prevalent condition in the
middle-aged, athletic population causing signicant phys-
ical impairments and functional limitations in tness, rec-
reational, and competitive activities. Many nonpharmacologic
interventions for the management of knee OA have been
researched in the past decade. Several research groups and
organizations, including OASIS, OARSI, and American
College of Rheumatology, have developed guidelines based
upon available evidence-based information in the literature.
Conservative interventions such as manual therapy,
therapeutic exercise, thermal and electromagnetic modal-
ities, patient education, weight management, and orthotic/
bracing/supports have been investigated. Overall, strong
evidence exists for utilization of manual therapy techniques
of joint and soft-tissue mobilization and passive and PNF
stretching in the management of knee OA. Also, ther-
apeutic exercise, including resistance (ie, closed-chain, iso-
kinetic, and PRE) training and cardiovascular training has
been suggested in many studies. Other strongly supported
interventions include patient education regarding activity
modication/pacing and symptom management and weight
management strategies, particularly in an overweight/
obese, middle-aged population.
Other nonpharmacologic management techniques for
treatment of knee OA include modalities, such as ES,
therapeutic US, LLLT, and thermal agents. In many
instances, conicting evidence abounds and often neither
supports nor refutes the benet provided by many of the
modality interventions. Although an abundance of evi-
dence-based research on OA has been developed, a void
remains in the research within a middle-aged athletic pop-
ulation in the context of knee OA and conservative
management.
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