Running with Knee Osteoarthritis-Part 3

Running with Knee Osteoarthritis-Part 3

By Lillian Wynn PT, DPT
Physical Therapist


40% of American adults (110 million people) report walking or running as part of a regular exercise routine.  Reports and ‘common knowledge’ about running and its impact on our joints are often conflicting. This is the third of three blog posts designed to look at current medical research regarding running on aging joints.

Article summary


This paper is a systematic review and meta-analysis, so the authors compiled research on knee osteoarthritis (OA) and running, and summarized the findings in order to provide a concise recommendation based on the general consensus of research. Articles were included if they: were level I-III evidence, written in English, used physician diagnosed OA with clinical and/or radiographic findings, and running was compared to non-running. Articles that compared running to other forms of exercises were not included in this study.


Literature searches were performed, and 1,907 articles were reviewed. Of those, 25 met their inclusion criteria. Statistical analysis was performed on those 25 studies to come to a meta-analysis, which summarizes and confirms the general recommendations based on significant research.


The authors concluded that recreational running was in fact associated with lower levels of OA when compared to sedentary individuals. Competitive running was associated with higher levels of OA than recreational runners. Overall, sedentary subject demonstrated the most symptomatic OA. The study also argues that this simply compares runners to non-runners. So the only conclusion that can be drawn is that running is better than being sedentary. More research should be done into seeing if running vs other forms of exercise is the best for of exercise.

 PTF approach

Here at PTF, we want to keep you active in the activities that matter to you. If walking and running are important to you, and you feel limited by your knees, an evaluation could be useful. There are many factors besides osteoarthritis that could be contributing to your knee pain while running. PTF does a complete evaluation and then designs a treatment plan individual to you and your body to keep you moving.

Original Article

Alentorn-Geli, E., Samuelsson, K., Musahl, V., Green, C., Bhandari, M., Karlsson, J. (2017). The Association of Recreational and Competitive Running with Hip and Knee Osteoarthritis: Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 47(6), 373-390. doi:10.2519/jospt.2017.7137

Cost-Effectiveness of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome

by Leah Flamm, PT,

César Fernández-de-las-Peñas, PT, PhD, DMSc, Ricardo Ortega-Santiago, PT, PhD, Homid Fahandezh-Saddi Díaz, MD, PhD, Jaime Salom-Moreno, PT, PhD, Joshua A. Cleland, PT, PhD, Juan A. Pareja, MD, PhD, José L. Arias-Buría, PT, MSc, PhD.


Carpal tunnel syndrome (CTS) costs more than $2 billion annually in the United States. Considered the most common nerve entrapment in the arm, CTS results in less work productivity and other healthcare costs. Surgery is most often recommended to treat CTS, perhaps because of limited evidence supporting nonsurgical treatments such as exercise and mobilization. A recent study found that compared to surgery, manual therapy (such as desensitization of the central nervous system) resulted in better short-term outcomes and similar long-term effects on pain intensity and function. This study compares healthcare costs between manual therapy and surgery in women with CTS.


Women younger than 65

Diagnosed with CTS based on clinical and electrophysiological findings

Must have had symptoms for at least 12 months


Alongside a randomized clinical trial in a hospital in Madrid, Spain, the researchers performed an economic evaluation to determine the cost-effectiveness of surgery versus manual physical therapy. Patients were randomly assigned to receive either manual physical therapy or a surgical procedure. Those in the manual physical therapy group received three 30-minute sessions once a week, with soft tissue mobilization at areas where the median nerve may be entrapped, lateral glides to the neck, and tendon- and nerve-glide exercises (which patients were also taught to do at home). Those in the surgery group had open or endoscopic release of the carpal tunnel and the same home exercises on tendon- and nerve-glides the manual physical therapy group received.

Economic Evaluation

For the economic evaluation, the researchers looked at direct healthcare costs, direct non-healthcare costs, and indirect costs due to CTS. For direct healthcare costs, they looked at the costs of each treatment (such as the number of sessions, number of visits to manual physical therapists), additional visits to healthcare providers, additional treatments received, prescribed medications, and professional home care. For direct non-healthcare costs, they looked at costs of over-the-counter medications, time spent visiting a healthcare provider, and travel expenses. They also looked at indirect costs of lost productivity due to CTS-related absence from work.


The researchers also measured health-related quality of life at baseline and at each follow-up period.


The researchers found the surgery group was significantly more expensive than the manual physical therapy group. Additionally, patients in the surgery group also received a greater number of other treatments, mostly complementary manual physical therapy, and also made more visits to their orthopaedic surgeon and/or neurologist than those in the manual physical therapy group.

Missing paid work was significantly higher within the surgery group than in the manual physical therapy group, both in terms of the number of people missing work (86.7% vs. 6.9%) and the number of days off from work (mean, 65 versus 28 days; total, 3360 vs. 112 days).

Mean cost (including work absence) was €12,147 for manual physical therapy and €167,143 for surgery. Similarly, mean cost per participant (including work absence) was statistically higher in the surgery group than in the manual physical therapy group (€2785 versus €209, P<.001).


The researchers found that manual physical therapy group was less costly (€−154,996) and more effective (5.844 Quality-Adjusted Life Years) than the surgery group.


The results showed that manual physical therapy was more cost-effective than surgery, and healthcare costs and missed work within the surgery group were significantly greater than in the manual physical therapy group.

The generalizability of the results may be limited, as only women from a single hospital in Spain were included and the study was conducted in a particular health system. However, the study suggests that manual physical therapy, including desensitization of the central nervous system, may be an intervention option for patients with carpal tunnel syndrome as a first line of management prior to, or instead of, surgery.

Here at Physical Therapy First, we perform a complete evaluation to try to figure out what is the underlying cause of every patient’s symptoms. We may examine any or all of the following: range of motion, strength, muscle imbalances, joint mobility, functional movement, posture, and more. Based on those findings, we create custom treatment plans to reduce symptoms and help our patients return to living a full and healthy life. Just as the study suggests, some of our treatments may include soft tissue mobilization and neural desensitization, as well as other interventions such as muscle strengthening and stretching, improving posture, and creating a home exercise program.

Original article:

Fernández-De-Las-Peñas, C., Ortega-Santiago, R., Díaz, H. F., Salom-Moreno, J., Cleland, J. A., Pareja, J. A., & Arias-Buría, J. L. (2019). Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy,49(2), 55-63. doi:10.2519/jospt.2019.8483

Peñas, C. F., Ortega-Santiago, R., Llave-Rincón, A. I., Martínez-Perez, A., Díaz, H. F., Martínez-Martín, J., . . . Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain,16(11), 1087-1094. doi:10.1016/j.jpain.2015.07.012

Cervicogenic Headaches and Conservative PT

by Sean Phillips, PT, DPT

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial
Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson


Headaches are a very common complaint, affecting nearly 47% of the population. Of these headaches, cervicogenic headaches (CGHs) account for ~20% and typically affect women more often than men. This condition can be debilitating and limit your ability to work, sleep, perform household chores, or even ruin the time you want to be relaxing. These types of headaches are very common following a trauma such as whiplash, but just because you may have never been in an auto-accident doesn’t mean you can’t have CGHs. Unfortunately, these can also be caused by the prolonged and poor postures many people assume in their everyday lives.

The International Headache Society (IHS) has classified CGHs as “pain referred from a source in the neck and perceived in one or more regions of the head and/or face”. This means that neck pain usually accompanies the headache, but it is also possible to complain of arm/shoulder pain, dizziness, nausea, lightheadedness, “eye” pain, and visual disturbance.

The next time that you are suffering from a headache, try feeling the back of your neck, specifically right below your skull, to see if there is any muscular tenderness. If so, you may be suffering from a CGH, especially if pressing into these muscles make your headache worse. But the big question is: “What do I do to make my headache go away?”

Review of existing research and literature:

In a systematic review by Racicki et al, researchers attempted to determine the effectiveness of conservative PT approaches to manage patients suffering from cervicogenic headaches. There have been many techniques utilized, including invasive and non-invasive treatments. Invasive approaches can include injections, dry needling, or surgery. Non-invasive treatments can include TENS, massage, mobilization, manipulation, and exercise.

The researchers were able to find a total of 6 articles that fit their criteria which required randomized control trials and an assessment on at least one type of conservative treatment. In these studies, the interventions which were utilized included: cervical manipulation and mobilization, self-mobilization (by the patient), exercise (cerico-scapular strengthening), and thoracic manipulation.

Although the studies reviewed different techniques, many involved similar outcome measures. These included headache frequency, intensity, and duration, as well as disability, neck pain, and amount of analgesic use (pain killers).


Although the studies assessed different techniques, the overall results demonstrated that the most effective conservative treatments for CGH pain included cervical mobilization and manipulation, as well as exercise to strengthen the cervicoscapular muscles. These were especially helpful in improving headache frequency, intensity, and neck pain.

In addition to the 6 articles that were utilized for this review, the authors reported that some articles that were not included indicated that conservative management could reduce analgesic use as well.

Although this article displayed good success with cervical manipulation and mobilization, the studies included did not report on many of the other conservative treatments that physical therapists offer. These can include deep tissue massage, modalities such as cold packs and TENS, or cervical traction, which could also provide benefits to this patient population.


Headaches are a common disorder facing many Americans everyday. Conservative physical therapy management, including mobilization, manipulation, and exercise have been shown to have a positive effect on reducing headache intensity, frequency, and neck pain.

If you are suffering from persistent headaches that are affecting your quality of life, physical therapy may be an effective way to reduce your pain and get you back to where you want to be, while teaching self-management techniques to potentially reduce their recurrence.

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial
Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson
Journal of Manual and Manipulative Therapy
2013; Vol. 21 ; No. 2

Physical Therapy Could be the Answer for Pain Reduction for People Suffering with Osteoarthritis

by Genevieve Bland, PT, DPT


Osteoarthritis (OA) is when the cartilage that lines the bone of joints breaks down, causing pain, swelling and problems moving the joint, according to the Arthritis Foundation. OA is the most common chronic condition of the joints, affecting approximately 27 million Americans. OA occurs mostly in the knees, hips, and low back but can occur in any joint. The primary symptom of OA is debilitating pain that leads to impaired function and decreased quality of life. According to Benson et al., knee pain and radiographic evidence of osteoarthritis joint degeneration are not always correlated. Heightened pain from osteoarthritis has two mechanisms.  One mechanism is hyperexcitability of central nociceptive pathways (path that sends information to the brain) which has been shown to produce enhanced pain response, spread pain and lead to chronic pain. The second mechanism for heightened pain in individuals diagnosed with osteoarthritis is ineffective pain inhibition. The purpose of this study by Carol et al., was to determine the effect of joint mobilization on impaired conditioned pain modulation (CPM), which is a method of an application of a noxious stimulus at a distant site causes inhibition of pain at the initial site.

 Literature search and data analysis to minimize pain in knees with osteoarthritis

In a recent search Carol et al. investigated knee joint mobilizations for pain reduction in individuals that have been diagnosed with osteoarthritis. CPM has been examined through use of protocols that typically include cold or ischemic pain. The effects of surgical and transcutaneous electrical nerve stimulation (TENS) interventions on impaired CPM have been studied, but not manual therapy consisting of joint mobilizations performed by physical therapists to minimize pain from OA in the knees. Carol et al. hypothesized that CPM would be more effective following the application of joint mobilization and the vibratory deficits would normalize following joint mobilization.


Two experimental groups

  1. Cutaneous input: hands on cutaneous input only to the knee. This technique was executed by lightly placing both hands on the subject’s knee
  2. Cutaneous input plus joint mobilization: oscillatory joint mobilizations into slight tissue resistance. Physical therapist placed both hands on knee and glided the tibia forward and back on the femur within a pain-free range, moving slightly into tissue resistance.

Almost all subjects had knee pain in both knees with one knee pain being worse than the other and 85% reported occasions of the knee giving way. All interventions were applied by the same physical therapist, who was fellowship trained in orthopedic manual physical therapy. Experimental condition was applied 2 times for 3 minutes, with a 30 second interval between applications. Pressure pain threshold was established at the experimental knee. The tip of an algometer was applied perpendicular to the most painful site at the medial knee on the affected limb, at a rate of 50 kPa/s, until the subject reported a change from pressure to a painful sensation. The procedure was performed 3 times at 20-second intervals, and the average was calculated to determine PPT. Pressure pain threshold at all 3 sites and resting knee pain were measured preintervention, postintervention, and post-CPM reassessment. Screening protocol for impaired CPM is as follows:

  • Subject in supine position with hip and knee flexed 20 degrees
  • Most painful site was identified on medial aspect of affected knee and confirmed through gentle palpation by tester
  • Pressure pain threshold


No effect was noted from cutaneous input only. The main finding of the current investigation was the impaired CPM was enhanced following application of the joint mobilization intervention. This study suggest joint mobilization enhances CPM in patient with painful OA, demonstrated by decrease in deep tissue sensitivity to pressure. The investigators of this study also found enhanced somatosensory (sensation regarding pressure, pain and warmth) acuity in the knee following joint mobilization.
osteoarthritis pain reduction

Physical Therapy First:

Here at Physical Therapy First we provide one on one hands on care for our patients with various diagnoses. Our manually trained physical therapists offer an individualized care plans to assist our patient to achieve their optimal health.


  1. Courtney, C.A. et al. Joint mobilization enhances mechanisms of conditioned pain modulation in individuals with osteoarthritis of the knee. Journal of Orthopaedic & Sports Physical Therapy. 2016: 46, 168-176

Running with Knee Osteoarthritis-Part 2

By Lillian Wynn PT, DPT
Physical Therapist


40% of American adults (110 million people) report walking or running as part of a regular exercise routine. Reports and ‘common knowledge’ about running and its impact on our joints are often conflicting. This is the second of three blog posts designed to look at current medical research regarding running on aging joints.

Article summary:


Men and women 45-79 years old, were grouped into 3 groups.
1: No symptoms of knee osteoarthritis, and deemed low risk for developing knee osteoarthritis
2: No symptoms of knee osteoarthritis, and deemed high risk
3: Symptoms of knee osteoarthritis


Patients were labeled as high volume runners, low volume runners, or non-runners. X-rays and pain questionnaires were provided at the start of the study, again at a 2 year follow up. Pain questionnaires were provided at the final 8 year follow up


Any history of running-low or high volume was associated with lower knee pain. There was slightly lower evidence of knee osteoarthritis on the x-rays of runners, but it was not statistically significant. Statistically the highest predictor of knee pain was BMI.


Other factors besides running seem to have more of an impact on symptomatic knee osteoarthritis. It is possible that wince runners tend to be more active and have lower BMI, that any potential damage is offset by the benefits of regular exercise.

PTF approach

Here at PTF, we want to keep you active in the activities that matter to you. If walking and running are important to you, and you feel limited by your knees, an evaluation could be useful. There are many factors besides osteoarthritis that could be contributing to your knee pain while running. PTF does a complete evaluation and then designs a treatment plan individual to you and your body to keep you moving.

Original Article

Lo, G., Driban, J., Kriska, A. McAlindon, T., Souza, R., Petersen, N., Storti, K., Eaton, C., Hochberg, M., Jackson, R., Kwoh, K., Nevitt, M., Suarez-Almazaor, M. (2017). History of Running is Not Associated with Higher Risk of Symptomatic Knee Osteoarthritis: A Cross-Sectional Study form the Osteoarthritis Initiative. Arthritis care res, 69(2), 183-191. doi:10.1002/acr.22939.

Running with Knee Osteoarthritis-Part 1

By Lillian Wynn PT, DPT
Physical Therapist


40% of American adults (110 million people) report walking or running as part of a regular exercise routine.  Reports and ‘common knowledge’ about running and its impact on our joints are often conflicting. This is the first of three blog posts designed to look at current medical research regarding running on aging joints.

Article summary

Often of most concern with running is whether the impact is harmful to the knee joint, as the thought is impact could cause and/or worsen osteoarthritis. Osteoarthritis is the term given to changes that occur along a joints surface as we age. The most common way to diagnose osteoarthritis is with an x-ray. A prospective study published in The American Journal for Preventative Medicine investigated whether running as we age increases the severity or frequency of knee arthritis.


45 long distance runners who were 50 years old or older, and had been running for at least 10 years; and 53 controls who were 50 years or older and did not run for exercise.


Initial x-rays were taken of both knees of all participants. Over the next 18 years, 5 follow up x-rays were taken of each patient. These x-rays were graded on a standard scale to quantify the severity of knee arthritis.


Runners did not show higher rates or more severe cases of knee osteoarthritis than non-runners


Models found that higher BMI, higher initial damage on x-ray, and age to be most strongly correlated with arthritis on x-ray. There was no data to suggest that running, gender, previous knee injury, or total exercise time contributed to osteoarthritis of the knee. In short-go out and go for your run!

 PTF approach

Here at PTF, we want to keep you active in the activities that matter to you. If walking and running are important to you, and you feel limited by your knees, an evaluation could be useful. Often tight and/or weak muscles, stiff joints, and poor movement patterns can contribute to pain while running. PTF does a complete evaluation and then designs a treatment plan individual to you and your body to keep you moving.

Original Article

Chakravarty, E., Hubert, H., Lingala, V., Zatarain, E., Fries, J. (2008). Long Distance Running and Knee Osteoarthritis A Prospective Study. American Journal of Preventative Medicine, 35(2), 133-138. doi:10.1016/j.amepre.2008.03.032.

Pilates Training May Be Your Answer to Improve Your 5K Run Performance

by Genevieve Bland, PT, DPT


Running performance depends on several variables, which include: high maximum oxygen consumption, the ability to sustain maximum oxygen consumption for long periods of time, and the ability to move efficiently. The ability to move efficiently depends on metabolic cost, which is the amount of oxygen spent to move a runner a certain distance at a submaximal intensity. The lower the metabolic cost results in less energy expenditure and lower oxygen consumption, which makes a more efficient runner. There are numerous ways to lower metabolic cost such as: endurance training, strength and aerobic training, and plyometric training. Another way to improve metabolic cost is by engaging the muscles of the trunk and lower limbs to establish better control during a run. Pilates training has been utilized to strengthen trunk muscles in correlation with breathing. Research suggests, Pilates training strengthen core musculature, which decreases the amount of activation during running and increases the runner’s efficiency thereby improving running performance.

Literature search and data analysis to improve a recreational runners speed

In a recent search Finatto et al. investigated the effects of strength training of the postural and trunk muscles. There is research indicating that strength training improves running efficiency and performance that incorporate maximal and explosive programs to the lower extremities.
Finatto et al. hypothesized that metabolic cost and trunk muscle activation will be reduced and consequently, running performance may be improved. They studied the effects of strengthening the muscles of the center of force by Pilates training on metabolic cost and the muscle activation pattern and biomechanical parameters that could improve metabolic cost, which would lead to improve running performance.


Two groups
1. Pilates group: underwent running training combined with Pilates training
2. Control group: running training only

Both groups trained for 12 weeks and were evaluated before and after the training period. Post-training evaluations were performed 72 hours after the last training session

Running training: both groups participated in a 12-week racetrack training program 2x/week.

Pilate’s training: classic mat Pilates training two one-hour weekly sessions performed on days alternate to the days of the running training for the Pilates group only.

Table 1. 12-week periodization of Pilates training

12 week periodization of Pilates training

During the second session, the participants were evaluated for the maximum isometric amplitude of the electromyographic (EMG) signal of trunk muscles which include: obliquus externus, obliquus internus, longissimus, bicep femoris, vastus lateralis, latissimus dorsi, and gluteus medius. Each participant exerted max force with isometric testing after walking for 5 minutes. Three measurements were taken pre and post training. EMG were performed during running as well. Metabolic cost was measured after treadmill testing and participants rested for 15 minutes in the sitting position and at rest for five minutes in the orthostatic position to determine resting heart rate and maximal oxygen consumption.


Running performance and respiratory variables were not significantly different between the groups in the pre-training period. In the post-training period, the Pilates group had significantly higher maximal oxygen consumption and significantly shorter 5-km running time with a significant lower metabolic cost. This suggests that distance runners are able to transfer effective gains from a slow-type core strength training method to the running movement.

Table 2

Effect of running training and running training combined with Pilates on performance and respiratory variables.

Data Represent the Mean Values (Standard Error) for 5-km Running Time, Maximum Oxygen Consumption (VO2max), Metabolic Cost at 10 km.h-1 (Cmet10), Metabolic Cost at 12 km.h-1 (Cmet12), Speed at the Second Ventilatory Threshold (VT2), and Oxygen Consumption at the Second Ventilatory Threshold (VO2 VT2).

Effect of running training and running training combined with Pilates on performance and respiratory variables

Physical Therapy First:

Here at Physical Therapy First we provide one on one hands on care for our patients to treat injuries, rehab after surgery and to help athletes optimize fitness performance. Our therapists can analyze your running technique and develop an individual treatment plan to assist you in achieving your goals for running.

What effect does hip strengthening have on running and single-leg squatting mechanics?

by Leah Flamm, PT, DPT

Looking at a study by Richard W. Willy, PT, PhD, OCS, and Irene S. Davis, PT, PhD, FAPTA


Abnormal hip and knee mechanics may be related to a number of running-related injuries, from stress fractures, to IT band syndrome, to patellofemoral pain syndrome (PFPS). PFPS has been linked to abnormal knee movements like excessive hip adduction, hip internal rotation, contralateral pelvic drop (when the opposite side of the pelvis drops), and knee external rotation during running, single-leg squats, single-leg jump landing, and step-downs. Studies suggest that women with PFPS may have weak hip muscles, and though hip strengthening programs have been shown to improve strength, it is not clear whether hip strengthening programs improve abnormal hip and knee mechanics while running and squatting. Though studies have looked at hip strengthening in healthy active females with normal mechanics, only two have looked at that of individuals with abnormal mechanics.

This study by Drs. Willy and Davis aimed to examine the effect of a hip-strengthening program that included movement training for the single-leg squat on hip and knee mechanics during running and squatting in females who exhibited abnormal mechanics during running.


The researchers hypothesized that peak hip adduction, hip internal rotation, contralateral pelvic drop, and knee external rotation would be reduced during single-leg squats due to the specific neuromuscular reeducation of that activity.


The researchers included female runners ages 18 – 35, who were running at least 10 km per week, and were required to not do any lower extremity resistance training for at least 90 days before the study. They were assigned to either the control group or the treatment group and were not told which group they had been assigned to. The researchers measured peak hip adduction (HADD) during running and squatting because excessive hip adduction is related to lower extremity injuries in runners. The researchers measured baseline hip abduction and external rotation strength at baseline and after a strengthening program or after the control group.

Physical therapists supervised the exercise progression and ensured participants were activating the hip abductors and hip external rotators. Exercises included side-lying hip extension and external rotation, squats with resistance band targeting hip external rotators, hip hikes against the wall, side-stepping with a resistance band to target hip abductors, and then single leg squats with resistance bands targeting hip abductors.


Results show that the treatment group showed significantly improved hip abduction and external rotation strength, and the control group did not. Though the running data did not show any difference in peak hip adduction between groups or between pre- and post-training, single-leg squat data did show significant improvement in peak hip adduction, hip internal rotation, and contralateral (opposite side) pelvic drop.

Discussion and conclusion

The researchers found that their hip abductor/external rotator strength training program was effective at changing hip mechanics during a single-leg squat. However, no changes in running mechanics were noted, which suggests that strengthening the hip muscles alone may not be enough to change movement patterns while running.

Why go to a physical therapist?

A physical therapist (PT) can examine and evaluate an individual’s mechanics while running, squatting, or performing any physical activity. Then the PT can determine what weaknesses and movement patterns may be present. Physical therapists can provide exercises to strengthen and stretch weak and tight muscles, but they can also work on retraining movement patterns that may be associated with injuries. Pure strengthening may not be enough to change the mechanics that may be underlying some injuries in athletes or anyone. For that reason, we may also focus on neuromuscular reeducation to change movement patterns so that we can address the root cause of the problem.

Original article

Willy, R. W., & Davis, I. S. (2011). The Effect of a Hip-Strengthening Program on Mechanics During Running and During a Single-Leg Squat. Journal of Orthopaedic & Sports Physical Therapy,41(9), 625-632. doi:10.2519/jospt.2011.3470

ACL Injury

by Scott Vocke, DPT, CMTPT
Physical Therapist

The ACL is one of four ligaments that helps to stabilize the knee. It is most commonly injured during quick stopping and twisting motions of the knee with the foot planted on the ground. Surgery can be performed to repair or reconstruct the damaged ligament. In many cases, ACL surgery is the best option for treatment. This is especially true for athletes that participate in physically demanding sports that involve cutting and pivoting movements, which require an intact ACL for optimal knee stability. However, research suggests in many instances nonoperative management may be a better option.

Research for ACL Operative vs. Non-operative Management

In a systematic review published in “The Knee” journal (an Official Publication of the British Association for Surgery of the Knee), researchers presented evidence that suggests ACL reconstruction surgery for a specific group of patients may not be any more beneficial than conservative management (also known as rehabilitation without surgery).1 Research has also been conducted to identify two categories of patients with ACL injury: “copers” and “non-copers.”2 Patients who are considered copers are individuals who are able to perform functional activities despite an ACL rupture. Non-copers are patients who are unable to perform functional activities and have repetitive episodes of the knee “giving-way” (also known as instability). These non-copers are less likely candidates for non-operative treatment. There are many evidence-based assessment tools that physical therapists can use to help determine if a patient is a coper or non-coper, thereby indicating whether conservative management is a potential treatment for their injury.

Research for Exercise to Improve Knee Function Early After ACL Injury(3)

A study published in the Journal of Orthopedic Sports Physical Therapy investigated a progressive five-week exercise therapy program early after ACL injury with the following goals:(3)
• Present a progressive exercise program that can be used for patients with ACL injury.
• Evaluate changes in quadricep and hamstring muscle strength
• Assess dynamic lower extremity muscular power and strength compared to the unaffected leg with validated single leg hop tests
• Determine changes in knee function based on self-assessment tools
• Study the difference between coper and non-copers after completion of the exercise program
• Examine potential risk of adverse events from an intensive exercise program early after ACL injury

Researchers hypothesized that patients would:

• Improve knee function based on strength measurements, hop test outcomes, and knee function self-assessment scores
• Non-copers would improve knee function more than copers
• Patients would not have any adverse events during the progressive therapy exercise program.


• 100 patients 13-60 years of age
• Participate regularly in pivoting sports
• Complete ACL tear verified by MRI within the 90 days of initial visit and without evidence of other structural damage to the knee.
• Ability to participate in exercise program two times per week

Exercise program

The exercise program was started as soon as knee joint swelling was eliminated and full range of motion was restored. Subjects participated in the exercise program two to four times per week, which included intensive muscle strength training, plyometric exercises and neuromuscular re-education exercises. Dosage of exercise was based on recommendations form the American College of Sports Medicine and the specific exercises from the program are identified in the following diagram from the research article:

ACL Injury Exercise


Findings from the study showed significant increases in knee function, increased hamstring and quad strength, and improved single leg hop test performance in both coper and non-coper groups. Based on these results, researchers concluded that the progressive exercise therapy program was low risk for adverse events. Therefore, the program should be used for non-operative management of ACL tears as well as to improve knee function prior to ACL surgery.

Physical Therapy First Approach

Determining if a patient is a candidate for non-operative management of an ACL injury is a multidisciplinary approach and may include an orthopedic surgeon. If non-operative management of an ACL injury is determined to be the best option for a patient with an ACL injury, he/she will undergo a full physical therapy evaluation to determine impairments and functional limitations.

These impairments and limitations will be addressed with evidence-based treatments, such as the exercise program from the article reviewed above. Physical therapy treatments to help recover from an ACL injury may include:

• Joint mobilization
• Soft tissue mobilization
• Specific muscle strengthening
• Neuromuscular re-education interventions
• Balance training
• Muscle stretching
• Correction of biomechanical faults in functional movement
• Home exercise program development
• Physical therapy modalities, such as, moist heat, cold packs, ultrasound, electrical stimulation, phototherapy/laser


1. Smith TO, Postle K, Penny F, McNamara I, Mann CJ. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. Knee. 2014;21:462–70. [PubMed]
2. Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2000;8:76–82. doi: 10.1007/s001670050190. [PubMed]
3. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Orthop Sports Phys Ther. 2010 November ; 40(11): 705–721. doi:10.2519/jospt.2010.3345.

Stationary Cycle and Treadmill

ACL Excercises

ACL Exercises

What are the Risk Factors for Reinjury Following an ACL Reconstruction?

by Alex Tan, PT, DPT OCS
Physical Therapist


Anterior cruciate ligament (ACL) rupture rate is the highest in young athletes who participate in sports involving cutting and pivoting (basketball, skiing, soccer) and when they occur tend to be season-ending injuries requiring surgical reconstruction. Female sex and young age have been viewed as common risk factors for initial injury. Even after successful surgical reconstruction and rehabilitation, reinjury to the reconstructed ACL and/or ACL of the opposite limb can occur. At this time, research suggests that environmental and genetic factors may be causes of reinjury. Recently, more studies have become available focusing on the rates of reinjury in younger active individuals, but their results have not been summarized.

Literature search and data analysis to determine possible risk factors for reinjury:

In a recent article by Wiggins et al researchers reviewed existing literature and analyzed data found within to evaluate whether a patient’s age and activity level could be seen as risk factors for another ACL injury following reconstruction.

The researchers narrowed down a database search to 19 articles for review. Then they recorded data from populations included in these articles regarding: total ACL reinjury rate (of the same side and/or opposite limb), specific sport an individual returned to if provided, the nature of the sport (low risk or high-risk involving cutting/jumping), and demographics.

The researchers hypothesized that returning to sport and a younger age would place individuals at higher risk for a second ACL injury.

An analysis was performed on the data from the entire included population and a separate analysis was performed on data sets broken down by individuals of a young age, those who returned to a sport, and from those who were young and returned to a sport.


  • In individuals across all ages who underwent ACL reconstruction: 7% reinjured the same ACL and 8% reinjured the opposite side
  • In individuals < 25 years old who underwent ACL reconstruction: 21% had another ACL injury with 11% being the opposite knee
  • In individuals who returned to sports following reconstruction: 20% had another ACL injury with 12% being the opposite knee
  • In individuals who were <25 years old who returned to high-risk sport following reconstruction: 23% had another injury with 12%

ACL Reinjury Data Graph


Individuals who return to a high-risk sport and those of a younger age are at risk for ACL reinjury. Almost one-fourth of individuals who are of a younger age (<20-25) and return to a high risk sport that involves pivoting and cutting will either reinjure the reconstructed ACL or injure the opposite side. Based on the current literature the majority of these secondary injuries occur in the knee that has not undergone previous surgical intervention.

What Can Physical Therapists Do to Prevent Reinjury?

Individuals who have or have not undergone a previous ACL repair can be examined by a physical therapist who can determine if they are at risk for injury/reinjury due to factors such as:

  • The individual’s improper performance of functional movements
  • Muscular imbalances
  • Strength and flexibility deficits
  • Improper running and landing mechanics
  • Balance deficits
  • Asymmetrical strength/power between limbs

Your therapist will then address these issues with a personalized plan of care which may include but is not limited to interventions such as:

  • Exercises to strengthen or improve flexibility in specific muscles
  • Plyometric or jump training
  • Activity modification recommendations
  • Neuromuscular re-education
  • Bracing

Original Article: Wiggins Amelia, Grandhi Ravi, Schneider Daniel, Stanfield Denver, Webster Kate, Myer Gregory. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis Am J. Sports Med. 2016 July; 44(&): 1861-1876