Guide to Anterior Cruciate Ligament (ACL) Tear

An anterior cruciate ligament (ACL) tear is an injury to the knee commonly affecting athletes, such as soccer players, basketball players, skiers, and gymnasts. Nonathletes can also experience an ACL tear due to injury or accident. Approximately 200,000 ACL injuries are diagnosed in the United States each year. It is estimated that there are 95,000 ruptures of the ACL and 100,000 ACL reconstructions performed per year in the United States. Approximately 70% of ACL tears in sports are the result of noncontact injuries, and 30% are the result of direct contact (player-to-player, player-to-object). Women are more likely than men to experience an ACL tear. Physical therapists are trained to help individuals with ACL tears reduce pain and swelling, regain strength and movement, and return to desired activities.

What is an ACL Tear?

The ACL is one of the major bands of tissue (ligaments) connecting the thigh bone (femur) to the shin bone (tibia) at the knee joint. It can tear if you:

  • Twist your knee while keeping your foot planted on the ground.

  • Stop suddenly while running.

  • Suddenly shift your weight from one leg to the other.

  • Jump and land on an extended (straightened) knee.

  • Stretch the knee farther than its usual range of movement.

  • Experience a direct hit to the knee.

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ACL Attachment: See More Detail

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How Does it Feel?

When you tear the ACL, you may feel a sharp, intense pain or hear a loud "pop" or snap. You might not be able to walk on the injured leg because you can’t support your weight through your knee joint. Usually, the knee will swell immediately (within minutes to a few hours), and you might feel that your knee "gives way" when you walk or put weight on it.

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How Is It Diagnosed?

Immediately following an injury, you may be examined by a physical therapist, athletic trainer, or orthopedic surgeon. If you see your physical therapist first, your therapist will conduct a thorough evaluation that includes reviewing your health history. Your physical therapist will ask:

  • What you were doing when the injury occurred.

  • If you felt pain or heard a "pop" when the injury occurred.

  • If you experienced swelling around the knee in the first 2 to 3 hours following the injury.

  • If you felt your knee buckle or give out when you tried to get up from a chair, walk up or down stairs, or change direction while walking.

Your physical therapist may perform gentle "hands-on" tests to determine the likelihood that you have an ACL tear, and may use additional tests to assess possible damage to other parts of your knee.

An orthopedic surgeon may order further tests, including magnetic resonance imaging (MRI), to confirm the diagnosis and rule out other possible damage to the knee.

Surgery

Most people who sustain an ACL tear will undergo surgery to repair the tear; however, some people may avoid surgery by modifying their physical activity to relieve stress on the knee. A select group can actually return to vigorous physical activity following rehabilitation without having surgery.

Your physical therapist, together with your surgeon, can help you determine if nonoperative treatment (rehabilitation without surgery) is a reasonable option for you. If you elect to have surgery, your physical therapist will help you prepare both for surgery and to recover your strength and movement following surgery.

 

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How Can a Physical Therapist Help?

Once an ACL tear has been diagnosed, you will work with your surgeon and physical therapist to decide if you should have surgery, or if you can recover without surgery. If you don’t have surgery, your physical therapist will work with you to restore your muscle strength, agility, and balance, so you can return to your regular activities. Your physical therapist may teach you ways to modify your physical activity in order to put less stress on your knee. If you decide to have surgery your physical therapist can help you before and after the procedure.

Treatment Without Surgery

Current research has identified a specific group of patients (called "copers") who have the potential for healing without surgery following an ACL tear. These patients have injured only the ACL, and have experienced no episodes of the knee "giving out" following the initial injury. If you fall into this category, based on the specific tests your physical therapist will conduct, your therapist will design an individualized physical therapy treatment program for you. It may include treatments such as gentle electrical stimulation applied to the quadriceps muscle, muscle strengthening, and balance training.

Treatment Before Surgery

If your orthopedic surgeon determines that surgery is necessary, your physical therapist can work with you before and after your surgery. Some surgeons refer their patients to a physical therapist for a short course of rehabilitation before surgery. Your physical therapist will help you decrease your swelling, increase the range of movement of your knee, and strengthen your thigh muscles (quadriceps).

Treatment After Surgery

Your orthopedic surgeon will provide postsurgery instructions to your physical therapist, who will design an individualized treatment program based on your specific needs and goals. Your treatment program may include:

Bearing weight. Following surgery, you will use crutches to walk. The amount of weight you are allowed to put on your leg and how long you use the crutches will depend on the type of reconstructive surgery you have received. Your physical therapist will design a treatment program to meet your needs and gently guide you toward full weight bearing.

Icing and compression. Immediately following surgery, your physical therapist will control your swelling with a cold application, such as an ice sleeve, that fits around your knee and compresses it.

Bracing. Some surgeons will give you a brace to limit your knee movement (range of motion) following surgery. Your physical therapist will fit you with the brace and teach you how to use it safely. Some athletes will be fitted for braces as they recover and begin to return to their sports activities.

Movement exercises. During your first week following surgery, your physical therapist will help you begin to regain motion in the knee area, and teach you gentle exercises you can do at home. The focus will be on regaining full movement of your knee. The early exercises help with increasing blood flow, which also helps reduce swelling.

Electrical stimulation. Your physical therapist may use electrical stimulation to help restore your thigh muscle strength, and help you achieve those last few degrees of knee motion.

Strengthening exercises. In the first 4 weeks after surgery, your physical therapist will help you increase your ability to put weight on your knee, using a combination of weight-bearing and non-weight-bearing exercises. The exercises will focus on your thigh muscles (quadriceps and hamstrings) and might be limited to a specific range of motion to protect the new ACL. During subsequent weeks, your physical therapist may increase the intensity of your exercises and add balance exercises to your program.

Balance exercises. Your physical therapist will guide you through exercises on varied surfaces to help restore your balance. Initially, the exercises will help you gently shift your weight on to the surgery leg. These activities will progress to standing on the surgery leg, while on firm and unsteady surfaces to challenge your balance.

Return to sport or activities. As athletes regain strength and balance, they may begin running, jumping, hopping, and other exercises specific to their individual sport. This phase varies greatly from person-to-person. Physical therapists design return-to-sport treatment programs to fit individual needs and goals.

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Can this Injury or Condition be Prevented?

Much of the research on ACL tears has been conducted with female collegiate athletes, because women are 4 to 6 times more likely to experience the injury. Preventive physical therapy programs have proven to lower ACL injury rates by 41% for female soccer players. Researchers have made the following recommendations for a preventive exercise program:

  • The program should be designed to improve balance, strength, and sports performance. Strengthening your core (abdominal) muscles is key to preventing injury, in addition to strengthening your thigh and leg muscles.

  • Exercises should be performed 2 or 3 times per week and should include sport-specific exercises.

  • The program should last no fewer than 6 weeks.

Although most exercise studies have been conducted with female athletes, the findings may benefit male athletes as well.

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Real Life Experiences

Anita is a 20-year-old student at a local university, and a star basketball player. Her team is off to a great start this year; the buzz around campus is that this could be a dream team!

But tonight, when Anita goes up for a rebound and lands off-balance, she hears a "pop" in her left knee and feels a sharp pain. When she tries to walk, she realizes that she can't put weight on her left leg. She's led back to the training room, where the school physical therapist conducts an evaluation. The test results indicate injury, and the physical therapist notices an increase in swelling around the knee just 30 minutes after the incident. She suspects an ACL tear, and refers Anita to an orthopedic surgeon. The next day, the surgeon confirms the diagnosis of an ACL tear, and tells Anita that her injury requires surgery.

After a short course of treatment by her new local physical therapist, including pain and swelling management, manual (hands-on) therapy, and knee range-of-motion and strengthening exercises, Anita has surgery the following month. Her surgeon schedules her to receive physical therapy 3 days after her surgery. She is advised to ice and elevate the knee several times per day.

Three days after surgery, Anita returns to her local physical therapist to begin her rehabilitation. He shows her how to use her crutches properly to gently begin to put weight on the operative knee. He guides her to contract/tighten the quadriceps muscle, and gently performs manual (hands-on) stretches for her to straighten the knee.

Over the next few weeks, Anita is able to gradually stop using her crutches, and begins to put her full weight on her left leg. She can also fully straighten her knee and tighten her quadriceps muscle without help from her physical therapist. She learns exercises she can safely perform at home.

After 5 weeks, Anita is able to walk normally, fully extending her knee with no pain or feelings of instability. During the next 2 months, she and her physical therapist work on her strength and balance. She finds the hardest exercises are the balance exercises, which require her to balance on a piece of foam or a rocker board while throwing a ball.

About 4 months after surgery, Anita's physical therapist designs a gentle jogging program for her. At 5 months, he allows her to begin a running program. He also adds exercises during Anita's physical therapy sessions that mimic basketball activities such as rebounding or taking a jump shot. During these activities, Anita’s physical therapist teaches her proper landing techniques to lessen the chance of reinjuring her knee when she returns to play.

After 8 months, Anita is allowed to practice with her team. They are thrilled and excited to see their star player is back. Last year was a good year for the team, but it ended in the first round of the playoffs.

Anita and her team begin a new year of full competition 11 months after her surgery. With Anita back in top form, they make the playoffs, blast through to the finals – and bring home the trophy!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

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What Kind of Physical Therapist Do I Need?

Although all physical therapists are prepared through education and experience to treat a variety of conditions or injuries, you may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic (musculoskeletal) problems.

  • A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic physical therapy and has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists with these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with ACL tears.

During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

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Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of ACL tears. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

Nyland J, Mattocks A, Kibbe S, Kalloub A, Greene JW, Caborn DN. Anterior cruciate ligament reconstruction, rehabilitation, and return to play: 2015 update. Open Access J Sports Med. 2016;7:21–32. Free Article.

Anderson MJ, Browning WM III, Urband CE, Kluczynski MA, Bisson LJ. A systematic summary of the systematic reviews on the topic of the anterior cruciate ligament. Orthop J Sports Med. 2016;4:2325967116634074. Free Article.

Anterior cruciate ligament injury. Medscape website. Accessed June 16, 2016.

Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ; Orthopaedic Section of the American Physical Therapy Association. Knee stability and movement coordination impairments: knee ligament sprain. J Orthop Sports Phys Ther. 2010;40:A1–A37. Free Article.

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. J Orthop Sports Phys Ther. 2010;40:705-721. Free Article.

Nyland J, Brand E, Fisher B. Update on rehabilitation following ACL reconstruction. Open Access J Sports Med. 2010;1:151–166. Free Article.

Risberg MA, Holm I. The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. Am J Sports Med. 2009;37:1958–1966. Free Article.

Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008;36:1476–1483. Article Summary on PubMed.

Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 1, outcomes. Am J Sports Med. 2008;36:40-47. Free Article.

Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36:267–288. Article Summary on PubMed.

Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006;34:490–498. Article Summary on PubMed.

Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichol CE. Treatment of anterior cruciate ligament injuries, part 2. Am J Sports Med. 2005;33:1751–1767. Article Summary on PubMed.

Fitzgerald GK, Piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2003;33:492–501. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Christopher Bise, PT, DPT, MS. Revised by Julie Mulcahy, PT. Reviewed by the editorial board.

Posterior Cruciate Ligament (PCL) Injury

The posterior cruciate ligament (PCL) is a thick band of tissue deep inside the knee that connects the thighbone to the shinbone. The PCL prevents the shinbone from sliding too far backward under the thighbone. Any force that pushes the shinbone backward under the thighbone can cause a PCL injury. The PCL may be stretched, partially torn, or completely torn.

Knee injuries that tear the PCL often damage other ligaments or cartilage in the knee. A PCL injury can also break a piece of bone loose within the knee. PCL injuries can occur quickly—with a blunt force injury to the knee—or slowly, as the ligament is stressed over time.

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How Does it Feel?

With an injured PCL, you may experience:

  • Sharp or dull pain deep inside the knee joint or the back of the knee

  • Pain in the knee when lifting a heavy load

  • Pain when walking longer distances

  • Swelling throughout the knee

  • Stiffness in the knee

  • A wobbly feeling in the knee

  • Difficulty walking on the injured leg

  • Difficulty going up or down stairs

  • Difficulty when starting to run

PCL injuries sometimes do not cause a "popping" sound or sensation when they first occur, and for that reason, people may not be sure of the exact time of their injury.

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist will also ask you detailed questions about your injury, such as:

  • How and when did you notice the pain?

  • Did you feel pain or hear a "pop" when you injured your knee?

  • Did your knee straighten out very quickly, past its normal position?

  • Did your knee get forcefully bent, past its normal position?

  • Did you receive a direct hit to the leg while the knee was bent?

  • Did you fall on a bent knee with the foot pointed downward?

  • Did you see swelling around the knee in the first 2 to 3 hours following the injury?

  • Does your knee feel like it is wobbling, locking, catching, buckling, or giving away when you try to use it?

Your physical therapist also will perform special tests to help determine the likelihood that you have a PCL injury. Your physical therapist will gently press on the front of your knee to determine if the ligament feels loose, and may perform additional tests to determine if other parts of your knee are injured. Your physical therapist will also observe how you are walking.

To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests, such as an x-ray, to confirm the diagnosis and to rule out other damage to the knee, including fracture.

How Can a Physical Therapist Help?

Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but improvement is generally noted in 2 to 12 weeks.

During the first 24 to 48 hours following your injury, your physical therapist may advise you to:

  • Rest your knee by using crutches or a brace, reducing the amount of weight you put on your injured leg, and avoiding any activity that causes pain.

  • Apply ice packs to the area for 15– to 20 minutes every 2 hours.

  • Consult with a physician for further services such as medication or diagnostic tests.

Your physical therapist will work with you over time to:

Reduce Pain and Swelling

Your physical therapist may use a variety of treatments and technologies to control and reduce your pain and swelling, which may include ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy, such as massage.

Improve Motion

Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and leg. These might begin with passive motions that your physical therapist performs for you to gently move your leg and knee joint, and progress to active exercises and stretches that you do yourself.

Improve Flexibility

Your physical therapist will determine if any of your leg muscles are tight, and teach you how to stretch them with gentle exercise.

Improve Strength

Certain exercises will aid healing at each stage of recovery; your physical therapist will choose and teach you the correct exercises and equipment to steadily restore your strength and agility. These may include the use of cuff weights, stretch bands, weight-lifting equipment, and cardio-exercise equipment, such as treadmills or stationary bicycles.

Improve Balance

Regaining your sense of balance is important after an injury. Your physical therapist will teach you exercises to improve your balance skills.

Restore Agility

Speed and accuracy of leg movement is important in athletic activities. Your physical therapist will help you regain these skills in preparation for a return to sports activities.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.

Your physical therapist will work with you to set your work, sport, and home-life recovery goals. Your treatment program will help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills to help you return to your regular activities.

If Surgery Is Necessary

Surgery is not usually required to treat a mild PCL injury. However, it may be needed if:

  • The PCL is completely torn

  • A piece of bone has broken loose

  • There are other ligament injuries

  • You constantly feel like your knee is going to buckle beneath you

Athletes may elect to undergo surgical replacement of the PCL to improve the stability of the knee during sports activities. If other parts of the knee are injured at the same time as the PCL, you may need different treatment for those injuries, including surgery. If surgery is needed, you will follow a recovery program over several weeks guided by your physical therapist. Your physical therapist will help you minimize pain, regain motion and strength, and return to normal activities in the speediest manner possible.

Can this Injury or Condition be Prevented?

Your physical therapist can recommend a home-exercise program to strengthen and stretch the muscles around your knee, upper leg, and abdomen to help prevent future injury. These may include strength and flexibility exercises for the leg, knee, and core muscles.

To help prevent a recurrence of the injury, your physical therapist may advise you to:

  • Always use a seat belt to help prevent injury during a car accident.

  • Position your car seat so it is not too close to the dashboard.

  • Avoid intentionally landing on the front of your shinbone or on your knees.

  • Always warm up before starting a sport or heavy physical activity.

  • Maintain or improve sport-specific conditioning and techniques that are right for your level of sport activity.

  • Wear shoes that are in good condition and fit well.

  • Maintain a healthy weight.

Real Life Experiences

Steven is a 35-year-old nurse. While driving home one day, he is involved in an accident. His knees hit his car's dashboard very hard. His left knee is bruised but otherwise fine;  the right knee feels painful and swells overnight. After a few days, the right knee does not feel better and starts to feel wobbly. He is not able work. He calls his physical therapist. 

Steven's physical therapist is able to see him immediately, and thoroughly examines the knee. She can see there is swelling throughout the knee-joint area. The bruised areas are painful when she gently touches them. She tests the ligaments of the knee and finds that the PCL is noticeably looser than the PCL on the other leg. She determines that the PCL is moderately sprained—overstretched, but not torn. She applies an ice pack and electrical stimulation to help reduce the pain and swelling, and a brace to support the knee and limit bending. She teaches Steven how to use crutches, and advises him to consult with his personal physician to rule out a bone fracture. His physician confirms the diagnosis of PCL sprain.

When Steven returns for his next session, his physical therapist teaches him gentle motion and strengthening exercises. Over the next few weeks, she helps him progress through a rehabilitation program that includes strengthening, stretching, and balance exercises. The physical therapy program reduces the swelling and restores the knee's motion and strength, so that Steven no longer needs crutches after 2 weeks, and he is able to stop using the brace after 3 weeks. After about 6 weeks, Steven is able to resume all of his normal daily activities, including his full-time duties as a nurse.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat PCL sprains. However, you may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic injuries. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of your injury. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Kopkow C, Freiberg A, Kirschner S, et al. Physical examination tests for the diagnosis of posterior cruciate ligament rupture: a systematic review. J Orthop Sports PhysTher. 2013;43:804-813. Article Summary on PubMed.

Kim JG, Lee YS, Yang BS, et al. Rehabilitation after posterior cruciate ligament reconstruction: a review of the literature and theoretical support. Arch Orthop Trauma Surg. 2013;133:1687-1695. Article Summary on PubMed.

Jansson KS, Costello KE, O'Brien L, et al. A historical perspective of PCL bracing. Knee Surg Sports Traumatol Arthrosc. 2013;21:1064-1070. Article Summary on PubMed.

Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2013;21:1071-1084. Article Summary on PubMed.

Rosenthal MD, Rainey CE, Tognoni A, Worms R. Evaluation and management of posterior cruciate ligament injuries. Phys Ther Sport. 2012;13:196-208. Article Summary on PubMed.

Chandrasekaran S, Ma D, Scarvell JM, et al. A review of the anatomical, biomechanical and kinematic findings of posterior cruciate ligament injury with respect to non-operative management. Knee. 2012;19:738-745. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Andrea Avruskin, PT, DPT. Reviewed by the editorial board.

Pes Anserine Bursitis

Pes anserine bursitis is a condition that produces pain on the inside of the knee and lower leg. It occurs most commonly in young people involved in sports (eg, running or swimming the breaststroke), middle-aged women who are overweight, and people aged 50 to 80 years who have osteoarthritis of the knee. Up to 75% of people who have osteoarthritis of the knee have symptoms of pes anserine bursitis. The condition is also commonly associated with type 2 diabetes; 24% to 34% of patients with type 2 diabetes who report knee pain are found to have pes anserine bursitis. However, in some cases no direct cause can be identified. Physical therapists treat people with pes anserine bursitis to reduce pain, swelling, stiffness, and weakness, as well as identify and treat the underlying cause of the condition.

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What is Pes Anserine Bursitis?

The pes anserine bursa is a small, fluid-filled sac located 2 to 3 inches below the knee joint on the inside of the lower leg. It lies beneath 3 tendons that attach to muscles of the thigh, and prevents the tendons from rubbing on the shinbone (tibia). The term “bursitis” describes a condition where the bursa has become irritated and inflamed. This condition is usually painful and associated with some swelling in the affected area. Certain positions, motions, or disease processes can cause increased friction or stress on the bursa, leading to the development of bursitis.

Pes anserine bursitis can be caused by:

  • Repetitive activities, like squatting, stair climbing, and other work or household activities that are often repeated

  • Incorrect sports training techniques, such as a lack of stretching, sudden increases in run distances, or too much uphill running

  • Obesity

  • Osteoarthritis of the knee

  • Valgus positioning of the knee (ie, a “knock-knee” position where the knees angle inward)

  • Turning the leg sharply with the foot planted on the ground

  • Injury, such as a direct hit to the leg

  • Tight hamstring (back of the thigh) muscles

  • A tear in the cartilage of the knee

  • Flat feet

How Does it Feel?

With pes anserine bursitis, you may experience:

  • Pain and swelling on the inside of the lower leg, 2 to 3 inches below the knee joint; this pain may also extend to the front of the knee and down the lower leg

  • Pain when touching the inside of the lower leg, 2 to 3 inches below the knee joint

  • Pain when bending or straightening the knee

  • Pain or difficulty walking, sitting down, rising from a chair, or climbing stairs

How Is It Diagnosed?

Your physical therapist will conduct a thorough examination that includes taking your health history as well as asking you detailed questions about your injury, such as:

  • How and when did you notice the pain?

  • Did you feel pain or hear a "pop" when you injured your leg?

  • Did you turn your leg with your foot planted on the ground?

  • Did you change direction quickly while running?

  • Did you receive a direct hit to the leg while your foot was planted on the ground?

  • Did you see swelling around the knee in the first 2 to 3 hours following the injury?

  • Does your knee feel like it is buckling or “giving way” when you try to use it?

Your physical therapist also will perform special tests to help determine the likelihood that you have pes anserine bursitis. Your therapist may:

  • Gently press on the inner side of your knee to see if it is painful to the touch

  • Assess the range of motion you have at the knee and hip, as well as the strength of some of the muscles at these joints

  • Observe how you are walking, squatting, and performing other functional and sports-specific tasks as appropriate

To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests, such as an x-ray, to confirm the diagnosis and to rule out other damage to the knee.

How Can a Physical Therapist Help?

Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities.

The First 24 to 48 Hours

If you see a physical therapist within 24 to 48 hours of your injury, your therapist may advise you to:

  • Rest the area by avoiding walking or any activity that causes pain.

  • Apply ice packs to the area for 15 to 20 minutes every 2 hours.

  • Consult with a physician for further services, such as medication or diagnostic tests.

Individualized Treatment

Depending on your condition and goals, your individualized rehabilitation plan may include treatments to:

Reduce pain and swelling. Your physical therapist may use different types of treatments to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy, such as massage.

Improve motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and leg. These might begin with "passive" motions that the physical therapist performs for you to gently move your leg and knee joint, and then progress to active exercises that you do yourself.

Improve flexibility. Pes anserine bursitis is often related to tight hamstring (back of the thigh) muscles. Your physical therapist will determine if your hamstring muscles or any other leg muscles are tight, and teach you how to stretch them.

Improve strength. Certain exercises will aid healing at each stage of recovery. Your physical therapist will choose and teach you the correct exercises and equipment to steadily restore your muscle strength and power. These may include using cuff weights, stretch bands, weight-lifting equipment, and cardio-exercise equipment, such as treadmills or stationary bicycles.

Improve balance. Regaining your sense of balance is important after an injury. Your physical therapist may teach you exercises to improve your balance skills.

Speed recovery time. Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you heal, return to a normal lifestyle, and reach your goals faster than you are likely to do on your own.

Return to activities. Initially, your physical therapist may recommend that you reduce or eliminate activities that aggravate your condition for a period of time. Your physical therapist will discuss your goals with you and set up a treatment program to help you meet them in the safest, fastest, and most effective way possible. You may learn specific exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your own unique goals.

Other Treatment Options

Studies have shown that some patients who do not respond to conservative treatment, such as physical therapy, may benefit from medical therapy. Your physical therapist may recommend that you discuss other treatment options with your physician, including surgery. Although surgery is rarely prescribed for pes anserine bursitis, it sometimes is needed. If surgery is required for your condition, you will follow a recovery program over several weeks guided by your physical therapist. Your physical therapist will help you minimize pain, regain motion and strength, and return to normal activities in the safest and speediest manner possible.

Can this Injury or Condition be Prevented?

Your physical therapist can recommend a home-exercise program to strengthen and stretch the muscles around your knees, upper legs, and abdomen to help prevent the onset or recurrence of pes anserine bursitis. These may include strength and flexibility exercises for the legs, knees, and core muscles.

To help prevent a recurrence of the injury, or prevent its onset if you seek guidance before injury, your physical therapist may advise you to:

  • Learn correct knee positioning when participating in athletic activities.

  • Follow a consistent flexibility and strength exercise program, especially for the leg and hip muscles, to maintain good physical conditioning.

  • Practice balance and agility exercises and drills.

  • Always warm up before starting a sport or heavy physical activity.

  • Avoid sudden increases in running mileage or uphill running.

  • Wear shoes that are in good condition and fit well.

  • Maintain a healthy weight.

  • Treat and manage diabetes very closely.

  • Wear orthotics to reduce flat feet and valgus (knock-knee) positioning of the lower extremities.

  • Wear a knee brace to support the knee and reduce strain on the inside of the joint.

Real Life Experiences

Martha is a 40-year-old secretary who has become obese. Her goal is to lose 100 pounds with diet and exercise. To reach that goal, Martha recently joined a gym, and decided to try the latest craze—a Zumba class. Martha enjoyed the first week of classes, but when leaving the gym after the fourth class, she felt a sharp pain in the inner, lower side of her right knee. It got worse when she bent and straightened her knee and when she walked upstairs to go to bed that night. The next day, the pain was still there, making it hard for her to get to work. She contacted her physical therapist.

Martha’s physical therapist performed special tests on the tendons and muscles around the knee, and found that her hamstring (back of the thigh) muscles were extremely tight and her quadriceps (front of the thigh) muscles were weak. Martha’s knee was tender to the touch, and mildly swollen 2 to 3 inches below the knee joint on the inner side of the leg, where the pes anserine bursa is located.

Martha's physical therapist explained that her pes anserine bursa was irritated and swollen. He applied ice and electrical stimulation to the area for 20 minutes. He also applied some tape to gently support Martha's hamstring muscles and alleviate the swelling and pain. He showed her how to stretch her hamstring muscles at home, and how to apply ice every few hours. He recommended that she not attend her Zumba class until her symptoms cleared up.

When Martha returned for her next visit, her physical therapist taught her some exercises to improve the strength of the muscles of her legs and “core,” and to improve her balance. Martha and her physical therapist worked together consistently over the next few weeks. Her treatment program, both in the clinic and at home, as well as her return to activity, were carefully adjusted to help ensure her safe and effective recovery.

Martha received physical therapy treatments for 6 weeks, at which time she felt almost 100% pain free—and much stronger. Martha returned to the gym to perform the exercises and stretches she learned in physical therapy as well as a modified fitness program. By the fourth week, she was able to participate in half of the Zumba class and by the fifth week, to finish the full class.

Martha has continued to do the stretches and exercises she learned from her physical therapist, and is proud to report to her friends and family that she is now pain free—and losing weight!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat pes anserine bursitis. However, you may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic injuries. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends, or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of pes anserine bursitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Uysal F, Akbal A, Gökmen F, Adam G, Reşorlu M. Prevalence of pes anserine bursitis in symptomatic osteoarthritis patients: an ultrasonographic prospective study. Clin Rheumatol. 2015;34(3):529–533. Article Summary in PubMed.

Klontzas ME, Akoumianakis ID, Vagios I, Karantanas AH. MR imaging findings of medial tibial crest friction. Eur J Radiol. 2013;82(11):e703–e706. Article Summary in PubMed.

Chatra PS. Bursae around the knee joints. Indian J Radiol Imaging. 2012;22(1):27-30. Free Article.

Helfenstein M Jr, Kuromoto J. Anserine syndrome [article in English and Portuguese]. Rev Bras Reumatol. 2010;50(3):313–327. Free Article.

Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007;13(2):63–65. Article Summary in PubMed

Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34:395–398. Article Summary in PubMed

Handy JR. Anserine bursitis: a brief review. South Med J. 1997;90(4):376–377. Article Summary on PubMed.

Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis [published correction in: Am Fam Physician. 1996;54(2):468]. Am Fam Physician. 1996;53(7):2317-2324. Article Summary on PubMed.

Hemler DE, Ward WK, Karstetter KW, Bryant PM. Saphenous nerve entrapment caused by pes anserine bursitis mimicking stress fracture of the tibia. Arch Phys Med Rehabil. 1991;72(5):336–337. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Revised by Daniel Farwell, PT, DPT, a board-certified sports clinical specialist. Authored by Andrea Avruskin, PT. Reviewed by the editorial board.

Osteoporosis

What is Osteoporosis?

Osteoporosis is a bone disease characterized by low bone density (thickness of the bone), decreased bone strength, and a change in the bone structure, which can lead to an increased risk of fracture. The normal bone structure becomes thinned out and porous with poor nutrition, aging, or when osteoporosis develops, lessening the ability of the bone to withstand the typical forces that are applied in everyday living. Fractures from low bone density and osteoporosis can be serious, causing pain and affecting quality of life.

Bone is living tissue. Normally, one type of cell removes bone and another type of cell adds bone in a balanced, ongoing process. In osteoporosis, bones weaken when not enough new bone is formed and/or too much bone is lost. This imbalance commonly begins in women during the first 5 years of menopause. However, it can also occur in men and in children, often due to diseases that affect bone development, such as celiac disease, inflammatory bowel disease, rheumatoid arthritis, spina bifida, cystic fibrosis, or kidney disease. Some medicines, such as steroids, may increase the risk of developing osteoporosis. Athletes who are underweight during the time of peak bone development are also susceptible.

There are many factors that can cause a person to be at risk for developing osteoporosis. It is important to know your risks so that you can be diagnosed and proactive in your treatment.


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Risk Factors for Osteoporosis

Noncontrollable risks

  • Female gender

  • Small frame

  • Advanced age

  • Hormone levels

  • Genetics

  • Predisposing medical conditions

Controllable risks

  • Cigarette smoking

  • Excessive alcohol intake

  • Inactive lifestyle

  • Excessive caffeine intake

  • Lack of weight-bearing exercise

  • Drugs (eg, steroids, heparin)

  • Poor health

  • Low weight

  • Calcium-poor diet

  • Low vitamin D levels

 


How Does it Feel?

Osteoporosis is a disease that can be "silent." There may be no outward symptoms until a fracture occurs. If you are middle-aged or older, you may notice a loss of height or the appearance of a humpback. You may also begin to experience pain between your shoulder blades or above the crest of the pelvis.

People with low bone density may experience fractures in everyday situations that would not occur in persons with healthy bones, such as breaking a hip or a wrist with a fall from a standing height, breaking a rib when opening a window or when receiving a hug, or breaking an ankle after stepping off a curb. These are called fragility fractures and are a red flag for bone disease. Spinal compression fractures, particularly those in the upper back or thoracic spine (area between the neck and the lower back), are the most common fractures, followed by hip and wrist fractures.


How Is It Diagnosed?

If you are seeing a physical therapist for back pain or other rehabilitation issues, the therapist will review your medical, family, medication, exercise, dietary, and hormonal history, conduct a complete physical examination, and determine your risk factors for osteoporosis. The assessment may lead the physical therapist to recommend further testing.

Osteoporosis is best diagnosed through a quick and painless specialized X-ray called the DXA, which measures bone density. The results are reported using T-scores and Z-scores.

  • The T-score compares your score to that of healthy 30-year-old adults. If you have a T-score of -1 or less, you have a greater risk of having a fracture.

  • If the T-score is -2.5 or less you will receive the diagnosis of osteoporosis.

  • The Z-score compares your bone mineral density to those of the same sex, weight, and age. It is used for those whose bone mass has not yet peaked, premenopausal women, and men older than 50.

Other methods of measuring bone density include X-ray, ultrasound, and CT scan. 


How Can a Physical Therapist Help?

Your physical therapist can develop a specific program based on your individual needs to help improve your overall bone health, keep your bones healthy, and help you avoid fracture. Your physical therapist may teach you:

  • Specific exercises to build bone or decrease the amount of bone loss

  • Proper posture to protect your spine from fracture

  • Proper alignment during activities of daily living

  • How to improve your balance so as to reduce your risk of falling

  • How to adjust your environment to protect your bone health

Healthy bone is built and maintained through a healthy lifestyle. Your physical therapist will teach you specific exercises to meet your particular needs.

The exercise component for bone building or slowing bone loss is very specific and similar for all ages. Bone grows when it is sufficiently and properly stressed, just as muscle grows when challenged by more than usual weight. Two types of exercise are optimal for bone health: weight-bearing and resistance.

It is best for a physical therapist to provide your individual bone-building prescription to ensure that you are neither overexercising nor underexercising. Typically, exercises are performed 2 to 3 times a week as part of an overall fitness program.

Weight-bearing exercises

  • Dancing

  • Jogging (if your bone density is higher than -3.0)

  • Racquet sports

  • Heel drops

  • Stomping

Resistance exercises

  • Weight lifting in proper spine and lower-extremity alignment

  • Use of exercise bands

  • Gravity resistance (eg, push-ups, prone trunk extension with cushion to protect lowest ribs, single-leg heel raises, squats, lunges, sustained standing yoga poses in neutral spine position)

  • Exercises that reduce or stabilize kyphosis (hunchback)

  • Balance exercises

If you are diagnosed with osteoporosis or low bone density, your physical therapist will work with you to:

  • Build bone or lessen the amount of bone loss at areas most vulnerable to fracture through exercise—hip, spine, shoulder, arms.

  • Improve your dynamic balance to avoid falls.

  • Improve your posture.

  • Adjust your work and living environments to limit risk.

  • Help you avoid exercises and movements that may contribute to spinal fracture, including any type of sit-up or crunch, and excessive spinal or hip twisting.

Conservative treatment of a fracture includes bed rest and appropriate pain treatment. Your physical therapist will work with you to:

  • Decrease your pain through positioning and other pain-relieving modalities. Individualized physical therapist regimens can help reduce pain without the need for medications, such as opioids.

  • Provide appropriate external devices, such as bracing, to promote healing and improve posture.

  • Decrease your risk of a fall, strengthen your muscles, and improve your postural alignment.

  • Avoid exercises that involve too much forward or side bending or twisting.

  • Avoid water or endurance exercises, as they have been shown to negatively affect bone density.

If your pain lasts longer than 6 weeks following a spinal fracture, you can discuss surgical options, such as vertebroplasty or kyphoplasty, with your physical therapist, primary care physician, and surgeon.

Children and adolescents. Physical therapists can educate families and youth groups on proper exercise and posture, and about the need to move daily to build bone strength and prevent bone loss. Children with health issues such as spina bifida, diabetes, Crohn's disease, and cerebral palsy are at a greater risk for bone disease and can particularly benefit from the guidance of a physical therapist. Proper physical conditioning is crucial for children and adolescents: the majority of bone is built during adolescence and peaks by the third decade of life.

Middle-aged and older adults. As people age, they may begin to notice postural, balance, and strength changes. Physical therapists work with middle-aged and older adults to:

  • Develop individualized exercise programs to promote bone growth or lessen bone loss

  • Improve dynamic balance to avoid falls

  • Improve posture

  • Improve the strength of back muscles

  • Improve hip strength and mobility


Can this Injury or Condition be Prevented?

Osteoporosis can be prevented by building adequate bone density through childhood, adolescence, and early adulthood. Building strong bones requires an adequate intake of calcium and vitamin D, and regular exercise.

There are steps to take to improve bone health at any age. An active lifestyle that includes resistance and weight-bearing exercise is important to maintain healthy bone. It is also important to avoid habits that promote bone loss, such as smoking, excessive alcohol consumption, and an inadequate intake of calcium in your diet. Maintaining good body mechanics and posture also contribute to good bone health. We have no control over the genetic tendencies we have inherited, but we can choose to manage osteoporosis through proper medication, diet, and appropriate exercise.

As with any health issue, an overall healthy lifestyle is important for staying well.


Real Life Experiences

Anna is a 69-year-old retired legal secretary. She has enjoyed her early years of retirement, taking long walks in beautiful settings across the United States. Two years into her retirement, however, she began having knee pain during some of her walks, which gradually grew worse. Last year, she had a total knee replacement due to arthritis. She now walks with a cane because of chronic knee and ankle pain, and has experienced a loss of balance. She also has developed a rounded upper back, and low back pain. She seeks the help of a physical therapist.

Anna's physical therapist performs an assessment that includes a medical review for osteoporosis risk factors and for other health issues. He evaluates her range of motion and strength, testing her arms, legs, and trunk—especially her upper back. He tests the flexibility of her spine and her balance, her walking ability, and her risk of falling. Anna's walking style is uneven and she leans heavily on her cane. A DXA scan reveals that Anna has lost bone density in her spine and both hips. A vertebral fracture assessment X-ray shows that she has painless compression fractures of her spine. Her physical therapist diagnoses osteoporosis of the spine.

Anna first works with her physical therapist to improve her posture and knee function through flexibility and strengthening exercises, so she can walk more normally while working on her balance to lower her fall risk. She tells him her main goal is to be able to take walks in the park again.

Anna’s physical therapist teaches her safe trunk movement to avoid spinal fracture. Anna agrees to wear a dynamic trunk brace 2 hours a day to help make her posture more upright. She practices weight-bearing exercises with considerations for her arthritis, and learns resistive strengthening exercises for her spine and hip. Anna's physical therapist designs a gentle home-exercise program for her as well.

By her last visit, the flexibility and strength of Anna’s trunk and legs and her tolerance of physical activity have improved. The quality of her walking and dynamic balance are measurably improved, and her risk of falling has decreased. Anna feels much more confident about managing her condition.

Just this past week, Anna joined a therapeutic senior walking group that meets at the local botanic garden twice a week. She is thrilled to be enjoying gentle walks in nature again, and looks forward to coordinating other activities with her new group of friends!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.


What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat those with osteoporosis. However, if you have a diagnosis of osteoporosis or low bone density, you may want to consider:

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy or geriatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

  • A physical therapist who specializes in the treatment of osteoporosis.

You can find physical therapists with these and other credentials by using Find a PT, the online tool by the American Physical Therapy Association that can help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have osteoporosis.


Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that can help them make health care decisions and also prepare them for a visit with their health care provider.

The following websites are important and reputable resources to obtain more information about improving your bone health:

National Osteoporosis Foundation. Accessed March 28, 2018.   

American Bone Health. Accessed March 28, 2018.

American Bone Health. FORE fracture risk calculator. Accessed March 28, 2018.

Osteoporosis Canada. Accessed March 28, 2018.

Osteoporosis Canada. Too fit to fracture series. Accessed March 28, 2018.

National Bone Health Alliance. Accessed March 28, 2018.

Own the Bone. Accessed March 28, 2018.

National Osteoporosis Foundation and Pilates Anytime. Safe movement video series. Accessed March 28, 2018.

MedBridge. Osteoporosis education courses for physical therapists. Accessed March 28, 2018.

Office of the US Surgeon General. The 2004 Surgeon General’s report on bone health and osteoporosis. Accessed March 28, 2018. 

Physical Activity Guidelines Advisory Committee, US Dept of Health and Human Services. Physical Activity Guidelines Advisory Committee Report, 2008Washington, DC: US Department of Health and Human Services. Published June 2008. Accessed March 28, 2018. 

The following articles provide some of the best scientific evidence related to physical therapy treatment of osteoporosis and fracture prevention. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a Pub Med* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Watson SL, Weks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211–220. Article Summary in PubMed.

Beck BR, Daly RM, Singh MA, Taaffe DR. Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport. 2017;20(5):438–445. Article Summary in PubMed.

Sözen T, Özışık L, Başaran NÇ. An overview and management of osteoporosis. Eur J Rheumatol. 2017;4(1):46–56. Free Article.

Giangregorio LM, McGill S, Wark JD, et al. Too fit to fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int. 2015;26(3):891–910. Free Article.

Bansal S, Katzman WB, Giangregorio LM. Exercise for improving age-related hyperkyphotic posture: a systematic review. Arch Phys Med Rehabil. 2014;95(1):129–140. Free Article.

Clark EM, Carter L, Gould VC, Morrison L, Tobias JH. Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening. Osteoporos Int. 2014;25(3):953–964. Article Summary in PubMed.

Siris ES, Adler R, Bilezikian J, et al. The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int. 2014;25(5):1439–1443. Free Article.

Silva BC, Boutroy S, Zhang C, et al. Trabecular bone score (TBS): a novel method to evaluate bone microarchitectural texture in patients with primary hyperparathyroidism. J Clin Endocrinol Metab. 2013;98(5):1963–1970. Free Article.

Cheung AM, Giangregorio L. Mechanical stimuli and bone health: what is the evidence? Curr Opin Rheumatol. 2012;24:561–566. Article Summary in PubMed.

Pfeifer M, Kohlwey L, Begerow B, Minne HW. Effects of two newly developed spinal orthoses on trunk muscle strength, posture, and quality-of-life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil. 2011;90:805–815. Article Summary on PubMed.

Kasukawa Y, Miyakoshi N, Hongo M, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28:82–87. Article Summary in PubMed.

Nikander R, Kannus P, Dastidar M, et al. Targeted exercises against hip fragility. Osteoporos Int. 2009;20:1321–1328. Article Summary in PubMed.

Hongo M, Itoi E, Sinaki M, et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial. Osteoporos Int. 2007;18:1389–1395. Article Summary in PubMed.

Vainionpaa A, Korpelainen R, Leppaluoto J, Jamsa T. Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women. Osteoporos Int. 2005;16:191–197. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Mary Saloka Morrison, PT, DScPT, MHS. Reviewed by the editorial board.




Osteoarthritis of the Knee

Osteoarthritis of the knee (knee OA) is the inflammation and wearing away of the cartilage on the bones that form the knee joint (osteo=bone, arthro=joint, itis=inflammation). The diagnosis of knee OA is based on 2 primary findings: radiographic evidence of changes in bone health (through medical images such as X-ray and magnetic resonance imaging [MRI]), and an individual’s symptoms (how you feel). Approximately 14 million people in the United States have symptomatic knee OA. Although more common in older adults, 2 million of the 14 million people with symptomatic knee OA were younger than 45 when diagnosed, and more than half were younger than 65.

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What is Osteoarthritis of Knee?

Knee osteoarthritis (knee OA) is a progressive disease caused by inflammation and degeneration of the knee joint that worsens over time. It affects the entire joint, including bone, cartilage, ligaments, and muscles. Its progression is influenced by age, body mass index (BMI), bone structure, genetics, muscular strength, and activity level. Knee OA also may develop as a secondary condition following a traumatic knee injury. Depending on the stage of the disease and whether there are associated injuries or conditions, knee OA can be managed with physical therapy. More severe or advanced cases may require surgery.


How Does it Feel?

Individuals who develop knee OA may experience a wide range of symptoms and limitations based on the progression of the disease. Pain occurs when the cartilage covering the bones of the knee joint wears down. Areas where the cartilage is worn down or damaged exposes the underlying bone. The exposure of the bone allows increased stress and compression to the cartilage, and at times bone-on-bone contact during movement, which can cause pain. Because the knee is a weight-bearing joint, your activity level, and the type and duration of your activities usually have a direct impact on your symptoms. Symptoms may be worse with weight-bearing activity, such as walking while carrying a heavy object.

Symptoms of knee OA may include:

  • Worsening pain during or following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position

  • Pain or stiffness after sitting with the knee bent or straight for a prolonged period of time

  • A feeling of popping, cracking, or grinding when moving the knee

  • Swelling following activity

  • Tenderness to touch along the knee joint

Typically these symptoms do not occur suddenly or all at once, but instead develop gradually over time. Sometimes individuals do not recognize they have osteoarthritis because they cannot remember a specific time or injury that caused their symptoms. If you have had worsening knee pain for several months that is not responding to rest or a change in activity, it is best to seek the advice of a medical provider.


How Is It Diagnosed?

Knee OA is diagnosed by 2 primary processes. The first is based on your report of your symptoms and a clinical examination. Your physical therapist will ask you questions about your medical history and activity. The therapist will perform a physical exam to measure your knee's movement (range of motion), strength, mobility, and flexibility. You might also be asked to perform various movements to see if they increase or decrease the pain you are experiencing.

The second tool used to diagnose knee OA is diagnostic imaging. Your physical therapist may refer you to a physician, who will order X-rays of the knee in a variety of positions to check for damage to the bone and cartilage of your knee joint. If more severe joint damage is suspected, an MRI may be ordered to look more closely at the overall status of the joint and surrounding tissues. Blood tests also may be ordered to help rule out other conditions that can cause symptoms similar to knee OA.


How Can a Physical Therapist Help?

Once you have received a diagnosis of knee OA, your physical therapist will design an individualized treatment program specific to the exact nature of your condition and your goals. Your treatment program may include:

Range-of-motion exercises. Abnormal motion of the knee joint can lead to a worsening of OA symptoms when there is additional stress on the joint. Your physical therapist will assess your knee’s range of motion compared with expected normal motion and the motion of the knee on your uninvolved leg. Your range-of-motion exercises will focus on improving your ability to bend and straighten your knee, as well as improve your flexibility to allow for increased motion.

Muscle strengthening. Strengthening the muscles around your knee will be an essential part of your rehabilitation program. Individuals with knee OA who adhere to strengthening programs have been shown to have less pain and an improved overall quality of life. There are several factors that influence the health of a joint: the quality of the cartilage that lines the bones, the tissue within and around the joints, and the associated muscles. Due to the wear and tear on cartilage associated with knee OA, maintaining strength in the muscles near the joint is crucial to preserve joint health. For example, as the muscles along the front and back of your thigh (quadriceps and hamstrings) cross the knee joint, they help control the motion and forces that are applied to the bones.

Strengthening the hip and core muscles also can help balance the amount of force on the knee joint, particularly during walking or running. The “core” refers to the muscles of the abdomen, low back, and pelvis. A strong core will increase stability throughout your body as you move your arms and legs. Your physical therapist will assess these different muscle groups, compare the strength in each limb, and prescribe specific exercises to target your areas of weakness.

Manual therapy. Physical therapists are trained in manual (hands-on) therapy. Your physical therapist will gently move your muscles and joints to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. The addition of manual therapy techniques to exercise plans has been shown to decrease pain and increase function in people with knee OA.

Bracing. Compressive sleeves placed around the knee may help reduce pain and swelling. Devices such as realignment and off-loading braces are used to modify the forces placed on the knee. These braces can help "unload" certain areas of your knee and move contact to less painful areas of the joint during weight-bearing activities. Depending on your symptoms and impairments, your physical therapist will help determine which brace may be best for you.

Activity recommendations. Physical therapists are trained to understand how to prescribe exercises to individuals with injuries or pain. Since knee OA is a progressive disease, it is important to develop a specific plan to perform enough activity to address the problem, while avoiding excessive stress on the knee joint. Activity must be prescribed and monitored based on the type, frequency, duration, and intensity of your condition, with adequate time allotted for rest and recovery. Research has shown that individuals with knee OA who walked more steps per day were less likely to develop functional problems in the future. Your physical therapist will consider the stage and extent of your knee OA and prescribe an individualized exercise program to address your needs and maximize the function of your knee.

Modalities. Your physical therapist may recommend therapeutic modalities, such as ice and heat, to aid in pain management.

If Surgery Is Required

The meniscus (the shock absorber of the knee) may be involved in some cases of knee OA. In the past, surgery (arthroscopy) to repair or remove parts or all of this cartilage was common. Current research, however, has shown that—in a group of patients who were deemed surgical candidates for knee OA with involvement of the meniscus—60% to 70% of those who first participated in a physical therapy program did not go on to have surgery. One year later, those results were unchanged. This study suggests that physical therapy may be an effective alternative for people with knee OA, who would prefer to avoid surgery.

Sometimes, however, surgical intervention, such as arthroscopy or a total knee replacement, may be recommended. There are many factors to consider when determining the appropriate surgical treatment, including the nature of your condition, your age, activity level, and overall health. Your physical therapist will refer you to an orthopedic surgeon to discuss your surgical options.

Should you choose to have surgery, your physical therapist can assist you prior to and following your surgery. The treatment you require following surgery will depend on a variety of factors such as the type of surgery performed, your level of function, and fitness prior to surgery. Contrary to popular belief, surgery is not the easy choice; you will still require treatment following your surgery to maximize your level of function.


Can this Injury or Condition be Prevented?

Many conditions, including knee OA, can be prevented with the right fitness and exercise program. Physical therapists are experts in movement. Some ways that a physical therapist can help you prevent knee OA include:

  • Developing an appropriate exercise program. Inactivity is a significant contributor to many problems that affect individuals, including knee OA. Strengthening the muscles around the knee, as well as surrounding joints, can help decrease stress to the knee joint. Exercises to improve flexibility can help you maintain motion in the knee joint, which helps keep the cartilage healthy. Your physical therapist can design an individualized treatment program to boost your strength and flexibility, based on your specific condition.

  • Weight loss. Excessive weight can increase stress to the knee joint, which in turn can contribute to the wearing away of the protective cartilage, leading to knee OA. Your physical therapist can assess your weight, perform testing to determine your fitness level, establish an exercise program, and recommend lifestyle changes. The therapist also may refer you to another health care provider, such as a dietician, for further guidance.

  • Activity modification. Individuals often move or perform activities in a way that is unhealthy or inefficient, or that places excessive stress on the body, including the knee joint. Your physical therapist can teach you better ways to move in order to ease stress on your body and your knees.

  • Taking a “whole body” approach to movement. Lack of strength, mobility, and flexibility in surrounding areas of the body such as the ankle, hip, and spine also can affect the knee. Taking these body regions into consideration is important to help prevent knee OA. Your physical therapist will work with you to help ensure your whole body is moving correctly, as you perform your daily activities.


Real Life Experiences

Luke is a 50-year-old businessman who has just moved his family to the city so he can start a new job. For the last 2 months, Luke has been working hard to fix up his family’s new home, carrying heavy boxes and moving furniture up and down stairs. He also has worked late into the night installing appliances.

After starting his new job last week, sitting through numerous orientation sessions and meetings, Luke notices that his right knee is really hurting. He is used to occasional knee discomfort, but this is the worst it has felt in a long time. During his junior year at college, Luke suffered a significant knee injury while playing basketball, which required surgery.

These days, Luke coaches his son’s Little League team, exercises several times each week, and plays pickup basketball with his friends. But occasionally, particularly after long road trips, his knee pain flares up, and he has to resort to medication, icing, and rest. These bouts are starting to occur more regularly. Luke decides it's time to seek a consultation with a physical therapist.

During Luke’s first appointment, his physical therapist asks him questions regarding his medical history, prior injuries, current symptoms and complaints, and goals for physical therapy. She examines his knee motion, strength, balance, and walking mechanics. She also uses special tests and measures to determine the nature of Luke’s pain, ruling out any other possible conditions.

Based on her findings, Luke's physical therapist determines that his current knee pain is a result of posttraumatic osteoarthritis. She diagnoses knee OA. She explains that his history of significant knee injury in college put him at risk of developing knee OA at a young age. The recent increased demand on his knee joint during his move is likely responsible for the current flare-up of pain and swelling.

Over the next 6 weeks, Luke works with his physical therapist to decrease his joint pain and improve his knee motion and full-body flexibility. She uses manual therapy techniques to improve the mobility of his knee joint. She prescribes a progressive exercise program to strengthen the muscles of his hip, knee, and core. She tailors this program so that Luke can complete it daily, based on the equipment available at his office gym facility.

Six weeks later, Luke is able to climb and descend stairs, squat, and jog without pain. He can sit through a full day of meetings without noticing stiffness or swelling in his knee. On his last day of therapy, Luke’s physical therapist provides him with a detailed home-exercise program and suggestions for maintaining the improvements he has made. With the summer approaching, he's preparing to coach his son's baseball tournaments—and take his family to the beach!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.


What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:

  • A physical therapist who is experienced in treating people with knee osteoarthritis and after knee replacement surgery. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified orthopedic clinical specialist. This physical therapist will have advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with arthritis.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.


Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of arthritis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full-text, so that you can read it or print out a copy to bring with you to your health care provider.

Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis; part two: strengthening exercise programs. Clin Rehabil. 2017;31:596–611. Article Summary in PubMed.

Deshpande BR, Katz JN, Solomon DH, et al. Number of persons with symptomatic knee osteoarthritis in the US: impact of race and ethnicity, age, sex, and obesity. Arthritis Care Res (Hoboken). 2016;68:1743–1750. Article Summary in PubMed.

Ackerman IN, Bucknill A, Page RS, et al. The substantial personal burden experienced by younger people with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2015;23:1276–1284. Article Summary in PubMed.

Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis [published correction appears in: N Engl J Med. 2013;369:683]. N Engl J Med. 2013;368:1675–1684. Free Article.

Segal NA. Bracing and orthoses: a review of efficacy and mechanical effects for tibiofemoral osteoarthritis. PM R. 2012;4(5 Suppl):S89–S96. Article Summary on PubMed.

Jansen MJ, Viechtbauer W, Lenssen AF, et al. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review. J Physiother. 2011;57:11–20. Free Article.

Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport. 2011;14:4–9. Article Summary on PubMed.

Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States, part II. Arthritis Rheum. 2008;58:26–35. Free Article.

* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Laura Stanley, PT, DPT, Board-Certified Clinical Specialist in Sports Physical Therapy. Reviewed by the MoveForwardPT.com editorial board.



Meniscus Tear

Meniscal tears are common injuries to the cartilage of the knee that can affect athletes and nonathletes alike. These tears can be either “acute,” meaning they happen as a result of a particular movement, or “degenerative,” meaning they happen over time. Your physical therapist can help you heal a meniscal tear and restore your strength and movement. If surgery is required, your physical therapist can help you prepare for the procedure and recover following surgery.

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What is a Meniscal Tear?

The meniscus is a cartilage disc that cushions your knee. Each of your knees has 2 menisci (plural of meniscus); one on the inner (medial) part of the knee, and the other on the outer (lateral) part of the knee. Together, they act to absorb shock and stabilize the knee joint.

Meniscal tears can be classified in 2 ways: acute or degenerative. An acute meniscal tear typically is caused by twisting or turning quickly on a bent knee, often with the foot planted on the ground. This mechanism of injury often produces related injuries, such as an ACL tear. Degenerative meniscal tears occur over time, due to repetitive stress being put on the knee, such as in a job or sport that requires a lot of squatting.


How Does it Feel?

When you tear the meniscus, you might experience:

  • A sharp, intense pain in the knee area

  • A "pop" or a tearing sensation in the knee area (acute injury)

  • Swelling within the first 24 hours of injury

  • Difficulty walking or going up or down stairs because of pain or a "catching or locking" sensation in the knee

  • Difficulty straightening or bending the knee fully


How Is It Diagnosed?

Your physical therapist will:

  • Conduct a thorough evaluation that includes a detailed review of your injury, symptoms, and health history.

  • Perform special tests to measure the range of motion (amount of movement) in your knee and determine which specific movements and positions increase your symptoms.

  • Use a series of tests that apply pressure to the meniscus to determine whether it appears to be damaged.

The results of these tests may indicate the need for further diagnostic tests—such as magnetic resonance imaging (MRI)—or a referral to an orthopedic surgeon for consultation.


How Can a Physical Therapist Help?

Meniscal tears can often be managed without surgery. A short course of treatment provided by a physical therapist can help determine whether your knee will recover without surgery. Your physical therapist can help control pain and swelling in the knee area and work with you to restore full strength and mobility to your knee. Your treatment may include:

Manual therapy. Your physical therapist may apply manual therapy—hands-on treatment that may include massage, stretching, or joint mobilization—to help reduce swelling and stiffness, and restore muscle function around the knee.

Icing. Your physical therapist will apply ice packs to the knee to help control any pain and swelling, and may instruct you to apply icing at home. Swelling is an important "guide" during your rehabilitation and can indicate your level of ability and recovery. If you experience an increase in swelling, your physical therapist will modify your treatment program or activity level to ensure your safest, most effective recovery.

Compression. Your physical therapist may recommend the use of compression bandages, stockings, or pumps to assist in the reduction of or prevent further accumulation of edema (swelling). Your physical therapist may include them as part of your regular treatments and teach you and your family how to use them at home.

NMES. Your physical therapist may use a treatment called neuromuscular electrical stimulation (NMES). NMES uses electrical current to gently stimulate/contract the muscles around your knee to help improve their strength.

Assistive devices. It may be necessary to use assistive devices such as crutches, a cane, or a walker in the short term. Your physical therapist will make recommendations about which device is best for you and will instruct you in how to use it properly.

Strengthening exercises. Your physical therapist will design exercises to build and maintain your strength during recovery and help restore full movement to the knee. You will be given a home program of exercises that are specific to your condition. Strengthening the muscles around the knee and throughout the leg helps ease pressure on the healing knee tissue.

Fitness counseling. As you recover, your physical therapist will advise you on ways to improve and maintain your fitness and activity levels, and will help you decide when you are ready to return to full activity.

If Surgery Is Required

Patients with more serious meniscal tears, or those who don’t respond to a course of physical therapy, may need surgery to repair the injured knee. Surgically removing the torn cartilage (a procedure called a meniscectomy) usually is a simple procedure that requires a course of physical therapy treatment following surgery. Many people are able to return to their previous level of activity, including sports, after approximately 4 months of treatment.

Meniscus removal. Following a simple meniscectomy, your rehabilitation will likely be similar to that for nonsurgical meniscal injuries. Your physical therapist may use ice and compression to control pain and swelling and will show you how to use these treatments at home. The focus of your treatment will be on helping you get back your strength and movement through a series of exercises performed in the clinic and at home, as well as with hands-on treatment (manual therapy). Initially, it is likely that you will need to use crutches or a cane for walking. Your physical therapist will help guide you in gradually placing your weight on the knee to stand or walk, to allow the meniscus and other tissue in the knee joint to slowly adjust to increased pressure.

Meniscus repair. Sometimes your surgeon will decide that the torn meniscus can be repaired instead of removed. Research studies show that if a meniscal repair is possible, it can reduce the risk of arthritis developing later in life. Rehabilitation following a meniscal repair is slower and more extensive than with meniscal removal because the repaired tissue must be protected while it is healing. The type of surgical technique performed, the extent of your injury, and the preferences of the surgeon often determine how quickly you will be able to put weight on your leg, stop using crutches, and return to your previous activities.

Following surgery for meniscal repair, your physical therapist will:

  • Help you control pain and swelling

  • Guide you through progressive reloading of weight to the knee to allow the cartilage to slowly adjust to increased compressive stress and pressure

  • Help restore your knee and leg range of motion

  • Teach you exercises to help restore your muscle strength

Return to Activity

Whether your torn meniscus recovered on its own or required surgery, your physical therapist will play an important role in helping you return to your previous activities. Your physical therapist will help you learn to walk without favoring the leg and perform activities like going up and down stairs with ease.

Return to work. If you have a physically demanding job or lifestyle, your physical therapist can help you return to these activities and improve how you perform them.

Return to sport. If you are an athlete, you may need a more extensive course of rehabilitation. Your physical therapist will help you fully restore your strength, endurance, flexibility, and coordination to help maximize your return to sports and prevent reinjury. Return to sport varies greatly from one person to the next and depends on the extent of the injury, the specific surgical procedure, the preference of the surgeon, and the type of sport. Your physical therapist will consider these factors when designing and adjusting your rehabilitation program, and will work closely with your surgeon to help decide when it is safe for you to return to sports and other activities.

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Can this Injury or Condition be Prevented?

There is little research at this time to support exercise or other interventions such as bracing for prevention of meniscal injuries. However, you can make choices to help improve your overall fitness and keep your knees as strong and as healthy as possible. Practices that can help keep your knees strong include:

  • Regular exercise to help strengthen the muscles that support your knees

  • Staying physically active to prepare your body for the demands of a sport or strenuous activity

  • Avoiding twisting or turning quickly while your foot is planted on the ground, to help prevent stress to the knee that can cause a meniscal tear

If you already have knee problems, your physical therapist can help you develop a fitness program that takes your knees into account. Some exercises are better than others for those with a history of knee pain. Many exercises can be modified to fit your specific needs.


Real Life Experiences

Beau is a college sophomore who plays on his intramural lacrosse team. During a recent practice game, Beau twisted his left knee while performing a sharp turn to make a catch. He immediately heard a “pop” and felt pain in his knee joint. He was helped off the field by teammates and led back to his room, where he applied ice and rested for the rest of the evening.

The next morning, Beau felt pain when he put weight on his leg to get out of bed, and found he had difficulty walking; he also noticed some swelling on the inside of his knee. His roommate is in the physical therapy program at his university; he suggested Beau see a physical therapist.

Beau’s physical therapist gets his medical history and asks him to describe what happened in the game to get a sense of what might have happened to his knee. She then performs some tests that include movements that selectively stress the tissues of the knee to see if the symptoms can be provoked. She tells Beau that his symptoms may indicate a meniscal tear. She recommends that he consult with an orthopedic surgeon, who orders magnetic resonance imaging (MRI). The surgeon confirms a diagnosis of a medial meniscal tear. After consultation with the surgeon, Beau chooses to have the tear “cleaned up,” and have a small piece of the meniscus removed—a procedure called a meniscectomy.

Prior to surgery, Beau works with his physical therapist, who prescribes exercises and manual therapy to reduce the swelling, improve the knee range of motion, and restore muscle function around the knee—treatments that have been shown to improve surgical outcomes.

Following his surgery, Beau’s physical therapist controls the swelling around the knee joint with ice, and shows Beau how to ice his knee at home. She applies electrical stimulation to speed the recovery of the quadriceps muscle. She teaches him range-of-motion exercises and tells him how often he should be doing them at home. She teaches him how to use crutches to avoid putting pressure and weight on the knee while its tissues heal.

After 1 week, Beau is able to walk without his crutches, but has difficulty bending his knee fully or straightening it when he walks. His physical therapist works with him on improving his walking pattern, and continues to address his knee range of motion, strength, swelling, and pain. His exercises are adjusted as he heals to continue to challenge him and move his recovery forward.

After 3 weeks, Beau has full range of motion and increased strength in his involved leg. He has good balance and no pain while walking. His physical therapist guides him as he returns to jogging and then running. She gives Beau feedback on how much he should be running, how running should feel, and what to do to ensure a symmetrical running pattern to keep his knee and his other joints safe.

At 4 weeks, Beau’s treatment progresses to sports-related rehabilitation activities, which include moving quickly from side to side and learning how to safely turn to field a catch. His physical therapist provides guidance and training to help Beau avoid reinjury. Beau reports his leg muscles have gained strength, and he feels more stable as he executes his movements.

After 6 weeks of treatment, Beau rejoins his team for a playoff game and, with newfound confidence, sets up his teammate for a winning goal!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.


What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic (musculoskeletal) problems or sports injuries.

  • A physical therapist who is a board-certified orthopaedic clinical specialist or who completed a residency or fellowship in orthopedic physical therapy or sports physical therapy has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with a meniscal tear.

During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.


Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of meniscal injuries. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

Beaufils P, Pujol N. Management of traumatic meniscal tear and degenerative meniscal lesions: save the meniscus. Orthop Tramatol Surg Res. 2017 September 2 [Epub ahead of print]. doi: 10.1016/j.otsr.2017.08.003. Article Summary in PubMed.

Moses MJ, Wang DE, Weinberg M, Strauss EJ. Clinical outcomes following surgically repaired bucket-handle meniscus tears. Phys Sportsmed. 2017 May 23 [Epub ahead of print]. doi: 10.1080/00913847.2017.1331688. Article Summary in PubMed.

Skou ST, Lind M, Holmich P, et al. Study protocol for a randomised controlled trial of meniscal surgery compared with exercise and patient education for treatment of meniscal tears in young adults. BMJ Open. 2017;7(8):e017436. Free Article.

Hare KB, Stefan Lohmander L, Kise NJ, et al. Middle-aged patients with an MRI-verified medial meniscal tear report symptoms commonly associated with knee osteoarthritis. Acta Orthop. 2017 August 8 [Epub ahead of print]. doi: 10.1080/17453674.2017.1360985. Free Article.

Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368:1675-1684. Article Summary in PubMed.

Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ. Knee pain and mobility impairments: meniscal and articular cartilage lesions. J Orthop Sports Phys Ther. 2010;40(6):A1-A35. Free Article.

Heckmann TP, Barber-Westin SD, Noyes FR. Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome. J Orthop Sports Phys Ther. 2006;36:795-814. Article Summary in PubMed.

Lowery DJ, Farley TD, Wing DW, et al. A clinical composite score accurately detects meniscal pathology. Arthroscopy.2006;22:1174-1179.  Article Summary in PubMed.

Fitzgerald GK, Piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2003;33:492-501. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

 Authored by Christopher Bise, PT, DPT, MS. Reviewed by the MoveForwardPT.com editorial board.




Hip Impingement (Femoroacetabular Impingement)

Hip impingement involves a change in the shape of the surface of the hip joint that predisposes it to damage, resulting in stiffness and pain. Hip impingement is a process that may precede hip osteoarthritis. It most often occurs in young, active people. A recent study found that 87% of teens and adults with hip pain showed evidence of hip impingement on diagnostic images taken of their hip joints. To treat hip impingement, physical therapists prescribe stretches and strengthening exercises to better balance the muscles around the hip to protect it, and use manual therapies to help restore range of motion and increase comfort.

What is Hip Impingement?

There are 2 types of hip impingement; they may occur alone or together.

Pincer-Type Impingement

  • In pincer-type impingement, the hip socket (acetabulum), which is usually angled forward, may be angled toward the back, or protruding bone may be present on the pelvis side of the hip joint making the socket a deeper recess that covers more of the ball or head of the femur bone.

  • The overgrown bone or incorrect angle of the socket causes the labrum, a rim of connective tissue around the edge of the hip socket, to be pinched. Over time, this extra pressure to the labrum when flexing (moving the leg forward) leads to wear and tear that can cause inflammation and could result in a tear. If this condition persists, eventually the cartilage that lines the hip joint can become worn and form holes.

  • This condition affects men and women equally; symptoms often begin early, appearing at any time between 15 to 50 years of age.

 

Cam-Type Impingement

  • In cam-type impingement, the shape of the bone around the head of the femur—the ball at the top of the bone in the thigh—is misshapen. It can vary from the normal round ball shape, or have overgrown bone formed at the top and front. The nickname “pistol grip” deformity is given to the appearance of the bony overgrowth on x-rays.

  • The overgrown or misshapen bone contacts the cartilage that lines the hip socket, and can cause it to peel away from the bone in the socket. The labrum can become worn, frayed, or torn as well.

  • This condition affects men to women at a ratio of 3 to 1; symptoms often manifest during the teen years and 20s.

HipImpingement-SM.jpg

Signs and Symptoms

Hip impingement may cause you to experience:

  • Stiffness or deep aching pain in the front or side of the hip or front of the upper thigh while resting.

  • Sharp, stabbing pain when standing up from a chair, squatting, rising from a squat, running, "cutting," jumping, twisting, pivoting, or making lateral motions.

  • Hip pain described in a specific location by making a "C" with the thumb and hand and placing it on the fold at the front and side of the hip, known as the "C-sign."

  • Pain that most often starts gradually, but can also remain after another injury resolves.

  • Pain that increases with prolonged sitting or forward leaning.

  • Feeling less flexible at the hips, including a decreased ability to turn your thigh inward on the painful side.

How Is It Diagnosed?

Your physical therapist will evaluate the range of motion (movement) of the hip and surrounding joints, and test the strength of the muscles in that area. Your therapist will feel the hip joint and surrounding muscles to evaluate their condition. The examination will include observing how you move, standing from a sitting position, walking, running, or squatting, as appropriate. Your physical therapist may perform special tests to help determine whether the hip is the source of your symptoms. For instance, the therapist may gently roll your leg in and out (the “log roll” test), or bend your hip up and in while turning the lower leg out to the side (the "FADDIR" test) to assess your condition.

If further diagnosis is needed, your doctor may order diagnostic tests to help identify any joint changes, including x-rays, magnetic resonance imaging (MRI), or diagnostic injections. Hip impingement can occur at the same time as low back, buttock, or pelvic pain, or from conditions such as bursitis or groin strain. The final diagnosis of hip impingement may take some time, especially when other conditions are present.

How Can a Physical Therapist Help?

Without Surgery

When an active person develops hip pain, but does not have severe symptoms or joint damage, the recommended treatment is physical therapy. The following interventions can help decrease pain, improve movement, and avoid the progression of hip impingement and the need for surgery:

  • Improving the strength of your hips and trunk. Strengthening of the hips and trunk can reduce abnormal forces on the already injured joint and help with strategies to compensate.

  • Improving hip muscle flexibility and joint mobility. Stretching tight muscles can reduce abnormal forces that cause pain with motion. Joint mobilization may help ease pain from the hip joint; however, these treatments do not always help range of motion, especially if the shape of the bone at the hip joint has changed.

  • Improving tolerance of daily activities. Your physical therapist can consider your job and recreational activities and offer advice regarding maintaining postures that are healthier for your hip and activity modification. Often this involves limiting the amount of bending at the hip to avoid further hip damage.

 

Following Surgery

Surgery for hip impingement is performed with arthroscopy. This is a minimally invasive type of surgery, where the surgeon makes small incisions in the skin and inserts pencil-sized instruments into the joint to repair damage. The surgeon may perform 1 or several techniques during your procedure as needed. The surgeon may remove or reshape the bone on the pelvis or femur side of the joint, and repair or remove the damaged labrum or cartilage of the hip joint.

Postsurgical physical therapy varies based on the procedure performed. It may include:

  • Ensuring your safety as you heal. Your physical therapist may recommend that you limit the amount of weight you put on the operated leg if there was a repair of the labrum. You may wear a brace to help limit the amount of bending at the hip. You might also use crutches to avoid overloading the leg if the bone on the femur was reshaped.

  • Improving your range of motion, strength, and balance. Your physical therapist will guide you through safe range-of-motion, strengthening, and balance activities to improve your movement as quickly as possible while allowing the surgical site to heal properly.

  • Instructions on returning to an active lifestyle. Most people return to normal daily activities about 3 months after surgery, and to high-level activities and sports 4 to 6 months after surgery. Your physical therapist will recommend a gradual return to activity based on your condition—research shows that 60% to 90% of athletes return to their previous playing ability depending on the surgical procedure performed and the sport.

Can this Injury or Condition be Prevented?

Currently there are no recommendations to prevent hip impingement. Despite a major increase in research to learn more about hip impingement, there is a great deal that is unknown. For instance, many active young people whose x-rays show hips as being abnormal do not have pain despite continuing to live active lives and participate in sports.

However, there is evidence that physical therapy interventions along with anti-inflammatory drugs can decrease pain, slow joint damage, and improve function. This is particularly important in those with mild hip impingement, those who are attempting to avoid surgery, and those who are not candidates for surgery.

Real Life Experiences

Lindsay is an active high school senior who plays shortstop for her school's softball team. Over the last several months, she has had progressively worsening pain on the front and side of her left hip. It started as an occasional sharp pain when she fielded ground balls at practice, and it eventually developed into aching and stiffness of the hip while resting. Lindsay occasionally develops hip pain while sitting in class or at the movies. In the past couple of weeks, she has found it hard to lean forward to tie her shoes. Her mom has been worrying about her pain and takes Lindsay to her physical therapist.

At the evaluation, the physical therapist finds that Lindsay has weakness around her hip and trunk muscles, decreased hip mobility, pain when flexing the hip, pain returning to a standing position after squatting, and decreased balance when standing on her affected leg. Her physical therapist diagnoses mild hip impingement in her left hip. Lindsay sees her physical therapist 1-2 times a week for the next 6 weeks.

Her treatments focus on developing a home program for strengthening her hips and trunk, and the therapist uses manual therapy for the hip to improve her comfort and allow her to perform more activities. The therapist works with Lindsay to change how she moves when standing from a seated position, and also to modify how she moves when playing the infield in softball. Lindsay also spends less time in the positions that bother her hip in the weight room and on the practice field, following recommendations from her physical therapist. After 3 weeks, the majority of her pain has subsided, and by 6 weeks, she is playing in games pain-free.

Lindsay meets her goal of finishing her senior year with the softball team. However, she is considering other ways to stay active after she graduates that don’t involve bending forward as much.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have hip impingement. You may want to consider:

  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with a sports or orthopaedic focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports or orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with hip impingement.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of problems related to hip impingement. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Byrd JW. Femoroacetabular impingement in athletes, part I: cause and assessment. Sports Health. 2010;2:321-333. Free Article.

Byrd JW. Femoroacetabular impingement in athletes, part II: treatment and outcomes. Sports Health. 2010;2:403-409. Free Article.

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Authored by Jennifer Miller, PT, MPT, SCS. Reviewed by the MoveForwardPT.com editorial board.