The general rule in medicine, and certainly one that I have professed in the many years of offering non-surgical options to joint pain, is that non-surgical options or conservative care should always be tried first, and, only when these treatments fail, should surgery be explored as a final option. Typically the traditional non-surgical methods of treating degenerative knee and hip pain include ice, rest, immobilizing the joint with tape, braces, splints, and anti-inflammatory medications, etc. Weight loss is always recommended as the hips and knees are weight-bearing joints, any weight loss will help reducing pain and pressure on the joints. I have written an article on the benefits of weight loss on knee pain. Please see Weight loss can be a knee replacement alternative treatment. Eventually injection treatments may be offered.
There is much research on the benefits of physical therapy and exercise either to help delay a knee or hip replacement, or in the helping of recovery after the joint replacement. In the knee the targeted areas for strengthening are the hamstrings and quadriceps. However physical therapy and exercise may not help prevent knee pain, back pain, and hip pain after knee replacement.
So why are people, some who want to avoid joint replacement, avoiding exercise and physical therapy?
The most common reasons for refusing physical therapy were “surgery is inevitable” (44%) and “unlikely to improve pain” (29%).
A June 2022 study (1) looked at how patients reacted to their doctor’s mandatory physical therapy requirements while they waited for a knee or hip replacement. This paper from the Rothman Orthopaedic Institute at Thomas Jefferson University noted: “(Insurance) coverage policies have recently begun requiring physical therapy prior to total hip arthroplasty and total knee arthroplasty. It remains controversial if such a mandate is appropriate for patients with end-stage, symptomatic osteoarthritis. The purpose of this study is to assess if such patients are amenable to delaying surgery for a trial of physical therapy.”
What the researchers suggest is that some of these people may be “too far gone” in the knee and hip osteoarthritis to have physical therapy offer any type of realistic option of preventing the joint replacement. Here is how the study went:
- Two hundred patients were successfully contacted and agreed to participate. The average age was 66 years, 47% were male, the mean body mass index put these patients into the obese range. Of the 200 patients, 66% were scheduled for total knee arthroplasty.
- In total, 157 patients (79%) stated they had not done physical therapy in the preceding 6 months, and 185 patients (93%) stated they would not want to delay surgery for mandatory physical therapy. The most common reasons for refusing physical therapy were “surgery is inevitable” (44%) and “unlikely to improve pain” (29%).
The physical therapists were skeptical of the surgeons were skeptical of the physical therapists.
Many patients think physical therapy will not help them. But what do the surgeons think? What do the physical therapists think?
Here is a study published in October 2020 (2) that seems to put physical therapists and surgeons at odds when it came to the recommendations for physical therapy prior to joint replacement. The researchers’ aim in this study was “to identify perceived facilitators and barriers–among orthopedic surgeons and physical therapists–towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise.” What the researchers were looking at was how well did the physical therapists and surgeons work together on pre-surgery physical therapy guidelines for shared patients. Here is what the researchers found: “We found that both physical therapists and orthopedic surgeons were challenged by coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise as evidenced by the identified facilitators and barriers. The intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons.
The physical therapists were skeptical about over-simplified exercise therapy but positive towards patient self-management. The orthopedic surgeons were skeptical about the potential lack of a long-term effect of exercise therapy in patients with severe knee osteoarthritis but acknowledged exercise therapy as an alternative treatment option in daily clinical practice. This ambivalence (contradiction) in the professional role is important to consider when planning implementation of the intervention as it may appear simple but is regarded as complex.”
Physical therapy does help many people with joint osteoarthritis
There is no question that strengthening muscles can postpone joint replacement surgery. IN SOME PEOPLE. Physical therapy however does not help everyone. The question I am often asked in my office by a new patient is: “Why didn’t physical therapy work for me?”
There are many reasons:
Not the right exercise program
Reason 1: According to doctors at the University of New South Wales Australia (3) who examined why exercise programs did not improve patient’s medical concerns: “If exercise is medicine, then how it is prescribed and delivered is unclear, potentially limiting its translation from research to practice.” In other words, research supports the use of exercise but clinically, it is unclear if patients are getting the right exercise program for them.
Did not help reduce need for painkillers – did not reduce pain
Reason 2: University of Southern Denmark researchers (4) investigated changes in opioid use after a supervised exercise therapy and patient education program among knee or hip osteoarthritis patients with chronic opioid use. They found: “Among patients with knee or hip osteoarthritis and chronic opioid use, a standardized treatment program did not change opioid use when regulatory changes in opioid prescribing were taken into account.”
Resistance training did not build muscle
Here is an interesting piece from a recently published August 2022 paper: (5) “Walking and mixed-exercise, but not resistance-training, may improve physical activity in people with knee osteoarthritis in the short-term.” Further noting: “Low certainty evidence indicated moderate and small increases in physical activity for resistance-training combined with education focused on pain coping skills and self-efficacy compared to education alone at medium-term follow-up ”
Here is an other study from July 2022 (6). In this study researchers investigated the effects of three different (based on how demanding the exercise program was, easier to more difficult) of one home-based, knee-extensor resistance exercise on knee-extensor strength in patients eligible for knee replacement. They also examined the influence of exercise on symptoms, physical function and decision on surgery. This is what they found: “In patients eligible for knee-replacement (it was) found no between-group differences in isometric knee extensor strength after 2, 4 and 6 knee-extensor resistance exercise sessions per week. (No matter the degree of exercise, easier to harder, the there was no difference in effectiveness). The researchers also wrote that there was no indication of an exercise dose-response relationship for isometric knee-extensor strength (the muscles did not strengthen). HOWEVER, more curiously, despite this lack of apparent success in muscle strength building, only one in three patients decided to have surgery after the simple home-based exercise intervention.
Resistance training did not build muscle – the failure of physical therapy
To build strength, you need to build muscle. Everyone knows that muscle is built through exercise, specifically a resistance exercise that is slightly more resistant or weight bearing than that muscle usually handles. When you lift more weight or have more resistance than usual, muscle hypertrophy occurs (the muscle grows). The keyword here is resistance. The muscle has to have resistance against something in order to be able to get the contraction it needs to strengthen. Where does the muscle get this resistance? From tendons and ligaments.
In the image bellow, you see the muscles converging on the knee. The muscles directly attach to the bone by way of tendons. The knee moves because the tendons pull on the bones when the muscle contracts. That is also the point of resistance, the tendon pulling on the bone to create movement.
In the knee are the: quadriceps tendon, the patella tendon, hamstring tendons, and the iliotibial band.
In the hip there are the:
- Hip abductor tendons are crucial for good gait and stability in the hip joint.
- Gluteal tendinopathy
- Iliopsoas tendons
You can learn more about these tendons here: Hip Tendonitis Injections.
When the tendons are weak and loose, physical therapy may not be beneficial. Regenerative medicine can strengthen the tendons.
Now we get to the point of why the physical therapy failed. If the tendons that provide the connection between muscle and bone are damaged and weak, they cannot facilitate the resistance that the physical therapy exercise needs to build muscle.
Over the years we have seen a lot of people with degenerative knee and hip problems with the accompanying joint instability. They have had many treatments including physical therapy which failed them and now they are looking for the joint replacement alternative.
Our treatment options to help strengthen the tendons and joint capsule are:
- PRP treatments which involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP utilizes the blood’s platelets and their healing and tissue repair factors.
- A demonstration of the treatment is shown in the video below.
In the video below is a demonstration of bone marrow stem cell therapy. This treatment helps repair cartilage damage.
Regenerative medicine injections may offer a solution as to why physical therapy did not help you. By strengthening the tendons and the tendon attachment to the bone, the necessary resistance may be achieved.
1 Grace TR, Eralp I, Khan IA, Goh GS, Siqueira MB, Austin MS. Are Patients With End-Stage Arthritis Willing to Delay Arthroplasty for Payer-Mandated Physical Therapy?. The Journal of Arthroplasty. 2022 Jun 1;37(6):S27-31.
2 Husted RS, Bandholm T, Rathleff MS, Troelsen A, Kirk J. Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial. PloS one. 2020 Oct 23;15(10):e0241175.
3 Hansford HJ, Wewege MA, Cashin AG, Hagstrom AD, Clifford BK, McAuley JH, Jones MD. If exercise is medicine, why don’t we know the dose? An overview of systematic reviews assessing reporting quality of exercise interventions in health and disease. British Journal of Sports Medicine. 2022 Jun 1;56(12):692-700.
4 Johansson MS, Pottegård A, Søndergaard J, Englund M, Grønne DT, Skou ST, Roos EM, Thorlund JB. Chronic opioid use before and after exercise therapy and patient education among patients with knee or hip osteoarthritis. Osteoarthritis Cartilage. 2022 Aug 18:S1063-4584(22)00803-2. doi: 10.1016/j.joca.2022.08.001. Epub ahead of print. PMID: 35988705.
5 Ec B, Ja W, Aj G, Km C, P O, Cj B. Does land-based exercise-therapy improve physical activity in people with knee osteoarthritis? A systematic review with meta-analyses. Osteoarthritis Cartilage. 2022 Aug 12:S1063-4584(22)00799-3. doi: 10.1016/j.joca.2022.07.008. Epub ahead of print. PMID: 35970256.
6 Husted RS, Troelsen A, Husted H, Grønfeldt BM, Thorborg K, Kallemose T, Rathleff MS, Bandholm T. Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: a randomized dose–response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial). Osteoarthritis and Cartilage. 2022 Apr 9.