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Osteoarthritis and Exercise

Do you experience joint pain? If so, it’s likely due to arthritis. The most common form is

osteoarthritis (OA). Simply put, OA is the breakdown of the cartilage that lines the joints. This can result from normal wear and tear over time or from traumatic injuries. While this was once thought to be the primary cause of OA, we now understand that factors such as genetics, biochemical reactions, and metabolic changes can also contribute to the pain and inflammation associated with OA (1, 2).


If you haven't yet been evaluated by a healthcare provider, it's important to do so, as there are various forms of arthritis and joint pain that require different treatments. However, if you've already been diagnosed with OA or suspect you might have it, keep reading! Today, we'll focus on two of the most commonly affected weight-bearing joints—the hip and knee. These joints account for the majority of total joint replacements and are a leading cause of disability (1). Knee OA, for example, affects around 250 million people worldwide, including more than 27 million in the United States (1). So, what can we do if we’re dealing with it, or to prevent it from getting worse?


OA is a progressive, degenerative disease, so treatments mainly aim to slow the disease and manage symptoms, rather than reverse it. Whenever possible, conservative treatments are the first recommended treatment. Joint replacements are invasive surgeries that carry potential risks, such as infections, and poor outcomes if there are co-morbidities or inadequate post-surgery rehabilitation. Once the joint is replaced, high-impact activities are generally discouraged. This is something to consider before opting for surgery.


That said, joint replacements certainly have their place, and I often recommend them sooner rather than a lot of other providers. Based on my 20 years of experience, the hardest aspect of post-joint replacement rehabilitation is addressing the altered gait and movement patterns that develop over time. Even after pain and limitations are gone, soft tissue changes over the years don't automatically improve. That’s why working with a physical therapist (PT) or engaging in conservative treatment beforehand can be so beneficial. The stronger and more mobile you are—and the fewer compensatory patterns you’ve developed—the better your outcome after surgery.


I always encourage people to continue conservative treatment until they no longer see improvement, or until their function declines to the point where it significantly interferes with their desired activities. So, what are the best conservative measures to try?


1. Education: Understanding OA and how it affects your body helps you avoid activities

that can exacerbate symptoms. It’s crucial to work with your PT to address not only the disease itself but other factors like diet, which can play a significant role in managing OA.


2. Weight Reduction: Obesity can increase the risk of knee OA, both due to the extra strain on the joint and the inflammatory molecules produced by fat tissue. “Cytokines like IL-6, TNF-alpha, and C-reactive protein are elevated in obese individuals and have been linked to cartilage degeneration” (3). Since the knee bears 3-5 times your body weight during activity, and the hip experiences similar forces, studies show that reducing body weight by just 1 kilogram can reduce knee OA risk by approximately 10% (3).


3. Exercise: Not only can exercise assist with weight loss, but muscle is your body’s best natural shock absorber. When cartilage wears down due to OA, building muscle can help compensate for the lost cushioning. The American College of Sports Medicine (ACSM) and other health organizations recommend:


*150-300 minutes of moderate-intensity aerobic activity per week (or 75-150 minutes of vigorous-intensity activity)


*At least two strength-training sessions per week, involving all major muscle groups.


For true muscle growth (hypertrophy), I would suggest strength training more than twice per week and with heavier loads.


Of course, don’t jump into heavy lifting right away. Progress gradually. Mild to moderate discomfort is normal when starting or progressing an exercise program, but joint swelling, significant loss of motion, or worsening pain lasting more than a few days after exercise may indicate you’ve overdone it. In that case, reduce the duration, intensity, or even the type of activity. Usually we can avoid the last one as long as you progress slowly. For some people, any weight beating activity will increase their pain or symptoms.  In this case, activities such as aquatic therapy, or using a stationary bike would be a great place to start.  Anything to minimize gravity and the impact to your joint is going to be tolerated better than activities such as running, jumping, or prolonged impact activities.

This doesn’t mean your workouts need to be easy—vigorous activities can still be achieved, but modifications may be necessary to avoid aggravating symptoms.


4. Over-the-Counter Medications: Acetaminophen and NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) can help manage pain and swelling. However, always check with your physician to ensure these medications are safe for you. Duloxetine, a serotonin and norepinephrine reuptake inhibitor, is another option to help control pain.


5. Corticosteroid Injections: For some, corticosteroid injections can provide relief, although their effectiveness varies depending on factors like the severity of inflammation in the synovial tissue and cartilage. If over-the-counter medications aren’t providing enough relief, this may be worth considering.


6. Newer Treatments (Still Under Research): Injections of autologous conditioned serum (ACS), platelet-rich plasma (PRP), and mesenchymal stem cells (MSC) aim to reduce inflammation and promote cartilage regeneration. However, these treatments are still being studied, and more research is needed to fully understand their effectiveness. Until more research is developed, Knee arthroscopies, PRP injections, and stem cell injections are not currently recommended for managing knee OA (Gibbs et al., 2023; O'Connor et al., 2022; Osteoarthritis Research Society International).


Exercises to Try:


Aerobic Activity:


Swimming, Biking (great for knees, but may aggravate hips depending on bike setup),


Elliptical, Walking, Hiking, Rowing (good for knees, may stress hips)



Beginner:

Start with 10 minutes at a mild to moderate intensity (you should be able to hold a conversation). Gradually increase to 10 minutes twice a day over the next 2-3 weeks, with a goal of eventually reaching 30 minutes most days of the week. If needed, break it up into 10-minute bouts.


Intermediate:

Start with 20-30 minutes at moderate intensity. By week 2, aim to increase either time or intensity. The goal is 30 minutes of moderate-intensity activity most days.


Advanced:

Begin with 20-30 minutes of moderate to vigorous activity. Depending on your symptoms and the type of exercise, you can progress to 20-30 minutes of vigorous activity 5-7 days per week, but typically 1-2 days of vigorous activity with the rest being moderate.


Strength Training:

Aim for at least two strength-training sessions per week, focusing on all major muscle groups. However, I recommend striving for three sessions per week, especially for individuals with hip and knee OA. Key areas to focus on include the posterior chain (hamstrings, glutes, calves) and lateral hip muscles. Proper form and maintaining an appropriate strength-to-muscle ratio are essential. Some effective exercises include:


Bridges and Progressions:


The point of the bridge is to activate the posterior chain: the hamstring, glute and calf. Make sure to engage your core first, and start small- pictured first is a static bridge. If this feels ok, progress to a single leg bridge. If this becomes easy (Able to perform 10-15 with good form- not allowing hips to shift), then progress to elevating your feet on a surface. Once you are able to do this, progress to single leg on an elevated surface. Once this becomes easier, you can elevate your trunk on a weight bench or elevated surface, use a weight over your hips (you may need a towel of cushion), and perform through a larger range of motion.
The point of the bridge is to activate the posterior chain: the hamstring, glute and calf. Make sure to engage your core first, and start small- pictured first is a static bridge. If this feels ok, progress to a single leg bridge. If this becomes easy (Able to perform 10-15 with good form- not allowing hips to shift), then progress to elevating your feet on a surface. Once you are able to do this, progress to single leg on an elevated surface. Once this becomes easier, you can elevate your trunk on a weight bench or elevated surface, use a weight over your hips (you may need a towel of cushion), and perform through a larger range of motion.


Banded Squats


This exercise is great for strengthening the legs, but also for retraining some of the important muscles in our hips to stabilize correctly. Many people with OA have difficulty squatting without pain. Come to my workshop or 6 week class to find ways to modify this if it is painful!
This exercise is great for strengthening the legs, but also for retraining some of the important muscles in our hips to stabilize correctly. Many people with OA have difficulty squatting without pain. Come to my workshop or 6 week class to find ways to modify this if it is painful!

Side-lying Hip Abduction (against the wall)


Our Gluteus Medius (muscle on the side of the hip/rear end) is an important muscle that helps to hold us upright when standing on one leg. This muscle tends to be weak on many people because of the amount of time we spend sitting, but especially weak with hip OA patients. It's also very important with stability of the knee. When performing this exercise, make sure to "stack your hips" on top of each other, and press the leg back into either a ball or a towel on the wall to make sure you don't cheat with the TFL muscle in the front of the hip.
Our Gluteus Medius (muscle on the side of the hip/rear end) is an important muscle that helps to hold us upright when standing on one leg. This muscle tends to be weak on many people because of the amount of time we spend sitting, but especially weak with hip OA patients. It's also very important with stability of the knee. When performing this exercise, make sure to "stack your hips" on top of each other, and press the leg back into either a ball or a towel on the wall to make sure you don't cheat with the TFL muscle in the front of the hip.


Planks and Plank Progressions


Planks are a great way to strengthen the core while working on leg strength. There are tons of progressions of planks, but the focus should be on engaging the core (Think belly button towards the back bone and "stopping yourself from passing gas" or breathing and pulling the pelvic floor up). Your back should stay flat, and hips and rear end stay in line with your body. From there, you can start in a full plank in a push up position, or down to the elbows, and once you are able to hold this for about 30 sec with good form, progress to raising a leg or arms (side note: the hip extension in the top right picture shows the leg that is moving with a slight bend in the knee-ideally the leg should be straight, but we did not want to retake pictures :) ). The bottom row shows a side plank progression, which can also be progressed to a full side plank with both legs out straight.
Planks are a great way to strengthen the core while working on leg strength. There are tons of progressions of planks, but the focus should be on engaging the core (Think belly button towards the back bone and "stopping yourself from passing gas" or breathing and pulling the pelvic floor up). Your back should stay flat, and hips and rear end stay in line with your body. From there, you can start in a full plank in a push up position, or down to the elbows, and once you are able to hold this for about 30 sec with good form, progress to raising a leg or arms (side note: the hip extension in the top right picture shows the leg that is moving with a slight bend in the knee-ideally the leg should be straight, but we did not want to retake pictures :) ). The bottom row shows a side plank progression, which can also be progressed to a full side plank with both legs out straight.


Romanian Deadlifts (RDLs)


Russian Dead Lifts (RDL) is a great overall exercise that focuses on the posterior chain, which is often needed for both hip and knee OA, but also works on core strength and balance at the same time. The idea is to progress to using heavier weight, but I always start with education on how to "hinge" at the hips. I often will use a PVC pipe or broom held against the client's rear end, back and head. The goal is to hinge forward onto one leg, but not let the straight object come away from the head or rear end. Once they have this form down, progress to either a straight leg or bent knee RDL and then eventually add weight.
Russian Dead Lifts (RDL) is a great overall exercise that focuses on the posterior chain, which is often needed for both hip and knee OA, but also works on core strength and balance at the same time. The idea is to progress to using heavier weight, but I always start with education on how to "hinge" at the hips. I often will use a PVC pipe or broom held against the client's rear end, back and head. The goal is to hinge forward onto one leg, but not let the straight object come away from the head or rear end. Once they have this form down, progress to either a straight leg or bent knee RDL and then eventually add weight.

Lateral Step Downs


Step ups and step downs are great functional strengthening exercises for the legs. Stepping forward off a stair or elevated surface is going to strength the quad the best, but also creates quite a bit of shear stress at the knee which is not always tolerated with OA. Stepping to the side is a nice way to start strengthening and is usually tolerated slightly better. Make sure to keep hips level, and try to just tap the foot down and come back up.
Step ups and step downs are great functional strengthening exercises for the legs. Stepping forward off a stair or elevated surface is going to strength the quad the best, but also creates quite a bit of shear stress at the knee which is not always tolerated with OA. Stepping to the side is a nice way to start strengthening and is usually tolerated slightly better. Make sure to keep hips level, and try to just tap the foot down and come back up.

Straight Leg Raises (SLR) with Mini Circles


Straight Leg Raise is a great way to strengthen both the hip flexor and quad muscle without compressing the joint in weight bearing. To make sure you are not cheating, tighten your core first, pressing your back into the floor. Then tighten up your quad muscle by pressing the knee down, and tightening the muscle above the knee. Keep this tight as you raise up and down. If you are able to perform 15 reps, then progress to a more difficult exercise by performing mini circles at the top, parallel with the opposite knee.
Straight Leg Raise is a great way to strengthen both the hip flexor and quad muscle without compressing the joint in weight bearing. To make sure you are not cheating, tighten your core first, pressing your back into the floor. Then tighten up your quad muscle by pressing the knee down, and tightening the muscle above the knee. Keep this tight as you raise up and down. If you are able to perform 15 reps, then progress to a more difficult exercise by performing mini circles at the top, parallel with the opposite knee.

Terminal Knee Extension Squats


The quad muscle is often hard to strengthen when you are struggling with knee OA pain. Patients often struggle with end range extension of the knee as well, and a Terminal Knee Extension is one exercise that can address this. I like to pair it with a squat for multiple reasons: It can make a squat more comfortable by adding a slight distraction to the knee, it engages our posterior chain a bit more which is usually needed, and it is more functional than just pushing the knee back!
The quad muscle is often hard to strengthen when you are struggling with knee OA pain. Patients often struggle with end range extension of the knee as well, and a Terminal Knee Extension is one exercise that can address this. I like to pair it with a squat for multiple reasons: It can make a squat more comfortable by adding a slight distraction to the knee, it engages our posterior chain a bit more which is usually needed, and it is more functional than just pushing the knee back!



By incorporating these strategies into your daily routine, you can better manage the symptoms of osteoarthritis, slow its progression, and enhance your quality of life. Stay consistent, and always consult your healthcare provider before making significant changes to your exercise or medication regimen.


Want more information or guidance, sign up for my FREE Knee and Hip OA Workshop scheduled for April 25 from 12-1pm.

SCHEDULE FOR WORKSHOP:  https://l.bttr.to/ycgZu


I will also be holding a 6 week exercise-based class specifically for both hip and knee osteoarthritis starting Tue, May 6. Go to my website or reach out for more information or to sign up. Space is limited! Cost is $200



References:


(1) Knee osteoarthritis: pathophysiology and current treatment modalities

Juan C Mora,Rene Przkora &Yenisel Cruz-Almeida.


(2) Intra articular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. Egemen Ayhan, Hayrettin Kesmezacar, Isik Akgun.


(3) Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Stephen P Messier, David J Gutekunst, Cralen Davis, Paul DeVita.

 
 
 

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