Applied Evidence

Consider these exercises for chronic musculoskeletal conditions

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Exercise interventions reduce pain and improve function in knee/hip OA, chronic low back pain, shoulder pain, Achilles tendinopathy, and lateral epicondylitis.


› Consider quadriceps strengthening for knee osteoarthritis with an initial period of supervision, which can provide greater pain relief than nonspecific, unsupervised lower limb exercises. B

› Consider a generalized exercise program for subacromial impingement syndrome, to relieve shoulder pain and improve function, range of motion, and strength. A

› Bear in mind that the Alfredson protocol for Achilles tendinopathy has yielded improvement in pain and function for up to 5 years, although other exercise regimens have also proven initially effective. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



Regular exercise confers several well-established benefits. In such conditions as coronary heart disease, stroke, heart failure, and diabetes, exercise has led to a reduction in mortality similar to that seen with pharmacotherapy.1 For patients with chronic musculoskeletal conditions, the benefits of exercise-based interventions are measurably reduced pain and improved daily function.2 However, prescribing of exercise is often neglected, with preference given to pharmacologic or surgical interventions.3 In part, the disregard of exercise as therapy results from unfamiliarity with appropriate exercise prescriptions,3 which include various forms of aerobic exercise, strength training, and stretching to increase flexibility (TABLE).

Types of exercise and common examples

As is true of many therapeutic modalities, exercise must be tailored to the condition and to a patient’s preferences to optimize its benefits. In this review, we describe exercise regimens well suited for common musculoskeletal conditions, examine the effectiveness of exercise in each condition, and provide examples for use in treating patients.

Osteoarthritis of the hip and knee

Osteoarthritis (OA), one of the most common chronic joint diseases, erodes the articular cartilage and subchondral bone of a synovial joint, eventually leading to joint failure. Pain and diminished muscle strength restrict physical activity and can lead to decreased fitness and impaired muscle function. Exercise helps reduce pain and improve muscle function and quality of life in patients with hip or knee OA regardless of age, disease severity, or level of pain and dysfunction.2

Knee exercises. Activities suitable for patients with OA include muscle strengthening, aerobic conditioning, and range-of-motion (ROM) exercises.4-6 A 2015 Cochrane review of OA of the knee showed that exercise reduced pain and improved physical function and quality of life in patients who completed a treatment program, and that pain relief persisted up to 6 months after intervention.5

For knee OA, supervised quadriceps strengthening may provide greater pain relief than nonspecific, unsupervised exercises.

When designing an exercise prescription for patients with knee OA, consider quadriceps strengthening with an initial period of supervision, which may provide greater pain relief than nonspecific, unsupervised lower limb exercises.4 Enhanced strength of the lower limb may lessen force through the knee, thereby decreasing pain and improving overall physical function.7 Simple, teachable exercises include squats, step-ups, knee extension/flexion while sitting in a chair, and hip abduction/adduction while standing or lying down. Elastic bands, dumbbells, or cuff weights may be used to increase resistance.

Hip exercises. Exercise can significantly reduce pain and improve function for up to 6 months for patients with mild-to-moderate symptomatic hip OA.6 Types of exercise for hip OA include strength training of hip and core muscles, functional exercises that imitate movements in daily activities, and flexibility training. These exercises help reduce pain and increase ROM. Exercise should include resistance training and should not exceed the limit for acceptable pain.8

Aquatic therapy is also appropriate for exercise and strength training and can decrease pain and disability and improve quality of life.9 Supervised physical therapy, including strength training, manual therapy, and balance training, are important for reducing pain and improving function. Physical therapy can also enhance adherence to a prescribed exercise program.10

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