Myofascial pain syndrome is often a nagging problem that has the potential to impair one’s mobility and degrade quality of life. While strategies like improving your posture can reduce the chances of developing myofascial pain and at-home prevention measures like the “WITY” exercises can alleviate pain if it does arise, in some cases, the problem persists. For those with lingering myofascial pain that won’t seem to go away, additional interventions from a trained professional are usually needed.

Most experts agree that the best way to treat myofascial pain syndrome is by starting with conservative, natural care first because it is easy to access, affordable, and has little to no side effects. Physical therapists are the best first choice to treat myofascial pain syndrome because it utilizes a conservative/natural interventions that have been proven to be effective as reported in medical literature.

As with every other condition, physical therapists create treatment programs for patients with myofascial pain syndrome that are custom-tailored to each individual based on their specific set of symptoms, physical abilities, and goals; however, there’s a strong chance that certain interventions will be used because they are known to be beneficial for this condition. Below, we review some of the most commonly used physical therapy techniques for myofascial pain syndrome:

• Manual therapy: this hands-on treatment involves the physical therapist moving the joints and muscles in specific directions and at different speeds to increase their mobility, flexibility, and function; manual therapy is frequently used for patients with myofascial pain syndrome, and research has shown that it is one of the most effective techniques for this condition
• Myofascial techniques: this is a variety of manual therapy techniques designed specifically for myofascial pain syndrome; it can be performed with several different methods—including the Graston Technique and Active Release Technique—but the basic principle is always the same: the therapist uses their hands, elbows, and/or an instrument to relieve pain, loosen stiff muscles and fasciae with the goal of “releasing” them
• Stretching and strengthening exercises: structured exercise is a crucial component of any treatment program for myofascial pain syndrome, as it will help to increase flexibility and boost strength and stability in the muscles of the upper back and shoulders affected by trigger points; research has also suggested that targeted exercises can reduce neck pain from frequent computer use, which is associated with myofascial pain; therefore, your physical therapist will guide you on how to perform a variety of stretching and strengthening exercises—such as the “WITY” exercises described in our last post—that you can perform on your own at home
• Posture training: if your physical therapist determines that poor posture may be a contributing factor to your case of myofascial pain syndrome, they will work to identify any posture deficits present and help you correct them by practicing proper postures for all positions
• Electrical nerve stimulation: this is another modality in which an electric current stimulates nerve fibers to reduce pain levels; research suggests that it may be beneficial for myofascial pain syndrome, but should only be used in addition to other targeted interventions
• Dry needling: in this treatment method, the physical therapist will insert a thin needle directly into a region with a trigger point, which inactivates or “resets” the trigger point, thereby reducing tightness and alleviating pain; a number of studies have supported dry needling as an effective intervention for myofascial pain syndrome, and it is frequently used by appropriately trained therapists

Myofascial pain syndrome clearly has the potential to impair your function and impede your quality of life, but it’s important to recognize that you have options that can help you deal with it. Seeing a physical therapist early on will increase the chances of a successful outcomes and help you avoid future complications. For this reason, we recommend contacting your local physical therapist first and fast if you’re experiencing any issues that may be caused by myofascial pain syndrome.

As we’ve explained in this newsletter series, myofascial pain syndrome is a common condition that can affect any muscle in the body, but the muscles of the upper back, neck, and shoulder region have a particularly high risk of being involved. The deep, aching pain and stiffness that results from the characteristic trigger points in myofascial pain syndrome often then go on to impair one’s mobility and reduce quality of life in the process.

If you happen to notice symptoms that could be related to myofascial pain syndrome, it’s important to realize that this is a very treatable condition that responds well to many interventions. Targeted exercises are generally regarded as a mainstay of treatment and one of the best initial steps you can take if you’re dealing with upper back pain. When performed correctly and regularly, these exercises will increase the strength and flexibility of the muscles often associated with myofascial pain, thereby alleviating pain over time.

“WITY” exercises

We strongly recommend a set of four exercises that are usually referred to by the acronym “WITY.” This title is a reflection of body’s position during each exercise, which resembles one of each of these four letters when being performed. All four exercises are to be done while you lie flat with your stomach on the ground, either on the floor, a workout bench, or the edge of a bed, so that your arms can move freely. You can do these exercises with a light weight (1-2 lbs.) or with no weights, and you should aim to perform about 2-3 sets of 10-12 repetitions for each exercise:

• “W”
• Muscles targeted: rhomboids and middle trapezius
• How to perform: your arms will resemble a “W” at the start of this motion. For this exercise, raise your arms out so they are perpendicular with the spine; your elbows bent at 90 degrees, and your arms are rotated so your palms face down. Raise your arms and squeeze your shoulder blades together as far as you can while keeping your elbows bent.
• “I”
• Muscle targeted: Latissimus dorsi and mid-back muscles
• How to perform: your arms will resemble an “i” at the starting point of this motion with your elbows straight and at your sides to start. Your shoulder blades together as you lift your arms behind you towards the ceiling; your shoulder blades should guide your movement while keeping your arms close to your body,
• “T”
• Muscles targeted: posterior deltoids, rhomboids, and middle trapezius
• How to perform: hold your arms out to your side, making a 90-degree angle with your body, and have your palms facing the ground; squeeze your shoulders together as you raise your arms up as far as you can go, and then back down to the ground; your body will resemble a “T” for the entirety of this exercise
• “Y”
• Muscle targeted: lower trapezius
• How to perform: start with your arms above your head and slightly out to the side on an angle to create the shape of a “Y”; point your thumbs up and use your shoulder blades to lift your arms up to the ceiling as high as possible; there should not be much shrugging involved when performing this exercise

For additional guidance on how to properly perform the WITY exercises, click here or here (WITY exercises start around 3:32) to watch physical therapist-led instructional videos. These exercises should provide some relief for your myofascial pain, but if you’re still experiencing painful limitations, a physical therapist can also help by setting you up with a personalized treatment program to address your condition. We will discuss the role of physical therapy for myofascial pain syndrome in our next post.

In our last post, we explained that although it’s not completely clear what causes myofascial pain syndrome, several factors have been identified that likely contribute to its development. One risk factor that’s worthy of our attention is the use of poor posture while sitting. And since working from home has become part of the new normal for millions of Americans this past year, using proper posture at your desk is perhaps more important now than ever.

Posture is essentially the position your body is in at rest and during all movements, but we’re going to focus specifically on posture while sitting at a workstation since this is where many individuals spend the majority of their time. Research has shown that simply performing computer-based work for prolonged periods can lead to pain in the upper trapezius, levator scapulae, and rhomboid muscles, with longer durations of sitting associated with greater levels of pain. But sitting with poor posture at a desk that’s not set up properly can further compound this problem, as it forces you to overexert your body, which can cause you to strain your muscles and lead to other issues like myofascial pain syndrome.

The current thinking is that practicing incorrect body posture can cause the stabilizing muscles of the upper back and shoulders into a state of constant contraction. When these types of postures are held for much of the day, several days a week, it can lead to the development of trigger points and myofascial pain. This has been supported by several recent studies, which have identified a connection between workstation postures involving a mouse and keyboard and myofascial pain.

Prevent myofascial pain by optimizing your workstation ergonomics and correcting your posture

This underlines the importance of practicing good posture to reduce your risk for painful conditions like myofascial pain. Improving posture starts with optimizing the ergonomics of your workstation. Ergonomics is the science of fitting the job to the person through strategies that allow you to perform your job efficiently and with the least amount of strain possible. And according to Ryan Fogel, a Certified Ergonomic Evaluation Specialist, using good ergonomics and proper posture not only prevents painful conditions form occurring, but can also increase productivity by reducing mental and physical fatigue.

“The key to workstation ergonomics is keeping a neutral posture while avoiding reaching and repetitive motions,” Fogel says. “One of the more common issues I see when performing ergonomic assessments is the position of the keyboard in a workstation setup. Many people don’t position it correctly, which can cause a forward leaning trunk and improper positioning of the arms. Improper monitor placement is another big one that can be easily corrected.”

Reaching too much can throw off your posture, so you should try to have everything at your desk within arms’ reach, or the “easy reach zone” as Fogel calls it. “If you were to draw a 12×12 inch box about 6 inches form your body, that would be your ideal zone that everything should be placed in to avoid overreaching. Anything beyond your arms’ length can lead to excessive or repeated twisting of the body which can cause the neck and back muscles to overwork.”

According to Fogel, it’s possible to achieve a “neutral posture” by making some basic modifications to your desk setup. Starting from the ground up, here’s how you can improve your workstation ergonomics:

• Feet: keep them secure and flat on a surface, either the ground or a footrest
• Knees: should be equal to or slightly below the chair’s height
• Back: push your hips back as far as they can go, so your back is completely supported by the chair; this allows the chair to support your spine and makes it easier for you to sustain your posture
• Elbows and wrist: keep your elbows by your side and aligned with the keyboard to avoid overreaching, and keep your wrists straight in a neutral position, at about the same height as your elbows and supported by the armrest or desk
• Keyboard: ensure that it’s centered with your body to minimize rotation of the back; if you’re using a traditional keyboard with a 10-key keypad at the bottom right, disregard the keypad and instead center yourself using only the letter portion of the keyboard
• Monitor: if using a single monitor, center it with your body; if using dual monitors, push them together and align the center of the monitors with the center of your body; monitors should be about 18-30 inches from your body, and your eyes should be about two inches from the top of the screen
• Shoulders: keep them relaxed and in a neutral position
• Other: there is a wide array of other devices that can be used to improve the ergonomics of your workstation, such as document trays to reduce head and neck movements, electric staplers, electric hole punchers, ergonomically designed keyboards, and ergonomically designed mice, which may be semi-vertical or completely vertical

To picture a neutral posture, think about how you would sit at a dining room chair with your hands on your lap, Fogel says. This is what you want to aim for.

Focusing on your workstation ergonomics and practicing good posture is a smart move that can lead to a host of benefits, including a lower risk for myofascial pain syndrome. Unfortunately, these changes are no guarantee, and myofascial pain may still develop nonetheless. Our next post explores how targeted exercises can alleviate pain in these cases.

The spine is one of the biggest problem areas of the body. Pain occurs frequently from the lower back up through the upper spine, neck, and shoulders, often leading to some degree of impairment in the process. In the middle and upper regions of the spine, there are several issues that may be responsible for pain. A condition called myofascial pain syndrome is a common problem in these areas and the subject of this post.

Fascia is a thin, connective tissue that surrounds and connects every muscle in the body. The fasciae—plural of fascia—hold muscles together and allows them to stretch and contract against one another smoothly, without creating any friction that can damage the muscles. This explains the root word “fascia” in myofascial pain syndrome, whereas “myo” refers to muscles the muscles that these fasciae connect.

Myofascial pain involves triggers points, which are areas of tenderness and stiffness within muscles and fasciae that reduce range of motion. These trigger points are essentially muscle fibers that are stuck in contraction, which causes the muscle(s) to tighten and eventually prevents blood from flowing to the area. Trigger points feel like small bumps or knots when touched, and when enough of these occur in a certain area, the result is myofascial pain.

Below, we provide answers to some of the most commonly asked questions about myofascial pain syndrome to help you better understand what it is and how to identify it.

Q: How common is myofascial pain syndrome?

A: It is estimated that myofascial pain affects approximately 44 million Americans, and according to the Cleveland Clinic, about 85% of people will experience it at some point in their lifetime. Middle-aged women who are not physically active appear to have the highest risk for myofascial pain syndrome.

Q: What other terms are commonly used to describe this condition?

A: Myofascial pain syndrome is also referred to as simply myofascial pain, neck strain, upper trapezius pain, rhomboid strain, thoracic strain, or myofascial trigger points.

Q: What muscles are usually involved?

A: Myofascial pain syndrome can affect any muscle in the body, but it is most common in the muscles of the upper back, shoulders, and neck. Notable muscles in this region include the following:

• Trapezius: the trapezius is a large, broad muscle shaped like a triangle that extends from the base of the skull to the middle of the back; it helps give you the ability to tilt and turn your head and neck, shrug and stabilize your shoulders, and twist your arms; the upper trapezius is one of the most common sites for myofascial pain because it takes on a significant amount of pressure, especially when carrying items
• Levator scapulae: this is a long and slender pair of muscles shaped like straps that run from the top of the spine to the top edge of the shoulders; the main function of these muscles is assisting with the raising and rotating of your shoulder blade; they also stabilize this region
• Rhomboids: this is a pair of upper back muscles that run diagonally from the inside border of the shoulder blades and attach to the middle back vertebrae of the spine; the rhomboids attach the shoulder blades to the spine and help to rotate and/or pull the shoulder blades together during contraction

Q: What causes myofascial pain syndrome?

A: Experts are still not entirely sure why myofascial pain syndrome occurs, but it’s believed that injury or trauma to the spine—from physical activity or repetitive muscle strain—likely plays a role in its development. Other possible causes include consistently using poor posture, which can strain muscles, as well as lack of muscle activity or muscle weakness, stress, working in cold environment, and a pinched nerve.

Q: What does myofascial pain syndrome feel like?

A: Although symptoms vary from person to person, pain is usually described as a deep aching, a throbbing sensation, or tightness and stiffness, which occurs either at the trigger point or in a nearby area (referred pain). Patients will also report the presence of trigger points that cause pain when touched—and sometimes without being touched—tender or sore muscles, and/or weakness, which can lead to reduced range of motion in the upper spine, shoulders, or neck.

Read our next post to learn more about how you can reduce your chances for developing myofascial pain syndrome by improving your posture.

When knee pain occurs, additional interventions are usually needed, which can range from noninvasive options like physical therapy to more intense procedures like surgery. Which option you choose can have a significant impact on your long-term outcome and the chances that you will eventually undergo additional interventions as well. To show you how this can play out, we discuss the findings of a recent study that evaluated outcomes in patients with both knee osteoarthritis and meniscus damage.

Over 7,000 patients monitored for more than two years

Knee osteoarthritis is a painful condition in which protective cartilage lining the end of bones gradually wears away. It is one of the most common causes of knee pain, particularly in older individuals, as it can affect up to 50% of those aged 45 and older. Damage to the meniscus—a crescent-shaped structure that acts as a cushion and absorbs shock in the knee—is also common, and the two conditions frequently occur together, with research showing that about 91% of knee osteoarthritis patients aged ≥50 years also having meniscal damage.

Some patients with these conditions will be treated conservatively, usually through a targeted physical therapy program that aims to reduce pain and improve physical function. But many others will undergo a procedure called knee arthroscopy instead, which is a minimally invasive procedure that involves several small incisions used to guide a camera and several instruments to view the structures of the knee and possibly make repairs. Although studies have shown that knee arthroscopy is not beneficial for patients with knee osteoarthritis, it remains one of the most commonly used procedures. In addition, this research did not focus on patients with both knee osteoarthritis and meniscal damage. With this in mind, investigators performed a study to investigate whether undergoing physical therapy or knee arthroscopy affected the chances of eventually having an additional knee surgery.

For the study, researchers looked for active individuals aged 45 years and older with both knee osteoarthritis and meniscal damage who were treated with knee arthroscopy or physical therapy only. This search led to 7,026 patients fitting the necessary criteria, with 69% undergoing knee arthroscopy and 31% undergoing physical therapy only. These patients were monitored for over two years to track whether they ended up having a more invasive surgical procedure (i.e., partial or total knee replacement, or fusion) and if their initial treatment had an effect on this.

Knee arthroscopy increases chances of having knee surgery by 30%

Results showed that patients who were older and who had multiple health conditions were more likely to undergo physical therapy only. More importantly, patients who had a knee arthroscopy were 30% more likely to require an invasive surgical procedure at some point in the future, and this difference was considered significant. In addition, the use of knee arthroscopy did not have any noticeable impact on the time to a major knee surgery, which is one of the primary reasons it is recommended.

Other research has also failed to detect any important differences between pain levels and the functional status of these patients when they undergo knee arthroscopy versus physical therapy. Based on these findings, it appears that knee arthroscopy does not provide any clear benefit for patients with knee osteoarthritis and meniscal damage, and it may increase the chances of having a major surgical procedure. Therefore, if you are currently dealing with knee pain that could be related to these conditions, we strongly recommend seeing a physical therapist first and to carefully consider the risks and benefits associated with a knee arthroscopy. Doing so could help you avoid expensive or unnecessary procedures while helping you retain and improve your knee function.

Knee pain is extremely common in the general population, and it can manifest through a number of conditions. If you’re personally dealing with knee pain right now, you may also be seeking outside solutions that will allow you to get around more easily. For those of you who fall into this category, one great option that can help for many causes of knee pain is an assistive device.

Assistive devices include canes, walkers, crutches, tape, braces, and other orthotic devices. While each of these has a different indication, they are all prescribed for the same general goal: make mobility easier. Below, we take a look at some of the most commonly used assistive devices for knee pain and how to use them properly.

Patellofemoral brace

• A knee brace may be recommended for patients with patellofemoral pain syndrome, or runner’s knee, a painful condition that is particularly common in runners and other active individuals
• A patellofemoral brace can help to alleviate the symptoms of runner’s knee (ie, pain around the front or along the edges of the patella that gets worse with certain types of activity or sitting), which will in turn allow for greater range of motion and more mobility in activities that involve the knee
• Patellofemoral braces accomplish this by providing extra support and compression for the knee, particularly by stabilizing the kneecap (patella) and allowing it to glide more smoothly on the thighbone (femur) while redistributing pressure away from the painful area to stronger regions of the knee
• Knee braces are available in a variety of sizes and styles, including basic bands, straps, compression sleeves, and wraparound braces for mild to moderate pain; for more severe pain, a hinged or customized brace may be considered
• If your doctor or physical therapist recommends a patellofemoral brace, they will explain how to put it on and whether it should be worn all the time or only when you are physically active; be sure to monitor if your brace moves during activity, which can be a sign of improper fit

Knee taping

• Taping the knee is a technique frequently used by physical therapists for a variety of conditions that cause knee pain, including runner’s knee, patellar tendinopathy (jumper’s knee), instability of the patella, and knee osteoarthritis
• Knee taping follows the same principles of knee bracing, as it is intended to provide additional support to the knee and realign the patella, thereby alleviating pain and improving knee function
• While a physical therapist is usually responsible for taping the knee, they can also teach you to do it yourself, so you can better manage your condition
• The taping technique performed depends on which condition is present, but one of the more commonly used approaches is called McConnell taping, or patellar taping, in which a rigid tape is applied across the patella, from the outside to the inside; other techniques include tendinopathy taping and Mulligan taping

Single point cane

• For patients with severe knee pain and those who are recovering from surgeries like ACL reconstruction or a knee joint replacement, assistive devices like a single point cane, front wheel walker, or crutches may be needed
• Older adults with balance issues and knee pain interfering with their ability to walk normally are also candidates for these assistive devices
• A single point cane helps to redistribute a patient’s weight from a lower extremity that is weak or painful to the cane; they also improve stability by increasing the patient’s base of support, and provide important information about the ground that will allow the individual to navigate it more effectively
• Canes should always be held with the top of the handle at your wrist in the hand opposite of the painful side; this means that if your left knee is painful, hold your cane in the right hand and advance it forward when your left leg steps forward
• The same concept applies to stairs: walk up with the cane and the good leg, and down with the cane and the bad leg

Front wheel walker

• A front wheel walker may be prescribed for patients recovering from a complete knee replacement, as the knee will be swollen and painful during the first few weeks after the procedure
• Walkers help these patients by providing a stable platform for walking that will prevent falls and aid their recovery by reducing the amount of weight and stress on the knees
• When using a front wheel walker, be sure to keep the front of your body in line with the back two posts of the walker; advance the walker a few inches in front of you first, and make sure all tips and wheels are touching the ground before taking a step
• When you’re ready to take a step, step forward with your bad leg first, followed by your good leg, placing it in front of your lead foot

Frequently asked questions about three of the most common knee conditions

The knee is the largest and one of the most complex joints in the body. It primarily joins the thighbone (femur) to the shinbone (tibia), but also includes the kneecap (patella) and fibula in the lower leg. These bones and the muscles that surround them are connected through a series of ligaments, tendons, and cartilage (menisci) which collectively stabilize the knee and allow it to bend, twist, and rotate.

The knee also acts as a shock absorber that takes on many of the forces from the upper body to the lower body, while allowing the leg to bend back and forth with minimal side–to–side motion.

The knee's design makes it extremely durable and capable of withstanding significant loads during everyday activities and physical performance, but like every other body part, it has limits. When the knee is pushed too far–either through a traumatic injury or from gradual, sustained damage over time–it can result in a number of painful conditions.

Knee pain ranks behind just back pain as the second most common condition affecting the muscles and bones, and it's the single greatest cause of disability in individuals who are 65 and older.

There are numerous conditions that can cause knee pain, and below, we answer some frequently asked questions about three of the most common knee–related conditions:

Patellofemoral Pain Q: What causes patellofemoral pain?

A: Patellofemoral pain syndrome, or runner's knee, is an umbrella term for any type of pain involving the patellofemoral joint (which is the joint between the kneecap [the patella] and the femur) or the area directly surrounding it. It accounts for about 20–25% of all reported knee pain and most commonly affects adolescents and young adults.

Runner's knee is an overuse injury that typically develops when the knee is overworked from excessive or repetitive movements, especially when athletes suddenly increase their activity levels. Excessive friction and stress on the patellofemoral joint and surrounding soft tissues can lead to irritation and inflammation within the joint. Poor joint alignment and weak thigh muscles may also contribute.

Q: Where does it usually hurt?

A: The most common symptom of runner's knee is pain around the front of the knee or along the edges of the patella, which frequently occurs when walking up or down stairs or hills, after long periods of activity or sitting, or after standing or walking on uneven surfaces.

Q: How can a physical therapist help?

A: Patients with patellofemoral pain may benefit from physical therapy, which is a natural, noninvasive intervention derived from a thorough evaluation of the knee and the joints above and below. Physical therapists treating runner's knee will design a program that typically includes education about the condition, stretching and strengthening exercises–with a strong focus on the hip muscles, the quadriceps, and the hamstring muscles of the thigh–sport–specific training for athletes, and possibly the use of taping or bracing and/or a foot orthotic device to help maintain the knee in an ideal position during movement.

Meniscus Tears Q: What causes a meniscus tear?

A: The meniscus is a tough, rubbery, C–shaped piece of cartilage that rests between the tibia and femur in the knee. Each knee has two menisci (plural of meniscus), with one on the inner and one on the outer side of the knee, and both absorb shock and stabilize the knee. Meniscus tears most commonly occur from twisting or turning too quickly on a bent knee, often when the foot is planted on the ground. But older adults can experience degenerative meniscus tears, in which the meniscus has weakened and worn thin over time, and can then tear from minor trauma.

Q: How can a physical therapist help?

A: Many patients with meniscus tears can be effectively treated without surgery through a physical therapy treatment program, which will typically include manual (hands–on) therapy, strengthening exercises, icing and other pain–relieving modalities, and possibly the use of an assistive device like a cane or crutches. If you decide to have surgery–which may be recommended for severe tears in athletes and active individuals–physical therapy can help you prepare for the procedure and recover afterwards.

Q: Do I need an MRI?

A: This depends on several factors, including the severity and duration of your symptoms. Before an MRI is performed, it makes good sense to seek out the care of a physical therapist. Quite often physical therapy is all you need. While MRIs are not needed for the vast majority of mild cases, doctors may recommend having an MRI if your symptoms are moderate or severe; however, it's important to understand that this is not always necessary, and the choice is ultimately up to you. Conservative, cost–effective, natural care is what should be done first. Scientific research suggests that you should try physical therapy before having any expensive tests. If physical therapy is unsuccessful, you'll be stronger, more flexible, and better prepared for an MRI and surgery if need be. Do know that having an MRI generally increases the chances of undergoing surgery, which has been found to raise the risk for osteoarthritis in the future.

Knee Osteoarthritis Q: What causes knee osteoarthritis?

A: Knee osteoarthritis is a disorder that involves the cartilage in a knee joint. In a normal knee, the ends of each bone are covered by cartilage, a smooth, very slippery substance that protects the bones from one another and absorbs shock during impact. In knee osteoarthritis, this cartilage becomes stiff and loses its elasticity, which makes it more vulnerable to damage. Cartilage may begin to wear away over time, which greatly reduces its ability to absorb shock and increases the chances that bones will touch one another.

Q: Where does it usually hurt?

A: Knee osteoarthritis typically leads to pain within and around the knee that tends to get worse with activities like walking, ascending/descending stairs, or prolonged sitting/standing. Other symptoms include swelling, tenderness, stiffness, and a popping, cracking, crunching sensation.

Q: Do I need an X–ray or MRI?

A: An X–ray of a knee with osteoarthritis can show a narrowing of the space between bones due to the loss of cartilage. MRIs provide much greater detail of the knee and will reveal specific changes in bones and soft tissue that may be related to knee osteoarthritis. However, these imaging tests are not often needed, and could lead to unnecessary interventions like surgery that may not alleviate the pain. This is due in part to the fact that although most individuals over 50 will have signs of knee osteoarthritis on imaging, many will not experience any symptoms. Even though an x–ray may show severe signs of cartilage loss, these findings do not mean you won't be successful with physical therapy and therapeutic exercise. Scientists have concluded that it's important for patients to try physical therapy/therapeutic exercise, rather than simply looking at an image and deciding against physical therapy treatment. In other words, no matter how bad the x–ray or MRI may look, physical therapy often helps.

Q: How can a physical therapist help?

Physical therapy is strongly recommended as an initial intervention for all cases of knee osteoarthritis. Although no treatment can slow or stop the loss of cartilage, a physical therapist can help to reduce your pain levels and preserve your knee function through movement–based strategies like stretching and strengthening exercises, hands–on therapy, bracing, and recommendations for activity modifications.

Skiing is a great form of exercise that works out many parts of the body while allowing you to experience the outdoors during the colder parts of the year. There are many steps to ensuring a successful day—and season—on the slopes, including the use of appropriate clothing, proper protective gear, and planning ahead. But another crucial component to this process that should never be overlooked is good hydration and nutrition.

What you eat and drink before, during, and after a day of skiing can have a major impact on your performance on the mountain. Sticking with a smart nutritional plan over time can also lead to better overall fitness and help you work towards optimal levels of strength, flexibility, balance, and endurance. This is particularly important for skiers, since the sport is associated a fairly high injury risk, with injuries to the knee—especially sprains and tears of the medical collateral ligament (MCL) and anterior cruciate ligament (ACL)—being most common. Therefore, focusing on proper hydration and nutrition could help you take your skiing skills to the next level while also reducing your risk for injuries to the knee.

Why is hydration important and how much do you need to drink?

Water is vital to our health and ability to function. Every cell, tissue, and organ relies on water, and it makes up about 60% of our body weight. Water is essential for many of the body’s most important biological tasks, and keeping the body hydrated helps the heart more easily pump blood to the muscles, which makes them work more efficiently.

On the other hand, when muscles are dehydrated, they are deprived of electrolytes that are necessary to proper functioning. This can impair both muscle strength and control, which can negatively affect your performance on the slopes. In one study, underhydrated individuals were significantly less capable of performing a resistance exercise compared to those who were adequately hydrated. Being dehydrated may also play a role in developing muscle cramps, but evidence is conflicting, and other factors are likely also at work.

It’s also important to realize how hydration needs are different when skiing. In cold weather, the body doesn’t get as hot, sweat evaporates more rapidly, and the body’s thirst response is diminished by up to 40%, even when you’re dehydrated. As a result, you may be fooled into thinking that you’re properly hydrated, even when your body requires more water to function properly. This is why you should never wait until you’re thirsty or notice symptoms of dehydration—such as little or no urine, dry mouth, confusion, nausea, headaches, fatigue—to start drinking water. Instead, aim to stay well hydrated (meaning your urine is pale yellow) before, during, and after skiing. Exactly how much water you’ll need varies from person to person depending on body weight, exercise intensity, and other factors, but the following ranges are a good starting point:

• Before skiing: 17-20 oz. of water at least 2 hours before getting on the mountain
• While skiing: 7-10 oz. of water for every 10-20 minutes on the slopes; try carrying a plastic, reusable water bottle with you and/or take frequent water breaks
• After skiing: 16-24 oz. of water for each pound lost due to sweating; it is particularly important to rehydrate if you’re skiing again the next day

What comprises a strong nutritional plan for skiing?

Making smart dietary choices while skiing may take some additional effort on your part, but doing so could make a real difference in your energy levels and how well you’re able to carve as a result. This means planning ahead and not relying only on the food offered at lodges, which don’t always provide the best possible options.

Before skiing

• Having a quality, nutritious breakfast is essential for starting your day off on the right foot; an ideal breakfast before skiing should include a slow-burning carbohydrate source combined with a protein source
• Consuming the right amount of carbohydrates will ensure that you have sufficient energy levels to get through an entire day of skiing
• Protein can help to improve physical performance in several ways, particularly by increasing the amount of muscle mass you’re able to gain while skiing
• Some of the best breakfast options that contain both carbs and protein include a smoothie made with bananas, nut or oat milk, and protein powder, yogurt with fruit, oatmeal with chia seeds, flax seeds, and/or nuts, and avocado toast with egg
• Try to avoid eating just protein or just carbs for your entire breakfast (like a piece of fruit), as it will fail to keep you full for an extended period of time

While skiing

• While a well-balanced breakfast is key for the day, aim to keep it relatively small, as eating too much can overburden your digestive system and lead to fatigue
• Instead, keep yourself sustained with easy on-the-go snacks throughout the day; pack a few low-sugar bars (especially whole foods-based nutrition bars with minimal ingredients), peanut butter packets, pieces of fruit, or a bag of nuts or raisins; these will keep your energy levels high and blood sugar stabilized as you burn calories while skiing
• Be sure to also eat a lunch that fills you up without overdoing it, with protein and carbs again being the main macronutrients to focus on; try to limit your intake of fats, as it can take more energy to digest high-fat foods
• Smart lunch options include a chicken or ham sandwich, fish tacos, a burger with a side salad (skip the fries), and soup/chili; if you’re able to cook on your own, here’s a great recipe for turkey chili
• We realize that cafeteria options are not always great on the mountain, so if your lunch is subpar, you can always make up for it with a healthy recovery dinner

After skiing

• Ideally, you should try to have another small snack within two hours of getting off the mountain—aprés ski usually fits the bill here—and then a fairly large meal for dinner; if you haven’t noticed, there’s a general trend here: you should be eating most of the day when skiing
• Consuming a meal loaded with a good balance of carbs and protein is also important after you’re done for the day and the recovery process begins
• These macronutrients are important for different reasons during your recovery, as protein will help with the repair and growth of muscle, while carbs will replenish your stocks of glycogen (energy storage for muscles) for the next day
• While fats should generally be avoided during the day, feel free to eat some fats with dinner (preferably healthy ones), which you can do by topping your food with avocado, using olive oil in meals, or fatty fishes like trout and salmon
• Great recovery dinners include meatballs with veggies and a small serving of pasta, herbed chicken with roasted broccoli and potatoes, miso ginger tofu bowl, and salmon with veggies