Physical Therapy Versus Glucocorticoid Injection for Osteoarthritis of the Knee

By Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


Osteoarthritis (OA) of the knee is a leading cause of disability in the United States. Treatment typically involves symptom management until late stages warrant a knee replacement surgery. Intraarticular glucocorticoid injections are commonly used as a primary treatment for OA but there are conflicting reports on the duration of symptom-relief. Physical therapy (PT) is also a standard treatment, however, referrals for treatment of knee OA have declined between 2007 and 2015, despite guideline recommendations. In the U.S. Military Health System, patients who were initially diagnosed with knee OA were more likely to be referred for glucocorticoid injection than for physical therapy (51% vs. 29%), and only 13% received both. The authors in the article, Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee, performed a randomized control trial comparing the long-term functional outcomes of patients who receive either physical therapy or a glucocorticoid injection for the treatment of knee OA.


Patients were either beneficiaries of the Military Healthy System (active-duty or retired service members) or their family members. Patients were eligible for the study if they were clinically diagnosed with OA and radiographs showed Grade I-IV arthritis of the knee joint. Patients were randomly assigned to either the PT group or the glucocorticoid injection group.

The injection group received one ml of triamcinolone acetonide and seven ml of 1% lidocaine and could receive up to three total injections in the 1-year trial period, as needed. This group had re-assessments performed at 4-months and 9-months. Patients in the PT group underwent eight sessions of PT over the initial 4-6-week period which included patient education, a written home exercise program, manual therapy, stretching and exercise. PT group patients could also attend an additional 1-3 sessions at the 4-month and 9-month reassessments as needed. All five treating therapists were board certified in orthopedic PT and fellowship-trained in orthopedic manual therapy.

The researchers assessed outcome measures at baseline and at one-year post-intervention physical function using the WOMAC and GROC questionnaires, and two functional tests which included the Timed Up and Go test and the Alternate Step Test.


A total of 156 patients were recruited for the study; 78 patients in each treatment group. The mean treatment-related costs for all knee-related medical care during the one-year trial period was similar in the two groups ($2,113 in the glucocorticoid injection group and $2,131 in the physical therapy group). The mean (±SD) WOMAC scores at 1 year were 55.8±53.8 in the glucocorticoid injection group and 37.0±30.7 in the PT group. At one year, the median score on the Global Rating of Change scale was +5 (“quite a bit better”) in the physical therapy group and +4 (“moderately better”) in the glucocorticoid injection group. Patients in the PT group performed better (lower mean times) on both functional tests than patients in the glucocorticoid injection group.


In conclusion, physical therapy for OA of the knee resulted in better absolute scores on the WOMAC and GROC scales and the Timed Up and Go and Alternate Step functional tests than glucocorticoid injection at one year.

Physical Therapy First Implications

The therapists at Physical Therapy First are board-certified orthopedic clinical specialists and are residency or fellowship-trained in manual therapy. If you are having knee pain and/or have been diagnosed with knee OA, PT treatment may improve your pain and long-term function.


Deyle, G., Allen, C., Allison, S., Gill, N., Hando, B., Petersen, E…Rhon, D (2020). Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. The New England Journal of Medicine. 382,15, pages 1420-1429.

Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients with Cervical Radiculopathy: A Randomized Controlled Trial

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


The use of thoracic spine manipulation is supported in literature for use on patients with neck pain. However, there is limited evidence for its use in patients with neck and arm pain due to cervical radiculopathy. The authors in the study, Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients with Cervical Radiculopathy: A Randomized Controlled Trial, observed the immediate and short-term effects of upper and mid-thoracic manipulation on neck and upper extremity pain, patient-perceived symptoms, neck disability, cervical active range of motion (AROM), deep neck flexor muscle endurance, upper extremity numbness and tingling, and symptom distribution.


Patients who were clinically diagnosed with cervical radiculopathy and who had a neck disability index (NDI) score of 10/50 or greater were recruited for the study. Patients were randomized into either a treatment (manipulation) group or a control group (sham manipulation). A total of 22 patients were placed in the treatment group and 21 in the control group. The manipulation group received a high-velocity, low-amplitude thrust manipulation bilaterally to the upper thoracic and mid thoracic spine. The sham manipulation was performed with a slightly different technique where the therapist’s fingers were extended on the thoracic segment and no thrust manipulation was performed. Both groups were instructed to resume normal activities until the next visit, with no home exercise or advice.

The primary outcomes were self-reported pain on the numeric pain-rating scale and changes in perceived improvement on the global rating of change scale (GROC). The secondary outcomes were disability using the neck disability index (NDI), cervical AROM, deep neck flexor muscle endurance, and patient-reported numbness, tingling, and distribution of symptoms.


There was a significant reduction in neck and upper extremity pain at 24- and 72-hours post-treatment in the intervention group. There was moderate improvement in the manipulation group of GROC scores at both time points. Improvements in secondary outcomes in the manipulation group were also evident on the NDI, deep neck flexor endurance test, and active cervical ROM in all motions except sidebending to the opposite side.


Patients who received thoracic manipulation as compared to the sham manipulation had greater improvements in neck pain, neck-related disability, and cervical impairments (ROM and deep neck flexor endurance) immediately and up to 48 to 72 hours after treatment. Fourteen (64%) of the participants in the manipulation group reported centralization of symptoms at 48 to 72 hours.


Patients that received the manipulation experienced improved pain, disability, cervical ROM, and deep neck flexor endurance compared to those patients in the control group.

Physical Therapy First Implications

Physical Therapy First therapists are highly trained in clinically diagnosing cervical radiculopathy in the presence of neck and arm pain. Our therapists are also proficient at performing thrust manipulations of the upper and mid thoracic spine in the treatment of cervical radiculopathy. If you are experiencing neck pain, arm pain, numbness, or tingling, physical therapy is a great option for diagnosis, management, and treatment of your symptoms.


Young, I., Pozzi, F., Dunning, J., Linkonis, R., Michener, L (2019). Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial. Journal of Orthopedic and Sports Physical Therapy. Vol 49, No 5, Pages 299-309.

The Benefit of Osteopathic Manipulative Therapy During Pregnancy

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


Back pain is a commonly reported symptom among pregnant women, especially those in the third trimester. This pain can lead to a temporary disability, sleep-disturbance, and may affect daily living and quality of life. Many women seek physical therapy, chiropractic care, massage therapy, and acupuncture treatment to manage their symptoms. The researchers in the study, Osteopathic Manipulative Treatment of Back Pain and Related Symptoms During Pregnancy: A Randomized Controlled Trial, looked at the effects of osteopathic manipulative treatment (OMT) on pain and function in pregnant women during the third trimester.

Materials and Methods

144 pregnant women between 28- and 30-weeks gestation were enrolled in the study and randomly assigned to one of three groups. The first group was usual obstetrical care (UOBC), the second group was usual obstetrical care and OMT (UOBC+OMT), and the third was usual obstetrics care and sham ultrasound treatment (UOBC+SUT). Each treatment group received seven, thirty-minute treatments spanning nine weeks in addition to their regularly-schedule obstetrics care. The two outcome measures utilized in this study included back pain, as measured on ascale from 0 to 10 and back-related function, measured by the Roland-Morris Disability Questionnaire.

The subjects assigned to the UOBC only group did not receive any treatments beyond conventional obstetrical care; however, they were expected to complete data collection forms on the same schedule as all other trial subjects. In group two, the OMT was performed by a licensed physician and included soft tissue, myofascial release, muscle energy, and range-of-motion mobilization. The physician performed these interventions to treat somatic dysfunction of the cervical, thoracic, and lumbar spine; thoracic outlet and clavicles; ribcage and diaphragm; and pelvis and sacrum. The study protocol prohibited use of high velocity, low amplitude (HVLA) techniques because the increasing ligamentous laxity that occurs in late pregnancy may pose a theoretical risk in performing such maneuvers. In group three, SUT used a nonfunctional ultrasound therapy unit that was modified for research purposes to provide both visible and auditory cues that could potentially elicit a placebo response.


A total of 49, 48, and 49 subjects were randomized to the UOBC+OMT, UOBC+SUT, and UOBC only groups, respectively. Subjects in the UOBC only group had the highest appointment attendance rate, while those in the UOBC +SUT group had the lowest appointment attendance rate.

Although there were no statistically significant differences in pain levels among treatment groups, mean pain levels decreased in the UOBC+OMT group, remained unchanged in the UOBC+SUT group, and increased in the UOBC only group. There were significant differences in back-related function among treatment groups. Back-related function deteriorated less in the UOBC+OMT group than in the UOBC only and UOBC+SUT groups. These outcomes suggest OMT could offer a clinical benefit when provided as complementary therapy to usual obstetrical care.


The study results indicate that OMT lessens or halts the deterioration in back-related function that often characterizes the third trimester of pregnancy. While there is evidence that OMT may provide an important clinical benefit in reducing back pain, the results are not as conclusive as they are for back-related function. Thus, taken together, these findings suggest that the beneficial effects of OMT on physical functioning during the third trimester of pregnancy may not be related simply to an analgesic effect on back pain, but may possibly involve other mechanisms.


There were a few limitations in this study. The first was the method of blocked randomization which did not adequately randomize subjects based on illicit drug use, vaginal bleeding, and race/ethnicity. In addition, the OMT protocol was limited to the third trimester of pregnancy. Theoretically, in clinical practice, it would be desirable to implement OMT earlier in the pregnancy to prevent or slow the progression of somatic dysfunction and back-related symptoms. Finally, the OMT protocol involved a standardized approach to treatment which may not adequately reflect the potential benefits seen in clinical practice, where there is a more individualized treatment approach for each patient.

Conclusions and Physical Therapy First Implications

The study results indicate that a larger Phase III trial with greater statistical power and better control of potential confounders is warranted to better assess the effects of OMT on back pain and related physical functioning during the third trimester of pregnancy. At Physical Therapy First, our therapists are proficient at performing the interventions used in this study including soft tissue, myofascial release, muscle energy, and range-of-motion mobilization. If you are pregnant and have experienced back pain at any point during your pregnancy, physical therapy is a great intervention for managing pain and improving function.


Licciardone, John., Buchanan, Steve., Hensel, Kendi., King, Hollis., Fulda, Kimberly., Stoll, Scott (2010). Osteopathic Manipulative Treatment of Back Pain and Related Symptoms during Pregnancy: A Randomized Controlled Trial. American Journal of Obstetrics and Gynecology. 202(1): 43.e1–43.e


Effects of Different Exercise Interventions on Risk of Falls, Gait Ability, and Balance in Physically Frail Older Adults: A Systematic Review

By Lisa Jerry, SPT


Frailty is a syndrome that can accompany increased age, especially in individuals over the age of 65, that decreases the body’s functional capacity to handle stresses. Frailty increases an individual’s risk of disability, falls, and hospitalization. Several issues associated with frailty include weight loss, decreased muscle strength, decreased endurance activity, and slower walking speed. This systematic review aims to look at the benefits of several different types of training and their impact on frailty, as prescribed by a Physical Therapist (PT).


20 randomized controlled trial studies had their data combined which focused on strength training, endurance training, balance training, and multi-component exercises (a combination of all three of these trainings). These studies described their participants as frail, pre-frail, elderly individuals with a history of falls, and recent illness-induced functional decline.

Types of Exercise Interventions

Strength training: Strength training is a common intervention utilized to counteract the changes that occur due to aging. Strengthening the hips and knees is a good foundation for these exercise programs looked at in the studies. Overall consensus between these studies was that strengthening these groups 3 times per week, 3 sets of 8-12 reps, and increasing resistance over time showed overall positive improvements in gait, stairs, and muscular strength.

Endurance training: Aging decreases the cardiovascular system’s capacity, making everydays tasks harder to perform. Different types of endurance activities that have proven to be effective include walking at different speeds, treadmill walking, stair climbing, and stationary cycling. The principle “start low and go slow” is an important principle during endurance training, so it is beneficial to start at just 5-10 minutes of endurance training at first and slowly progress up to 30-60 minutes.  It is important to consult with your physician before beginning a new exercise program.

Balance training: The best way to improve balance is to work on balance! There are countless balance interventions used during these studies including: walking in a straight line, stepping practice, throwing and tossing a ball, changing the surface a person stands on, and Tai-Chi. One study showed that 15 weeks of Tai-Chi reduced the risk of falls by 58%. Similar to the other two training types, balance training should start easier and safely progress into the more challenging activities as tolerated.

Multi-component exercises: This type of training encompasses all three of the interventions mentioned above. Targeting several different training types will allow the body to better adapt to stresses placed on it. One study found that 12 weeks of multi-component exercises resulted in an increase in strength by 75% as well as 25% fewer falls in the frail population. Another study showed that 1 year of this type of program resulted in 40% fewer falls.

Conclusion and PTF Implications

This review shows that a combination of strength, endurance, and balance training increases strength and decreases the fall risk, thus improving quality of life. Here at Physical Therapy First, we listen to each individual and what they want to improve upon. We use our knowledge and experience to create a unique progressive training program that is right for each individual to help them get back to doing what they love.

Original Article

Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Research. Vol 16, Number 2, pages 105-114.

The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective

By Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


In physically active individuals, the knee is the joint in the lower extremity which sustains the highest percentage of injuries. Research conducted over the last several decades suggests that knee injury may have proximal influence from the hip and trunk. The authors of the commentary, The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective, provide a literature review on this topic, specifically addressing common knee injuries such as anterior cruciate ligament tear (ACL tear) iliotibial band syndrome (ITBS), and patella-femoral pain (PFP) and the role of the hip and the trunk in these injuries.

Proximal Contributions to Abnormal Tibiofemoral Joint Kinetics

During the stance phase of running and jumping, the femur adducts, internally rotates (IR), and flexes at the hip joint. These motions are primarily controlled by the hip extensors, abductors, and external rotators. Excessive femoral motion into flexion, IR, and adduction places abnormal stresses at the tibiofemoral joint.

In the presence of proximal hip weakness, some compensatory strategies of the pelvis and altered movement patterns of the lower extremity occur. The first compensatory strategy is in the presence of hip abductor weakness, the contralateral pelvis drops (Trendelenburg sign). This compensation causes increased strain to be placed on the iliotibial band and lateral collateral ligament. In compensated Trendelenburg, where the trunk leans over the stance limb, the stress is shifted to the medial knee, particularly the ACL and medial collateral ligament. The second compensatory strategy is in the presence of hip extensor weakness, a posterior trunk lean is common. This places stress through the anterior knee, possibly leading to quadriceps muscle strain, patella tendinopathy, patellofemoral joint compression, and ACL strain.

Tibiofemoral Joint Injury Mechanisms

ACL tears are one of the most common knee injuries sustained by individuals who engage in athletic and recreational activities. The rate of ACL tears is significantly higher in women, possibly due to the predisposed factor of a wider pelvis which causes an increased Q-angle at the knee. The Q-angle is the angle of the patella in relation to the pelvis and the tibia. Several studies have reported that reduced hip strength is related to greater knee valgus angles. Weakness of the hip extensors and abductors has been theorized to play a role in increased risk of females sustaining an ACL injury, however, the finding is not consistent across all studies. Additional factors, such as impaired motor control, may play a role with respect to movement pattern that are thought to be associated with ACL injury.

ITBS is a common cause of lateral knee pain and is the second most common overuse injury in runners, behind PFP. The strongest predictors of athletes who develop ITBS are excessive hip adduction and knee IR with running due to the increased stress on the lateral knee with these motions. In addition, studies show that hip abductor strength of the involved limb in runners with ITBS was significantly reduced when compared to the noninvolved limb and the control groups.

Patellofemoral Joint

PFP is the most prevalent lower extremity condition seen in orthopedic practice and has been cited as the most common overuse injury in persons who are physically active. Females with PFP tend to have excessive IR of the femur and a greater dynamic Q-angle during running. This increased angle on the knee displaces the patella medially and increases the pressures within the patellofemoral joint.

Those with PFP tend to exhibit impaired strength of the hip extensors, abductors, and external rotators. Despite the fact that altered hip motion and diminished hip strength are common findings in females with PFP, only two studies have evaluated hip strength in conjunction with hip kinematics in this population. One study reported significant reductions in isometric hip external rotator and hip abductor strength in females with PFP compared to a control group, but no differences in hip adduction and internal rotation motion during stair descent were observed. A second study reported that females with PFP exhibited diminished hip muscle strength, but only isotonic hip extension endurance was found to be correlated with excessive hip internal rotation during running.

Pelvis and Trunk Stability

The hip abductor muscles are important to maintaining the pelvis level in the frontal plane. In theory, improving performance of the hip abductors would result in a more optimal alignment of the pelvis during single-limb activities and, in turn, protect the knee joint from excessive frontal plane moments created by compensatory adjustments of the trunk and the resulting movement of the body center of mass.

Excessive anterior tilting of the pelvis resulting from weakness of the posterior rotators of the pelvis (ie, gluteus maximus, hamstrings, and abdominals) and/ or tightness of the hip flexors may result in a posterior shift in the trunk position, placing more stress on the knee joint. Given the fact that impaired trunk proprioception and deficits in trunk control have been shown to be predictors of knee injury, the development of “core” programs should consider dynamic pelvis stability as an important piece.

Dynamic Hip Joint Control

While there is some debate whether abnormal hip kinematics are the result of diminished hip muscle strength or impaired motor control, both aspects of muscle performance should be considered when implementing a rehabilitation or injury prevention program. In particular, the gluteus maximus and gluteus medius should be the targeted muscles due to their important roles in dynamic hip stability. The gluteus maximus is best suited to provide 3-dimensional stability of the hip, as this muscle resists the motions of hip flexion, adduction, and internal rotation and is a strong hip extensor and external rotator. In contrast, the gluteus medius mainly functions to stabilize the femur and pelvis in the frontal plane.

Summary and Physical Therapy First Implications

It can be argued that interventions which address proximal impairments including pelvis and trunk stability and dynamic hip control may be beneficial for patients who present with various knee conditions. The therapists at Physical Therapy First are proficient at evaluating the strength and dynamic control of the trunk and pelvis, and creating individualized treatment plans and home exercise programs to address proximal impairments which could be contributing to knee pain.


Powers, Christopher (2010). The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective. Journal of Orthopedic and Sports Physical Therapy. Vol 40, Number 2, pages 42-51.