Arthritis and Exercise: Rules of Engagement

Cleveland Clinic Arthritis Advisor, July, 2009

There is a fine line between exercise that strengthens the joints of the body and increases flexibility and those that could make the symptoms of osteoarthritis (OA) worse. Even the results of research can send conflicting messages. Some studies show an association between mechanical strain, weak muscles, and knee arthritis, while many others have proven that strengthening joint-supporting muscles can reduce pain, and enhance both flexibility and mobility.

A.J. Cianflocco, MD, Program Director for Cleveland Clinic Primary Sports Medicine Fellowship, and physical therapist Dr. George Sibel, provide some direction regarding which exercises to avoid, and they suggest the types of activities that could help you diminish or prevent some of the symptoms that accompany osteoarthritis.
“Activities to avoid are the ones that hurt, particularly while you are engaged in the activity,” says Dr. Cianflocco. “Pain is a red flag that tells you to stop what you’re doing and perhaps eliminate it from your exercise routine. If the discomfort develops only after an activity, you may be able to get back to doing it with either less intensity, fewer repetitions, or for a shorter period of time.”

What Are the Risks?

The risks of engaging in dangerous exercises are as clear as they are simple: pain and further injury to a joint that has already been damaged. “An arthritic knee may not be as strong or as stable as a healthy one,” explains Cianflocco. “The wrong kind of exercise could aggravate the condition, cause more pain, and lead to progression of the disease. In the case of knee osteoarthritis, the joint could buckle under the weight of your body.”

The impact of dangerous exercises depends on you. What kind of shape are you in? Is your weight in an acceptable range? Are you used to participating in a particular activity? If you already have severe OA, you could make a bad condition even worse. If you are in the beginning stages of the disease, you might get away with temporary discomfort and a warning sign that tells you to take a second look at what you’re doing to your body.

Dr. Cianflocco has painted a broad picture of potentially dangerous exercises, George Sibel gets more specific. “Be careful with leg extension exercises that are normally used to strengthen the quadriceps muscles (on front of the upper leg) and leg curls for hamstring (on back of the upper leg) strengthening,” he says. “Both should be done in a pain-free arc, avoiding full extension and avoiding flexion (bending the knee) more than 45 degrees. Specific activities that risk knee damage are those that cause high impact, such as running, aerobic exercise on hard surfaces, skiing, and playing singles in tennis.” In addition, let’s assume that your football, soccer, and full court basketball days are already over.

Dr. Cianflocco adds this advice regarding muscle and joint pain during and after exercise. “There may be some discomfort, but there does not have to pain or soreness for exercise to be effective. The premise of no pain, no gain does not apply. It is possible to work within a comfortable range and still make progressive gains in strength.”

Arthritis-friendly Exercises and Activities

Having knee osteoarthritis is not a reason to discontinue a resistance training, range of motion exercise programs, or all sports. “The key term is ‘low-impact,” says Dr. Cianflocco. “Swimming, walking, cycling, dancing, bowling, resistance training, tai chi, and golf are okay unless they aggravate symptoms. From there, you may be able to move up to doubles in tennis, softball, or even common-sense basketball, depending on the severity of the condition and the amount of pain these activities cause.”

Both Cianflocco and Sibel agree that water exercise is an acceptable activity for those with knee OA, but only in the proper context. “Everybody needs a basic land-based quad and hamstring strengthening program. The stronger the quads, the more stable the knee and the amount of pain. Following that basic program, you can add a water-based program, but understand that in doing so, you are working against resistance that is 50 percent of what it would be on dry land. The next level of exercise would bring into play seated leg presses, stationary bicycle work against resistance, and step-ups — stepping up and down a single step, using body weight for resistance.”

Guidelines

Regardless of the kind of exercises, there are guidelines for people with OA to follow. Here are four to follow:

• Warm-up before beginning an activity. You can even warm up before you warm up. “I’m a guy who turns on his car heater regardless of the time of year to warm up my back on the way to the golf course,” Cianflocco confides.

• Start slowly and increase the exercise intensity and duration gradually. Follow the ten percent rule: Never increase exercise intensity, frequency, or duration more than 10 percent a week.

• Be careful with or avoid rapid movements of affected joints. Slow and moderate-speed body movement is okay.

• Adapt your favorite activity to your situation. Doubles is safer than singles in tennis. Walking is safer than jogging. Swimming and cycling may be more appropriate than running or walking.

Forty-eight hours between activities may be more appropriate than 24 hours. You can get around that rule by participating in different activities (that involve different joints) on alternate days.

Take-to-the-Gym Message

Participating in a program of exercise, physical activities, and even sports might be even more important now than it was before the onset of osteoarthritis. It will not get better without your intervention, and it doesn’t have to ruin the quality of your life.

Drop the exercises that are dangerous. If that is not an option, modify them to reduce the risk of pain and further damage. If that doesn’t work for you, it may be time to find new and challenging physical activities that are enjoyable, healthy, and safe, and within the restrictions imposed by a condition that is likely to last as long as you do.

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What You Can Do to Avoid Dangerous Exercises and Activities

• Use pain as a guide to safe exercise. If an activity hurts, stop doing it.

• If you feel pain only after an exercise has been completed (or on the next day), try doing the exercises the next time with fewer repetitions, less intensity, or for shorter periods of time.

• Avoid high-impact activities such as running, playing singles in tennis, and aerobic exercise on hard surfaces.

• Choose low-impact activities such as swimming, walking, cycling, dancing, bowling, resistance training, tai chi, and golf, as long as they do not cause pain.