Joint protection program for the lower limb

INTRODUCTION — Every patient with a chronic joint disorder should be educated regarding the principles of joint protection, as excess stress and strain on arthritic joints can add to inflammation and degeneration [1]. The goal of lower extremity joint protection is to avoid overloading vulnerable joints/tissues, prevent recurrent sprains and strains, reduce pain and inflammation, and thus preserve joint integrity.

Joint protection is best achieved through patient education, behavior modification, energy conservation; in selected cases, use of orthotic devices, splints, adaptive devices; and, in the case of the lower extremities, proper footwear. Conservative care includes preventive care, and joint protection is a fundamental way to provide preventive joint care.

Joint protection for the lower extremities will be reviewed here. An overview of joint protection and joint protection for the upper extremities and neck are discussed elsewhere. (See "Overview of joint protection" and "Joint protection program for the upper limb" and "Joint protection program for the neck".)

PRINCIPLES OF JOINT PROTECTION — The principles of joint protection are derived from the simple, practical application of proper body mechanics, posture, and positioning of joints. Joint protection reduces local joint stress and preserves joint integrity. Guiding the patient to perform a task in a manner that puts less stress on joints is generally preferred to prohibiting the task [2,3].

The principles of joint protection include:

●Respect pain

●Reduce excess body weight

●Demonstrate proper posture and body mechanics

●Use minimum force for energy conservation and injury prevention

●Participate in regular exercise, as tolerated, to maintain function, range of motion, strength, and balance

These principles and their application are discussed in detail in the sections below.

Respect pain

●Pain may be interpreted as a signal for the patient to modify or avoid the activities that cause pain. In the acute phase of pain (less than 12 weeks since onset), respecting pain and minimizing activities that cause an excessive load on the joint is a useful strategy. In chronic pain states (more than 12 weeks since onset), it is important to also recognize that loss of strength, flexibility, coordination, and function create significant cognitive and psychological distress that may hinder long-term recovery. In this instance, the recovery may require gradual reconditioning with the guidance of clinicians, physical therapists, personal trainers, and pain psychologists. In this latter state of chronic pain, the patient needs to make regular movement part of the daily regimen, not contingent on whether or not there is pain ongoing.

●Patients should warm up before doing exercises or vigorous activity and cool down afterwards. A warm up should consist of 5 to 10 minutes of gentle joint range-of-motion exercises or any gentle activity that increases the heart rate. A cool down should involve gently slowing down the activity/exercise to help gradually decrease the heart rate followed by gentle stretches and/or range-of-motion exercises for approximately 10 minutes.

●We advise that patients should choose footwear with comfort, support, and utility in mind, and that patients should not wear shoes that cause pain or fatigue. Individualized assessment is an important component of a joint protection intervention. If a shoe hurts, it is likely placing excessive stress on the joints and soft tissues, which could contribute to injury and long-term problems, especially in arthritic joints.

The history of past shoe wear may be important for women with current foot pain. Women who wore "good shoes," compared with women who wore "average shoes," in the past were 67 percent less likely to report hindfoot pain [4]. This study, using data from the Framingham (MA) study, defined "good shoes" as low-risk shoes, including athletic and casual sneakers with rigid heel counters, fixation, or firm, non-flexible soles. "Average shoes" included those with hard or rubber soles, special shoes, and work boots. "Poor shoes" included those that lack support and sound structure, including high-heeled shoes, sandals, and slippers.

A systematic review found evidence that special shoes and orthoses may benefit patients with rheumatoid arthritis (RA) [5]. However, patient dissatisfaction with footwear often resulted in decreased usage, while participation in the design stage of specialized footwear improved usage, decreased pain, and improved foot health [6].

The following issues should be noted:

•Patient acceptance of footwear is needed for clinical benefit [6].

•Appropriate shoes should provide support and comfort for the weightbearing foot, with room for the toes to extend fully and to broaden out during weightbearing. A certified pedorthist can construct custom shoes, with a doctor's prescription, for patients with structural foot deformities. In addition, orthotics may be obtained from a medical equipment company with the advice and assistance of a treating physical therapist or podiatrist. If a patient has a structural deformity that may require custom-made orthotics, then it is advised that the patient pursue a podiatry consultation.

•Proper fit should be determined by having the foot size measured while standing.

•Attention should be given to wearing shoes with an appropriate heel height (usually a one-inch heel). They should fit the description of a "good shoe," as specified above, and should be checked often for signs of wear.

•Cushion soles with shock absorbing material should be used if walking or working on concrete.

•Running shoes, walking shoes, or aerobics shoes are more supportive and comfortable to the flexible or arthritic foot. Good running shoes and arch supports are important. It is important to remember to replace running or walking shoes regularly. Running and walking shoes should be replaced every 300 to 500 miles.

•A metatarsal pad or bar can be used to relieve pressure or pain at the forefoot. A certified orthotist can make a custom fit orthotic with a metatarsal pad. A metatarsal pad helps unload the metatarsal heads, which can decrease pain at the forefoot. Metatarsal pads can be purchased over the counter or online; however, patients with special footcare needs or foot deformities may need to have a custom fit metatarsal pad made by an orthotist.

•Footwear that is especially designed for a particular sport should be used for participation in that activity.

•In patients who do not respond with a reduction in pain to the more simple measures described above, we recommend evaluation by a podiatrist.

•Orthoses can provide needed support and positioning assistance. We suggest consultation with an experienced professional regarding the choice of an orthosis, whether having it custom-made or obtaining it over-the-counter. For patients with structural foot deformities, custom orthoses can be fit and made by a certified orthotist, physical therapist, podiatrist, or a certified pedorthist, with the appropriate prescription from a podiatrist (or physical therapist). Orthoses should then be used in both sports shoes and everyday shoes.

There is no consensus on the choice of foot orthoses used for managing pathology in the rheumatoid foot, although there is strong evidence that foot orthoses do reduce pain and improve functional ability. The type of foot orthoses used range from simple cushioned insoles to custom-made rigid cast devices [7].

●A 2008 systematic review [8] found that, for people diagnosed with RA, custom-made foot orthoses, which can be made by a certified orthotist, pedorthist, or physical therapist with a prescription or by a podiatrist, are:

•More effective than no intervention for reducing rear foot pain up to 30 months

•Not more effective than a standard intervention of supportive shoes or non-custom foot orthoses for reducing metatarsophalangeal (MTP) joint pain or for improving function after six weeks or three months

●Individuals with joint hypermobility/laxity should be particularly careful to protect the ankles and feet. Sprains and strains can increase joint instability.

●If synovitis or synovial effusion is present, joint aspiration and injection, where indicated clinically, can result in a more rapid response to physical therapy and joint protection principles.

●The weightbearing load should be distributed over stronger joints and/or larger surface areas.

●Patients should avoid overloading the joints and should instead use the muscles that surround the joint. For example, the thigh muscles can be used to rise from a chair.

●Patients should avoid maintaining the same joint position for prolonged periods. Straightening the knees or standing up at least every 30 minutes during prolonged periods of sitting relieves pressure and stretches tight muscles.

●Assistive devices such as a cane or a walker should be considered if joint pain, swelling, and/or inflammation alter gait mechanics or lead to joint instability. A physical therapist can be consulted to determine the most appropriate device and fit. A physical therapist will also instruct a patient on how to properly and safely use the appropriate assistive device. For example, canes are frequently misused and placed in the same hand as the affected limb. A cane should be used in the hand opposite the affected joint/limb to effectively reduce the load on the affected joint/limb, which helps normalize gait mechanics. It is important to avoid using a cane in the same hand as the affected limb as this will not effectively reduce loading on the affected joint/limb or help to correct existing gait abnormalities. For example, if the left knee is swollen and painful then the cane should be used in the right hand to effectively reduce the load on the left knee. (See "Falls: Prevention in community-dwelling older persons", section on 'Assistive devices'.)

Reduce excess body weight — We advise that patients maintain an appropriate weight to reduce stress on the knees, feet, and ankles. Increased body mass index is associated with onset and progression of osteoarthritis (OA) of the knee (but not the hip) [9]. In addition, the combination of modest weight loss plus moderate exercise provides improvements in overall pain and performance measures of mobility in older overweight obese adults with knee OA compared with either intervention alone [10]. (See "Obesity in adults: Overview of management" and "Epidemiology and risk factors for osteoarthritis", section on 'Obesity'.)

Posture and body mechanics — We advise that patients use good posture and proper body mechanics. The following points should be reviewed with patients, depending upon their individual activities or symptoms:

●Hip and buttock region pain may result from bending at the waist while the knees are locked straight. Persons with joint laxity are more likely to bend improperly (picture 1).

●When lifting heavy loads, it is better to bend at the knees and hips and not at the waist and to avoid allowing both knees to pass over the toes. Lifting should be done with thigh muscles, straightening the knees first then the back (picture 2).

●If the patient's job or task requires prolonged standing at one site, placing a 12-inch long 2X4-inch board on the floor, then placing one foot on and off of it at intervals, alternating feet, can reduce lower limb fatigue (picture 3).

●Twisting should be avoided while carrying a heavy load, which should be held close to the body. It is better to move the body as a unit when carrying a heavy load to avoid excessive stress and strain on the low back, hips, knees, and ankles (picture 4 and picture 5).

●When lifting heavy objects, the load should be kept centered in front of the body. Carrying heavy items in one hand at the side of the body should be avoided (picture 6).

●Knee pain can be caused by foot disorders; the entire lower leg should be evaluated when investigating this complaint.

●Patients should modify or avoid knee-twisting dance steps or exercises.

●Patients should try to sit with lumbar support and with feet in contact with the ground. Sitting with a leg folded under or in a crossed-legged position should be avoided (picture 7).

●The knee should not pass over the toes when squatting. This helps prevent placing excessive stress on the knee joint (picture 8).

●It is preferable to avoid loading the knee joint at angles greater than 45 degrees [11]. For example, deep knee squats and squatting for prolonged periods of time should be avoided.

●Ergonomic assessments/interventions are very useful in preventing work-related injuries and play an important role in joint protection. Results from a pilot study on an ergonomic assessment tool for arthritis (EATA) indicate that it is a feasible and a comprehensive process for identifying ergonomic job accommodations for patients with inflammatory arthritis [12].

Minimum force — Patients should be advised to use the minimum amount of force necessary to complete the job. This not only protects the joints but also plays a role in energy conservation.

●Balance activity with rest:

•It is recommended to take rest breaks when performing an activity prior to reaching the point of exhaustion or pain.

•Taking 5- to 10-minute breaks during longer activities can help prevent excessive fatigue/pain. If pain starts, then either modify the activity to eliminate the pain or stop and take a break.

•It is important to get enough sleep at night to help with healing/restoration.

●Proper footwear helps minimize force. (See 'Respect pain' above.)

●Knee joint protection: Knee joint loading is an important factor in the progression of OA. Excessive medial joint loading of the knee occurs with a high adduction moment, which increases as the knee becomes more varus. Patients with a varus alignment demonstrate a higher incidence of medial compartment OA. Therefore, varus alignment is widely accepted as an indicator of the extent of medial compartment loading. A 1 percent increase in adduction moment increases the risk of OA progression by 6.46 times and is a useful research measure for evaluating treatment strategies designed to slow disease [13].

Valgus knee bracing: One conservative nonsurgical intervention, which can reduce the adduction moment at the knee for patients with medial compartment OA, is the use of a valgus knee brace [14]. Adjustable valgus bracing is effective in reducing medial compartment load and improved pain in a group of patients with knee OA [14].

●A gait analysis study with 40 subjects with medial knee OA found that wearing shoes increases medial knee joint load, compared with walking barefoot, and that the use of a cane significantly reduces medial knee loading [15]. Off-the-shelf shoes predisposed knee OA patients to excessive joint loading, and use of a cane had a protective effect on disease progression.

●Footwear for knee protection: Off-the-shelf footwear recommendations for patients with medial compartment OA include [16]:

•Avoid shoes with medial arch supports

•Wear shoes with heels 1.5 inches or less

•Choose shoes with flexible soles in preference to supportive shoes promoting stability

●The mobility shoe, designed to simulate natural foot motion during barefoot walking, decreased knee joint loading compared with off-the-shelf footwear and with long-term use may also help improve the biomechanics of walking in people with knee OA [17,18].

●To date, there is little research on the benefits of shock-absorbing insoles and textured insoles, though there is anecdotal evidence of benefit [16].

●The use of lateral wedge insoles for knee OA is no longer recommended for medial compartment knee OA. However, there may be a role for medially wedged insoles for patients with lateral tibiofemoral OA and valgus deformity. The use of insoles for knee OA are discussed in detail separately. (See "Management of knee osteoarthritis", section on 'Insoles and other specialized footwear'.)

Recommendations to patients for knee protection include [1]:

●Use a mechanic's or milker's stool when working on the floor or on the ground. Sit with the legs apart and reach forward to perform tasks such as gardening or scrubbing floors.

●Use protective knee pads if you must work on hands and knees.

●In patients with chronic joint disorders or joint pain who are avid gardeners, raised-bed or container gardening are excellent options, as it is easy to garden on a stool, which reduces stress and effort on the body and joints.

●Avoid deep knee bending; use "reacher" tools for assistance. Simplify work by using efficiency principles: plan, organize, and balance work with rest.

●Run on dirt or track surfaces; avoid running on concrete or asphalt.

●Remain active to maintain/increase strength and range of motion.

Regular exercise — Regular exercise helps to maintain function, joint range of motion, strength, and balance.

A 2009 systematic review of 121 randomized trials, which examined the benefits of progressive resistance strength training (PRT) for improving physical function in older adults, found that PRT, performed two to three times a week at high intensity, improved physical ability, strength, gait, and performance of functional tasks [19]. Participants with OA reported a reduction in pain in five studies. Still, caution should be taken in generalizing from these results to clinical practice, as adverse events such as muscle pain and joint pain were poorly recorded in some of the studies.

One essential component of preventive care for lower extremity joint protection is fall prevention. Evaluation of lower-extremity strength and balance, typically as part of an interdisciplinary assessment, is an important component of effective fall-prevention programs for older adults [20]. (See "Falls in older persons: Risk factors and patient evaluation".)

Population-based fall-prevention programs have been shown to be effective and can form the basis of public health practice [21]. A 2007 systematic review of the benefits of exercise for improving balance in older people, involving 34 studies, found that balance significantly improved with exercise interventions compared with usual activity. Multiple types of exercise, including gait, balance, coordination, functional exercises, and muscle strength, appeared to have the greatest impact on balance. There was a trend toward improvement in balance from riding a stationary bike. However, based on these studies, there is limited evidence that effects were long-lasting [22]. The Centers for Disease Control and Prevention (CDC) has published a guide on evidence-based fall-prevention programs that have been shown to actually reduce the incidence of falls. It includes a number of fall-prevention programs such as the Stepping On Program, which is an example of a multifaceted fall-prevention program, as well as the Otago Exercise Program, which is an exercise-based program [23].

A randomized trial involving 120 patients found benefit of increased self-efficacy in arthritis self-management education programs. Those in the treatment group had increased self-efficacy for using cold and hot compresses, using two to three joint protection practices, and increased duration of light exercise. Increased perceived self-efficacy was associated with increased performance [24].

Exercise advice for lower limb joint protection includes:

●Strengthening the thigh muscles (quadriceps/hamstrings) to protect the knee. A home-based quadriceps exercise program improves symptomatic OA of the knee to the same degree as nonsteroidal antiinflammatory drugs (NSAIDs) [25]. In addition, research indicates that strengthening not only the knee musculature but also the hip musculature may help in correcting muscle dysfunctions/weaknesses that are present in those people with hip and knee pain [26,27]. One study found that women with patellofemoral pain demonstrated a significant reduction in hip abduction strength and hip external rotation compared with those who were asymptomatic [28]. Another study also found that significant hip strength deficits exist in patients with knee OA [29]. It has also been shown that those with hip OA benefit from a therapeutic exercise program, as demonstrated by a reduction in pain [27]. A comprehensive therapeutic exercise program developed by a physical therapist can help address any functional or strength deficits that may need to be addressed in the lower extremity.

●Exercise guidelines – A review written to guide health professionals in exercise prescription for people with arthritis provided the following recommendations to the patient regarding aerobic exercise [30]:

•Include an adequate warm-up and cool-down phase to minimize risk of injury

•Allow for variations in disease activity and joint status

•Be safe, comfortable, and easy to perform

•Be enjoyable and promote exercise confidence

•Place minimal stress (impact, torsional, shearing forces) on the affected joint(s)

•Allow for correct posture and joint alignment

•Appropriate aerobic exercise should not cause pain or increase local disease activity during performance or immediately afterward

•Use splints and recommended joint protection measures as medically indicated

•Avoid unwanted or deforming joint positions

•Exercise should not increase or lead to muscle imbalances about a joint

•Desired or recommended exercise intensity and duration should be permitted

•Exercise should be readily available, convenient, and inexpensive

•Exercise can promote socialization and peer support

Examples of the type of exercise recommended for people requiring lower limb joint protection can include the following [30]:

●Stationary biking:

•Stationary biking provides safe, low-impact exercise (figure 1). The seat height should be adjusted so that the knees are slightly bent at the low point of the downstroke and are no more than 90 degrees flexed on the upstroke. Increase resistance gradually.

•In patients for whom an upright stationary bike is too difficult or uncomfortable, a recumbent bike can be an effective alternative.

●Walking:

•Short, brisk walks will increase leg circulation and exercise muscles

●Aquatic exercise:

•Water is an excellent medium in which to exercise for anyone with a rheumatologic disorder. It is sometimes the only environment that allows for pain-free movement [31].

A study in 2007 found that a six-week aquatic physical therapy program resulted in significantly less pain and improved physical function, strength, and quality of life for people with hip and knee arthritis [31].

●Tai chi:

•Tai chi has been shown to be helpful in improving/controlling knee OA symptoms while also improving balance. It is a practice that can be continued long term as it is a low-impact, gentle practice and is generally well tolerated by individuals with knee OA. (See "Management of knee osteoarthritis", section on 'Exercise'.)

•A study comparing tai chi directly with physical therapy for the treatment of knee OA found that the tai chi group demonstrated just as much improvement in pain and function while also demonstrating greater improvements in depression symptoms and quality of life [32]. The added benefit of the mind-body component makes tai chi an excellent complement to any wellness program. Arthritis-specific tai chi classes can be found in some areas.

●Yoga:

•A gentle yoga program geared towards those with joint pain or arthritis can also be beneficial. It is important to be cleared medically before starting a yoga program; however, yoga has been shown to help in reducing joint symptoms such as pain, tenderness, and swelling while also improving disability, self-efficacy, and mental health [33].

The following is also advised:

●Perform a regular stretching program for the muscles of the upper and lower leg. Tight muscles can contribute to knee problems.

A physical therapist can provide guidance on specific stretches that will target tight areas. Instruction on proper form, hold time, and number of repetitions per day helps to avoid overloading joints and prevents potential injury while performing a stretch.

●Engage in exercise and sports activities on a regular basis, rather than occasional weekend participation. Include warm-up and cool-down activities as well as appropriate stretching in your routine.

Support for the benefits of exercise were shown in a trial to examine the effects of diet and exercise on pain and function in overweight patients with knee pain, in which 389 such patients were randomly assigned to a home-based program with one of four conditions: dietary intervention plus quadriceps strengthening, dietary intervention alone, quadriceps strengthening alone, and advice leaflet only [34]. At 24 months, those in exercise interventions had a significantly greater frequency of achieving a moderate reduction in knee pain and improved knee function compared with those in the other groups. While moderate sustained weight loss was achieved with dietary intervention and was associated with decreased depression, there was no apparent impact on pain or function.

It is important to note that people having an active RA flare can engage in an exercise program, as tolerated. One study found that moderate- or high-intensity weightbearing exercises are safe with respect to disease activity and radiologic damage of hands and feet; however, caution should be taken when prescribing long-term, high-intensity weightbearing exercises to patients who have significant radiologic damage to larger joints [35,36]. In addition, a short-term intensive exercise program in active RA patients was shown to be more effective in improving muscle strength than a conservative exercise program and did not have any negative effects on disease activity [37].

UPRIGHT AND RECUMBENT CYCLING — Both upright stationary cycling and recumbent cycling are useful for maintaining fitness and are good alternatives to walking, especially when walking may be too painful or difficult. When selecting a specific cycling modality, it is important to ensure that the exercise does not increase pain and that the person using a recumbent or upright bike can get on and off safely. The choice of modality depends upon several factors:

●For people with osteoarthritis (OA) of the knee, upright cycling at both high and low intensity levels is usually safe and effective; it can help improve function, gait, and aerobic capacity, and reduce pain [38].

●In individuals with functional deficits in performing sit to stand and step-ups, and those who have mobility limitations, a recumbent bike should be considered. Additionally, a recumbent bike is preferred following repair of the anterior cruciate ligament (ACL) and for those with anterior or posterior knee instability.

●In people with generalized or low back pain, the recumbent bike may be a better alternative because it provides much more support to the back and may be more comfortable. The recumbent bike is also considered a safer alternative to the upright bike during rehabilitation, due to ease of access because of the larger and lower seat, back support, and side rails [39,40].

Cycling minimizes stress to the knee, as forces generated at the knee are no greater for cycling than for walking [41,42]. Additionally, cycling results in lower tibiofemoral compressive forces compared with walking (forces comparable to bodyweight with cycling and 2.8 to 3.5 times bodyweight when walking at about 5 km [about 3 miles] per hour), while still improving general health [43,44].

In one study, findings suggested that riding the recumbent bike had a reduced knee extensor moment and may promote the use of the hip extensors, as the hip-extension moment was higher when compared with the upright bike [39]. This finding could translate to improvements in functional movements such as sit to stand and step-up. Another study determined that recumbent cycling was an effective specific training modality for the sit to stand and step up movements, particularly when used in the early rehabilitation process, when a person does not have the strength to perform the task [40]. In addition, the higher hip extensor moment and reduced knee extensor moment is an important consideration when rehabilitating the postop ACL patient or persons post-ACL or -posterior cruciate ligament (PCL) injury, as the upright cycling position was found to have higher anterior and posterior shear forces [39,45].

RESOURCES FOR TASK-RELATED PAIN (OCCUPATIONAL INJURIES)

For patients:

www.webmd.com

Provides general information including: Ask the Expert, Medical Library, Message Boards & More

www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/index.asp

Written by rheumatologists

http://www.cdc.gov/niosh/docs/2001-111/pdfs/2001-111.pdf

Ergonomics for farm workers

http://orthopedics.about.com/

Written by orthopaedists

www.ccohs.ca

Canadian Centre for Occupational Health and Safety

www.sammonspreston.com

A catalog of energy saving devices, adapted ADL equipment and splints

http://www.arthritis.org

Arthritis Foundation: Provides information and resources for people living with various forms of arthritis, including information on advocacy

For clinicians:

Human Factors and Ergonomics Society

Box 1369

Santa Monica, CA 90406

310-394-1811

Website: http://www.hfes.org/

Applied Ergonomics (journal)

Elsevier Science Ltd.

Langford Lane

Kidlington

Oxford,OX5 1GB,UK

Website: www.sciencedirect.com/journal/applied-ergonomics

U. Department of Health and Human Services

4676 Columbia Pkwy

Cincinnati, OH 45226

Website: www.hhs.gov

American Industrial Hygiene Assn

2700 Prosperity Ave, Ste 250

Fairfax, VA 22031

Website: www.aiha.org

Job Accommodation Network

809 Allen Hall

PO Box 6123

West Virginia University

Morgantown, WV 26506-6123

800-526-7234

Website: janweb.icdi.wvu.edu

SUMMARY AND RECOMMENDATIONS

●Patients with chronic joint disorders should be educated regarding the principles of joint protection, as excess strain on arthritis joints can worsen inflammation and joint injury. (See 'Introduction' above.)

●The principles of joint protection are derived from the simple, practical application of proper body mechanics, posture, and positioning of joints. Guiding the patient to perform a task in a manner that puts less stress on joints is generally preferred to prohibiting the task. (See 'Principles of joint protection' above.)

●It is important for patients with any arthritic condition to understand that pain is usually an indicator that a particular activity is placing an excessive load on the joint; pain may thus be interpreted as a signal for the patient to modify or avoid the activity. Patients should warm up before doing exercises or vigorous activity and perform a cool down after the activity/exercise. We advise that patients should choose footwear with comfort, support, and utility in mind, and that patients should not wear shoes that cause pain or fatigue. Individualized assessment is an important component of a joint protection intervention. (See 'Respect pain' above.)

●We advise that patients maintain an appropriate weight to reduce stress on the knees, feet, and ankles. (See 'Reduce excess body weight' above.)

●We advise that patients use good posture and proper body mechanics. These points should be reviewed with patients and should be individualized depending upon their particular activities or symptoms. (See 'Posture and body mechanics' above.)

●Patient should be advised to use the minimum amount of force necessary to complete the job. This not only protects the joints but also plays a role in energy conservation. Specific strategies should be individualized to the patients' activities and needs. (See 'Minimum force' above.)

●Regular exercise is recommended to help maintain function, joint range of motion, strength, and balance. Patients requiring lower-limb joint protection may benefit from exercises such as stationary biking, walking, or aquatic exercise, and should participate in exercise activities on a regular rather than occasional basis. (See 'Regular exercise' above.)

●Multiple resources are available to assist both patients and clinicians in strategies for joint protection. (See 'Resources for task-related pain (occupational injuries)' above.)