Version July 2025
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]. Effective preventive care is a cornerstone of conservative management and depends heavily on protective strategies for patients with joint problems.
The goal of lower-extremity joint protection is to avoid overloading vulnerable joints/tissues, prevent recurrent sprains and strains, and reduce pain and inflammation, thus preserving joint integrity. Joint protection is best achieved through patient education, behavior modification, and energy conservation; in selected cases, use of orthotic devices, splints, adaptive devices; and, in the case of the lower extremities, proper footwear.
Joint protection for the lower extremities will be reviewed here. An overview of joint protection as well as joint protection for the upper extremities and neck are discussed elsewhere:
●(See "Overview of joint protection".)
●(See "Joint protection program for the upper limb".)
●(See "Joint protection program for the neck".)
OVERVIEW OF THE 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. The optimal way to respond to pain depends on the phase of the joint injury. In the acute phase of pain (less than 12 weeks since onset), it is important to respect pain and minimize activities that cause an excessive load on the joint. In chronic pain states (more than 12 weeks since onset), continuing to limit activities can be maladaptive through loss of strength, flexibility, coordination, and function and may create significant psychological distress that may hinder long-term recovery. 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. The recovery may therefore require gradual reconditioning with the guidance of clinicians, physical therapists, personal trainers, and pain psychologists.
More information about respecting pain, including the "two-hour pain rule," activity pacing, and factors affecting activity-related joint pain, is provided separately. (See "Overview of joint protection", section on 'Respect pain'.)
Activity pacing — Activity should be balanced with rest, which can help avoid cycles of overuse and worsening pain. Patients should be advised to take rest breaks prior to reaching the point of exhaustion or pain (eg, taking 5- to 10-minute breaks during longer activities). If patients develop pain during an activity, they should modify it or stop and take a break. (See "Overview of joint protection", section on 'Respect pain'.)
Optimizing footwear — 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. 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.
●Key features in supportive footwear – 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. Typically, this includes athletic or casual sneakers with rigid heel counters, fixation, or firm, inflexible soles. Proper fit should be determined by having the foot size measured while standing. Cushion soles with shock-absorbing material should be used if walking or working on concrete. Attention should be given to wearing shoes with an appropriate heel height (usually a one-inch heel). They should be checked often for signs of wear.
For patients who exercise, good running shoes with arch supports are important and should be replaced every 300 to 500 miles. Footwear that is designed for a particular sport should be used for participation in that activity.
●The importance of patient acceptance – As with any treatment, optimizing footwear is only effective if the footwear is used regularly, underscoring the importance of patient acceptance of the modified footwear. In a trial of specialist therapeutic footwear for patients with rheumatoid arthritis (RA), 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 [4].
If patients have persistent pain despite optimizing their footwear, we refer them to a podiatrist. Potential interventions include the following:
●Custom shoes – For patients with structural deformities, a certified pedorthist can construct custom shoes with a doctor's prescription.
●Orthotics – Orthoses can provide needed support and positioning assistance; when they are required, they should be used in shoes for exercise as well as everyday activities. The type of foot orthoses range from simple cushioned insoles to custom-made rigid cast devices [5]. Whether orthoses are custom-made or obtained over the counter, patients should discuss the choice of orthosis with an experienced professional. 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).
●Metatarsal pads – Metatarsal pads or bars can relieve pressure or pain at the forefoot by unloading the metatarsal heads. They 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.
Evidence to support the use of comfortable over-the-counter shoes is limited. In a large retrospective study, females who wore "good shoes" (athletic and casual sneakers with rigid heel counters, fixation, or firm, inflexible soles) were 67 percent less likely to report hindfoot pain compared with those who wore "average shoes" (hard or rubber soles, special shoes, and work boots) [6].
The use of custom shoes and orthoses for patients with RA is supported by several systematic reviews, and there is strong evidence that foot orthoses reduce pain and improve functional ability [7,8]. However, footwear does not necessarily need to be custom made. As an example, a systematic review found that custom-made foot orthoses for people with RA were more effective than no intervention for reducing rear foot pain up to 30 months; however, they were 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 [8].
REDUCE EXCESS BODY WEIGHT —
We advise that patients maintain an appropriate weight to reduce stress on the knees, feet, and ankles. More information on this principle of joint protection is discussed separately. (See "Overview of joint protection", section on 'Reduce excess body weight'.)
POSTURE AND BODY MECHANICS —
We advise that patients use good posture and proper body mechanics. 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.
The following points should be reviewed with patients, depending upon their individual activities or symptoms:
●Bending at the waist – 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).
●Lifting and carrying heavy loads – 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 and then the back (picture 2). The load should be held close to the body in the center; twisting and carrying heavy items in one hand at the side of the body should be avoided (picture 3). 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).
●Prolonged standing – 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 6).
●Sitting – 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).
●Squatting – 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 [9]. For example, deep knee squats and squatting for prolonged periods of time should be avoided.
●Twisting the knee – Patients should modify or avoid knee-twisting dance steps or exercises.
Additional information on posture and body mechanics, as well as ergonomic interventions at work, is provided separately. (See "Overview of joint protection", section on 'Use good posture and body mechanics' and "Overview of joint protection", section on 'Using a computer workstation'.)
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. (See "Overview of joint protection", section on 'Use the minimum necessary force'.)
Footwear for patients with knee osteoarthritis — For patients with osteoarthritis (OA) of the knee, loading of the knee joint is an important factor in disease progression. 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 [10].
To minimize knee loading in patients with OA in the medial compartment of the knee, we generally advise patients to wear shoes that have flexible soles and avoid shoes with medial arch supports and heels that are over 1.5 inches high. Other types of specialized interventions have been proposed for patients with knee OA, including valgus knee bracing, specialized footwear and insoles, and wedged inserts. 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 and other specialized footwear for knee OA is discussed in detail separately. (See "Management of knee osteoarthritis", section on 'Insoles and other specialized footwear'.)
Activity modifications for patients with knee pain — Other specific recommendations to minimize force on the knee include the following [1]:
●When working on the ground or floor, use a mechanic's or milker's stool. 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 your hands and knees. For gardening, using stools or raised-bed or container gardens are excellent options.
●Avoid deep knee bending; use "reacher" tools for assistance.
●Run on dirt or track surfaces; avoid running on concrete or asphalt.
Assistive devices — 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 use the appropriate assistive device properly and safely. As an example, canes are frequently misused and placed in the same hand as the affected limb. Instead, 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 (eg, if the left knee is painful, then the cane should be held 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'.)
REGULAR EXERCISE —
Regular exercise helps to maintain function, joint range of motion, strength, and balance and can be effective in many different forms. Exercise may be especially beneficial for patients with certain conditions, such as osteoarthritis (OA) of the hip or knee [11]. An overview of the role of physical exercise in joint protection is provided separately. (See "Overview of joint protection", section on 'Remain active'.)
Warming up and cooling down — Patients should warm up before doing vigorous activity or exercise 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.
Stretching and strengthening key muscle groups — Regularly stretching the muscles of the upper and lower leg is important, as tight muscles can contribute to mechanical imbalance and subsequent joint 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.
Likewise, it is important to strengthen muscles in the lower extremities to improve joint stability and body mechanics. Sometimes this may require the help of a physical therapist. (See 'Prescribing an exercise program' below.)
●Strengthening the thigh muscles (quadriceps/hamstrings) can help protect the knee. A home-based quadriceps exercise program improves symptomatic OA of the knee to the same degree as nonsteroidal antiinflammatory drugs (NSAIDs) [12].
●Strengthening the hip musculature may help correct muscle dysfunctions/weaknesses that are present in people with hip and knee pain [13,14]. One study found that females with patellofemoral pain demonstrated a significant reduction in hip abduction strength and hip external rotation compared with those who were asymptomatic [15]. Another study also found that significant hip strength deficits exist in patients with knee OA [16].
Types of exercise — Examples of the type of exercise recommended for people requiring lower limb joint protection can include the following [17]:
●Walking – Short, brisk walks will increase leg circulation and exercise muscles.
●Aquatic exercise – Aquatic exercise can be especially helpful for patients with lower-extremity pain as it reduces the weight on these joints. It is sometimes the only environment that allows for pain-free movement [18].
●Tai chi – Tai chi has been shown to be helpful in controlling symptoms of knee OA 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'.)
Certain forms of tai chi may also be helpful in preventing falls in community dwelling older adults. [19].
●Qigong – Qigong offers a low-intensity exercise option comparable to tai chi and may also be helpful for adults with different forms of painful and disabling arthritis [20].
●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 [21].
Upright and recumbent cycling — Both upright stationary cycling and recumbent cycling are particularly helpful for maintaining fitness in patients with lower limb pain, especially when walking may be too painful or difficult. 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, and resistance should be increased gradually. In patients for whom an upright stationary bike is too difficult or uncomfortable, a recumbent bike can be an effective alternative (figure 2).
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:
●Knee osteoarthritis – For people with 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 [22].
●Mobility limitations and functional difficulties – In individuals with mobility limitations and/or functional deficits in performing sit to stand and step-ups, 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.
●Back pain – 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 [23,24].
Cycling minimizes stress to the knee, as forces generated at the knee are no greater for cycling than for walking [25,26]. 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 approximately 5 km [3 miles] per hour), while still improving general health [27,28].
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 [23]. 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 [24]. In addition, recumbent bicycling may be preferable when rehabilitating the postoperative 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 [23,29].
Prescribing an exercise program — A physical therapist can prescribe individualized strength-training/neuromuscular exercises/programs to address the specific lower-extremity muscle weaknesses/neuromuscular deficits identified during an evaluation. An exercise program typically includes the intensity (number of sets and repetitions), the mode (eg, weights, exercise bands, balancing/body weight), frequency (eg, two to three times per day, every day), and duration (eg, 30-second hold for a balancing exercise). Physical therapists can recommend a variety of exercises and create an individualized exercise program that is modified for form, exercise tolerance, and exercise progressions for each individual.
Fall prevention programs — One essential component of preventive care for lower-extremity joint protection is fall prevention, especially in older adults. This includes evaluation of lower-extremity strength and balance, typically as part of an interdisciplinary assessment [30]. More details on evaluating patients who are at risk of falls and interventions to prevent falls are discussed separately. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in community-dwelling older persons".)
OTHER ASPECTS OF JOINT PROTECTION —
Other aspects of joint protection include the following:
●Simplify work by using efficiency principles – Planning, organizing, and balancing work with rest can help reduce joint stress. (See "Overview of joint protection", section on 'Simplify work by using efficiency principles'.)
●Avoiding prolonged immobility – 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. (See "Overview of joint protection", section on 'Avoid prolonged immobility'.)
●Caution in patients with hypermobility – Individuals with joint hypermobility/laxity should be particularly careful to protect the ankles and feet. Sprains and strains can increase joint instability.
●Optimizing management of the underlying condition – Depending on the cause of joint pain, patients may require other treatments to optimize their participation in joint protection. As an example, a patient with a flare of rheumatoid arthritis affecting the knee may benefit from knee aspiration and an intraarticular glucocorticoid injection control pain and allow more active participation in physical therapy.
●Prioritizing sleep – It is important to get enough sleep at night to help with healing/restoration.
RESOURCES FOR TASK-RELATED PAIN (OCCUPATIONAL INJURIES)
For patients
https://rheumatology.org/patients/diseases-and-conditions
Written by rheumatologists.
www.cdc.gov/niosh/docs/2001-111/pdfs/2001-111.pdf
Ergonomics for farmworkers.
Canadian Centre for Occupational Health and Safety.
The Arthritis Foundation provides information and resources for people living with various forms of arthritis, including information on advocacy.
www.cdc.gov/arthritis/interventions/physical-activity.html
The Centers for Disease Control and Prevention (CDC) has a webpage dedicated to providing information about recognized community-based physical activity programs that help to improve the quality of life for people with arthritis as well as for the general adult population.
For clinicians
Human Factors and Ergonomics Society
(202) 367-1114
Website: www.hfes.org
Applied Ergonomics journal
Website: www.sciencedirect.com/journal/applied-ergonomics
US Department of Health and Human Services
Website: www.hhs.gov
American Industrial Hygiene Association
(703) 849-8888
Website: www.aiha.org
Job Accommodation Network
800-526-7234
Website: askjan.org
SUMMARY AND RECOMMENDATIONS
●Overview of the principles of joint protection – 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. 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 'Overview of the principles of joint protection' above.)
●Respect pain – 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.
•Activity pacing – Activity should be balanced with rest, which can help avoid cycles of overuse and worsening pain. (See 'Respect pain' above.)
•Optimizing footwear – 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. If patients have persistent pain despite optimizing their footwear, we refer them to a podiatrist for consideration of additional interventions including custom footwear and orthoses. (See 'Optimizing footwear' above.)
●Reduce excess body weight – We advise that patients maintain a healthy weight to reduce stress on the knees, feet, and ankles. (See 'Reduce excess body weight' above.)
●Posture and body mechanics – Patients with lower-extremity pain may benefit from modifying activities such as bending at the waist, lifting or carrying heavy loads, prolonged standing, sitting, and squatting. (See 'Posture and body mechanics' above.)
●Minimum force – Patient should use the minimum amount of force necessary to complete the job in order to avoid pain and conserve energy. (See 'Minimum force' above.)
•Activity modifications for patients with knee pain – Patients with knee pain may benefit from certain activity modifications such as using a stool when working on the ground or floor, gardening in raised-bed or container gardens, or running on dirt or track surfaces instead of concrete or asphalt. (See 'Activity modifications for patients with knee pain' above.)
•Assistive devices – 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. (See 'Assistive devices' above.)
●Regular exercise – Regular exercise is recommended to help maintain function, joint range of motion, strength, and balance. (See 'Regular exercise' above.)
•Strengthening and stretching key muscle groups – Regularly stretching and strengthening the muscles of the upper and lower leg is important, as tight muscles can contribute to mechanical imbalance and subsequent joint problems. A physical therapist can provide guidance on specific stretches and strengthening exercises that will target tight or weak areas. (See 'Stretching and strengthening key muscle groups' above.)
•Types of exercise – Patients requiring lower limb joint protection may benefit from exercises such as walking, aquatic exercise, and tai chi and should participate in exercise activities on a regular rather than occasional basis. Both upright stationary cycling and recumbent cycling are particularly helpful for maintaining fitness in patients with lower limb pain. (See 'Types of exercise' above and 'Upright and recumbent cycling' above.)
•Fall prevention programs – An essential component of preventive care for lower-extremity joint protection is fall prevention, especially in older adults. More details on evaluating patients who are at risk of falls and interventions to prevent falls are discussed separately. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in community-dwelling older persons".)
●Resources for task-related pain – Multiple resources are available to assist both patients and clinicians in strategies for joint protection. (See 'Resources for task-related pain (occupational injuries)' above.)
