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Joint protection program for the lower limb

Sharon Alzner, MPT
Zacharia Isaac, MD
Section Editor
Robert H Shmerling, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH


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".)


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:

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Literature review current through: Nov 2017. | This topic last updated: Mar 04, 2016.
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  1. Sheon RP, Orr PM. Appendix B. A Joint protection guide for rheumatic disorders. In: Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, Third Edition, Sheon RP, Moskowitz RW, Goldberg VM (Eds), Williams & Wilkins, Baltimore 1996.
  2. Barlow JH, Turner AP, Wright CC. A randomized controlled study of the Arthritis Self-Management Programme in the UK. Health Educ Res 2000; 15:665.
  3. Streibelt M, Hansmeier T, Müller-Fahrnow W. [Effects of work-related medical rehabilitation in patients with musculoskeletal disorders]. Rehabilitation (Stuttg) 2006; 45:161.
  4. Dufour AB, Broe KE, Nguyen US, et al. Foot pain: is current or past shoewear a factor? Arthritis Rheum 2009; 61:1352.
  5. Farrow SJ, Kingsley GH, Scott DL. Interventions for foot disease in rheumatoid arthritis: a systematic review. Arthritis Rheum 2005; 53:593.
  6. Williams AE, Rome K, Nester CJ. A clinical trial of specialist footwear for patients with rheumatoid arthritis. Rheumatology (Oxford) 2007; 46:302.
  7. Clark H, Rome K, Plant M, et al. A critical review of foot orthoses in the rheumatoid arthritic foot. Rheumatology (Oxford) 2006; 45:139.
  8. Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev 2008; :CD006801.
  9. Grotle M, Hagen KB, Natvig B, et al. Obesity and osteoarthritis in knee, hip and/or hand: an epidemiological study in the general population with 10 years follow-up. BMC Musculoskelet Disord 2008; 9:132.
  10. Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 2004; 50:1501.
  11. Minor M. Physical activity and management of arthritis. Ann Behav Med 1991; 13:117.
  12. Backman CL, Village J, Lacaille D. The Ergonomic Assessment Tool for Arthritis: development and pilot testing. Arthritis Rheum 2008; 59:1495.
  13. Miyazaki T, Wada M, Kawahara H, et al. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Ann Rheum Dis 2002; 61:617.
  14. Pollo FE, Otis JC, Backus SI, et al. Reduction of medial compartment loads with valgus bracing of the osteoarthritic knee. Am J Sports Med 2002; 30:414.
  15. Kemp G, Crossley KM, Wrigley TV, et al. Reducing joint loading in medial knee osteoarthritis: shoes and canes. Arthritis Rheum 2008; 59:609.
  16. Hinman RS, Bennell KL. Advances in insoles and shoes for knee osteoarthritis. Curr Opin Rheumatol 2009; 21:164.
  17. Shakoor N, Lidtke RH, Sengupta M, et al. Effects of specialized footwear on joint loads in osteoarthritis of the knee. Arthritis Rheum 2008; 59:1214.
  18. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009; :CD002759.
  19. Luukinen H, Lehtola S, Jokelainen J, et al. Pragmatic exercise-oriented prevention of falls among the elderly: a population-based, randomized, controlled trial. Prev Med 2007; 44:265.
  20. McClure R, Turner C, Peel N, et al. Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database Syst Rev 2005; :CD004441.
  21. Howe TE, Rochester L, Jackson A, et al. Exercise for improving balance in older people. Cochrane Database Syst Rev 2007; :CD004963.
  22. Yip YB, Sit JW, Fung KK, et al. Effects of a self-management arthritis programme with an added exercise component for osteoarthritic knee: randomized controlled trial. J Adv Nurs 2007; 59:20.
  23. Doi T, Akai M, Fujino K, et al. Effect of home exercise of quadriceps on knee osteoarthritis compared with nonsteroidal antiinflammatory drugs: a randomized controlled trial. Am J Phys Med Rehabil 2008; 87:258.
  24. Westby MD. A health professional's guide to exercise prescription for people with arthritis: a review of aerobic fitness activities. Arthritis Rheum 2001; 45:501.
  25. Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther 2007; 87:32.
  26. Jenkinson CM, Doherty M, Avery AJ, et al. Effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain: randomised controlled trial. BMJ 2009; 339:b3170.
  27. de Jong Z, Vliet Vlieland TP. Safety of exercise in patients with rheumatoid arthritis. Curr Opin Rheumatol 2005; 17:177.
  28. de Jong Z, Munneke M, Zwinderman AH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum 2003; 48:2415.
  29. van den Ende CH, Breedveld FC, le Cessie S, et al. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis 2000; 59:615.
  30. Mangione KK, McCully K, Gloviak A, et al. The effects of high-intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci 1999; 54:M184.
  31. Gregor SM, Perell KL, Rushatakankovit S, et al. Lower extremity general muscle moment patterns in healthy individuals during recumbent cycling. Clin Biomech (Bristol, Avon) 2002; 17:123.
  32. Kerr A, Rafferty D, Moffat F, Morlan G. Specificity of recumbent cycling as a training modality for the functional movements; sit-to-stand and step-up. Clin Biomech (Bristol, Avon) 2007; 22:1104.
  33. Ericson MO, Nisell R. Patellofemoral joint forces during ergometric cycling. Phys Ther 1987; 67:1365.
  34. Ericson MO, Nisell R. Tibiofemoral joint forces during ergometer cycling. Am J Sports Med 1986; 14:285.
  35. Ericson M. On the biomechanics of cycling. A study of joint and muscle load during exercise on the bicycle ergometer. Scand J Rehabil Med Suppl 1986; 16:1.
  36. Breugem SJ, Haverkamp D, Sierevelt IN, et al. The important predictors of cycling use in three groups of knee patients. Disabil Rehabil 2011; 33:1925.
  37. Johnston TE. Biomechanical considerations for cycling interventions in rehabilitation. Phys Ther 2007; 87:1243.