Friday, April 22, 2016

When Physical Therapy and Steroid Injections Don’t Seem to Matter

I came across an interesting study not long ago – not about knees, but tennis elbow (it's no longer up, so I can't link to it).

It turned out that about three-quarters of people with tennis elbow (who have damage to tendons in their forearm) recovered on their own after about a year.

Okay, maybe not surprising. The next part is though:

There was no significant difference between people who received no medical intervention and spontaneously got better and those who had both steroid shots and physical therapy sessions.

After a year, both groups were doing roughly the same.

The study involved 157 people, from ages 18 to 70. One group received six weeks of physical therapy and two steriod injections (the second group had the therapy and placebo injections). Then the third group got no special treatment.

The most aggressive combo, of physical therapy and steroid injections (to knock down the inflammation), showed a marked benefit at six weeks, no improvement at 12 weeks, and worse symptoms at 26 weeks.

Then, at the one-year mark, this article tells us:
Overall, improvement with physical therapy plus placebo injection or steroid injection was about the same as with no treatment at all.
Okay, now here’s my take.

First, steroid injections are dangerous. I really believe these are a deal with the devil: a quick “ah” sensation of relief, at the cost of leaving damaging chemical residue in your joint that weakens it.

As for physical therapy, good physical therapy can be a life saver, but all too often we get bad physical therapy. For example, I recall my own experience when I had knee pain and along the way developed tendinitis diagnosed as golfer’s elbow (which is similar to tennis elbow).

Here’s some of what was done and prescribed:
(1) electrical stimulation (worthless for me, I’m quite sure – but others have had success with this)
(2) stretching exercises (may have damaged the tendon further – how much sense does it make to stretch a cold tendon? Doing so may have created a few microtears in the tissue.)
(3) exercises that were probably too low repetition to stimulate constructive tendon healing.

If that’s similar to the physical therapy that someone gets for tennis elbow, then I wouldn’t be in the least surprised to find out it’s basically ineffective.

However, the right physical therapy can change your life. I devised a program of eccentric exercises, thanks to Doug Kelsey and other sources online, that I’m pretty sure helped me rescue the tendons in both arms. That program I bet would’ve changed some outcomes in this study.

Anyway, for knee pain the right move is not to do nothing and hope it resolves. Don’t take away that message. The point is rather that the solutions we’re directed to, such as conventional physical therapy and high-powered anti-inflammatories, may not be good solutions at all.


  1. Hi Richard
    I have been following the advice from your blog and Doug Kelsey's book to fix my knee pain. I used to have severe pain on even walking a little bit. But now I have improved to the point where I can walk for kilometres without much pain.
    However, while my knees were in a weak state I used my arms quite a bit to get in and out of chairs (among other things). This started causing some pain/stiffness in my right wrist. After a few weeks my pain/stiffness has progressed to the point where my right wrist/elbow/forearm constantly hurt at a low level. And ofcourse if put a lot of pressure on that arm it hurts even more. I think I have established that my joints have a tendency to get injured even when slightly overloaded in the wrong way. I am wondering what you did to fix pain in your wrist/elbow when you were dealing with your knee pain. I would like to point out that I have seen significant improvement in my knees just following a progressive "walking" cycles for the past few months. I am unsure how to do something similar for my wrist/elbow since those joints are much harder to rest on a day to day basis.

    I really appreciate any input you have on this. Thanks a lot for reading this and for writing your blog.


    1. I'm not sure what will work best for you. In my case, I had sore tendons. I did eccentric bicep curls (if you Google "eccentric exercises bicep curls" you'll find descriptions and videos). I had good success with those. I would not be the first to observe that, when you have bad knees, often other joints mysteriously develop problems too. Good luck with healing it, and glad to hear the walking program is working well.

  2. Hi all, I would like to know if anyone unable to use stairs due to chondromalacia patella found it useful wearing knee brace for accessing stairs. I am unable to use stairs and had avoided stairs for the past 6 months. Iam about to join a new job but using stairs in my apartment in 2nd floor becomes mandatory and also my new workplace has few steps. Would be glad to have your inputs on this. Just thinking if I can use a knee brace until I shift my residence to the one without stairs.


  3. This is slightly off the subject of this post but this is pretty interesting. Only 54% of the improvement in inflammatory markers was down to weight loss which implies that the pain coping strategies were responsible for the rest. Is this more evidence of the power of thought in influencing physical changes in the joint as TriAgain was suggesting in a previous discussion?