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09/29/2020

Sticking to It: A Scoping Review of Adherence to Exercise Therapy Interventions in Children and Adolescents With Musculoskeletal Conditions

Journal of Orthopaedic & Sports Physical Therapy
Published Online:August 31, 2020Volume50Issue9Pages503-515
https://www.jospt.org/doi/10.2519/jospt.2020.9715

Objective
To identify and categorize barriers, facilitators, and strategies to boost exercise therapy adherence in youth with musculoskeletal conditions to inform research and clinical practice.

Study Design
Scoping review.

Literature Search
We searched MEDLINE, CINAHL, SPORTDiscus, Scopus, PEDro, and ProQuest from inception to October 1, 2019.

Study Selection Criteria
Studies written in English, with original data featuring an adherence barrier, facilitator, or boosting strategy for exercise therapy in youth (age, 19 years or younger) with musculoskeletal conditions, were included.

Data Synthesis
Arksey and O'Malley's framework and the PRISMA Extension for Scoping Reviews guided data synthesis. Study quality was assessed with the Mixed Methods Appraisal Tool. Descriptive consolidation included study and sample characteristics, exercise therapy details, and adherence measurement specifics. Inductive thematic analysis of adherence barriers, facilitators, and boosting strategies followed Braun and Clarke's 6-step guide.

Results
Of 5705 potentially relevant records, 41 studies, representing 2020 participants (64% girls; age range, 2–19 years) with 12 different musculoskeletal conditions and multiple exercise therapy interventions, were included. Despite poor reporting of adherence concepts, time constraints, physical environment (eg, location), and negative exercise experiences were commonly identified barriers. Social support and positive exercise experiences were frequently identified facilitators. Reinforcement, exercise program modification, and education were recurring boosting strategies, despite being infrequent barriers or facilitators.

Conclusion
A diversity of barriers to and facilitators of exercise therapy for youth with musculoskeletal conditions were identified. Efforts to link adherence-boosting strategies to an individual's needs should be considered. Making exercise enjoyable, social, and convenient may be important to maximizing adherence in this population. J Orthop Sports Phys Ther 2020;50(9):503–515. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9715
https://www.jospt.org/doi/full/10.2519/jospt.2020.9715

Objective To identify and categorize barriers, facilitators, and strategies to boost exercise therapy adherence in youth with musculoskeletal conditions to inform research and clinical practice. St...

06/10/2020

https://www.jospt.org/doi/abs/10.2519/jospt.2019.9125

Prevalence, Severity, and Correlates of Pain Flares in Response to a Repeated Sit-to-Stand Activity: A Cross-sectional Study of 14 902 Patients With Knee and Hip Osteoarthritis in Primary Care
AUTHORSAFFILIATIONSJournal of Orthopaedic & Sports Physical TherapyPublished Online:May 31, 2020Volume50Issue6Pages309-318https://www.jospt.org/doi/10.2519/jospt.2019.9125SectionsAbstract
Objective
Design
Methods
Results
Conclusion
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Objective
To determine prevalence, severity, and clinical correlates of pain flares in response to a repeated sit-to-stand activity.Design
Cross-sectional.Methods
The analyses included 11 013 patients with knee osteoarthritis (OA) and 3889 patients with hip OA who completed a 30-second chair-stand test before starting the Good Life with osteoArthritis in Denmark treatment program. Prevalence and severity of pain flares were evaluated by change in self-reported joint pain intensity on an 11-point numeric rating scale after the test. Correlates with pain flares (an increase on the numeric rating scale of 2 points or greater) were assessed using regression analyses.Results
One out of 3 patients with knee OA and 1 out of 5 patients with hip OA experienced pain flares (numeric rating scale of 2 or greater). Low knee/hip confidence, 3 or more painful body sites, fewer than 12 chair stands in 30 seconds, and body mass index of 30 kg/m2 or greater were associated with pain flares in response to the 30-second chair-stand test in patients with knee and hip OA. Low self-efficacy and joint stiffness were associated with pain flares in patients with knee OA. Using pain medication was associated with pain flares in patients with hip OA.Conclusion
Pain flares in response to a repeated sit-to-stand activity were common in patients with knee and hip OA. The clinical correlates associated with pain flares included joint confidence, functional performance, and body mass index, and are potentially modifiable with patient education, exercise therapy, and weight loss, respectively. J Orthop Sports Phys Ther 2020;50(6):309–318. Epub 6 Sep 2019. doi:10.2519/jospt.2019.9125Figures
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📷Volume 50, Issue 6June 2020Pages: 281-345📷
Keywordship
knee
osteoarthritis
pain
physical activity

CorrespondenceAddress correspondence to Dr Søren Thorgaard Skou, Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, 55 Campusvej, DK-5230 Odense M, Denmark. E-mail: stskou@health.sdu.dkDisclosureAccording to the local ethics committee of the North Denmark Region, ethics approval was not required, but Good Life with osteoArthritis in Denmark (GLA:D) has previously been approved by the Danish Data Protection Agency (SDU; 10.084). The GLA:D program is partly funded by the Danish Physiotherapy Association's fund for research, education, and practice development; the Danish Rheumatism Association; and the Physiotherapy Practice Foundation. Dr Skou is currently funded by the Danish Council for Independent Research (DFF-6110-00045) and the Lundbeck Foundation. The funders did not have any role in this study other than to provide funding. Dr Roos is deputy editor of Osteoarthritis and Cartilage, the developer of the Knee injury and Osteoarthritis Outcome Score and several other freely available patient-reported outcome measures, and cofounder of GLA:D, a not-for-profit initiative hosted at the University of Southern Denmark and aimed at implementing clinical guidelines for osteoarthritis in clinical practice. Dr Skou is associate editor of the Journal of Orthopaedic & Sports Physical Therapy and has received grants from the Lundbeck Foundation and personal fees from Munksgaard, all of which are unrelated to this article. He is also a cofounder of GLA:D. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.

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Objective To determine prevalence, severity, and clinical correlates of pain flares in response to a repeated sit-to-stand activity. Design Cross-sectional. Methods The analyses included 11 013 pat...

01/21/2020

https://www.medbridgeeducation.com/blog/2019/12/the-ultimate-challenge-when-to-return-your-athletes-with-acl-reconstruction-to-play/?utm_content=Return%20to%20Play%20After%20ACL%20Reconstruction%3A%20Addressing%20Misconceptions&sub=yes&utm_source=Newsletter&utm_medium=email&utm_campaign=012120-PT-S-Content-Malone

When to Return Your Athletes with ACL Reconstruction to Play
By Terry Malone, PT, EdD, AT-Ret., FAPTA on December 10, 2019
Categories: Athletic Training, Lower Quarter, Orthopedics, Physical Therapy, Return to Sport, Sports

ACL Reconstruction & Return to Sport
In my 2016 article, “When to Return to Sport? A Brief History of ACL Rehabilitation Approaches,” I presented my concerns that our current return-to-play protocols following ACL reconstruction were flawed and not nearly as predictable as perceived.

Unfortunately, between that time and now, we have only seen increasing evidence of this issue, and we now appreciate a significant problem: Our ability to appropriately direct and advise an athlete in return-to-play decisions after ACL reconstruction is not adequate. This creates a true crisis for any athletic trainer working with an athlete who is adamant that they are ready.

A Brief History of the Literature: The ‘80s and ‘90s
In that original article, I referenced the 1981 work of Paulos, et al., which included the quote, “The classic parameters of return to play do not indicate healing of ligament tissue and must not be substituted for time restraints.”1

In 1990, Shelbourne and Nitz published their study in which they followed non-compliant individuals to be certain their accelerated approach had not led to early failure or poor long-term outcomes. They concluded, “Furthermore, comparative data from the two groups in this study population demonstrate that range of motion, strength, and function can be achieved by an accelerated rehabilitation regimen without compromising stability or putting the graft at risk.”2

In June of 1992, the Journal of Orthopaedic and Sports Physical Therapy dedicated their pages to the care of those who had an injured ACL, with several MD/PT teams presenting their approaches to ACL post-operative management within the context/comparison of the Shelbourne and Nitz protocol. We provided a historical comparison to extra-articular surgery and noted how many of the “accelerated concepts” were reflective of the management applied in these cases.3

Unfortunately, even though many of the published surgeons and therapists urged caution, the next several years devolved into a scenario of “the sooner the better” for return to play. If other practitioners promised a nine-month return to play, then six months was seen as better. Soon, there were no longer any time frames—the practitioner who promised the earliest return to activity was seen as the best.

The Literature from 2000 Onward
In the 2000 text Knee Ligament Rehabilitation, edited by Todd Ellenbecker, the neuromuscular concepts chapter presents a lengthy discussion related to the short- and long-term implications of ACL ligament reconstruction.4 The authors cite Levine, et al., who demonstrated that neurogenic inflammation is impactful for several months.5 The chapter authors proposed “that some of the challenges seen in the first weeks and months following significant insult (injury or surgery) are related to this neurally mediated process.”

Over the past 15 years, greater attention to surgical technique and outcome scrutiny have begun to swing the pendulum away from the mantra of “get them back as soon as possible.” A 2015 study conducted by Kim, et al., made surgeons carefully consider the orientation and impact of anatomy and attempts at better restoring such during reconstruction.6 In another study, several of these same researchers outlined the loading seen in grafts after implementation and, thus, during rehabilitation.7 This work points toward greater direct loading to the graft when it is placed anatomically, thus asking clinicians to consider if early rehabilitation may need to be less intense and less likely to improperly allow excessive loading.

Two additional articles bring into focus the concern of second ACL injury upon return to play. The MOON Consortium has provided significant data to recommend specifics on graft use as well as guidelines for rehabilitation.8, 9 Paterno, et al., followed a mixed cohort on return to play and provided quite concerning data showing that young females have about a 25 percent chance of sustaining a second ACL injury within the first year after returning to full participation.10

Challenging the Status Quo
Since that original article, several other intriguing studies have really challenged the status quo. Grindem, et al., directly state that applying basic decision rules will reduce re-injury risk by greater than 80 percent.11 Most frightening to athletic trainers: They espoused that returning to level 1 sports leads to a fourfold increase in re-injury over a two-year window.

After examining biologic and functional data, Nagelli and Hewett wish us to consider a two-year wait on return to play following surgery.12 And in 2019, Kaplan and Witvrouw completed a systemic analysis of the literature related to safe return to sport following ACL reconstruction. Their conclusion was that as a result of high re-rupture rates (especially in young athletes), a delayed return to play of nine or more months is supported.13

This information requires us to question how to best inform our athletes. We must also recognize that those returning early are at greatest risk. Balancing that risk and making the best recommendations is incredibly difficult.

Informing Your Athletes
So as an AT working in the high school or intercollegiate setting—what should your message be to your athletes following ACL reconstruction?

Ardern, et al., provided a 2016 consensus statement on return to sport following injury. This document was generated through a 17-clinician panel that examined the issue from multiple perspectives, concluding that the decision should be an ongoing process throughout rehabilitation and not just a checkbox at the end of formal rehabilitation.14 Biopsychosocial factors and an assessment of risk and risk tolerance specific to the individual should be part of this process.

Importantly, research evidence to support return-to-sport decisions is scarce and not definitive. In a later article, Ardern, et al., established a series of queries to address when considering return-to-play decisions. These include:

• How do you determine readiness for return?
• Is physical recovery alone enough for return to play?
• What is successful return to play?
• What are the clinician’s responsibilities within the sports medicine team to the athlete?
• Should the athlete return to play?15

Werner, et al., and Burland, et al., documented that physical performance alone may not be an ideal outcome measure and that psychosocial factors are of great significance in return to sport after ACL reconstruction.16, 17

These recent references all point to using an integrative model and recommend consideration of risk, with one example being the Shrier Strategic Assessment of Risk Tolerance. This assessment includes a stepwise approach to assessing risks, starting with:

• Health risk, including age and symptoms
• Activity risk, including sport, position played, competition level, and patient-reported outcomes
• Risk tolerance, including seasonal relationships, desire to compete, external pressures, and fear with litigation18

Making Return-to-Play Decisions
The reality is that these return-to-play decisions must be made by the sports medicine team in concert with the best management for the individual athlete. And these decisions become more complex every day as data continues to emerge. For instance, one obvious issue is that data continues to point to a minimum of nine months being required for optimal return to play after ACL reconstruction. As this number becomes more accepted, it will be more difficult for earlier return to play without significant discussions with the athlete and school officials.

ATs who work in schools may consider establishing protocols that clearly delineate nine months as the return expectation and have the team physician as well as school legal review these protocols before acceptance and implementation.

If an earlier return is considered, what are some factors you can use in the scholastic or collegiate setting? Kline, et al., demonstrated that performance of an 8-inch single-leg step down and 90-degree isometric quadriceps values were significantly correlated as clinical predictors for return to sport.19 They showed that performance at three months was predictive of six months, making it valuable as an early predictor. An important note is that those who fail to meet expected performance values of 90 percent at six months often continue to experience significant deficits for the next 18 months.20 Curran, et al., show that although improved at 12 months, significant asymmetries were the rule, begging the question of the often-espoused six-month return-to-play criteria.21

In the previous article, I concluded by quoting songwriter Paul Simon: “Slow down—you move too fast.” This remains excellent advice for athletic trainers when considering whether or not to return their athletes to play following ACL reconstruction.

These return-to-play decisions must be made by the sports medicine team in concert with the best management for the individual athlete. And these decisions become more complex every day as data continue to emerge.

09/16/2019

Does Early Specialization Lead to Greater Success?
By John Snyder, PT, DPT, OCS, CSCS on August 19, 2019
Categories: Athletic Training, Injury Prevention, Physical Therapy, Sports

Early Specialist
Growing up and playing competitive hockey, my goal was always to obtain a college scholarship and maybe, just maybe, make it to that next level. So I did what any other talented young athlete would do: I listened to my well-meaning coaches and scouts and focused all of my energy on “my” sport at a young age. I thoroughly enjoyed playing hockey, and I was happy to do so two hours a day, five day a week year-round.

My story of early specialization is all too common in competitive athletics. A recent study by Post and colleagues found that the vast majority of Division I athletes who specialize early do so because:

They enjoy that sport the most.
They have an opportunity to earn a scholarship to play in college.
They have a chance to be the best at that sport.
Only 9.9 percent of athletes said that parental influence most influenced their specialization decision.1

All of these reasons make perfect sense, but do athletes who specialize early actually have more success than multi-sport athletes?

According to the same study, the prevalence of highly specialized athletes (defined as an athlete who participates in year-round training of more than eight months per year, who chooses a single main sport, and who quits all other sports to focus on that single sport) increased significantly from freshman (16.9 percent) to senior year (41.1 percent) of high school. In a separate study conducted among high school athletes, 29.5 percent classified themselves as one-sport athletes and 36.4 percent were considered highly specialized in their chosen sport.2 Based on this information, there does not seem to be a significant difference between Division I athletes and the general high school athlete population with regards to specialization.

Furthermore, nearly 90 percent of 20163 and 20174 NFL draft picks played multiple sports during high school. In agreement with this trend, 100 percent of 2016 national college football award winners, including all 5 Heisman Trophy finalists, were not highly specialized or single-sport athletes in high school.5 Looking closer at the two teams who played in Super Bowl LIII, more than 90 percent of the players on both teams were multi-sport athletes in high school.6

The current evidence does not necessarily look favorable for the highly specialized athlete.

How Does Early Specialization Impact Risk of Injury?
To be successful, you need to be healthy, and the literature once again does not give favor to specialization.

Athletes with high competition volume, who participated in a club sport, or who were highly specialized had:

2.08 times greater odds of reporting a previous lower extremity injury than those with low competition volume
1.50 times greater odds than those with no club sport participation
2.58 times greater odds compared to those with low specialization7
Building upon this information, another study found that highly specialized athletes were more likely to report a previous injury of any kind or an overuse injury in the previous year compared with athletes in the low specialization group. Athletes who played their primary sport more than eight months of the year were 1.68 times more likely to report an upper extremity overuse injury or 1.66 times more likely to sustain a lower extremity overuse injury.8 When looking at serious overuse injuries, highly specialized athletes were 2.38 times more likely than multi-sport athletes.9

What About the Psychological Impact of Early Specialization?
One psychological effect of early specialization is an increased level of dropout in highly specialized athletes.

Among ice hockey players, those who began off-ice training earlier and invested a larger number of hours training at a younger age were more likely to drop out of their sport. One study followed hockey players who started playing at 5 years old and found that the athletes who ended up dropping out began off-ice training at 11.75 years old in comparison to 13.8 years old in those who continued playing.10 Additionally, those who continued playing their sport invested an average of 6.8 hours to off-ice training versus 107 hours per year in the dropout group.11

Dropout can occur for any number of reasons, from psychological to physical factors. Studies looking into the reasoning behind burnout in competitive tennis players found burned-out players had less input into training and sport-related decisions and practiced fewer days with decreased motivation.12 While sport specialization has not necessarily been linked to burnout, the underlying stressors related to the early and highly specialized athlete mimic those reasons for dropout.

What Can Athletes, Coaches, Parents, and Healthcare Providers Do?
Take a break. Actually take the off-season off and find another sport or passion during this time.
Develop overall athleticism. There’s a reason multi-sport athletes are generally more successful at higher levels. They have been exposed to different movements and stresses, which their primary sport does not provide.
Listen to your body and your mind. Are you feeling burnt out or are you suffering from a nagging injury? Take the time to have these factors addressed. See a physical therapist, a sports psychologist, or the appropriate medical professional.
Have fun! Sports are meant to be a positive influence on your life, not a physical or mental drain.
We as a culture need to make a change in how youth and competitive sports are positioned. The highly specialized athlete is not necessarily more successful, is more likely to sustain an overuse or serious injury, and demonstrates the psychological profile of those who drop-out of their sport. We need to embrace the need for varying experiences and movement activities. The literature is fairly definitive, and we need to push our children, athletes, and coaches to focus on the aspect of enjoying their athletic career and developing overall athleticism during this timeframe.

Below, watch John Snyder discuss factors affecting return to sport in a short clip from his MedBridge course, The Athlete's Hip: Return to Sport.

John Snyder, DPT, CSCS
About John Snyder, PT, DPT, OCS, CSCS
John is a graduate of the University of Pittsburgh’s Doctor of Physical Therapy program and currently treats patients in Columbus, Ohio. He created and frequently contributes to SnyderPhysicalTherapy.com, a website devoted to promoting evidence-based management of orthopedic conditions and patient education.

Post, E. G., Thein-Nissenbaum, J. M., Stiffler, M. R., Brooks, M. A., Bell, D. R., Sanfilippo, J. L., et al. (2017). High school sport specialization patterns of current Division I athletes. Sports Health, 9(2): 148–153.
Bell, D. R., Post, E. G., Trigsted, S. M., Hetzel, S., McGuine, T. A., & Brooks, M. A. (2016). Prevalence of sport specialization in high school athletics: a 1-year observational study. American Journal of Sports Medicine, 44(6): 1469–74.
Branstad, M. (2016). 88.5% 2016 NFL Draft picks played multiple sports in high school. TrackingFootball.com. Retrieved from https://www.trackingfootball.com/blog/88-5-2016-nfl-draft-picks-played-multiple-sports-high-school/
Spilbeler, B. (2017). Tracking Football finds 88% of 2017 NFL Draft picks were multiple sport athletes in high school. TrackingFootball.com. Retrieved from https://www.trackingfootball.com/blog/tracking-football-finds-88-2017-nfl-draft-picks-multiple-sport-athletes-high-school/
Spilbeler, B. (2017). Tracking Football finds 88% of 2017 NFL Draft picks were multiple sport athletes in high school. TrackingFootball.com. Retrieved from https://www.trackingfootball.com/blog/tracking-football-finds-88-2017-nfl-draft-picks-multiple-sport-athletes-high-school/
Coach & A.D.com (2019). More than 90% of Super Bowl LIII players were multisport athletes. Retrieved from https://coachad.com/news/more-than-90-of-super-bowl-liii-players-were-multisport-athletes/
Post, E. G., Bell, D. R., Trigsted, S. M., Pfaller, A. Y., Hetzel, S. J., Brooks, M. A., & McGuine, T. A. (2017). Association of competition volume, club sports, and sport specialization with s*x and lower extremity injury history in high school athletes. Sports Health, 9(6): 518–523.
Post, E. G., Trigsted, S. M., Riekena, J. W., Hetzel, S., McGuine, T. A., Brooks, M. A., & Bell, D. R. (2017). The association of sport specialization and training volume with injury history in youth athletes. American Journal of Sports Medicine, 45(6): 1405–1412.
Post, E. G., Bell, D. R., Trigsted, S. M., Pfaller, A. Y., Hetzel, S. J., Brooks, M. A., & McGuine, T. A. (2017). Association of competition volume, club sports, and sport specialization with s*x and lower extremity injury history in high school athletes. Sports Health, 9(6): 518–523.
Jayanthi, N., Dugas, L., Fischer, D., Pasulka, J., & LaBella, C. (2014). Risks of intense, specialized training and growth for injury in young athletes: a clinical evaluation. British Journal of Sports Medicine, 48(7): 611.
Jayanthi, N., Pinkha, C., Dugas, L., Patrick, B., & LaBella, C. (2012). Sports specialization in young athletes: evidence-based recommendations. Sports Health, 5(3): 251–257.
Gould, D., Udry, E., Tuffey, S., Loehr, J. (1997). Burnout in competitive junior tennis players: III. Individual differences in the burnout experience. Sport Psychologist, 11(3): 257–276.

https://www.medbridgeeducation.com/blog/2019/08/does-early-specialization-lead-to-greater-success/?utm_content=Early%20Sports%20Specialization%3A%20Does%20It%20Offer%20an%20Edge%3F&sub=yes&utm_source=Newsletter&utm_medium=email&utm_campaign=091619-PT-S-Content-Snyder

The 2016 NFL Draft had the highest percentage of high school multiple sport athletes drafted since 2013. According to Tracking Football research, 224 out of the 253 (88.5%) draftees had also participated in a sport other than football during their high school career. Below are the participation perc...

06/27/2019

https://areyouawellbeing.texashealth.org/should-you-be-concerned-about-noisy-joints/?utm_source=joint-3559&utm_medium=email&utm_campaign=joint-journey&utm_content=June-blogpost
Should You Be Concerned About Noisy Joints?

June 6, 2019Health & Well-Being
Popping backs, knees that crack when you stand up, wrists that snap when you rotate them— we’ve all had experience with talking joints. But what are they trying to say, and should you be concerned? We talked to Karim Elsharkawy, M.D., an orthopedic surgeon and joint replacement specialist on the medical staff at Texas Health Allen and at Texas Center for Joint Replacement, a Texas Health Physicians Group practice, to translate all those pops, cracks and snaps.



How It Works
According to the Arthritis Foundation, snapping and popping of joints is common and isn’t a cause or sign of arthritis. Fluid exists in the joints to reduce friction, and thus reduce wear and tear. When you pull on a joint, you can create a gas bubble within that fluid. That’s when we hear the popping sounds that these knuckles and many other joints make.

“It’s not uncommon for joints to pop and click,” Elsharkawy explains. “I sometimes even demonstrate for my patients how a normal functioning knee can pop by flexing my own knee! With no pain, there is no concern.”

Noisy joints can also be caused by tight ligaments sliding from one bone to another. This commonly occurs in the ankle and knee. Pops that occur in your neck and back are mostly caused by minor misalignments — hence your back cracking so loudly during a chiropractic visit, or when you twist around in your desk chair to try to relieve the tension from sitting for so long.



Is It Safe?
As Elsharkawy mentions, joint sounds become something to worry about only when they are accompanied by pain or swelling. The most common cause for this combination of pain and noise is arthritis, but there are other culprits, as well.

Karim Elsharkawy, M.D., Orthopedic Surgeon

Arthritis, most common in the knee and ankle, is when cartilage begins to wear down or tear — a condition that can eventually lead to a need for joint replacement. Popping sounds in conjunction with severe pain in the joint can also signal tearing or rupturing of the hamstring, Achilles tendon or anterior cruciate ligament.

“Sometimes it’s one bone rubbing against another bone when all cartilage and lubrication are gone, but it could also be from bone spurs secondary to knee or hip arthritis,” Elsharkawy adds. “I tell my patients if there is pain, or functional limitations associated, they need to get it checked.”

While noisy joints may be a bit of nuisance, if there is no accompanying pain, they are typically harmless. Although popping your knuckles or cracking your back every now and then isn’t going to put you on the fast track to arthritis (and sure feels good!) Elsharkawy notes one of the best ways to keep your joints healthy is to include low-impact aerobic exercise such as power walking, swimming, using the elliptical or riding a stationary bike.

We’ve all had experience with talking joints. But what are they trying to say, and should you be concerned? An orthopedic surgeon translates.