FR Specialty: Sports Injury

What Actually Helps a Child With ADHD, Ranked by Evidence Instead of Popularity

Medically reviewed by Dr. Jason Forward, DC, July 2026

Search this question and you get omega-3 five times over. The evidence ranks omega-3 fifth, and the intervention with the best evidence barely appears at all.

Start with the finding nobody states

No trial in this literature tested whether any of these interventions lets a child stop medication. They measure symptom improvement, executive function, or emotional regulation. Not one measures successful discontinuation as an endpoint.

That matters because almost every parent-facing page on this topic implies otherwise. The honest answer to "what can we do instead of medication" is that several things reduce symptoms and build capability, and none of them has been shown to replace a prescription, because nobody has run that study.

Everything below is framed as what improves symptoms and capability. Not as a route off medication. The difference is the whole article.

The ranking

Rank	Intervention	Why it sits here
1	Sleep	The only one tested in children already taking stimulants. Benefits sustained to 6 months.
2	Behavioural parent training	Grade A guideline recommendation. Builds capability that persists.
3	Cognitively engaging exercise	Large effects, but the TYPE matters far more than the amount.
4	Micronutrients	Largest single effect in the set, but 8 weeks and an unmedicated cohort.
5	Omega-3	Small, needs 4 or more months, and only if the child is actually low.
6	Elimination diets	Subsets with food sensitivity only. High family burden.
7	Gut-lining protocols	Not supported. See the last section.

1. Sleep, and why it outranks everything

Answer first: a brief behavioural sleep intervention modestly improved ADHD symptom severity, and most benefits were still present six months later.

Hiscock and colleagues ran a randomised controlled trial across 21 general pediatric practices in Victoria, Australia, with 244 children aged 5 to 12. The detail that makes this study different from everything else on this list: most participants were already taking stimulant medication. It is the only intervention here tested in the population most parents are actually asking about.

The delivery burden is almost nothing. Two fortnightly consultations plus one follow-up phone call.

Two appointments and a phone call, tested in medicated children, with benefits that held at six months. Nothing else on this list has that combination, and it is nearly invisible on the first page of search results.

2. Behavioural parent training, the half that gets skipped

Answer first: for children aged 6 to 12 the American Academy of Pediatrics recommends medication along with parent training in behaviour management, behavioural classroom interventions, or both. Both arms carry Grade A evidence and a strong recommendation.

This is not an alternative treatment. It is the other half of the standard of care, and it is the half most often left out.

The Multimodal Treatment of ADHD study, funded by the National Institute of Mental Health and running from 1994 to 2014, found that by 36 months none of the randomly assigned groups differed on any of five outcomes. For academics and other outcomes sitting alongside the core symptoms, medication and behavioural treatment came out equivalent, with combined treatment looking stronger than either alone.

Behaviour management builds skills and structures that do not stop working when a dose wears off.

3. Exercise, where the type matters more than the amount

Answer first, and this is the most actionable finding in the set: plain aerobic exercise showed no benefit to cognitive flexibility. Cognitively engaging exercise showed a large one.

Across 2024 and 2025 meta-analyses of randomised trials, exercise that requires continuously monitoring other people and adapting a strategy, meaning team sports and water sports, produced large improvements. In 9 studies with 301 children the effect on cognitive flexibility was large. In 11 randomised trials with 388 children it was medium to large. In 9 trials with 398 children the effect on working memory was large.

Running laps did not do this. Soccer did.

Nobody tells parents that the treadmill and the soccer team are not interchangeable. On this evidence they are not.

The honest counterweight: one broader meta-analysis found a non-significant effect on executive functioning overall, g = 0.492, p = 0.215, 95% CI -0.286 to 1.269. That interval is wide and crosses zero. The field is not unanimous, and the specific finding about exercise type is stronger than the general claim that exercise helps.

4. Micronutrients, the biggest single number with the biggest caveats

Answer first: in a fully blinded placebo-controlled trial, 54 percent of children on a 36-ingredient micronutrient formula were rated treatment responders versus 18 percent on placebo.

That is the MADDY study, a three-site 8-week randomised trial of 126 children aged 6 to 12 with ADHD plus at least one impairing irritability symptom. A separate analysis found response was independent of baseline diet quality, which undercuts the assumption that only poorly fed children benefit.

The caveats are load-bearing. Eight weeks is short. Enrolment required irritability, so it does not generalise cleanly to children without it. And critically, the cohort was not medicated, so this tells you nothing about what adding it to an existing prescription does.

5. Omega-3, the one everyone writes about

Answer first: pooled across all randomised trials the effect was not statistically significant, SMD -0.16, 95% CI -0.34 to 0.01, p = 0.07.

Duration is what separates the trials that worked from the ones that did not. Trials running at least four months showed SMD -0.35, 95% CI -0.61 to -0.09, p = 0.007. Short trials fail.

Two practical points that contradict how these products are sold:

Baseline status is the modifier. Children with the lowest starting EPA and DHA showed the largest improvements. A child who is already replete has less room to gain.
Neither a high EPA dose nor a high EPA to DHA ratio improved outcomes. Paying more for a higher-EPA formula is not supported by the data.

Omega-3 is the most written-about intervention for childhood ADHD and the fifth strongest on this evidence. That gap between coverage and evidence is the reason this article exists.

6. Elimination diets, deliberately demoted

Effects concentrate in subsets of children with food sensitivity or atopy, these trials are difficult to blind properly, and the burden on a family is high relative to what the evidence supports. Worth discussing with your prescriber if there is a specific suspicion. Not worth running on spec.

7. The gut-lining claim, and why it is not a target

Answer first: the claim that ADHD is caused by a damaged gut lining, and that healing it resolves symptoms, is not supported.

The evidence usually cited traces to a single small case-control study of zonulin, a marker of intestinal permeability, where the group difference was marginal and the variation within each group was nearly as large as the difference between groups. A larger 2023 study specifically in children with ADHD found no difference in zonulin at all.

Every study in this area is case-control or cross-sectional, which means none of them can establish cause even in principle. Intestinal permeability is a legitimate research question. It is not a treatment target.

What this means for you

Ask about sleep first. It has the best evidence in medicated children and the lowest burden of anything here.
Ask whether behavioural parent training is actually in place. It is a Grade A guideline recommendation, not an optional extra, and it is the piece most often missing.
If your child is going to do a sport, favour one requiring constant reading of other players. Team and water sports outperformed plain aerobic work on the outcomes that matter for learning.
Treat supplements as a prescriber conversation, not a purchase. Dosing and interactions are real, and this article deliberately names no doses.
Do not read any of this as a plan to stop medication. That question is answered separately, and the honest answer is that nobody has studied it.

What we do not know

The single largest gap is the one at the top of this article. Not one of these trials used discontinuation as an endpoint, so the question parents most want answered has not been asked in a study design capable of answering it.

Beyond that: the sleep trial is one RCT in one country. The micronutrient result is 8 weeks in an unmedicated, irritability-selected cohort. The exercise literature disagrees with itself at the general level even while the type-specific finding holds. And effect sizes across all of this are modest next to stimulant medication, which is the comparison most families are actually weighing.

Reader questions

Can these replace ADHD medication?
No trial has tested that. Every intervention here was measured against symptom or function outcomes, never against successful discontinuation, so there is no evidence base for using them as a replacement.

Which single change has the best evidence for a medicated child?
Sleep. A brief behavioural sleep intervention is the only one of these tested in a population where most children were already taking stimulants, and its benefits were sustained to six months.

Does exercise help ADHD?
It depends on the type. Plain aerobic exercise showed no benefit to cognitive flexibility, while cognitively engaging exercise such as team and water sports showed large effects across multiple meta-analyses.

Is omega-3 worth trying?
Pooled results were not statistically significant, p = 0.07. Trials of four months or longer did show benefit, and children with the lowest baseline EPA and DHA improved most. Higher EPA doses and ratios did not perform better.

Do micronutrients work for ADHD?
A placebo-controlled trial found 54 percent responders versus 18 percent on placebo, but over only 8 weeks and in children who were not taking medication, so it does not tell you what adding it to a prescription does.

Should we try healing my child's gut to treat ADHD?
The evidence does not support it. The zonulin finding rests on a small case-control study, a larger 2023 study in children with ADHD found no difference, and all of the research is cross-sectional and cannot establish cause.

Citations

Hiscock H, Sciberras E, Mensah F, et al. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ. 2015;350:h68.
Johnstone JM, Hatsu I, Tost G, et al. Micronutrients for Attention-Deficit/Hyperactivity Disorder in Youths: A Placebo-Controlled Randomized Clinical Trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2022;61(5):647-661.
Wolraich ML, Hagan JF, Allan C, et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528.
National Institute of Mental Health. Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study. 1994 to 2014.
Asbjornsdottir B, et al. Zonulin-Dependent Intestinal Permeability in Children Diagnosed with Mental Disorders: A Systematic Review and Meta-Analysis. Nutrients. 2020;12(7):1982.
Lee SY, Li SC, Yang CY, Kuo HC, Chou WJ, Wang LJ. Gut Leakage Markers and Cognitive Functions in Patients with Attention-Deficit/Hyperactivity Disorder. Children (Basel). 2023;10(3):513.

This article is educational and is not medical advice. Decisions about starting, changing, or stopping any prescription, supplement, or diet belong to you and the physician who treats your child. I am a chiropractor. I do not prescribe or manage ADHD medication, and nothing here should be read as a recommendation to alter your child's treatment. Chiropractic care is not a treatment for ADHD and this article makes no such claim.

July 30, 2026

Hands-On Therapy for Plantar Fasciitis: What a 2026 Study Found
Medically reviewed by Dr. Jason Forward, DC, July 2026
Last updated: July 2026
That first step out of bed, when your heel feels like it is splitting, is the reason most people finally look up plantar fasciitis, and it is also the symptom a new study watched change the fastest.
Short answer: a 2026 prospective cohort study tested manual therapy for plantar fasciitis, meaning hands-on manipulation of the small foot joints paired with a corrective insole. Across 50 patients, that hallmark first-step-in-the-morning heel pain dropped from 6.79 to 2.69 on a 0 to 10 scale over 6 to 8 weeks, with gains holding at 26 weeks. This is early, promising evidence, not proof.
What the 2026 study on manual therapy for plantar fasciitis found
Dutch researchers followed 50 adults with plantar fasciitis through a course of foot-joint manual therapy plus a corrective insole. Morning heel pain fell from 6.79 to 2.69, activity pain fell from 6.64 to 2.66, and the plantar fascia itself got measurably thinner on ultrasound, from 5.34 mm to 3.70 mm on the affected side. All of those changes were statistically significant.
The tissue did not just feel better. It measurably remodeled, thinning from 5.34 to 3.70 millimeters on ultrasound.
Here is the setup. van der Linde and colleagues, publishing in the journal PeerJ in 2026, ran a single-arm cohort of 50 patients, 31 women and 19 men, aged 27 to 73. The protocol was five visits over the first 6 to 8 weeks, then one more visit at 26 weeks to check whether the gains held. The hands-on work was manipulation of the foot joints, and it was combined with a corrective insole. Pain was tracked on the numeric pain rating scale, a plain 0 to 10 score, and the plantar fascia was measured by ultrasound.
The results were consistent across every measure the team looked at. Rest pain dropped from 2.98 to 1.39. The Foot Function Index improved on its pain, disability, and activity subscales. Quality-of-life physical scores went up. And notably, the researchers saw meaningful improvement as early as 1 to 2 weeks after the first session, with the benefit sustained out to 26 weeks. If you have lived with heel pain for months, a change you can feel in a week or two is worth paying attention to.
Why foot and ankle joint mechanics matter for heel pain
The plantar fascia is a thick band along the sole that supports your arch. It gets overloaded when the joints above it, the ones in the midfoot, ankle, and heel, stop moving well and dump extra strain onto that band with every step. Restore motion to those stiff joints and you take load off the fascia, which is exactly what manual therapy targets.
Plantar fasciitis is rarely just the fascia. It is the whole foot mechanism putting too much strain on one overworked band.
People are surprised that a chiropractor works on feet at all. The reflex is to think chiropractic means the spine and nothing else. In reality, chiropractic is joint mechanics, and you have 26 bones and 33 joints in each foot. When a few of those joints lock down, the arch loses some of its spring, and the fascia absorbs what the joints should have handled. That is the mechanical story behind a lot of stubborn heel pain, and it is why hands-on plantar fasciitis treatment looks at the entire foot, not just the sore spot on the heel.
This is the same reason I care about how the whole chain moves. A stiff ankle changes how you load the knee, and a stiff foot changes how you load the hip. If you want the bigger picture on that, I have written about whether running is bad for your knees and about hip pain and its mechanical drivers. The foot is the foundation, and restoring joint mobility is often where lasting heel relief starts.
What this means if your first steps in the morning are the worst
If morning heel pain is your worst symptom, this study is directly relevant, because that is the exact measure that improved most, from 6.79 to 2.69. Manual therapy for plantar fasciitis will not fix the fascia overnight, but the evidence points to real change within a few weeks when the foot joints are the problem.
The morning first step is the classic plantar fasciitis tell, and it is the number that moved the most.
The morning-first-step pattern happens because the fascia tightens and heals in a shortened position overnight, then gets yanked when you stand. That signature is one of the strongest clues that you are dealing with true plantar fasciitis and not something else. Runners see it constantly, and so do people who spend all day on hard floors. If you run, this connects to broader load management, which I cover for runners in Tulsa and for the barbell-and-box-jump crowd in my piece on CrossFit injuries.
One honest caveat from the study itself: it combined manual therapy with a corrective insole. That means the researchers cannot fully separate how much of the relief came from the hands-on work versus the insole. Both are reasonable, low-risk tools. In practice they work together, but I want you to know the study cannot hand you a clean either-or answer.
How I approach manual therapy for plantar fasciitis at Vanguard Chiropractic
At Vanguard Chiropractic, I screen the whole foot and lower chain first, then use hands-on joint work to restore motion where it is missing, and I am direct about what I can and cannot help. If your heel pain is mechanical, manual therapy for plantar fasciitis is a sensible, drug-free thing to try.
I would rather tell you in the first visit that this is not a foot-joint problem than string you along for six.
My read on this study lines up with how I already work. I assess how the ankle, midfoot, and big toe joint move, I look at the calf, and I check how you load the arch when you walk. Where a joint is restricted, I restore it. That is chiropractic applied to the foot, and it is standard joint mechanics, not a gimmick. A shoe insert or supportive footwear often earns its place alongside the hands-on work, the same pairing the study used.
Worth noting from the study: 8 of the 50 patients turned out to also need spine treatment and were moved into a different care path. That tracks with real life. Sometimes what feels like a foot problem has a contributor further up the chain, which is why low back mechanics can matter even for heel pain. You get a full screen, not a one-size assumption.
When it is not plantar fasciitis, and when to get imaged
Not every heel or arch pain is plantar fasciitis, and a few red flags mean you should get evaluated or imaged before anyone works on your foot. Manual therapy is for mechanical problems, not for stress fractures, nerve entrapment, or systemic disease.
The skill is not only knowing how to treat the foot. It is knowing when the foot is not the real problem.
See a physician or get imaging, rather than starting hands-on care, if any of these fit you:
- Suspected stress fracture: heel or midfoot pain that started after a jump in mileage or training, pain that worsens the longer you are on it, or a focal spot that is tender to press on the bone rather than the fascia.
- Nerve entrapment signs: burning, tingling, or numbness in the sole or heel, which can point to tarsal tunnel or a nerve issue rather than the fascia.
- Signs of infection or inflammatory arthritis: a hot, swollen, red foot, fever, or heel pain in both feet along with other stiff or swollen joints, which can signal a systemic condition that needs a medical workup.
- Trauma: a recent fall, twist, or direct blow with immediate swelling or inability to bear weight, which needs imaging to rule out a fracture.
- No improvement: pain that has not budged after a reasonable trial of conservative care deserves a second look and possibly imaging.
This is exactly the kind of triage that belongs in the first visit. If something points to a fracture, a nerve problem, or an inflammatory disease, I will tell you plainly and send you to the right provider. You can see the range of what I do and do not handle on my page covering the conditions I treat.
The honest limitations of this study
This was a cohort study, not a randomized controlled trial, which is a lower tier of evidence. There was no comparison group, so we cannot be certain how much of the improvement came from the treatment versus natural recovery or the insole. Read it as promising, not proven.
A cohort study can show a group got better. It cannot prove the treatment is why.
Let me be specific about the weak spots, because they matter. This was a single-arm cohort of 50 patients, and only 32 completed the full 26-week follow-up, so dropout could have skewed the results toward the people who did well. There was no placebo or control group, which is the biggest limitation, because plantar fasciitis often improves on its own over months. The therapists varied in experience, the ultrasound was not read by a single standardized examiner, and, as the authors themselves flag, the manual therapy and the insole were bundled so their individual effects cannot be teased apart. The researchers were careful to say the results should be interpreted with caution and that controlled trials are needed to confirm them. I agree with that read completely.
None of this means the study is worthless. It means it belongs in the honest middle: encouraging evidence that hands-on foot care helps plantar fasciitis, waiting on stronger trials to nail down how much. That is the same posture I take at the table. I will try what the evidence supports, I will not oversell it, and if it is not working for you, I will say so.
Common questions about manual therapy for plantar fasciitis
Can a chiropractor treat plantar fasciitis?
Yes, because plantar fasciitis is largely a joint-mechanics problem, and joint mechanics is what chiropractic addresses. Hands-on work restores motion to stiff foot and ankle joints so the fascia carries less strain. The 2026 cohort study found significant pain relief with foot-joint manual therapy, though as a cohort study it is promising rather than definitive evidence.
How fast does manual therapy for plantar fasciitis work?
In the 2026 study, patients reported meaningful improvement as early as 1 to 2 weeks after the first session, with gains sustained at 26 weeks. Morning first-step pain dropped from 6.79 to 2.69 on a 0 to 10 scale over 6 to 8 weeks. Individual results vary, and some cases take longer or need a different approach.
Does the treatment actually change the plantar fascia, or just mask pain?
The study measured the fascia by ultrasound and found it got thinner over time, from 5.34 mm to 3.70 mm on the affected side, alongside the pain relief. That suggests a real tissue change, not just symptom masking. Because there was no control group, this cannot be proven to be caused by the treatment alone.
Do I need custom orthotics too?
The study paired manual therapy with a corrective insole, so the two were used together. A supportive insert or good footwear often helps offload the fascia while the joints are being treated. You do not necessarily need expensive custom orthotics to start. We can talk through what fits your foot and your budget.
When should I see a doctor instead of getting my foot adjusted?
Get a medical evaluation or imaging first if you have signs of a stress fracture, burning or numbness suggesting a nerve problem, a hot swollen red foot or fever, recent trauma with inability to bear weight, or pain that has not improved with reasonable conservative care. Those are not mechanical foot-joint problems, and I will refer you out if I see them.
Do I need insurance or a referral to come in?
No. Vanguard Chiropractic is cash-pay and walk-in friendly. No referral, no insurance, no contract. It is 40 dollars per visit, and you decide how often you come.
Come see me in Brookside
If morning heel pain is running your day, hands-on foot care is a low-risk, drug-free thing to try, and I will give you a straight read on whether your case is mechanical or needs a different provider. As a Navy veteran running a veteran-owned clinic, that honesty is the whole point.
Vanguard Chiropractic
Walk in at 1334 E 41st St, Brookside, midtown Tulsa. No appointment needed.
40 dollars per visit. No contracts. Stop any time.
Hours: Monday through Friday 10am to 7pm, and Saturday 10am to 2pm.
Call or text: (918) 948-7990
New here? Start with what to expect on your first visit, see how the 40 dollar flat cost compares in Tulsa, and learn why patients choose a walk-in chiropractor.
Sources
van der Linde JG, Somers R, van Egmond MA. Pain relief in plantar fasciitis within 6-8 weeks using (ortho)manual therapy of the foot joints: a prospective cohort study. PeerJ. 2026;14:e21280. doi.org/10.7717/peerj.21280. PMID 42222496. Cohort study, lower certainty than a randomized trial.
Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain - Plantar Fasciitis: Revision 2023. Clinical practice guideline. J Orthop Sports Phys Ther. 2023;53(12):CPG1-CPG39. doi.org/10.2519/jospt.2023.0303. PMID 38037331.
Buchanan BK, Sina RE, Kushner D. Plantar Fasciitis. StatPearls. National Center for Biotechnology Information, National Institutes of Health. ncbi.nlm.nih.gov/books/NBK431073. PMID 28613727.
This article is educational and is not medical advice. It does not replace evaluation by a licensed clinician. Chiropractic care addresses mechanical conditions and is not a treatment for fractures, infections, nerve entrapment, or systemic disease. If you have any red-flag symptom listed above, seek appropriate medical care.
Related reading: Plantar fasciitis treatment in Tulsa, chiropractor for runners, CrossFit injuries and chiropractic, mobility and joint care, conditions I treat in Tulsa.
July 23, 2026
Why Treating the Mid-Back Helps the Shoulder: 2026 Thoracic Manual Therapy Evidence
Medically reviewed by Dr. Jason Forward, DC, July 2026
Last updated: July 2026
A patient points at their shoulder, and I spend the first few minutes pressing on their mid-back. That surprises people, so let me explain why the two are wired together.
Short answer: the shoulder does not move in isolation. It rides on the thoracic spine, the stiff section of your upper back between the shoulder blades. A 2026 systematic review of 12 randomized trials and 508 patients found that thoracic manual therapy reduced shoulder pain and disability, with the clearest signal from Maitland mobilization, which cut pain by about 2 points on a 10 point scale (mean difference -2.02, 95% CI -2.95 to -1.10).
What the 2026 review actually studied
Yu and colleagues searched six databases through October 2025 and pooled 12 randomized controlled trials covering 508 people with shoulder dysfunction. They asked a focused question: if you treat the mid-back instead of the sore shoulder itself, does the shoulder get better? The pooled answer was yes for pain and disability, and the effect was strongest with one specific technique.
The study treated a joint the patient was not complaining about, and the joint they were complaining about improved.
The numbers worth knowing: Maitland mobilization of the thoracic spine, a graded low-force glide, beat the control condition for pain (mean difference -2.02, 95% CI -2.95 to -1.10) and for disability (standardized mean difference -0.87, 95% CI -1.39 to -0.35) in people with subacromial impingement syndrome. That is the most common mechanical shoulder problem I see, the pinch you feel reaching overhead or behind your back.
The review was honest about what did not work as well. High-velocity low-amplitude thrust techniques, the classic quick adjustment, showed no significant effect for subacromial impingement or for adhesive capsulitis, better known as frozen shoulder. Evidence for the Mulligan technique was too thin to judge. So this is not a blanket win for every method. It is a specific finding that graded thoracic mobilization helps the shoulder, and that the tool matters.
Why does treating the mid-back help the shoulder?
The concept is called regional interdependence. A problem in one area shows up as symptoms in a neighboring area because the body moves as a connected chain. The thoracic spine sits directly under the shoulder blade, so when the mid-back stiffens, the shoulder pays the bill.
Your shoulder blade has no bony socket. It floats on your rib cage, and your rib cage is your thoracic spine.
Here is the mechanism in two sentences. To lift your arm fully overhead, your thoracic spine has to extend, meaning it straightens out of its normal forward curve, and your shoulder blade has to tilt back and rotate upward to clear space for the arm bone. If the mid-back is stuck in a flexed, hunched position, the shoulder blade cannot rotate the way it needs to, and the space where your rotator cuff tendons pass gets crowded. That crowding is the impingement.
This is not a fringe idea. The etiology of subacromial impingement is multi-factorial, and abnormal scapular motion driven by posture is one of the documented drivers (Varacallo et al., StatPearls). Restore motion to the thoracic segments and the shoulder blade gets its room back. That is why the mid-back is a legitimate treatment target for a shoulder complaint, not a detour.
Scapulohumeral rhythm and thoracic extension
Scapulohumeral rhythm is the coordinated ratio between how much your arm bone moves and how much your shoulder blade rotates as you raise your arm. In a healthy shoulder that ratio stays smooth. In an impinged shoulder it breaks down, and thoracic stiffness is part of why.
When the mid-back will not extend, the shoulder blade cannot keep its side of the bargain, and the rhythm falls apart.
A 2014 study using dynamic imaging found that athletes with impingement syndrome showed a scapulohumeral rhythm that decreased significantly through arm elevation compared with healthy athletes, likely a compensation for the shoulder blade sitting in a poor resting position (Delkhoush et al., Iranian Journal of Radiology). Translation: the shoulder blade starts in a bad spot and the whole lifting motion is off from the first inch.
A thoracic spine locked in flexion is one common reason the shoulder blade starts in that bad spot. This is the same postural chain behind tech neck and the rounded-forward posture I address in posture correction. It also overlaps with the neck, which is why the 2026 meta-analysis on thoracic manipulation for neck pain keeps landing in the same neighborhood. The mid-back is a hub, and a lot of upper-body complaints route through it.
What this means for overhead athletes and CrossFit
If you press, snatch, jerk, or do wall balls, your shoulder demands a lot of thoracic extension. A stiff mid-back forces the shoulder to make up the difference, and over time that is where the pinch and the tendon irritation show up.
Most overhead shoulder pain I see in lifters is not a bad shoulder. It is a good shoulder writing checks a stiff mid-back cannot cash.
I train at CrossFit Jenks, so I watch this in real time. An athlete who cannot get the bar overhead in a clean line often does not have a shoulder problem first. They have a thoracic spine that will not extend, so they compensate by cranking the shoulder or arching the low back. Chest-to-bar pull-ups, kipping and butterfly work, and heavy overhead pressing all magnify that limitation. Free up the thoracic segments and the overhead position gets cleaner, which takes load off the rotator cuff.
None of this replaces loading the tissue. Mobility work opens the door, but the rotator cuff still needs to get strong to hold the position under a barbell. That is why I pair mid-back work with the loading approach in my review of rotator cuff exercise for shoulder pain, and why I treat these together in CrossFit injury care.
What this means for you
If your shoulder pinches when you reach overhead and standard shoulder-only treatment has stalled, getting the thoracic spine assessed is a reasonable next step. The 2026 evidence supports treating the mid-back as part of shoulder care, especially with graded mobilization.
You are an adult making your own call. My job is to hand you the real trade-offs, not a sales pitch.
In practice, that means I assess how your mid-back moves before I decide the shoulder is the whole story. For a mechanical shoulder complaint tied to impingement, my approach is graded mobilization of the thoracic segments plus targeted rotator cuff loading, reassessed as you go. A shoulder that has been guarding for months rarely resets in one visit. For a recurring mechanical pattern like impingement, I usually recommend ongoing care, often weekly, for at least 12 weeks after the acute phase settles, then tapering based on whether symptoms return. That is not a package and not a contract. Every visit is 40 dollars and you can stop any time.
If your shoulder pain is more about a stiff, freezing joint than a reaching pinch, that is a different pattern with a different course, and I walk through it in my page on frozen shoulder care in Tulsa. For general shoulder complaints, start with shoulder pain care.
Where the shoulder needs more than an adjustment
Some shoulder symptoms are not mechanical and need urgent medical evaluation, not a mobilization. Knowing the difference protects you, and screening for it is the first thing I do.
Skip the clinic and get evaluated urgently if you have any of these:
- Cardiac warning signs: left shoulder or arm pain with chest pressure, shortness of breath, sweating, or nausea. That can be a heart attack. Call 911.
- Recent significant trauma or deformity: a fall or hit followed by a visibly out-of-place shoulder, which can mean a dislocation or fracture. Go to urgent care or the ER.
- Infection signs: a hot, red, swollen shoulder with fever, especially after an injection or with a weakened immune system.
- Progressive weakness or numbness: weakness that keeps worsening, or numbness spreading down the arm, which points to a nerve problem that needs a medical workup.
- Cancer history: a past cancer diagnosis with new, unexplained shoulder or arm pain.
If your problem belongs with a cardiologist, an orthopedist, or the ER, I will tell you plainly and refer you out. That is the deal. Chiropractic treats mechanical problems, and it is not a substitute for emergency care.
The honest limitations
The finding is encouraging but not the last word. The review pooled a modest number of trials, the techniques were not all equal, and thrust manipulation did not show the same benefit as graded mobilization.
The evidence favors gentle graded mobilization of the mid-back for the shoulder, not the fast thrust and not a promise of a cure.
Twelve trials and 508 patients is a real but limited base, and the authors called for more high-quality studies to confirm the effect and to nail down the best protocol. The strongest result came from Maitland mobilization in subacromial impingement. High-velocity thrust showed no significant benefit for impingement or frozen shoulder, and the Mulligan technique did not have enough data to judge. So the responsible read is narrow: for the right shoulder problem, adding graded thoracic mobilization to care is supported and low risk. It is not a miracle, and it does not replace loading the shoulder or referring out when the case calls for it. Individual results vary.
Common questions about mid-back and shoulder pain
How can my mid-back be the cause when my shoulder is what hurts?
Because your shoulder blade floats on your rib cage, and your rib cage is your thoracic spine. To lift your arm fully, the mid-back has to extend and the shoulder blade has to rotate up and tilt back. If the thoracic spine is stiff, the shoulder blade cannot move right and the tendon space gets crowded. Treating the mid-back gives the shoulder its room back.
Does the 2026 study prove thoracic treatment cures shoulder pain?
No, and it does not claim to. The review found that thoracic manual therapy reduced shoulder pain and disability, with the clearest benefit from Maitland mobilization for subacromial impingement. That is meaningful help, not a cure. Evidence was limited to 12 trials, and individual results vary.
Is this the fast, popping kind of adjustment?
Not for this. The technique that worked in the review was graded mobilization, a controlled low-force glide, not a high-velocity thrust. In fact thrust manipulation did not show a significant benefit for impingement in this study. For a shoulder complaint I favor the graded approach and match the force to what your body tolerates.
I lift overhead at the gym. Will this help my shoulder pinch?
It often does when the pinch comes from a stiff mid-back limiting your overhead position. Pressing, snatching, and wall balls all demand thoracic extension. Freeing those segments can clean up the overhead line and take load off the rotator cuff. Mobility is half of it though. The cuff still needs loading to hold the position.
How many visits will I need?
For a recurring mechanical pattern like impingement, I usually recommend ongoing care, often weekly, for at least 12 weeks after the acute phase, then tapering based on symptom return. It is not a package or a contract. Every visit is 40 dollars and you can stop any time.
Do I need a referral or insurance to come in?
No. Vanguard Chiropractic is cash-pay and walk-in friendly. No referral, no insurance, no contract. It is 40 dollars per visit and you decide how often you come.
Come see me in Brookside
If your shoulder pinches overhead and shoulder-only treatment has stalled, getting the mid-back assessed is a low-risk next step. As a Navy veteran running a veteran-owned clinic, I will give you the straight read on whether care fits your case and refer you out if it does not.
Vanguard Chiropractic
Walk in at 1334 E 41st St, Brookside, midtown Tulsa. No appointment needed.
40 dollars per visit. No contracts. Stop any time.
Hours: Monday through Friday 10am to 7pm, and Saturday 10am to 2pm.
Call or text: (918) 948-7990
New here? Start with what to expect on your first visit, see how the 40 dollar flat cost compares in Tulsa, learn why patients choose a walk-in chiropractor, or read more on back pain care in Tulsa.
Sources
Yu S, Chen S, Yang Z, Ma X, Gou L, Yang L. The effects of different types of thoracic manual therapy for shoulder dysfunction: a systematic review with meta-analysis. Musculoskelet Sci Pract. 2026;84:103565. doi.org/10.1016/j.msksp.2026.103565. PMID 42068776.
Delkhoush CT, Maroufi N, Ebrahimi Takamjani I, Farahmand F, Shakourirad A, Haghani H. Dynamic comparison of segmentary scapulohumeral rhythm between athletes with and without impingement syndrome. Iran J Radiol. 2014;11(3):e13931. PMC4090642.
Varacallo MA, El Bitar Y, Sina RE, Mair SD. Rotator Cuff Syndrome. StatPearls. Treasure Island (FL): StatPearls Publishing. NBK531506.
This article is educational and is not medical advice. It does not replace evaluation by a licensed clinician. Chiropractic care addresses mechanical conditions and is not a treatment for medical emergencies. If you have any red-flag symptom listed above, seek emergency care.
Related Forward Reviews: Thoracic manipulation for neck pain (2026 meta-analysis), Rotator cuff exercise for shoulder pain, Shoulder pain care in Tulsa, Frozen shoulder care in Tulsa, CrossFit injury care in Tulsa.
July 23, 2026
Home›The Forward Review›Rotator Cuff Shoulder Pain and Exercise
The Forward Review Live Commentary Vol. I · Issue 6 · July 2026
Systematic Review Volume 1 · Issue 6 Rotator Cuff Exercise Therapy
Shoulder Pain Without Surgery: What the 2025 Evidence Says About Exercise
Rotator cuff shoulder pain is the most common cause of a sore shoulder, and the 2025 research is clear about what actually rebuilds it. Active exercise and strength training move the needle. Passive care and early surgery, for most people, do not. Here is the honest read of the evidence and how to load a cranky shoulder the right way.
Jason Forward, DC, US Navy veteran, Vanguard Chiropractic, Brookside, Tulsa, Oklahoma Published July 7, 2026
✓ Medically reviewed by Dr. Jason Forward, DC, July 2026. Last updated July 2026.
Reviewing
Zhang B, Raguzzi IA, Dupuis F, Gianola S, Morgan-Daniel J, Roy JS, Pozzi F. Addressing Shoulder Weakness in Individuals With Rotator Cuff-Related Shoulder Pain: A Systematic Review With Meta-analysis. Journal of Orthopaedic and Sports Physical Therapy. 2026;56(2):67-84.
DOI: 10.2519/jospt.2025.13445 · PMID: 41620837
Key Points
Rotator cuff-related shoulder pain, or RCRSP, is the single most common cause of shoulder pain and one of the most common musculoskeletal complaints anywhere (Zhang W and colleagues, 2025).
A 2026 systematic review pooled 28 studies and found that rehabilitation improved shoulder strength, with a moderate effect on external rotation strength (standardized mean difference 0.56). The catch: only programs that included active exercise or strength training produced any strength gain. Programs without exercise produced none (Zhang B and colleagues, 2026).
A 2025 Bayesian network meta-analysis of seven exercise types ranked concentric strengthening training as the most effective single approach for both pain and function (Zhang W and colleagues, 2025).
Surgery is not the automatic first move. A 2019 Cochrane review found rotator cuff repair probably gives little or no pain improvement over exercise at one year (Karjalainen and colleagues, 2019), and a 2018 Lancet trial found keyhole decompression surgery no better than a sham procedure (Beard and colleagues, 2018).
The mechanism is load tolerance. A painful cuff is usually a cuff that has lost capacity. Progressive strengthening rebuilds that capacity and restores the scapular mechanics that keep the shoulder moving cleanly.
Some shoulders are not a rehab problem. A true traumatic tear with real weakness, night pain with fever or weight loss, or a new lump needs medical evaluation first, not exercise.
Plain Language Summary
If your shoulder hurts to lift, reach overhead, or lie on at night, the most likely cause is your rotator cuff being irritated and underpowered, not necessarily torn. The best 2025 evidence says the fix is to strengthen it, gradually and on purpose. Rest, gadgets, and hands-off treatments do not build a shoulder back.
Two large 2025 and 2026 research reviews point the same direction. Exercise that actually loads the shoulder improves strength and function. Passive care that does not load it changes very little. And for most people, surgery does not beat a good exercise program.
This does not mean push through every pain. It means load the shoulder in a controlled, progressive way, respect the warning signs that mean something more serious, and get a hands-on evaluation if you are stuck at the starting line. At Vanguard Chiropractic in Brookside, that first look is $40, no contract, and you can stop any time.
Why This Question Matters
Shoulder pain sends people down two wrong roads: total rest, or a rush to surgery. Rotator cuff shoulder pain is the most common shoulder complaint, so getting the first move right matters for a lot of people. The 2025 evidence points to a third road, active loading, that most patients never hear about.
"A painful rotator cuff is rarely a shoulder that needs rest. It is usually a shoulder that has lost capacity and needs to earn it back."
Start with the scale of it. Rotator cuff-related shoulder pain, which clinicians shorten to RCRSP, is described in the 2025 research as the most common cause of shoulder pain and one of the most common musculoskeletal conditions affecting the shoulder at all (Zhang W and colleagues, 2025). It is the umbrella term for the everyday sore shoulder: the pain when you reach for a seatbelt, lift a bag into an overhead bin, or roll onto that side at night. Most of these shoulders are not catastrophically torn. They are irritated and underpowered.
Here is why the framing matters. When a shoulder hurts, the two instincts are to stop using it or to get it scoped. Both feel logical. Both, for most people, are the wrong first move. The 2025 and 2026 evidence lands on a different answer, and it is worth walking through carefully because it changes what you should do on day one.
The Studies
Two 2025 to 2026 systematic reviews anchor this commentary. The first pooled 28 studies and asked whether rehabilitation actually restores shoulder strength in rotator cuff shoulder pain. The second compared seven different exercise styles head to head to find which one works best. Together they answer whether to exercise, and how.
The anchor is a 2026 systematic review with meta-analysis in the Journal of Orthopaedic and Sports Physical Therapy by Zhang B and colleagues (2026). The team searched seven databases and pooled 28 studies of adults with RCRSP, deliberately excluding people who had shoulder surgery or a diagnosis limited to a full-thickness tear. They measured objective strength before and after at least six weeks of treatment. The question was simple and practical: does rehab put real strength back into a painful cuff, and which kind of rehab does it.
The companion is a 2025 Bayesian network meta-analysis in the Journal of Orthopaedic Surgery and Research by Zhang W and colleagues (2025). A network meta-analysis is a statistical method that lets you rank several treatments against each other even when no single trial tested them all side by side. This one pulled randomized trials of RCRSP and compared seven exercise types, ranking them for pain and for function. The pain analysis pooled 15 studies with 913 participants, and the function analysis pooled 16 studies with 947 participants.
"One review asked whether exercise works. The other asked which exercise works best. The answers line up."
These are not small mechanistic experiments. They are pooled analyses of many trials, which is the level of evidence that should move clinical decisions. The limitations, covered in full below, are real, but the direction of both reviews is consistent and hard to wave away.
What Rotator Cuff Shoulder Pain Actually Is
The rotator cuff is four small muscles that center the ball of the shoulder in its socket while bigger muscles move the arm. Rotator cuff shoulder pain usually means those muscles and their tendons have lost load tolerance, often paired with sluggish shoulder-blade mechanics. It is a capacity problem far more often than a structural tear.
Picture the shoulder as a golf ball sitting on a tee. The big muscles, like the deltoid and the lats, swing the arm around. The four rotator cuff muscles do a quieter job: they pull the ball snugly into the socket so it rotates cleanly instead of sliding around. When the cuff is strong, the ball stays centered and the shoulder moves through its range without pinching. When the cuff loses capacity, the mechanics get sloppy, tissues get irritated, and the brain protects the joint by making movement hurt.
Two mechanical ideas do most of the explaining. The first is load tolerance. A tendon is a living tissue that adapts to the demand you place on it. Ask too little of it for too long, after an injury or a stretch of inactivity, and its tolerance drops. Then a normal reach can exceed what the tissue can currently handle, and that mismatch is felt as pain. The second is scapular mechanics. Your shoulder blade has to rotate and tilt out of the way as you lift your arm, opening space for the cuff tendons to glide. When the muscles that control the blade are weak or poorly timed, that space narrows and the tendons get compressed and cranky.
This is why "rest until it feels better" so often backfires. Rest lowers the demand, the pain quiets for a while, but the underlying capacity keeps dropping. The shoulder gets more fragile, not less, and the next reach re-lights the same pain. Understanding the shoulder as an underpowered system, rather than a broken part, is the whole key to why loading it is the fix.
What the Evidence Shows: Exercise Builds It, Passive Care Does Not
The 2026 review found that rehabilitation improved strength across every direction tested, with a moderate effect on external rotation (effect size 0.56). The decisive detail: only programs with active exercise or strength training produced gains. Programs without exercise produced no strength benefit at all. The 2025 network analysis then ranked concentric strengthening as the best single approach.
"Interventions with strength training helped every strength measure. Interventions without it helped none. That is about as clean as clinical evidence gets."
Start with the strength question. Across 28 studies, Zhang B and colleagues (2026) found that rehabilitation produced a moderate improvement in external rotation strength, with a standardized mean difference of 0.56 and a confidence interval from 0.39 to 0.74. External rotation is the cuff's signature job, so that is the most telling number. They also found smaller but real improvements in abduction (0.47), internal rotation (0.41), scaption (0.48), and flexion (0.25). In plain terms, rehab measurably rebuilt strength in the exact directions the cuff controls.
Then comes the sentence that should change practice. The authors reported that interventions which included strength training or active exercise had small-to-moderate effects on all strength outcomes, while interventions without exercise or strength training had no effects. The active ingredient was the loading itself. If a program did not make the shoulder work, it did not make the shoulder stronger.
2026 Meta-analysis: Strength Gains From Rehabilitation
Strength Direction Effect Size (SMD) Read
External rotation 0.56 Moderate
Scaption 0.48 Small to moderate
Abduction 0.47 Small to moderate
Internal rotation 0.41 Small to moderate
Flexion 0.25 Small
Now layer on the second review. Knowing that exercise works is useful. Knowing which exercise works best is more useful. Zhang W and colleagues (2025) ranked seven exercise types and found concentric strengthening training, meaning controlled work where the muscle shortens under load, came out on top for improving both pain and function. Eccentric strengthening, where the muscle lengthens under load, and traditional strength work were moderately effective and clearly beat lower-load options like motor control drills and isolated scapula exercises. When concentric work was not a fit for a patient, the authors named eccentric strengthening and motor control exercise as reasonable alternatives.
Put the two together and the message is not vague. Load the shoulder, favor real strengthening over gentle movement drills, and you get measurable gains in the strength, pain, and function that matter. This is the opposite of the "rest it and baby it" advice most people start with.
Does Surgery Beat Exercise for Rotator Cuff Shoulder Pain?
For most people, no. A 2019 Cochrane review found rotator cuff repair probably gives little or no pain improvement over exercise at one year, with only a small function difference of uncertain importance. A 2018 Lancet trial found keyhole decompression surgery performed no better than a placebo operation. Surgery has a role, but it is not the automatic first step.
This is where honest reporting matters, because the surgical option carries real cost and real risk, so the bar to justify it should be high. The 2019 Cochrane review by Karjalainen and colleagues synthesized randomized trials comparing rotator cuff repair against non-operative care, which was exercise with or without a steroid injection. At one year, across three trials and roughly 260 participants, moderate-certainty evidence showed surgery probably provided little or no improvement in pain compared with exercise. Function was about six points better with surgery on a 100-point scale, a small difference rated low-certainty. Patient-rated success was 873 in 1000 with exercise and 943 in 1000 with surgery, a gap that did not reach statistical significance (Karjalainen and colleagues, 2019).
"When a placebo operation matches the real one, the benefit was never coming from the scalpel."
The 2018 Lancet trial sharpens the point. Beard and colleagues ran the CSAW study, a placebo-controlled surgical trial for subacromial shoulder pain. They compared arthroscopic decompression, a placebo arthroscopy with no decompression, and no treatment. The decompression surgery produced no clinically important benefit over the placebo operation (Beard and colleagues, 2018). A sham surgery matching the real one is the strongest signal in medicine that the mechanism people assumed was helping was not the thing helping.
None of this says surgery is never right. A large traumatic tear in an active person, or a shoulder that fails a genuine trial of loaded rehab, can be a real surgical candidate, and that decision belongs with an orthopedic surgeon. The point is narrower and well supported: for the common, non-traumatic rotator cuff shoulder pain most people have, exercise is the reasonable first move, and surgery does not reliably beat it.
What This Means Clinically
In my practice, the job with a cranky shoulder is rarely to rest it and rarely to refer it straight to surgery. It is to confirm it is a load problem, calm the irritated tissue enough to start moving, and get the patient loading the cuff and shoulder blade progressively. Hands-on care lowers the cost of that first rep. The exercise does the rebuilding.
I see this shoulder in the office every week. Someone reaches for a shelf, feels a catch, starts avoiding the movement, and three weeks later the whole shoulder feels weak and guarded. They come in braced for the worst, half-expecting to hear they need a scan and a surgeon. Most of the time what they need is the opposite of rest: a graded return to loading the shoulder, plus enough hands-on work to make the first sessions tolerable. The evidence above is exactly what I am leaning on when I tell them that.
Hands-on care has an honest and limited role here, and I keep it in its lane. Soft-tissue work to the guarded muscles, joint mobilization to restore clean motion, and mobilizing a stiff mid-back and shoulder blade can take enough pressure off an irritated cuff that the first strengthening reps stop hurting. That is the value: I lower the barrier to entry so the patient can actually start the exercise that rebuilds the shoulder. I am not adjusting a tendon back to strength. The load does that. If someone wants to understand which shoulder and neck problems I treat and how they connect, I lay it out on the conditions we treat page.
The same upper-quarter logic runs through a related Forward Review commentary on the neck. Manual therapy that frees up a stiff segment, paired with exercise, tends to beat either one alone, a pattern I covered in the review of thoracic manipulation for neck pain. The shoulder blade sits on the rib cage right below that region, which is why a stiff mid-back so often shows up in a stubborn shoulder.
Patient Translation: How to Load a Cranky Shoulder
Start with light external rotation and rows using a band or a light weight, work in a range that provokes no more than mild, settling discomfort, and add a little load each week. Some ache during and shortly after is acceptable if it calms within a day. Sharp, spreading, or worsening pain, or true weakness, means stop and get evaluated.
The most common mistake is treating the shoulder as fragile. People do nothing, wait for it to feel normal, and it never does, because doing nothing is what let the capacity slip in the first place. The fix is a small, repeatable dose of loading, not a hero workout. A daily set of light external rotations with a band, a few controlled rows, and gentle overhead progressions as tolerated will do more over six weeks than any amount of rest.
Use pain as a dial, not a wall. Discomfort that rises during the exercise and settles within a day is generally fine and is often part of the process of loading a sensitized tendon. Pain that spikes sharply, spreads down the arm, or is clearly worse the next morning is a sign you outran the tissue's current tolerance, so you scale back and rebuild slower. The goal is steady progress in load, not a race. The cuff adapts to what you ask of it, so ask a little more each week.
"Load the shoulder like you are building a callus, not testing a limit."
If everything hurts and you cannot find a starting point that feels safe, that is exactly when a hands-on evaluation earns its place. Getting the irritated tissue to calm down and the shoulder blade moving again can open a window where the first loaded reps are tolerable, and that first tolerable rep is where most people get stuck. From there, the plan is progression, not protection.
When It Is Not a Rehab Problem, Get It Checked
Most rotator cuff shoulder pain is a load and irritation problem that responds to progressive strengthening. A few presentations are different and need medical evaluation before any exercise plan. Get checked promptly, and go to urgent or emergency care for the acute items, if you have any of these:
A sudden injury, a fall, or a heavy lift followed by true weakness, meaning you genuinely cannot lift or hold the arm, which can signal a full-thickness rotator cuff tear
Night pain paired with fever, unexplained weight loss, or feeling generally unwell, which can point to infection or something systemic
A new lump, mass, or visible swelling around the shoulder or upper arm
Numbness, pins and needles, or weakness spreading down the arm, or a hand that is getting clumsy, which points to a nerve, not the cuff
A shoulder that looks deformed or out of place after trauma, which may be a dislocation or fracture
A careful evaluation screens for each of these before any loading begins. Honest care means knowing what a rotator cuff problem is not.
Limitations: What We Do Not Know
The 2026 anchor review measured strength, not every outcome patients care about, and the pooled studies varied in how they trained and tested people, reflected in moderate-to-high statistical heterogeneity for some measures. It also excluded people with surgery or a diagnosis limited to a full-thickness tear, so its findings speak to the common cuff-related pain, not to every torn shoulder.
The 2025 network meta-analysis ranks exercise types using indirect comparisons, which are useful but weaker than head-to-head trials, and the individual trials were modest in size. A top ranking means most probable best on the available evidence, not proven best. The favored approach, concentric strengthening, is a direction of care, not a rigid prescription for every shoulder.
The surgical evidence has its own caveats. The Cochrane function difference favoring surgery was small and low-certainty, and both the Cochrane review and the CSAW trial concern specific populations and procedures rather than every shoulder surgery. Individual candidates, especially those with large traumatic tears, may still benefit from an operation.
Finally, this is editorial commentary, not a treatment plan. It concerns elective, non-emergency shoulder pain and does not apply to the red-flag presentations above, which require medical evaluation. What is right for your shoulder depends on an exam.
The Bottom Line
For the common rotator cuff shoulder pain most people have, the 2025 and 2026 evidence points one way: load it. Active exercise and strength training rebuild the shoulder, passive care does not, and surgery does not reliably beat a good exercise program. A painful cuff is usually an underpowered cuff. The fix is to earn the capacity back, and a hands-on reset can be the on-ramp that makes the first rep possible.
Get a Straight Answer on Your Shoulder
Walk in to Vanguard Chiropractic in Brookside
If your shoulder hurts to lift or reach and you are not sure whether to rest it, load it, or get it scanned, come in and get evaluated. I will tell you straight whether it is a load problem we can rebuild, or one of the few that needs a referral. No appointment needed.
Vanguard Chiropractic
1334 E 41st St, Brookside, midtown Tulsa, OK 74105
$40 per visit. No contracts. Stop any time.
Walk-in hours: Mon-Fri 10am-7pm and Sat 10am-2pm
Veteran-owned. Cash-pay, no insurance hassle.
Call (918) 948-7990
Frequently Asked Questions

Can rotator cuff shoulder pain heal without surgery?
For most people, yes. Rotator cuff shoulder pain is usually a load and irritation problem, not a full tear, and it responds to progressive strengthening. A 2026 review of 28 studies (Zhang B and colleagues) found rehabilitation with active exercise measurably rebuilt shoulder strength, while passive care did not. Surgery is reserved for specific cases like large traumatic tears or a shoulder that fails a real trial of loaded rehab.

What is the best exercise for rotator cuff shoulder pain?
A 2025 Bayesian network meta-analysis (Zhang W and colleagues) ranked concentric strengthening training, meaning controlled work where the muscle shortens under load, as the most effective single approach for both pain and function. Eccentric strengthening and traditional strength work were the next best. Simple external rotations and rows with a band or light weight are a practical place to start, adding a little load each week.

Should I rest or exercise a rotator cuff injury?
For the common non-traumatic case, controlled exercise beats rest. Rest lowers the demand and quiets pain briefly, but it also lets the cuff lose more capacity, so the shoulder gets more fragile over time. The 2026 evidence shows only programs that actually load the shoulder produce strength gains. Load it in a graded, tolerable way rather than avoiding movement. If a sudden injury caused true weakness, get evaluated first.

Does surgery work better than exercise for rotator cuff shoulder pain?
Usually not. A 2019 Cochrane review (Karjalainen and colleagues) found rotator cuff repair probably gives little or no pain improvement over exercise at one year, with only a small function difference of uncertain importance. A 2018 Lancet trial (Beard and colleagues) found keyhole decompression surgery no better than a placebo operation. Surgery has a role for specific injuries, but it is not the automatic first step for common cuff pain.

How long does it take to rebuild a rotator cuff with exercise?
The pooled trials measured change after at least six weeks of exercise, and meaningful strength gains typically build over that time frame and beyond. Tendons and muscles adapt gradually to progressive load, so consistency matters more than intensity. Expect a slow, steady climb rather than an overnight fix. If you have seen no progress after a genuine, well-scaled loading program, that is a reason to get re-evaluated.

When is shoulder pain a red flag that needs a doctor?
Get evaluated promptly, or go to urgent or emergency care for acute signs, if you have a sudden injury followed by true weakness or inability to lift the arm, night pain with fever or unexplained weight loss, a new lump or swelling, numbness or weakness spreading down the arm, or a shoulder that looks deformed after trauma. These can signal a full-thickness tear, infection, a systemic problem, a nerve issue, or a dislocation, none of which are rehab-first problems.

Cite This Commentary Forward J. Shoulder pain without surgery: what the 2025 evidence says about exercise. The Forward Review. 2026;1(6). https://vanguardchiro.com/research/rotator-cuff-shoulder-pain-exercise-2026/
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written and medically reviewed by Jason Forward, DC, a licensed chiropractor and US Navy veteran at Vanguard Chiropractic in Brookside, Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original study authors, the Journal of Orthopaedic and Sports Physical Therapy, the Journal of Orthopaedic Surgery and Research, Cochrane, The Lancet, or any institution. Individual results vary.
Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes hands-on care intended to restore movement and support exercise-based rehabilitation. No financial relationships with the cited authors or publishers.
Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.
Level of evidence: Two systematic reviews with meta-analysis (primary), one Cochrane systematic review, and one placebo-controlled randomized surgical trial. Certainty ranges from low to moderate depending on the outcome.
July 7, 2026

Randomized Trial Volume 1 · Issue 7 Weight Loss Knee Osteoarthritis

Ozempic and Knee Pain: What the 2024 NEJM Study Actually Shows

A landmark 2024 trial put the GLP-1 medication semaglutide up against knee osteoarthritis, and the knees got better as the weight came off. Here is the honest read of what the study proves, what it does not, and why the real headline is about mechanical load per pound, not a miracle drug. From a chiropractor who does not prescribe it and has no stake in whether you take it.

Jason Forward, DC, Vanguard Chiropractic, Brookside, Tulsa, Oklahoma Published July 7, 2026

✓ Medically reviewed by Dr. Jason Forward, DC, July 2026. Last updated July 2026.

Reviewing

Bliddal H, Bays H, Czernichow S, et al. Once-Weekly Semaglutide in Persons with Obesity and Knee Osteoarthritis (STEP 9). New England Journal of Medicine. 2024;391(17):1573-1583.

DOI: 10.1056/NEJMoa2403664 · PMID: 39476339

Key Points

In the STEP 9 trial, adults with obesity and knee osteoarthritis who took once-weekly semaglutide lost 13.7 percent of their body weight over 68 weeks, versus 3.2 percent on placebo (Bliddal and colleagues, 2024).
Their knee osteoarthritis pain also fell further. WOMAC pain scores improved by 41.7 points on semaglutide versus 27.5 points on placebo, on a 0 to 100 scale where higher means worse pain.
The mechanism most likely doing the work is mechanical. Every pound of body weight lost takes roughly four pounds of compressive load off the knee with each step (Messier and colleagues, 2005).
A separate 2024 network meta-analysis found that meaningful knee osteoarthritis pain relief can be expected once a person loses at least about 7 percent of body weight (Shahid and colleagues, 2024).
Semaglutide is not approved to treat knee osteoarthritis. STEP 9 is a strong signal about weight and joint load, not a green light to use the drug for a knee.
The durable, board-safe takeaway: reducing the load through the joint helps arthritic knees. Weight management, movement, and hands-on conservative care are the levers a chiropractor actually works with, alongside whatever a patient decides about medication with their physician.

Plain Language Summary

People taking Ozempic and similar drugs are noticing their knees hurt less. A 2024 study in the New England Journal of Medicine tested that head-on. Adults with obesity and knee arthritis who took semaglutide lost a lot of weight, about 13.7 percent of their body weight, and their knee pain dropped more than it did for people on a placebo.

The interesting part is why. The drug does not go to the knee and fix the cartilage. It helps people lose weight, and losing weight takes a huge amount of pressure off the knee joint with every single step. That is the real story here, and it is not new. We have known for twenty years that weight loss unloads the knee.

Ozempic is one way to lose weight. It is not the only way, and it is not a knee treatment. A chiropractor does not prescribe it. What we do is help you move better and hurt less while you work on the load side of the equation. This is an honest look at the evidence, not a pitch for a medication.

Why Everyone Is Asking About Ozempic and Knee Pain

GLP-1 drugs like Ozempic and Wegovy are everywhere, and people on them keep reporting that their joints feel better. The STEP 9 trial tested whether that is real for knee osteoarthritis. It is a fair question because knee arthritis is one of the most common and disabling joint problems in adults.

"The question worth answering is not whether the drug works. It is what the drug is actually doing to the knee."

Knee osteoarthritis is one of the most common causes of chronic joint pain in adults, and body weight is one of its biggest modifiable drivers. So when a wave of patients on GLP-1 weight-loss medications started saying their knees hurt less, researchers had a clear question to test. The STEP 9 trial, published in the New England Journal of Medicine in 2024, was built to answer it directly (Bliddal and colleagues, 2024).

Here is why this matters for anyone searching "ozempic knee pain" at 11pm with an aching joint. The internet is full of drug-company press releases and reblogged headlines, and almost none of them explain the biology in plain terms or tell you what the study cannot prove. I am a chiropractor. I do not prescribe semaglutide, I do not sell it, and I have no financial stake in whether you ever take it. That is exactly why I can give you a straight read of the evidence.

The short version: the study is legitimate and the result is real, but the headline most outlets missed is the mechanical one. The knee felt better largely because the load on it went down. That principle applies whether the weight comes off through a medication, a diet, or a barbell.

The Study: What STEP 9 Actually Measured

STEP 9 was a randomized, double-blind, placebo-controlled trial of 407 adults with obesity and moderate knee osteoarthritis. They were assigned 2 to 1 to once-weekly semaglutide 2.4 milligrams or placebo, both with lifestyle support, for 68 weeks. The two main measures were body weight change and knee pain measured by the WOMAC pain score.

Let me lay out the design so you can judge the weight it carries. STEP 9 enrolled 407 adults who had obesity and a clinical and radiographic diagnosis of knee osteoarthritis, specifically Kellgren-Lawrence grade 2 or 3, which is moderate structural change on X-ray. Participants were randomly assigned in a 2 to 1 ratio to receive either once-weekly injectable semaglutide at 2.4 milligrams or a matching placebo, and both groups also got lifestyle counseling. The trial ran for 68 weeks (Bliddal and colleagues, 2024).

"A randomized, placebo-controlled, double-blind trial is about the strongest single-study evidence a question like this can get."

That design matters. Randomized means chance decided who got the drug, so the groups start out comparable. Double-blind means neither the patients nor the researchers knew who got what, which strips out the placebo-driven bias that plagues pain research. Placebo-controlled means the comparison is against an inactive injection, not against nothing. This is a well-built trial, and it is the reason its result deserves to be taken seriously rather than dismissed as hype.

The two co-primary outcomes were the percentage change in body weight and the change in knee osteoarthritis pain as measured by the WOMAC pain score. WOMAC is a validated questionnaire that scores knee pain from 0 to 100, where a higher number means worse pain. A key secondary outcome was physical function, measured with the SF-36 questionnaire. So the trial was asking two linked questions at once: does the drug take weight off, and does the knee feel and work better when it does.

What STEP 9 Found

Both goals were met. Semaglutide produced a 13.7 percent average drop in body weight versus 3.2 percent on placebo. Knee pain improved by 41.7 WOMAC points versus 27.5 on placebo, a between-group edge of about 14 points. Physical function improved more too. The drug clearly beat placebo on weight and knee pain.

"The knees improved on placebo too. They just improved a lot more when the weight came off."

The weight result was large. People on semaglutide lost an average of 13.7 percent of their body weight over the 68 weeks, compared with 3.2 percent for those on placebo (Bliddal and colleagues, 2024). For a person starting at 250 pounds, 13.7 percent is roughly 34 pounds. That is not a trivial change, and it is squarely in the range where the knee-load research predicts a real benefit.

The knee result tracked the weight result. WOMAC pain scores improved by 41.7 points in the semaglutide group and by 27.5 points in the placebo group. Notice that both groups got better, which is normal in a supported trial where everyone is getting lifestyle attention. The point is that the semaglutide group improved by about 14 points more. Physical function, measured on the SF-36, also improved more with semaglutide, a mean gain of about 12 points versus 6.5 on placebo.

STEP 9 at a Glance (68 Weeks)

Outcome	Semaglutide 2.4 mg	Placebo
Body weight change	-13.7%	-3.2%
WOMAC pain improvement (0 to 100)	41.7 points	27.5 points
SF-36 physical function gain	~12 points	~6.5 points
Participants	407 adults, obesity + KL grade 2 to 3 knee OA

One number to keep in the front of your mind: semaglutide is not approved to treat knee osteoarthritis. STEP 9 studied people who had both obesity and knee arthritis, and the trial itself frames the finding as the effect of weight reduction on the joint. It is evidence about what happens to a knee when a person loses substantial weight. It is not a recommendation to take the drug for a knee problem, and I am not making one.

Does Losing Weight Actually Help Knee Pain?

Yes, and the biology is well established. The knee carries a multiple of your body weight with every step, so each pound lost removes roughly four pounds of compressive load per step. Research shows meaningful knee arthritis pain relief once weight drops by about 7 percent or more, with larger benefits near a 10 percent loss.

This is the part the drug headlines skip, and it is the part that actually helps you. The knee is a load-bearing joint. When you walk, the compressive force passing through it is several times your body weight because of how the muscles and levers around the joint work. That force multiplier is why weight matters so much at the knee specifically.

"Lose one pound and the knee feels about four pounds lighter with every step you take."

Put a number on it. A foundational 2005 study found that each single pound of body weight lost was associated with roughly a fourfold reduction in the compressive load through the knee per step (Messier and colleagues, 2005). Multiply that across the thousands of steps you take in a day, and a modest weight loss becomes an enormous reduction in cumulative joint stress over weeks and months. That is the engine underneath the STEP 9 result. Take weight off the frame and you take load off the joint.

How much do you need to lose before the knee notices? A 2024 systematic review and network meta-analysis of weight-loss trials in knee osteoarthritis found that significant pain relief can be anticipated once a person achieves at least about a 7 percent reduction in body weight (Shahid and colleagues, 2024). And the well-known IDEA trial showed that a weight loss of 10 percent or more, achieved through diet plus exercise, produced greater reductions in pain, better function, and measurably lower knee compressive loads than exercise alone (Messier and colleagues, 2013). The STEP 9 group cleared both of those thresholds comfortably at 13.7 percent.

OARSI 2019 osteoarthritis guideline (Bannuru and colleagues): the core, first-line treatments for knee osteoarthritis are patient education and structured land-based exercise, with dietary weight management for people who are overweight. Medications and procedures sit on top of that foundation, not in place of it.

What this means in plain terms: every major guideline body puts weight management and movement at the base of knee arthritis care. However the weight comes off, the load-reduction benefit to the joint is the same. For general, non-commercial background on osteoarthritis, the National Institute of Arthritis and Musculoskeletal and Skin Diseases is a solid starting point.

For the full guideline: Bannuru RR, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019.

What This Means Clinically

In practice, an arthritic knee has two problems: the structural wear, which no one can undo, and the load and movement around it, which we can change. Weight management lowers the load. Hands-on care and targeted exercise improve how the joint and the muscles around it move. Those are the honest levers, and they stack.

Here is how I think about a painful knee when someone walks into my clinic. There are two separate things going on. One is the structural change inside the joint, the cartilage thinning and the bony change you see on an X-ray. I cannot reverse that, and neither can anyone else with a conservative treatment, and any chiropractor who tells you otherwise is selling something. The other thing is everything around that structure: how much load passes through it, how well the joint glides, how strong and balanced the muscles that support it are. That second bucket is where real improvement lives, and it is a big bucket.

"You cannot un-wear the cartilage. You can change almost everything around it, and that is usually enough to hurt less and move more."

Weight management is the load lever, and STEP 9 is a vivid reminder of how powerful it is. Whether a patient gets there through a medication their physician prescribes, through diet, or through building an exercise habit, the payoff at the knee is the same reduction in mechanical stress. My job is not to weigh in on the drug. My job is to help with the movement side while that load work happens, and to be honest that the two work best together.

The knee is one of well over a hundred conditions I see, and it rarely travels alone. A stiff hip, a locked-up lower back, or a guarded gait all pile extra work onto a sore knee. Addressing the whole chain, not just the loudest joint, is the point of a full evaluation. You can see the range of what conservative care covers on our guide to the conditions we treat, and the knee sits inside that larger picture of how the body loads and moves.

There is also a bigger metabolic thread worth naming honestly. Excess weight, high blood sugar, and musculoskeletal pain tend to cluster together, which is one reason weight-focused treatments ripple out to the joints. I dug into the metabolic side of that overlap in a separate commentary on what a 2026 meta-analysis shows about diabetes and spine pain. The knee and the spine are different joints, but the lesson rhymes: metabolic health and mechanical pain are connected, and the honest fix works on both.

What Chiropractic Can and Cannot Do for an Arthritic Knee

Chiropractic does not cure osteoarthritis and does not prescribe weight-loss drugs. What conservative care can do is improve joint mobility, address the hips and back that overload a bad knee, guide safe strengthening, and lower the pain enough to keep you moving. Movement plus weight management is the combination the evidence supports.

Let me be plain about the boundary, because honesty is the whole point of this review. Chiropractic care does not regrow cartilage, does not cure osteoarthritis, and has nothing to do with prescribing or managing GLP-1 medications. If a patient asks me whether they should go on Ozempic, my answer is that it is a conversation for them and their physician, full stop. I report the evidence here. I do not steer that decision.

"The strongest thing conservative care offers an arthritic knee is this: it keeps you moving while the load comes down."

What conservative care can honestly offer is meaningful. Hands-on work can improve how the knee and the joints above and below it move, so the knee is not fighting a stiff hip or a guarded ankle. Targeted, progressive strengthening of the muscles that support the knee changes how force is shared across the joint. And getting pain down to a tolerable level is not a small thing, because pain is what stops people from walking, and walking is exactly the activity that both manages weight and feeds the joint. The goal is a loop that turns in the right direction: less pain, more movement, better load management, less pain again.

None of that is a cure, and I will not dress it up as one. For a knee with real structural arthritis, the realistic aim is better function and less pain, not a new joint. When the pain is a recurring mechanical pattern rather than a one-off flare, ongoing periodic care can help hold the gains, and I am straight about the time course involved. It is always a flat 40 dollars a visit, no contract, and you stop whenever you want. The medication question stays with your doctor. The movement and load question is where I can help.

When Knee Pain Needs a Doctor or the ER, Not a Chiropractor

Most knee osteoarthritis is a slow, mechanical problem that responds to load management and movement. A few knee presentations are not that, and they need medical evaluation right away, not conservative care. Seek prompt medical or emergency attention if you have any of these:

A hot, red, swollen knee with fever or feeling ill, which can signal joint infection (septic arthritis)
Calf pain, warmth, and swelling below the knee, which can signal a blood clot (deep vein thrombosis)
A knee that locks, gives way, or cannot bear weight after an injury, which can signal a fracture or an internal derangement
Rapidly worsening swelling after trauma, or an obvious deformity
New knee pain in someone with a history of cancer, or with unexplained weight loss and night pain

A careful evaluation screens for these before any hands-on treatment or exercise advice. Knowing what a problem is not is part of honest care.

Limitations: What STEP 9 Does Not Prove

STEP 9 studied semaglutide in people who had both obesity and knee osteoarthritis. It does not show that the drug helps knees in people who are not obese, and it does not compare the drug against diet or exercise achieving the same weight loss. So it cannot tell us whether semaglutide does anything for the knee beyond the weight it removes.

The trial ran 68 weeks. Osteoarthritis is a decades-long condition, so we do not know from this study whether the pain benefit holds up over years, or what happens to the knee if the weight returns after stopping the medication, which is a known pattern with GLP-1 drugs.

Semaglutide is not approved for osteoarthritis, and it carries its own side-effect profile, most commonly gastrointestinal. Those are matters for a prescribing physician, not a chiropractor, and nothing in this commentary should be read as medical advice about taking or not taking any medication.

Finally, this commentary covers ordinary, non-emergency knee osteoarthritis. It does not apply to the red-flag presentations listed above, which require medical evaluation.

The Bottom Line

STEP 9 is a strong trial with a simple lesson underneath a flashy headline: take substantial weight off the frame and the knee feels it, because each pound removes about four pounds of load per step. The drug is one way to lose the weight. It is not a knee treatment, and a chiropractor does not prescribe it. What conservative care can do is keep you moving and lower the pain while the load comes down, and movement plus weight management is the combination the evidence keeps pointing to.

If a Sore Knee Is Keeping You Off Your Feet

Walk in to Vanguard Chiropractic in Brookside

If knee, hip, or back pain is the wall between you and the movement that keeps weight off and joints healthy, a hands-on evaluation is a straightforward first step. Walk in, get assessed, and get a plan for moving better. No referral and no appointment needed.

Vanguard Chiropractic
1334 E 41st St, Brookside, midtown Tulsa, OK 74105
$40 per visit. No contracts. Stop any time.
Walk-in hours: Mon to Fri 10am to 7pm and Sat 10am to 2pm
Veteran-owned. Cash-pay, no insurance hassle.

Call (918) 948-7990 Or call now to ask a question

Frequently Asked Questions

Does Ozempic help with knee pain?

In the 2024 STEP 9 trial, adults with obesity and knee osteoarthritis who took semaglutide, the drug in Ozempic and Wegovy, had greater knee pain relief than those on placebo, with WOMAC pain improving 41.7 points versus 27.5 (Bliddal and colleagues, 2024). The benefit tracked closely with weight loss. The most likely reason the knee felt better is that losing weight took mechanical load off the joint, not a direct drug effect on the cartilage.

How much weight do I need to lose to help my knees?

A 2024 network meta-analysis found that meaningful knee osteoarthritis pain relief can be expected once a person loses at least about 7 percent of body weight (Shahid and colleagues, 2024). The well-known IDEA trial found even larger benefits around a 10 percent loss (Messier and colleagues, 2013). The mechanism is mechanical: each pound lost removes roughly four pounds of compressive load through the knee per step, and that adds up across thousands of steps a day.

Is Ozempic approved to treat knee osteoarthritis?

No. Semaglutide is not approved as a treatment for knee osteoarthritis. STEP 9 studied it in people who had both obesity and knee arthritis, and the finding is best understood as the effect of substantial weight loss on the joint. Whether to use the medication is a decision for a patient and their prescribing physician. A chiropractor does not prescribe it, and this commentary is not medical advice about any drug.

Can losing weight another way help my knees as much?

The benefit to the knee comes from the weight loss itself, which reduces the mechanical load through the joint, so it does not depend on how the weight comes off. Diet and exercise trials such as IDEA show the same load reduction and pain benefit (Messier and colleagues, 2013). The drug is one route to weight loss, not a special knee therapy. Movement and weight management are first-line care in every major osteoarthritis guideline.

Can a chiropractor cure knee osteoarthritis?

No, and any provider who claims to cure osteoarthritis is overpromising. The structural wear inside an arthritic joint cannot be reversed with conservative care. What a chiropractor can do is improve how the knee and the joints around it move, guide safe strengthening, address a stiff hip or back that overloads the knee, and lower pain enough to keep you active. The realistic goal is better function and less pain, not a new joint.

When is knee pain an emergency rather than arthritis?

Get prompt medical care, not a chiropractor, if you have a hot, red, swollen knee with fever (possible joint infection), calf pain with warmth and swelling (possible blood clot), a knee that locks or cannot bear weight after an injury (possible fracture), rapid swelling or deformity after trauma, or new knee pain with a history of cancer. These are not mechanical arthritis and need medical evaluation right away. A careful screen rules them out before any treatment.

Cite This Commentary Forward J. Ozempic and knee pain: what the 2024 NEJM study actually shows. The Forward Review. 2026;1(7). https://vanguardchiro.com/research/ozempic-knee-pain-semaglutide-2026/

Editorial Disclosure

The Forward Review is editorial commentary, not peer reviewed. Written and medically reviewed by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Brookside, Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the STEP 9 investigators, the New England Journal of Medicine, Novo Nordisk, OARSI, or any institution. It is not medical advice, and it is not advice about starting, stopping, or dosing any medication. Individual results vary.

Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes hands-on care intended to restore movement. He does not prescribe, sell, or profit from any weight-loss medication. No financial relationships with the cited authors or publishers.

Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.

Level of evidence: One randomized controlled trial (primary), two randomized weight-loss trials, one systematic review with network meta-analysis, and one international guideline. Certainty ranges from moderate to high for the weight-and-load relationship.

July 7, 2026

Home›The Forward Review›Running and Knee Arthritis
The Forward Review Live Commentary Vol. I · Issue 5 · July 2026
Meta-Analysis Volume 1 · Issue 5 Running Knee Arthritis
Is Running Bad for Your Knees? The Evidence Says the Opposite
The fear that running grinds your knees into arthritis is one of the most repeated ideas in fitness. A meta-analysis of 125,810 people found knee and hip arthritis in 3.5 percent of recreational runners versus 10.2 percent of people who did not run. Here is the honest read of what running does to a knee, and the load-management rules that actually protect it.
Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published July 7, 2026
✓ Medically reviewed by Dr. Jason Forward, DC, July 2026. Last updated July 2026.
Reviewing
Alentorn-Geli E, Samuelsson K, Musahl V, Green CL, Bhandari M, Karlsson J. The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2017;47(6):373-390.
DOI: 10.2519/jospt.2017.7137 · PMID: 28504066
Key Points
A 2017 systematic review and meta-analysis of 25 studies and 125,810 people found hip and knee osteoarthritis in 3.5 percent of recreational runners, compared with 10.2 percent of sedentary non-runners (Alentorn-Geli and colleagues, 2017).
The same analysis found a higher rate, 13.3 percent, in competitive and elite runners. The relationship is a U-shape: too little movement and very high-volume competitive load both sit above the recreational sweet spot.
A separate cross-sectional study of 2,637 adults in the Osteoarthritis Initiative found no increased risk of symptomatic knee arthritis in runners, and stated plainly that in people without arthritis, running does not appear to be detrimental to the knees (Lo and colleagues, 2017).
Cartilage responds to a run by thinning a small amount, roughly 3 to 5 percent, then recovering. A 2023 meta-analysis of 446 knees found these changes small and transient, not damage (Coburn and colleagues, 2023).
The mechanism is adaptation. Cartilage and bone get stronger in response to repeated, tolerable load, the same way muscle does. The real risk is not running, it is bad load management: too much, too soon, or training through a warning-sign injury.
Structured exercise is a core, first-line treatment for knee osteoarthritis, not something to avoid once arthritis is present (OARSI guideline, Bannuru and colleagues, 2019).
Plain Language Summary
The idea that running wears out your knees sounds obvious, and it is mostly wrong. When researchers pooled data on more than 125,000 people, recreational runners had less knee and hip arthritis than people who sat still. Running was linked to healthier joints, not more broken ones.
There is a catch, and it is honest. The lowest arthritis rate belonged to recreational runners. People who ran at a very high competitive volume for many years had a higher rate. So the protective effect is about a sensible dose, not unlimited mileage. Your knee is a tissue that adapts to load, and like any tissue it can be overloaded.
What actually hurts knees is not the act of running. It is going from zero to too much, or ignoring a real injury and pushing through it. If your knees are stiff, sore, or you are starting from scratch, the fix is to scale the load and build tolerance, and sometimes to get the joint moving well first. That is exactly what hands-on care is for.
Why This Question Matters
Millions of people avoid running because they believe it destroys their knees. If that belief is wrong, they are skipping one of the cheapest, most effective things a person can do for long-term health. Knowing what running actually does to cartilage is one of the most practical questions in exercise medicine.
"The clinical question is not whether running is safe for knees. It is what dose, and how you build up to it."
Almost every week, someone in my office tells me they quit running because a friend, a relative, or an old coach warned them it would grind their knees to bone. It is one of the most durable myths in fitness. It feels intuitive: pounding a hard surface thousands of times must wear something down. The problem is that the human knee is not a machine part, and the data do not support the fear.
This matters because inactivity is genuinely dangerous. Osteoarthritis is the most common form of arthritis, and its risk factors include age, prior joint injury, obesity, and joint overuse (National Institute of Arthritis and Musculoskeletal and Skin Diseases). Two of those, obesity and deconditioning, get worse when people stop moving out of fear. If the fear of running is unfounded, then talking someone out of that fear is real preventive care.
The Study: 125,810 People
Alentorn-Geli and colleagues pooled 25 studies covering 125,810 people to compare hip and knee arthritis rates across three groups: recreational runners, competitive or elite runners, and sedentary controls. It is the largest synthesis of its kind, and it separated ordinary runners from high-volume athletes, which is the distinction that matters most.
The 2017 review published in the Journal of Orthopaedic and Sports Physical Therapy set out to answer the exact question people worry about. The authors gathered every study they could find comparing joint arthritis in runners versus non-runners, then split the runners into two meaningful groups. Recreational runners were everyday runners with no elite competition history. The competitive group was made of professional, elite, or ex-elite athletes with very high training volumes over many years (Alentorn-Geli and colleagues, 2017).
Splitting those groups is the whole point. Lumping a weekend 5K runner together with someone who logged 100-mile training weeks for two decades hides the real signal. Separated, the pattern is clear and, honestly, more useful than a simple yes or no.
This is a meta-analysis of mostly observational studies, so it reports associations, not proof of cause. I cover what that limits below. But the sample size and the sensible group split make it the anchor for any honest answer to the knee question.
What They Found: A U-Shaped Curve
Recreational runners had the lowest arthritis rate at 3.5 percent. Sedentary non-runners were far higher at 10.2 percent. Competitive and elite runners came in at 13.3 percent, above the sedentary group. The relationship is a U-shape: the middle dose protects, while both no movement and extreme volume sit higher.
"Recreational running was linked to less than half the arthritis rate of sitting still."
Here is the finding that should end the myth for most people. Across the pooled data, hip and knee osteoarthritis showed up in 3.5 percent of recreational runners, 10.2 percent of sedentary controls, and 13.3 percent of competitive runners (Alentorn-Geli and colleagues, 2017). Read that again. The everyday runners had the healthiest joints in the study, better than the people who did not run at all.
Hip and Knee Osteoarthritis Prevalence, Alentorn-Geli 2017
Group OA Prevalence 95% Confidence Interval
Recreational runners 3.5% 3.4% to 3.6%
Sedentary controls 10.2% 9.9% to 10.6%
Competitive / elite runners 13.3% 11.6% to 15.2%
The competitive number is the honest caveat, and I will not bury it. Runners at the elite end, very high mileage for many years, often with old injuries and surgeries in the mix, had the highest rate of the three. That is why the true shape of the relationship is not a straight line but a U. Too little load and extreme chronic load both associate with more arthritis. The recreational middle is the sweet spot.
Two other large studies point the same direction. A meta-analysis in the American Journal of Sports Medicine found no meaningful difference in knee symptoms between runners and non-runners and even a protective association against needing knee surgery (Timmins and colleagues, 2017). And a cross-sectional analysis of 2,637 people in the Osteoarthritis Initiative found runners had no increased risk of symptomatic knee arthritis, concluding that in people without arthritis, running does not appear to be detrimental to the knees (Lo and colleagues, 2017).
Does Running Wear Out Cartilage?
A single run does thin knee cartilage slightly, by roughly 3 to 5 percent, but it rebounds within hours to days. A 2023 meta-analysis of 446 knees found these changes small and temporary, not a sign of damage. Over time, repeated tolerable load makes cartilage and bone adapt and get more resilient, not weaker.
The intuition behind the myth is that cartilage is like a brake pad that only wears down. That is not how living tissue works. When researchers imaged knees before and after running, they did see cartilage compress and lose a little thickness and volume right after a run, in the range of about 3.3 to 4.9 percent depending on the region. But those changes were small, and they recovered. The authors of that 2023 review concluded a single bout of running is not detrimental to knee cartilage (Coburn and colleagues, 2023).
"Cartilage is not a brake pad. It is a living tissue that adapts to the load you give it."
Think of it the way you think about muscle. Load it in a tolerable dose, let it recover, and it comes back stronger. Cartilage and the bone beneath it behave similarly. Repeated, moderate impact signals the joint to maintain and strengthen its tissue. That is the load-then-recover adaptation model, and it is the same principle that governs the companion research on why movement, not rest, is first-line care for ongoing pain, which I break down in this Forward Review on activity and chronic pain. Rest does not condition a joint. Sensible load does.
The failure mode is not impact itself, it is overload without recovery. When you exceed what the tissue is currently ready for, whether through a sudden mileage jump, poor recovery, or training through an injury, you tip from adaptation into irritation. That is where knee problems actually come from, and it is entirely a load-management problem, not an argument against running.
OARSI 2019 guideline (Bannuru and colleagues): for knee osteoarthritis, structured land-based exercise and arthritis education are core treatments, strongly recommended for nearly all patients regardless of disease severity or other conditions.
What this means in plain terms: even after arthritis is diagnosed, the guideline says the answer is more appropriate movement, not less. Motion is medicine for the arthritic knee, prescribed and progressed sensibly.
For the full guideline: Bannuru RR, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019.
What This Means Clinically
In practice, the question is rarely whether a patient should move. It is how to get a stiff, guarding knee moving well enough to build the load tolerance that protects it. Restoring motion at the knee, hip, and ankle, then progressing activity on purpose, is how running becomes protective rather than punishing.
The runners and lifters I see in Tulsa almost never have a running problem. They have a load-management problem wearing a running costume. Someone doubles their weekly mileage before a race and their knee flares. Someone comes back from a layoff and trains like they never left. Someone has a cranky hip or a stiff ankle that quietly forces the knee to absorb load it was never meant to. The knee gets blamed, but the knee is usually the victim, not the culprit.
This is where hands-on care earns its place. When the hip or ankle loses motion, the knee compensates, and the tissue around it guards and tightens. Restoring mechanical motion up and down the chain, plus targeted soft-tissue work, can take the abnormal load off the knee so the joint can do its real job. I am not claiming an adjustment cures arthritis or rebuilds cartilage. I am saying it can restore the movement that lets you load the joint the way the research says keeps it healthy. Knee, hip, and gait complaints are part of the full list of what I work with, laid out on the conditions we treat in Tulsa page.
If You Already Have Knee Arthritis
A diagnosis of knee osteoarthritis is not a stop sign for movement. The guideline evidence is clear that structured, progressed activity is core treatment, not a risk (Bannuru and colleagues, 2019). What changes is the dose and the supervision. For an arthritic knee, that often means starting with lower-impact loading, building the muscle that supports the joint, and progressing carefully rather than avoiding load out of fear. When a knee keeps flaring in a recurring mechanical pattern, ongoing care makes sense: keep the joint and the chain moving, reassess as symptoms change, and adjust the plan. At Vanguard, that is a $40 walk-in visit, no contract, and you stop whenever you want. The goal the whole time is to keep you moving on your own.
Patient Translation: Manage the Load, Keep the Knee
Protect your knees by scaling load, not by quitting. Build mileage slowly, respect recovery days, keep your hips and ankles moving, and add strength work. Aches that ease as you warm up are usually fine. Sharp pain, swelling, locking, or a knee that gives way means back off and get it checked.
The biggest mistake I see is people going from zero to too much, hurting themselves, and concluding that running is the enemy. It is not. Bad progression is. If you are starting from a stiff, deconditioned baseline, a short easy run or brisk walk you can repeat the next day beats a heroic effort that leaves you limping for a week. Consistency builds tolerance. Tolerance builds resilient tissue.
"The knee-saver is not avoiding load. It is respecting the dose your tissue is ready for today."
This scaling rule is not just for beginners, and I hold myself to it. I train at CrossFit Jenks, and the same principle governs a loaded barbell and a gymnastics movement as it does a recovery run. A kipping pull-up, a butterfly pull-up, or a chest-to-bar pull-up is a great movement when your shoulders, grip, and midline are ready for it, and a fast way to get hurt when they are not. The fix is never to quit moving. It is to scale the movement to the body in front of it, build the prerequisite strength, and progress on purpose. Knees are no different. Build the tissue, then ask more of it.
A few practical rules protect knees without giving up running. Increase weekly volume gradually rather than in big jumps. Keep at least one or two easy or rest days so tissue can recover and adapt. Strengthen the muscles around the hip and knee, because strong muscle is a shock absorber the joint relies on. And keep the neighboring joints, the hips and ankles, moving well so the knee is not forced to cover for them. If everything is stiff and you do not know where to start, that is exactly the moment a hands-on reset helps most, by getting motion back so the strengthening and the miles become possible.
When to Skip the Clinic and Get Urgent Care
Most knee aches from running are mechanical and respond to load management and hands-on care. A few signs are not mechanical and need prompt medical evaluation, not a chiropractor. Seek urgent or emergency care if you have any of these:
A hot, red, swollen knee with fever or feeling unwell, which can signal joint infection
A knee that locks, buckles, or gives way, or a pop with immediate swelling after a twist or fall, which can signal a ligament or meniscus tear
Inability to bear weight or put the leg straight after an injury, which can signal a fracture
Calf pain, swelling, warmth, or redness in one leg, which can signal a blood clot and needs same-day evaluation
Numbness, spreading weakness, or a foot that drags, which points to a nerve problem, not a simple joint ache
A careful evaluation screens for these before any treatment or exercise advice. Honest care means knowing what a joint problem is not.
Limitations: What We Do Not Know
The anchor meta-analysis pools mostly observational studies, so it shows association, not cause. Runners may self-select for healthier joints, lower body weight, and fewer prior injuries, and those factors, not running itself, could drive part of the lower arthritis rate. The design cannot fully separate them.
The competitive-runner finding of 13.3 percent comes from elite athletes who often carry old injuries and surgeries, so it should not be read as proof that mileage alone causes arthritis. Confounding by injury history is likely.
The cartilage-imaging evidence for the load-then-recover model is rated low certainty by its own authors, and the follow-up windows were short. It supports that a single run is not harmful, not that any amount of running is safe for every knee.
These findings are about people without significant existing joint disease starting or continuing recreational running. They do not override individual medical advice for a knee that is already injured, unstable, or severely arthritic. If you have red-flag signs or a known joint problem, get evaluated before changing your training.
The Bottom Line
Running does not wear out normal knees. The largest analysis we have found arthritis in 3.5 percent of recreational runners versus 10.2 percent of people who sat still. Cartilage adapts to sensible load and recovers from it. The real risk is bad load management, not impact. Scale the dose, respect recovery, keep the whole chain moving, and your knees are more likely to thank you for running than to punish you for it.
Get Your Knees Moving Right
Walk in to Vanguard Chiropractic in Brookside
If a stiff, cranky knee is keeping you from the movement you know would help, a hands-on evaluation can find where the load is going wrong and get the joint moving again. Walk in, get assessed, and train with a plan. No referral and no appointment needed.
Vanguard Chiropractic
1334 E 41st St, Brookside, midtown Tulsa, OK 74105
$40 per visit. No contracts. Stop any time.
Walk-in hours: Mon to Fri 10am to 7pm and Sat 10am to 2pm
Veteran-owned. Cash-pay, no insurance hassle.
Call (918) 948-7990
Frequently Asked Questions

Is running bad for your knees?
For most people, no. A 2017 meta-analysis of 125,810 people (Alentorn-Geli and colleagues) found hip and knee arthritis in 3.5 percent of recreational runners, compared with 10.2 percent of sedentary non-runners. Everyday running was linked to healthier joints, not more arthritis. The exception is very high competitive mileage over many years, which sat higher at 13.3 percent. Sensible recreational running appears protective for normal knees.

Does running cause knee arthritis?
The evidence does not support that for recreational running. A cross-sectional study of 2,637 adults (Lo and colleagues, 2017) found no increased risk of symptomatic knee arthritis in runners and concluded that in people without arthritis, running does not appear to be detrimental to the knees. What raises risk is prior joint injury, obesity, and overload, not the act of running at a sensible dose.

Does running wear down cartilage?
A single run thins knee cartilage a small amount, roughly 3 to 5 percent, then it recovers within hours to days. A 2023 meta-analysis of 446 knees (Coburn and colleagues) found these changes small and transient, not damage. Cartilage adapts to repeated tolerable load and gets more resilient over time, similar to how muscle responds to training. It is living tissue, not a brake pad that only wears out.

Can you run if you already have knee arthritis?
Often yes, with the right dose and guidance. The OARSI 2019 guideline (Bannuru and colleagues) lists structured exercise as a core, first-line treatment for knee osteoarthritis. For an arthritic knee that usually means starting lower-impact, building supporting muscle, and progressing carefully rather than avoiding movement. Get evaluated first if your knee is unstable, severely arthritic, or showing red-flag signs, then build a plan you can progress safely.

How do I protect my knees when I run?
Manage the load. Increase weekly mileage gradually instead of in big jumps, keep easy or rest days for recovery, strengthen the muscles around the hip and knee, and keep your hips and ankles mobile so the knee is not forced to compensate. Aches that ease as you warm up are usually fine to work through. Sharp pain, swelling, locking, or a knee that gives way means back off and get it checked.

Can a chiropractor help with knee pain from running?
Often, when the pain is mechanical. Runners' knee pain frequently traces to a stiff hip or ankle or to guarding muscles that dump extra load onto the knee. A hands-on assessment can find where motion is lost and restore it, plus targeted soft-tissue work, so the joint loads correctly again. At Vanguard Chiropractic in Brookside, that is a $40 walk-in visit, no contract, and you stop any time. It supports your training, it does not replace it.

Cite This Commentary Forward J. Is running bad for your knees? The evidence says the opposite. The Forward Review. 2026;1(5). https://vanguardchiro.com/research/is-running-bad-for-your-knees-2026/
Related Reading
Return to The Forward Review
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written and medically reviewed by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original study authors, their institutions, or the guideline bodies cited. Individual results vary.
Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes hands-on care intended to restore movement. No financial relationships with the cited authors or publishers.
Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.
Level of evidence: Three systematic reviews or meta-analyses and one large cross-sectional cohort (primary evidence), one international clinical guideline, and one government health resource. Certainty ranges from low (cartilage-imaging data) to moderate (pooled prevalence).
July 7, 2026

Strength Direction	Effect Size (SMD)	Read
External rotation	0.56	Moderate
Scaption	0.48	Small to moderate
Abduction	0.47	Small to moderate
Internal rotation	0.41	Small to moderate
Flexion	0.25	Small

Group	OA Prevalence	95% Confidence Interval
Recreational runners	3.5%	3.4% to 3.6%
Sedentary controls	10.2%	9.9% to 10.6%
Competitive / elite runners	13.3%	11.6% to 15.2%

FR Specialty: Sports Injury

What Actually Helps a Child With ADHD, Ranked by Evidence Instead of Popularity

Start with the finding nobody states

The ranking

1. Sleep, and why it outranks everything

2. Behavioural parent training, the half that gets skipped

3. Exercise, where the type matters more than the amount

4. Micronutrients, the biggest single number with the biggest caveats

5. Omega-3, the one everyone writes about

6. Elimination diets, deliberately demoted

7. The gut-lining claim, and why it is not a target

What this means for you

What we do not know

Reader questions

Citations

Hands-On Therapy for Plantar Fasciitis: What a 2026 Study Found

What the 2026 study on manual therapy for plantar fasciitis found

Why foot and ankle joint mechanics matter for heel pain

What this means if your first steps in the morning are the worst

How I approach manual therapy for plantar fasciitis at Vanguard Chiropractic

When it is not plantar fasciitis, and when to get imaged

The honest limitations of this study

Common questions about manual therapy for plantar fasciitis

Can a chiropractor treat plantar fasciitis?

How fast does manual therapy for plantar fasciitis work?

Does the treatment actually change the plantar fascia, or just mask pain?

Do I need custom orthotics too?

When should I see a doctor instead of getting my foot adjusted?

Do I need insurance or a referral to come in?

Come see me in Brookside

Why Treating the Mid-Back Helps the Shoulder: 2026 Thoracic Manual Therapy Evidence

What the 2026 review actually studied

Why does treating the mid-back help the shoulder?

Scapulohumeral rhythm and thoracic extension

What this means for overhead athletes and CrossFit

What this means for you

Where the shoulder needs more than an adjustment

The honest limitations

Common questions about mid-back and shoulder pain

How can my mid-back be the cause when my shoulder is what hurts?

Does the 2026 study prove thoracic treatment cures shoulder pain?

Is this the fast, popping kind of adjustment?

I lift overhead at the gym. Will this help my shoulder pinch?

How many visits will I need?

Do I need a referral or insurance to come in?

Come see me in Brookside

Key Points

Why This Question Matters

The Studies

What Rotator Cuff Shoulder Pain Actually Is

What the Evidence Shows: Exercise Builds It, Passive Care Does Not

Does Surgery Beat Exercise for Rotator Cuff Shoulder Pain?

What This Means Clinically

Patient Translation: How to Load a Cranky Shoulder

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Frequently Asked Questions

Editorial Disclosure

Key Points

Why Everyone Is Asking About Ozempic and Knee Pain

The Study: What STEP 9 Actually Measured

What STEP 9 Found

Does Losing Weight Actually Help Knee Pain?

What This Means Clinically

What Chiropractic Can and Cannot Do for an Arthritic Knee

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Frequently Asked Questions

Editorial Disclosure

Key Points

Why This Question Matters

The Study: 125,810 People

What They Found: A U-Shaped Curve

Does Running Wear Out Cartilage?

What This Means Clinically

If You Already Have Knee Arthritis

Patient Translation: Manage the Load, Keep the Knee

Walk in to Vanguard Chiropractic in Brookside

Frequently Asked Questions

Editorial Disclosure