A Plea For Your Knee
In our physical therapy clinics, we treat patients with knee pain on a daily basis. It has become more common to train younger clients with a history of knee injury and ongoing knee pain. Jane Brody’s recent *article in the New York Times has some excellent advice on the care and management of knee pain problems. I have some further suggestions and clarifications.
The mass portion of the Force = Mass x Acceleration formula needs to be at an appropriate level for your knees to stay healthy. Carrying extra body fat creates an environment that invites knee wear and tear. The common knee pulverizing mistake is to perform high impact exercise activities in an effort to lose fat. If you are twenty pounds overweight, do not run, stadium step, soccer, tennis, or pickleball. Start with strength training and low impact cardio. Lose the fat first, and even then, the lower impact activity will be healthier for your knees. From the overweight client limping into the clinic I get the “I need to move around to lose weight” protest. I am sorry, but fat loss is primarily a function of dietary alteration. Exercise has very little impact on body fat levels if you do not eat properly.
Train the Way You Wish to Play
A properly planned fitness program makes your knees more durable (fewer injuries) when you participate in your favorite recreational activity. The training must be tailored to your activity goals. If your goal is to play tennis, then you must perform three dimensional deceleration / acceleration activities as part of your training program. Yoga will not prepare your knees for tennis. If you want to water ski, then you must perform strength training for your back, hips, and knees. Distance running will not prepare your knees for water skiing. If hockey is your recreational past time, you need to be strong, well conditioned and competent in all planes of motion. Long duration recliner intervals will not prepare your knees for hockey.
If your hips do not move well, your knees will pay the price. In this age of all day sitting and minimal physical activity, hip function is at an all time low. Physical therapy patients with knee pain nearly always present with glaring restrictions in hip range of motion and strength. If your knees hurt, dedicate some training time to restoring hip rotation and hip extension movement. Learn how to perform some remedial gluteal activation drills. Learn a proper hip hinge, squat and a pain free lunge pattern.
Participation in a single inappropriate activity can produce a lifetime of knee trouble. That box jump workout of the day- maybe not. The warrior, electric shock, mud hole, death run–bad idea. Trampoline with the grandchildren–what were you thinking!
Be Proactive and Seek Treatment For Knee Pain
“Training through the pain” can take a graceful athlete and turn them into a lifelong speed limper. The presence of pain changes the way your brain controls movement. Left untreated, it can permanently alter neural signals and produce movement patterns that linger long after the pain has resolved. Live with enough cycles of inefficient movement and you develop early breakdown in the knee.
Michael O’Hara, PT, OCS, CSCS
*What I Wished I’d Known About My Knees, Jane Brody, New York Times. July 3, 2017
Read the NY Times article here: https://www.nytimes.com/2017/07/03/well/live/what-i-wish-id-known-about-my-knees.html?_r=0
We all need basic competence in fundamental movement patterns to function at an optimal level. A deep and stable squat keeps us free from injury and competent on the field of play. In physical therapy, we evaluate performance of the squat pattern with nearly every patient. One of the most common and damaging squat faults is an inward deviation of the knee during the squat.
Genu valgus is the term given to the inward deviation of the knee during a squat. Female athletes often land from a jump in a valgus knee position. Lower back pain patients are often unable to transfer out of a chair or ascend a step without significant inward deviation of the knee. This movement fault is not a healthy method of moving and should be trained away as quickly as possible. One of the simplest exercises to remedy genu valgus is the mini band squat.
Prepare to be frustrated when attempting to restore a movement pattern. Training movement demands higher neurological control than muscle isolation type training. Anyone can quickly master the preacher bench curl or seated knee extension, but restoring a squat pattern is hard work. Repetition drives the neural retraining that produces results.
MINI BAND SQUAT
You will need a mini resistance band. You can purchase them from www.performbetter.com ($2-$3 each). Place the band just above your knees. Position the feet shoulder width apart. The toes can point out about 20-30 degrees. Grip the floor with the feet—push the toes into the floor. Reach the arms forward and push the hips back. Descend into a squat and at the same time drive your knee outward into the resistance of the mini band. Hold the bottom position for five seconds and then return to the starting position. You should feel the gluteal muscles working while in the bottom part of the squat.
Pick an easy resistance level. Do not start with a heavy blue or black band. Only travel to a squat depth you can move through and remain comfortable and pain-free. You do not have to squat to the floor. As your motor control improves, you will be able to travel into a fuller movement pattern.
Perform five repetitions and then rest. Work up to four sets of five repetitions.
-Mike O’Hara, P.T., OCS, CSCS
To view a video demonstration of Mini Band Squats, click on the link below:
The knee meniscus is a cartilage structure located on the top of the tibia, the bottom bone of the knee. Most of us are unaware of our meniscus until it becomes damaged. At present, we can only repair or remove a meniscus, leaving a less than optimal operational environment for the knee joint. Melinda Beck wrote an interesting article in the May 4, 2015 edition of The Wall Street Journal on breakthroughs with meniscus replacements. The research looks promising, and hopefully, it will soon be available to the aging baby boomer population. In the meantime, what steps can we take to keep our knees healthy and pain-free.
Maintain a normal body weight
Larger loads on your legs produce more wear and tear forces on your joints.
This becomes more important as you get older. A single ill-conceived activity can produce a lifetime of knee trouble. That box jump workout of the day? Maybe not. Spartan, warrior, electric shock, mud hole, death run? Bad idea. Trampoline with the grandchildren? What were you thinking? We hear this in the clinic every day.
Reduce the number of lower extremity impact events in your fitness program
The current trend in fitness is toward a greater number of high speed deceleration events in a training session. This increases the opportunity for break down in the joint and a visit to the orthopedic surgeons office. My suggestion is that we devise training programs that produce a strong metabolic and/or strengthening response while managing impact.
Get stronger in lunges, squats, step ups, and hip hinge exercises
Your knee functions with the foot on the ground, in the standing position. The knee joint operates in coordination with the joints above and below the knee. The neurological component of balance and proprioception is involved in every knee activity. Training in a seated, non-weight bearing position with no coordination or balance demands is a waste of valuable training time and often makes knee pain problems worse. Get better at movement patterns that teach the joints and muscles of the lower extremity to work as a team.
Don’t ignore pain
The majority of our brain is devoted to managing movement. The presence of pain neurologically changes brain signals and alters how we move. Left untreated it can permanently alter neurological control, creating aberrant movement patterns that linger long after the pain has resolved. Perform enough cycles of inefficient movement and you develop early breakdown of essential joint structures. “Training through the pain” can take a graceful athlete and turn him or her into a lifelong speed limper.
Get a Functional Movement Screen (FMS)
To make the fitness journey as efficient and productive as possible, you must begin with an evaluation. I advise everyone have a FMS evaluation every six months. It is the fitness equivalent of taking your blood pressure during your annual physical. Find out where you excel and where you struggle in basic movement patterns. Let the FMS help guide your fitness decisions and your road will be smoother and more direct.
To read the article “New Fixes for Worn Knees,” click on the link below:
-Michael O’Hara, P.T., OCS, CSCS
Last summer, Marty started having pain in the front of his right knee. Initially, he only had pain at the end of a work day, or whenever he had to perform more stair climbing. Rest resolved the pain, but over time, it took less activity to recreate the symptoms. Marty had an x-ray that showed arthritis in his knee and significant thinning of the joint cartilage. After evaluation by an orthopedic surgeon, Marty had visco-supplementation injections. The injections did not produce any improvement in his knee pain, and in August, Marty was referred for physical therapy by his family physician.
The most significant finding during Marty’s evaluation was a deficit in his knee flexion range of motion. In prone lying, he could bend his left knee 125 degrees, but his right knee only bent 90 degrees. Passive right knee flexion past 90 degrees recreated the pain in the front of his knee. The right knee would bend fully in supine and seated and was pain-free. Palpation revealed sensitive trigger points in a muscle called the rectus femoris.
The rectus femoris is one of four muscles that make up the quadriceps (big front thigh muscle). The rectus femoris muscle is unique in that it crosses both the hip and the knee joint. In order to fully mobilize this muscle, you must extend the hip and flex the knee at the same time. Most of us never perform a full range stretch of this muscle. Trauma to the front of the thigh can cause myofascial adhesions to develop in the rectus femoris muscle. Overuse is not uncommon in soccer players, bicycle riders, and runners. Rectus femoris muscle trigger points refer pain across the front of the knee and thigh.
Rectus femoris strain is a fairly common sports injury. Last summer, we treated a soccer player who tore her rectus femoris completely off the hip origin and had to have surgical repair. Sitting places the rectus femoris in a shortened position, and given enough time, the muscle will adaptively shorten. Exercise machines such as stair steppers, ellipticals, and stationary bikes are devoid of the movement pattern that elongates the rectus femoris muscle. You need hip extension combined with knee flexion to move the rectus femoris through a complete stretch.
Marty was started on a physical therapy treatment program of soft tissue mobilization and daily low-level stretching of the rectus femoris. After three sessions, Marty reported his pain was no longer present with walking and he felt 50% better. Prone knee flexion was full range in three weeks, and he was able to graduate to standing rectus femoris mobility exercise—see video. Marty was pain-free in four weeks and graduated physical therapy with a foam roll for self myofascial release and a daily home program of exercise.
If you sit for extended periods of time and have developed pain in the front of the knee, give the prone knee flexion exercise a try and see if your pain decreases. Stay with the prone stretch for a few weeks and then try the standing rectus femoris stretch. It is surprising how often this simple exercise resolves the pain. More stubborn cases can be resolved with some hands on myofascial treatment.
To view video demonstration of the rectus femoris mobility exercise, click on the link below:
-Michael O’Hara, P.T., OCS, CSCS