Tackling Knee Pain (Part 1)
A discussion and guide to helping you overcome knee pain and find joy and delight in movement again. Causes, what to do and what to avoid.
I’ve been getting a lot of questions about shoulder, back and knee pain lately and how to address them. Shoulder, back, and knee pain are some of the most common areas of joint pain but I’ve gotten a bit more questions about knee pain so I wanted to put something out that can help you in this area if you happen to be suffering from it. Some of the recommendations discussed here can also transfer over into the alleviation of other problem areas especially when it comes to proper form during movement and exercise in general which adds stability to the body and helps every joint from top to bottom.
Knee pain can arise from various causes, ranging from common issues to less common conditions. Understanding these various potential causes helps in identifying the underlying problem.
I became certified as a Specialist in Exercise Therapy because I understand how frustrating knee pain and joint pain in general can be and how it can steal the joy of movement and daily living. Often, the root cause is as simple as poor form or posture, dysfunctional movement patterns, which proper form during exercise and movement can correct or improve. Other times it may not be so simple and might require diagnostic tests, scans, surgery and additional medical treatment. In any case, proper movement and exercise can be the therapy you need to help address or improve the problem and start feeling and moving better. Because exercise IS therapy.
More Common Causes
Injuries and Overuse
Injuries from improper form and faulty movement mechanics prevent evenly distributed sharing of the load through all the muscle and joints that should be involved in a movement. This causes too much strain to be placed on one body part and pain, injury or dysfunction could be the result. Always make sure your body is aligned. This means tucking your hip or stacking your ribcage over your pelvis, a properly braced core (slight lateral expansion of the abdomen on inhale and contracting the core muscles on exhale, along with small sips of air as you're breathing while performing the exercise), a tucked chin for cervical spine alignment and your knee tracking over your second or third toe next to your big toe and preventing any knee valgus (inward collapse).
Also, always exercise in a balanced way. A balanced exercise program will include an equal or close to equal amount of opposite or antagonist movement of any exercise. Like making sure our quads and hamstrings are both sufficiently trained or you’re performing the opposite or reverse of the movement that you do a lot of. For instance, if performing 3 sets of bicep curls, include 2-3 sets of reverse curls to strengthen the elbow in both directions and in opposite movements. This prevents imbalances and pain as a result of overuse in one direction or of one movement pattern. Do the same for leg extensions and leg curls for the knee. So, some causes or contributing factors of knee pain can be from injuries or overuse such as:
Ligament tears (e.g., ACL injury)
Meniscus tears
Tendinitis often caused by repetitive activities or overuse.
Bursitis resulting from repeated pressure on the knee.
Iliotibial (IT) band syndrome, which is fairly common among runners.
Medical
Osteoarthritis, especially common after age 50.
Rheumatoid arthritis: An autoimmune condition.
Gout caused by uric acid buildup.
Lupus: A long-lasting immune system condition.
Physical Factors
Being overweight or obese, which puts extra pressure on the knees or joints.
Aging, leading to degeneration of bones and joints. I will make a point here that non-use or disuse causes degeneration of joints and the body just as much as overuse does. The key is to regularly stay active, challenge the body in sufficient and safe ways along with proper rest and recovery. Light to moderate movement every day, light to moderate resistance training every week and doses of heavy and intense exercise and resistance training, once you’re able to, 1-3 times per week is a good general lifestyle to live.
Previous injuries that didn’t heal properly.
Less Common Causes
Structural
Hoffa’s syndrome, involving the fat pad beneath the kneecap.
Saphenous nerve palsy or inflammation.
Medical
Infrapatellar contraction syndrome: A rare cause of anterior knee pain.
Baker’s cyst: A fluid-filled swelling behind the knee.
Reactive arthritis which can occur after infections like salmonella.
Septic arthritis: an infection within the knee joint.
Other Unusual Causes
Slipped capital femoral epiphysis: A hip condition that can cause knee pain.
Knee tumors, including cancers that spread to or begin in the bones.
Hypermobility, especially in young women, which can make the joint unstable due to loose ligaments that can’t adequately hold the joint in place. This makes the joint prone to dislocations and injuries. And for some, this can also cause joint pain.
Referred pain from hip osteoarthritis or lower back nerve compression. This can happen to any joint. I myself have first-hand experience of referred pain in the shoulder from nerve compression in the cervical spine. So, even though uncommon, I can personally attest to the fact that referred pain can and does happen and can be quite painful.
Some Things to Remember
Before diving into how to exercise with knee pain and what to avoid, keep in mind that certain movements are only harmful when the knee is compromised, such as if you’re already dealing with a current or recent injury or you have an existing condition. If the condition or pain is due to dysfunctional movement patterns, with time, this can be easily be fixed by correcting form and technique and really learning how to engage the core in every movement. Proper core bracing is extremely important so let me briefly list how to do this in a few simple steps:
Inhale
Inhale deeply through your nose, expanding your abdomen, waist, low back, and pelvic floor. Avoid chest breathing, and keep your ribs down.
Exhale
Exhale during the most difficult part of the exercise to contract your core muscles. You can also try the vacuum technique, which involves drawing your abdominal wall inward toward your spine while exhaling fully.
Maintain tension
After you exhale, maintain slight tension in your core with tension from your pelvic floor through the waist and into your ribs.
This will help you create intra-abdominal pressure (IAP) which will stabilize your spine, improve your posture and help alleviate knee pain, especially if your knee pain is due, even in part, to poor posture and instability.
Now, knee problems can also be due to overuse either because of not enough rest between workouts so the joints and body have a chance to recover or because of an imbalanced training approach when it comes to load placement, limb bias or, again, not equally training the opposing body part. Whether due to dysfunctional movement, overuse or imbalanced training, once these issues are addressed the knee can start to heal, strengthen and ultimately be able to (and should be able to) handle increased loads and pressure and at differing angles and positions such as the knees going past the toes, squatting deeper than 90 degrees and even the knee staying strong and stable when moving inward past the big toe (known as knee valgus). These movements that are deemed “incorrect” or “bad” by some in the fitness community (and understandably so) are actually normal movements that are done briefly without a second thought during normal day to day activity. Your knees go past your toes anytime you’re walking down a flight of stairs, squatting down while on your toes or pulling something while walking backwards. Your knees move inward (valgus) if you’re playing a sport and making a cut, sharp turn or performing certain shifts in movement. And all human beings should be able to and want to develop the ability to squat deeply (squatting deeper than 90 degrees) as this is a primal movement and signifies optimal mobility and healthy ankles, feet, hips and knees and actually decompresses the spine. It does this by providing and slight natural curve in the low back that helps to open up the discs and allow for better fluid and blood flow, thus providing relief from the constant compressive forces of chronic sitting or standing.
Example of knees going past toes on a TRX suspension trainer which is a natural position and can actually help strengthen the knee. Start by moving knee forward past the toes just to the degree where you feel no pain or is tolerable.
You can do this supported by holding on to something fixed in place or even by doing it in a B-stance (staggered stance) position without holding on to anything and gradually push your knees past your toes to your level of tolerance and pushing back through your toes back to the original position where your knee is behind your toes and your entire foot flat on the ground.
You can do 3 sets of 12-15 reps. Gradually increase how far the knees go past the toes over a few weeks or months until you build enough strength and stability to have your toes almost in the middle of your shin (or farther) without pain.
You can also start by elevating your front foot on a platform higher than the floor and perform a forward lunge with your with your foot flat on the platform and your knees going past your toes. Being up on the toes places more pressure on the knee, but again can be done without worry once your knee is strong enough. You want to be able to have your knees go past your toes both with entire foot on the ground and while your up on your toes or the balls of your feet. The sissy squat is a great exercise that builds tremendous strength in the knees and quadriceps. Work your way up to it and start by doing it supported. These are also some great exercise for building strength and mobility including and starting with your knees going past your toes.
How to Exercise with Knee Pain
If you have any numbness or tingling it could be nerve related or a herniated disc which could require specific treatment like physical therapy or surgery. Check with your doctor. In general though, to help with knee pain during movement and exercise, practice and keep in mind a few things:
Keep kneecap aligned with second toe. The kneecap should be aligned with the second toe next to the big toe. A band around the knees can help and serve as a cue and something to press knees outward against.
Work within a range of motion that is pain free.
Do reverse lunges. Reverse lunges place more emphasis on the hip, unlike the standard forward lunge which places more emphasis on the knee. Step backward with the support leg, and push off the bent front leg through the mid-foot or heel as you bring the support leg forward again and even with the working leg.
Align and "stack" your pelvis directly under your ribcage. This activates glutes and supports the low back which helps alleviate stress on the knees due to more even load distribution because of correct form.
Brace your core. Take a deep breath and breath out expanding your abdomen laterally. Act like you're laughing, coughing or bracing for punch to the stomach.
Practice supported exercises: Do exercises on or with things such as TRX ropes, a couch, table or chair. This relieves pressure on knee while still allowing enough pressure to be therapeutic, build strength and help alleviate pain.
Start Retro Walking (Backwards Walking). Walking backwards is something the Chinese have been doing for generations. This helps strengthen the patellar tendon as well as the vastus medialis oblique (VMO), which is the tear drop shaped muscle on the inside of your leg right next to the knee cap. Strengthening these areas will stabilize the knee and help to relieve pain. Walking backwards has additional benefits such as improved cognition, proprioception (balance and coordination), activating strengthening the hamstrings and glutes to a greater degree (muscle that also need to be strong for healthy knees) and boosting metabolism. Find a safe open place or use a treadmill (even better if walking backward at a slight incline) and hold on to the rails.
Practice specific exercises. Exercises such as terminal knee extension (very good for rehab and strengthening the knee after surgery or injury), Chair squats or halfway-down chair squats, wall sits, leg curls, seated leg extensions with a focus on the negative or eccentric (lowering) phase of the movement where you take about 1 second to lift the weight and 3-5 seconds to lower the weight which greatly help to strengthen the tendons and ligaments of the knee. You can even work your way up to 10 second or more lowering phases. If your pain significantly increases, see a physician and rest until your condition is medically assessed. Applying alternating heat and ice can help, about 20 minutes of heat and 20 minutes of cold.
Wear a Knee brace or compression wrap. Passive therapy is great because you don’t think about out or exert effort to do it. Knee wraps and compression sleeves help increase blood flow to the area at a constant rate. Blood flow, just like proper movement, is healing. Just make sure it’s not too tight. If the amount of compression is uncomfortable or you can’t wear it for a few hours without an issue then it’s too tight. If it’s too tight it will do the opposite and restrict blood flow rather than increase it. Knee braces are great to stabilize the knee and prevent excess movement and re-injury after injury or surgery until you build the strength and stability where you don’t need it.
Exercise or walk outside and get direct sunlight on the joint itself. Sunlight, particularly its ultraviolet B (UVB) rays has been shown to reduce swelling, pain, and inflammation and low vitamin D can cause bone pain. This can be beneficial for various types of arthritis and joint pain. Sunlight exposure helps the body produce vitamin D, which is crucial for bone health and can help reduce inflammation. Maintaining adequate vitamin D levels could help prevent the progression of osteoarthritis which of course prevent any pain associated with the condition. Red light therapy has also been show to help with pain and inflammation reduction which makes sense since sunlight itself can help and sunlight contains the full spectrum of light including red light.
What to Avoid
If you have knee pain, it’s important to avoid activities and movements that can exacerbate the condition. Again, these activities should be be avoided only until you are at a healthy weight and have built up sufficient strength in the joint and the surrounding muscles, tendons and ligaments to be able to withstand greater forces to the area. However, here are some to consider:
•High-Impact Exercises: Running, jumping, and kickboxing, as these can jar the joints. If you are taking part in any exercise where you are briefly exposed to such forces, make sure you are wearing properly cushioned and fitted shoes (wide toe box with flat sole or zero drop heel is best) and using a good arch support if you have a low arch/flat feet or suffer from plantar fasciitis. High-Impact should generally be avoided when overweight. However, depending on the person and your existing structural integrity and strength level, you may be able to partake in brief bouts of high-impact exercise even if overweight. But I do emphasize brief and keeping good form and wearing cushioned impact absorbing and as naturally fitting as possible footwear. The amount of cushion in your footwear can be reduced as you come down to a healthy weight. But naturally and properly fitted footwear should always be worn.
If you have pain even with low impact exercises such as prolonged walking, standing or using an elliptical machine and you're over weight, you may need to get down to a healthy weight to relieve the knees of chronic stress. This is where I would recommend things like swimming or seated or supported exercises (such as rowing, cycling, seated leg press, using TRX suspension trainers, resistance bands or other supported exercises where you lean or hold on to something. Theses types of exercises give you more control over the amount of pressure you're subjecting your knee to and prevents you from putting your entire weight on the knee until you:
Are down to a healthy weight for your height and not placing chronic stress on your knee, rather than only during periods of exercise, training or therapy.
Know how to practice proper form and technique with lower body movements.
Build the strength to handle increased loads and achieve positions and angles that are now ok and even good for the knee joint when done with proper form and you're at a healthy body weight (such as the knees coming past the toes and deep squats).
•Deep Knee Bends requiring you to push or resist all of your bodyweight: Exercises like deep squats and lunges put a lot of stress on the knees and should be avoided until proper mechanics and a healthy weight is achieved.
•Uneven Surfaces: Walking on uneven surfaces or steep inclines can increase the risk of falls and knee strain.
•Excessive Weight-Bearing, Even if Low-Impact: Activities that require heavy lifting (either in addition to your own body weight or just using excessive heavy external weight) or prolonged standing or walking can worsen knee pain due to the chronic nature of the ever present pressure on the knee without rest or relief from that pressure in your day to day activities. Lighten the load and rest when you need to.
Keep in mind that rest and work are synergists. They work together, not against each other. When you're overweight, you're placing your body and joints under high load constantly without ever letting them rest. Constant excessive load on the knee is problematic even if you're at a healthy weight but are overtraining. The joints become inflamed, overly stressed and weaker rather than stronger. This happens to athletes at a normal weight who have training days and rest days, let alone for someone who is overweight and placing their joints under strain 24/7. So, in this case of being overweight, anytime you're resisting your full body weight or your full weight is coming down directly on you, the only weight you need to use is yourself and perhaps even lessen some of that weight by doing the exercise or movement supported or in a horizontal direction (such as a leg press) where you can control the amount of weight used or use less weight than your body weight. Adding additional weight to your own body weight only increases the pressure even further and can be at the least, the cause of pain, and at the worst, injury. Anyone who does calisthenics or plyometrics will tell you all you will ever need to get an effective workout (up to a certain level) is your own body. This is even more true (if I can put it that way) for the person who is overweight, which is often why, with these individuals, we seek to reduce the load, not increase it.
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