Knee pain is a very common issue people face that affects their training and daily living. Apart from back pain, it would be the most common problem we see each week in our training studio affecting people of all ages. The most popular article on our website (VMO strength) and second most popular video on YouTube is also about knee pain, which proves just how many people are looking for a solution to what is an ongoing problem. And while in most cases we are able to make a massive impact on how these people move and show them strategies to reduce their pain, identify the cause of their injury, and be able to successfully correct their problem. There are some people where the problem is so severe, or been there for so long, that we must find ways to manage their pain and prevent any further aggravation of their injury. This is more common in the older adult who has been told they need a knee replacement or has severe osteoarthritis that impacts their daily movement. In this article, I am going to share with you some simple methods and strategies we successfully use with people in this situation.
The Key Is To Align & Control The Knee
Most knee issues have to do with non-optimal alignment and control of the femur and tibia. More specifically, it is when the femur excessively and internally rotates, and/or the tibia relatively externally rotates, and/or the knee abducts (moves into a valgus position). Both result in increased stress upon the meniscus, anterior cruciate and collateral ligaments, and cartilage of the knee. If left untreated for long periods severe osteoarthritis will set in.
The most important thing to understand here is, THE KNEE ITSELF IS NOT THE PROBLEM!
You must look at the joints above and below, being the foot/ankle and the hip/pelvis, for they are responsible for maintaining the optimal alignment of the knee joint. This is vital to know when trying to treat any knee injury and also with trying to prevent an injury, for we know this is where the problems are created. With people who come to see us for help with severe knee problems, we have found in over 90% of these cases that there is a significant loss of foot stability, ankle mobility, and hip mobility. We know that it will be impossible to restore optimal alignment within integrated movements like squats, lunges and even walking if these issues are not addressed. And this is the base of our initial programming. The good news is these exercises are simple to do and by improving these areas you can achieve great progress with managing your knee pain. I will provide you with some simple solutions for each of these shortly.
Also, make sure you read our article on what causes knee pain for a full breakdown of how this works - When You Have Knee Pain Rarely Is The Knee The Problem
What About Surgery?
For some people surgery is the only option as things have progressed too far, however many people mistakenly think the surgery will "fix them" and make it all go away. I always like to treat surgery as a last resort. For a torn or ruptured ACL, surgery is absolutely necessary as the ligament has no way of repairing itself and if left unattached the knee will constantly give way and buckle causing more damage to the ligaments and cartilage within the knee. However, with other knee related problems, surgery is merely an attempt to treat the symptom without addressing the root cause.
In the book "Surgery The Ultimate Placebo" by Dr. Ian Harris a practicing orthopedic surgeon he makes reference to the value of surgery for common knee problems.
"For knee arthroscopy, the bottom line is that if you have pain and degenerative changes in your knee (like mild arthritis or an undisplaced meniscus tear), then regardless of your symptoms you have (mechanical or not), regardless of what your X-rays look like, regardless of where your arthritis is, regardless of how bad your pain is, regardless of whether or not the MRI scans show your meniscus to be torn, or whether or not you have an MRI at all, having an arthroscopy will not increase your chance of getting better, compared to a sham surgery. Nor will it reverse the degenerative changes in your knee. Believe me, I would love for arthroscopy to work (it is a great operation and pays well) but for arthritis and degenerative tears in the meniscus (which is most patients with knee pain) it doesn't."
Always remember that surgery is not treating the cause of the problem. Surgery is fantastic at helping people from car accidents and trauma-related injury, but it is not a great solution if your pain is caused by poor movement function, poor posture, and muscle imbalance. Watch the quick video below that explains how to treat osteoarthritis at the root cause. I love the quote seen in the image below.
We know that surgery is not addressing the cause and the implementation of corrective exercises and drills are the key. But where do you start?
Start With An Assessment
The first thing to do is start with a thorough assessment of your body. We always begin by assessing individual joints to rule out any mobility restrictions before progressing to movement skills, stability, and isolated strength. For people with chronic knee pain usually, the mobility exercises are a great starting point for they are easy to do, and take some pressure off the restrictions causing the pain. They do not fix the problem, but definitely make it easier to implement the more complex exercises and movements you need to do later on.
You can read in our article - Everything You Need To Know About Mobility for more detailed information about how to do this.
To help you out for knee pain specifically, below I have provided some videos and links to detailed articles for the 3 "big" areas of concern with knees. This would be my starting point with an exercise program for someone with severe pain as all these following strategies will place little to no stress on the knee.
Feet Stability
The feet are so important to look at and act like a shock absorber to our skeletal system when working well. The foot needs to act like a spring being a soft flexible foot to cushion the stress of each step we make, and then instantly become stiff enough to provide enough power to move us forwards or upwards. Any loss of stability here will send problems up the leg to the knee. Below are two great videos to watch with information and exercises to use.
Great article to read with detailed information is here - Exercise Solutions For Weak Or Rigid Feet
Ankle Mobility
The ankle differs to the foot in that it needs a high degree of mobility. This joint is designed to provide us with a multi-directional movement that the knee is unable to provide, with any loss of mobility at this joint forcing the knee into poor alignment and potentially twisting and rotating it during movement as seen with many ACL injuries. Below are two videos with detail on how to do this.
Great article to read with more information about ankles is here - Why Poor Ankle Mobility Causes A Chain Reaction Of Problems
Hip Mobility
Next thing we need to look at is the hip. This joint is very similar to the ankle in that it provides our ability for multi-directional movement. Our modern society with excessive sitting has created this joint to easily stiffen itself and sacrifice it's mobility again forcing the knee into positions of poor alignment during movement. It is vital to constantly try to improve and preserve your hip mobility. In combination with the mobility exercises, I would also highly encourage working on pelvic stability. Below are some videos of how to do this. The second video featuring the swissball stretch is our preferred stretch but often this may be too difficult to do and you may need to perform this lying face down with a partner helping you to push your foot towards your butt as seen in the first video.
Great articles to read about hips are below.
Even with the implementation of these simple drills, they are not enough to change key movements. We know that for every tight and stiff muscle that needs mobilizing, there is an opposing weak and lengthened muscle that needs strengthening. By ignoring this weakness the problem will continue to worsen. What exercises are good to use that will not cause more knee pain? Here are our preferred choices.
1: Wall Drill To Encourage Hip Hinge Movement
This is a video that shows 3 ways we can teach people who typically have severe knee pain or balance problems how to use their hips and glutes more effectively.
I first saw these used by Evan Osar in his book for hip and shoulder injury and could see how these would benefit some of my clients straight away. People with severe osteoarthritis and scar tissue in their knees that made it impossible to do many exercises without compensation and pain. These drills made it easier to progress to more challenging movements with load or even stabilizing drills with them having a feeling or how to "hip hinge" correctly to engage the posterior chain of muscles. It is amazing to watch how easily they can move laterally when doing this exercise and how it is also pain-free, for when you observe them walk it is very difficult. I like these drills for they encourage a great deal of weight shifting from right to left as you would need when walking, without the complication of needing stability. Using the wall for support aids in this process.
The wall actually provides several things:
- It helps to encourage more hip movement instead of knee flexion.
- It helps with balance.
- It helps improve thoracic extension which is another area of real stiffness in people with gait or knee issues.
2: Hip Extension & Deadlifts
Both of these exercises are great strength choices because the demands on the knee are minimal, as opposed to the squat which places a high demand on the knee. Both the hip extension and deadlift are excellent for developing critical strength into the posterior chain of the glutes and hamstrings, my preferred choice is the deadlift. This is because it forces you to maintain an anteriorly tilted pelvis, that allows greater control for aligning the lower limbs and protecting the spine. A common mistake people make with these exercises is by over-contracting the glutes, hamstrings, and external hip leading to a posterior pelvic tilt and reversal of the lumbar spine curve. This position inhibits optimal alignment and control of the lumbar spine and pelvis, and make it increasingly difficult to achieve anterior pelvic rotation. This not only exposes you to a potential bulging disc in your back but this strategy directly contributes to ‘quad dominance’ and ‘gluteal amnesia’ as it tends to inhibit one’s ability to achieve anterior pelvic rotate which is required for optimally loading and thereby developing the muscles of the posterior hip complex.
Great article to read about this is below
3: Modified Walking Drills & Step Up Exercises
These last two videos are examples of how you can use integrated movements to help the body learn how to correctly align the knee during a walking movement. You will need some rubber tubing to do these drills. These can be absolute game changers for people with enough practice and repetition teaching the body an alternative movement approach that does not create more pain. I would also encourage you to do these drills barefoot to force better foot stability during the movement.
For more information on exercises, we use for walking impairments read this article - 6 Ways To Improve Your Ability To Walk
Advanced Programs
Obviously, there is a lot more we would need to do, but the exercises and drills shown here are a great start. For further help with knee pain we have some great resources below you can download with the detailed assessments and a 6 phase programs provided in a step by step format. Click here to find out more about these programs.
Summary
I hope this article sheds some light on some of the simple strategies you can use to help manage severe knee pain. As I mentioned earlier sometimes surgery is the only option, but it is well worth exhausting all the less invasive and simpler options first for there is no going back once you have a knee replacement. The real cause of these problems is not old age, it really comes back to poor movement strategy. It is up to you to identify these dysfunctional movements and use exercises to change them to the more optimal positioning and alignment.
Lastly if you live in Melbourne and would like to know more about our programs and how we can help you with your knee pain please click the image below to request a free consultation.
