The amount of hip and knee related injuries we see with people over 40 is becoming increasingly common. We know that exercise can be a great way to prevent the onset of these injuries but being able to train when you have hip and knee injury or stiffness can be very painful. Doing nothing is not a solution either as the joint will become weaker and more unstable resulting in a much bigger problem and a continuation of more pain. In one of our previous articles we provided some great ideas for training with severe knee pain (see best exercises for severe knee pain) which prompted many emails asking about the relevance of these exercises if you had a hip problem. There is a direct link with hip dysfunction to knee pain. For many surgery may seem like the best solution, yet I have met several people in their late 40's and early 50's who have had knee replacements only to be left in more pain than they had before the operation. Or worse still, developed other injuries and complications as a result of the surgery! This article we look at the reasons behind chronic problems at the hip and the knee and what you can do about it and try to avoid surgery if you can. Sometimes it may be all you can do, but it should be the last resort and the only option left after all alternatives have been tried first.

How Common Is Osteoarthritis Of The Knee & Hip?

You only have to look at the statistics to see how prevalent osteoarthritis is.

But why do these injuries occur?
Is it due to old age?
Is it due to genetics and bone structure?
Is surgery the only solution?
And is there anything you can you do to prevent the onset of hip and knee arthritic conditions?

I remember when I was 26 I had a very sore knee for no reason at all and sore several therapists for advice on treatment. I was told my left knee looked like the x-ray of a 70 year old and that I should stop running and playing sports immediately or I will need a knee replacement when I am 40. I didn't listen to that advice luckily and that is where my journey into strengthening and learning to move began. I am now 45 years old and can tell you that my hips and knees have been able to do more now than I ever thought and even after suffering a few traumatic injuries I can still run, lift weights, jump and do many things with no limitation or pain.

What Is Osteoarthritis?

Osteoarthritis is a degenerative condition of the joints, which over time become painfully inflamed. If you have joint degeneration without pain, the condition is known as osteoarthrosis. With both conditions there is deterioration of the joint ‘cartilage’ – a smooth substance that covers bone endings, allowing bones to glide over each other with minimal friction. Cartilage also cushions force as it is transmitted through the joints and when you have used it up, there is no way to create more!

Research on footballers and rugby players suggests that they are at increased risk of osteoarthritis around their knees, hips and ankles during and after their playing careers. This risk is significantly increased if they have sustained an injury in those areas or a lack of stability that they ignored and compensated around. Although contact sports appear to carry the greatest risk of degenerative joint disease, non contact sports like tennis and track and field, with their constant pounding of joints, can also lead to problems in later life.

But what about the person who never plays sport, how do you explain how they develop osteoarthritis? They may never have had any previous injury or the wear and tear from playing sports year in year out. A great quote from Dr Evan Osar sums this is up.

"Osteoarthritis, more accurately described as degenerative joint disease, is just one manifestation of poor movement strategies and is not simply a process of getting older" - Dr Evan Osar

This means that osteoarthritis IS NOT caused by old age. For if it was due to old age how do you explain the people who do not have osteoarthritis? Are they just lucky?

This can even happen to kids, and unfortunately we see a lot of this and it is no surprise to see how many kids are suffering with ACL injuries in sports as a result! Teaching kids how to move correctly should be a high priority.
Read our detailed article about this here - Why Kids Must Learn Change Of Direction Skills If They Play Sports

The real reason we see osteoarthritis surface in older adults is that the length of time the person has spent moving poorly eventually ends up completely wearing and tearing the joints, cartilage, ligaments to a point where pain sets in. Added on top of this is a lack of muscle and you now have the perfect recipe for unstable joints that create stiffness, osteoarthritis and eventually pain. This is how a person who has never played sports before can suffer with pain from just activities of life like walking.

Peak bone mass is reached at around 25 years of age and normally remains relatively stable until around the age of 50. After the age of 50, progressive losses of of bone mineral density begins to occur. As bones lose their density they become weaker and the risk of fracture during regular activities increases. Normally bone density remains stable. What we are seeing more often these days is symptoms of Osteoporosis in people aged in their early 40's and some even in their 30's! Osteoporosis is now so common I am working with many clients with severe postural problems causing severe injuries like disc bulges in the lower back and neck due to their bones becoming so weak and brittle.

What prevents osteoporosis and weak bones? Strength training! Read our article - How To Reduce Arthritis Symptoms & Improve Bone Density

Watch the quick video below.

What About Anatomy?

We are all not designed exactly the same and the shape of our bone structure can be very different. In one of Dr Stuart McGill's lectures at Stanford University he compared the pelvic ring of various people and highlighted how different our hip anatomy can be. This research showed that Polish people had the best pelvic and hip anatomy for deep squatting and it is no surprise that many of the world's best weightlifters come from this region of the world. A shallow roof does not allow for deep squatting needed in Olympic Weightlifting, but will allow for tremendous power with kicking as seen in martial arts.

This means that we will not all be able to move perfectly in the same movements. This is why we cannot force people into deep squat positions as they may anatomically never be able to do much in this position. Doing this will cause you to wear cartilage and create problems. The same thing is true with deadlifts, bent over rows or anything that requires the pelvis to move into anterior tilt. There will be considerable risk with loading too heavily or training under fatigue for the person is unable to maintain optimal positioning to handle this stress.

However a person who struggles to squat well may demonstrate considerable strength into lunges and step ups and positions with the demands of a "posterior tilt" of the pelvis.

Even though there is a big difference in our anatomy this alone does not guarantee osteoarthritis. For there are many people with different shaped pelvic rings with no pain or signs of arthritic conditions. If they were to force poor movement however, then the chance of arthritis rises greatly.

Again it comes back to HOW WELL YOU MOVE!

What About Surgery?

This is an interesting question for I will never go against medical advice however I have met countless number of people who came to me for help after having surgery that has left them in more pain than they had before. Always remember that surgery is not addressing the cause of the problem, it is merely treating the symptoms and replacing a part as if your body was like a car. When it comes to traumatic accidents this is great, but when this is trying to rectify what is really a movement and stability problem this only serves to create more dysfunction and pain.

Sometimes surgery is the last resort as the condition has deteriorated so much that any exercise intervention may be pointless. But it should always be a last resort after everything has been exhausted first.

In the book "Surgery the Ultimate Placebo" the author Dr Ian Harris sheds light on several surgeries being used today that are either completely useless and even harmful.

"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 the kind of symptoms you have (mechanical or not), regardless of how bad your pain is, and regardless of whether or not the MRI scans show your meniscus to be torn, and of whether or not you have an MRI at all, having an arthroscopy will not increase your chances 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. " -  Dr Ian Harris.

He also makes an interesting statement confirming that not all people develop arthritis even when things do not look right under a scan.

"It should be noted, though, that most people over 40 have a meniscus tear, nearly everyone with osteoarthritis has a meniscus tear, and of all the people in the community who have a meniscus tear, most do not have knee pain. The link between the presence of a meniscus tear and knee pain is not strong, and the link between taking it out and relieving pain is even more tenuous, but we continue to do this procedure in record numbers." - Dr Ian Harris.

How Does This Apply To The Hip?

I have trained with several older clients who have had hip replacements and they were perfectly fine afterwards, if not better than ever. But I have also met several people who were not much better and even worse. What was the main difference? The people who did well completed strengthening exercises prior to the operation and continued long after spending considerable time improving movement strategies with bending, squatting, single leg stance and lunging. The better they moved and the stronger they became stiffness went away and pain was a distant memory.

What about surgery to correct injuries like FAI (hip impingement)? Here is an interesting study that explored this very question.

Hip Impingement Study - Surgery vs Therapy

Eighty patients were selected for the study. All patients were diagnosed with hip impingement (FAI). The ages ranged from 18 to 60 years old. They were randomly separated into two groups of 40 patients each.

Group 1: Surgery Group - The surgery options involved one or more of the following:

• Changing the shape of the hip bones. An “abnormal” bone shape is considered a cause of FAI, like cam impingement or pistol grip deformity.
• Hip labral tear surgery.

The final decision on which surgery to perform for each patient was based on the surgeon's clinical judgment. After the surgery, the patients went through a postoperative physical therapy protocol.

Group 2: Rehab group - This group underwent a supervised physical therapy program. The sessions were twice a week and 45 minutes long, with a total of 12 sessions. The techniques included therapeutic exercise, and manual therapy to the hip, lumbar spine, and pelvis. The outcomes of each patient were obtained at six months, one year, and two years. The primary outcome was the Hip Outcome Score (HOS).

Results Of The Study

So how did physical therapy for hip impingement compare to surgery? Is the cost of surgery worth the results?

Let’s take a look at the results:

• Over time, there was no statistically significant difference between both groups. The overall perception was “no improvement”.
• The mean cost of hip-related care over the two year-period was three times greater in the patients who underwent surgery compared to those who didn’t.
• Patients who underwent surgery had more complications, including surgery on the other hip, revision surgery, and a diagnosis of hip osteoarthritis.

Why did the manual therapy not work? The researchers designed the protocol based on the belief that bone shape and/or a hip labral tear caused pain for these patients. So, the femoroacetabular impingement physical therapy treatment addresses it as a bone issue:

• The manual therapy techniques try to “open” the space between the femoral head and the hip to ease the movement of the joint.
• The strengthening exercises aim at hip muscles without regard for proper sequencing or mechanics. More specifically, the quads and adductors are activated far too much in the entire program.
• The stretching routine and tissue release techniques relax the TFL, quadriceps, and the piriformis.

The reason the manual therapy did not work correctly for it assumed every person was the same and applied a model of treating the muscles and not how you coordinate movement. The mechanism behind the pain is found in the way each person uses key movement patterns like bending, squats and lunges. Some people will complete these movements poorly as they may be hyper-mobile, whereas the next person will move poorly due to being extremely stiff and inflexible. Therefor, the treatment for each person will be completely different. That is why testing is so important so you use the correct treatment method for your body.

What Is The Best Solution?

The simple solution is to move correctly and improve your strength. Obviously this is not that simple, especially when you have an injury and not sure where to begin and what you need to do. There is 2 FREE REPORTS below that provide great information and specific programs to use to learn how to do this. Click the image of the report you need to download.

The very first thing you should ever do is complete an assessment to identify any mobility restrictions, weaknesses, and dysfunctional movement patterns.

Read the article  - How To Use Functional Movement Correctly to see detailed examples of the 7 key movements for ideas on what to look for and how we go about assessing  movement.

In many of our other articles we explain how poor mobility of one joint can set in motion a chain reaction of compensation at the joints above and below. This is known as the joint by joint approach and this can guide you on what you are looking for.

1. Feet - The feet have a tendency to being lazy, and easily losing strength and motor control. The feet need exercises to make them stronger and more stable.
2. Ankle - The ankle tends to develop stiffness very easily and needs more focus on mobility in order to provide all the multi directional movements of the lower limb.
3. Knee - The knee is basically a hinge joint and incapable of multi directional movement like the ankle. It needs Stability and strength work to ensure it does not get injured as in ACL tears.
4. Hip - This joint is often the cause of many problems. Like the ankle it provides multi directional movements but for reasons we will look at shortly they have a tendency towards stiffness and as a result benefit from flexibility and mobility work.
5. Lumbar Spine - The lumbar spine needs stability to prevent unwanted flexion or extension. A bit like the knee joint this is just a hinge and incapable of rotation.
6. Thoracic Spine - Requires mobility and like the hips is pivotal in providing the athletic rotational movements in tennis, golf etc.
7. Glenohumeral Joint - Requires a mixture of stability and mobility. This along with the scapula are a unique joint in that they require both. Another reason why they are often injured and difficult to treat.

But why do the knee and the hip seem to suffer with osteoarthritis more so than the other joints? When you consider that the hip joint is a very unique joint in that it has the capacity for multi directional movement and high degree of mobility like the shoulder. But at the same time the hip has to absorb our body weight and remain stable.

The simple movement of standing on one leg increases the weight on the hip by two and a half times the body weight and walking up stairs increases by three times!

Weakness at the hip leaks into the lumbar spine above and the knee below. Both of those joints require stability but will be forced to sacrifice this if the hips do not have adequate mobility to complete their function. For the knee this can be a double hit to it's stability if the feet are not working optimally, which is another extremely common problem with people these days due to poor footwear. This also helps to explain why knee pain is steadily on the rise. Performing surgery and various other knee specific therapy is pointless if the problems at the feet and hip are left unchecked. For this reason we find the single leg exercises the best along with the bending movements like the deadlift are critical for improving both hip and knee stability.

Learn How To Do The Romanian Deadlift (RDL)

In the rehab field the RDL is often referred to as a hip-hinge as it requires very little knee movement but a large degree of hip movement. Anyone working with lower limb injuries will know how much influence the hips have with these injuries and often tightness with the hip flexors and weakness with the hip extensors is a big part of the problem. The deadlift and in particular the RDL is a perfect remedy for these injuries as it demands hip mobility with strength from the posterior chain.

Why does the single leg deadlift work so well with hip, back and knee injury?

With most common hip problems such as femoral acetabulum impingement (FAI) and Piriformis Syndrome, you will find weakness in the posterior muscles of the glutes and the beginning of what is referred to “anterior femoral glide syndrome". This is where the femoral head has moved excessively forward and is overly compressed in the acetabulum, creating the impingement feeling at the front of the hip and a reaction of trigger points in the glutes to try to restore the lost stability.

The RDL and especially the single leg RDL work perfectly with this problem to realign the femoral back deep into the glutes by releasing the hip and strengthening the glutes. The anterior pelvic tilt is essential for this to happen and allow the glutes to generate their full capacity for strength.

Watch the video below for a detailed explanation of this.

In addition to this you will need to improve your hip mobility. Get this right and you are one big step towards being free of pain and instability. Avoid it and it will be just a matter of time until you too become a hip or knee pain statistic. There really is a ton of ways to go about this and I suggest to read the articles in the links below for more detail on each of these factors.

For more information you can get from our You Tube channel or the website. If you go to our index page of articles you can search via specific areas to find what you need.

Below are some of the more specific articles to help you.

Read these articles to see more
•    Are your tight hips the cause of your knee and back pain
•    Best exercises for improving hip and pelvic stability
•    7 Best Squats from easiest to hardest
•    How to do the deadlift correctly
•    Best Exercises To Use When You Have Severe Knee Pain

Knee Pain Online Program

Due to the overwhelming number of questions I have received about our Knee rehab program I decided to document ALL of my assessments, stretches, stability, strength, power exercises and programs and put it all into one big bundle so anyone could follow the path I had spent many years developing. If you want to see a quick trailer video of what is inside click here.

Below are both of our options and I highly encourage you to at least get the 60-minute video as this has over 60 exercises with instructions and detailed explanations on how we have helped hundreds of clients in the past few years.

CLICK HERE to get both the 60-minute download video and PDF report complete with 6 months of programs to get you started right now!

Summary

I hope you have enjoyed this article and it gives you some greater insight into the true cause of problems. We have been convinced that arthritis and pain is just a part of getting older but I can tell you that this is not true at all. Everyday I witness people as old as 80 years of age in our studio complete 65kg deadlifts, sprinting, walking up stairs with 16 kg kettlebells, push ups, chin ups and doing almost every movement you can think of with no pain and the intention of pushing themselves. This is not good luck, for when these people came to use they did not move like that. They learned how to do it well and gradually progressed. It shows that even at that age the body can improve and make some incredible changes.

The secret is in MOVING WELL. Learn to move well, then move more and never stop.

If you live in Melbourne and would like to know more about this or any of our programs click the image below to request a free consultation.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Functional Anatomy of the Pelvis and the Sacroiliac Joint - By John Gibbons
• The Vital Glutes - By John Gibbons
• Movement - By Gray Cook
• Corrective Exercise Solutions - by Evan Osar
• Back Pain Mechanic - by Dr Stuart McGill
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Dr Stuart McGill
• Ultimate Back Fitness & Performance - by Dr Stuart McGill
• Core Stability - by Peak Performance
• Athletic Body in Balance - by Gray Cook
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek
• Twist Conditioning Sports Strength - By Peter Twist
• Twist Conditioning Sports Movement - By Peter Twist
• Functional Training For Sports - By Mike Boyle
• Athletes Acceleration Speed Training & Game Like Speed - by Lee Taft
• Knee Injuries In Athletes - by Sports Injury Bulletin
• The ACL Solution - by Robert G Marx
• Understanding & Preventing Non-Contact ACL Injuries - American Orthopaedic Society For Sports Medicine