What many people fail to recognize until it is too late is that they are slowly destroying their hip or knee joints from not moving enough or moving very poorly. At first they don’t have any pain just some slight awkwardness or weakness but after doing this for so long eventually they hit 40, their joints have become so stiff to protect them from more damage that they can barely move. Resting and use of NSAID’s or cortisone injections are regularly used to get rid of the pain and reduce the inflammation. However while these methods might actually achieve that goal they do not address the weakness and instability that was causing the pain in the first place. (See the article about cortisone injections for more detail on this.) For many surgery may seem like the best solution, and perhaps it is if the problem has become so great they cannot move. Yet I have met several people in their late 40’s and early 50’s who could have tried exercise intervention but chose to have a knee replacement instead 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! In 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?
Long before a knee or a hip replacement is even considered the person has been suffering with severe osteoarthritis of these joints leading to more pain and decreased movement. While we come to expect that with older people what is more concerning is that is becoming increasingly more common in younger people.
You only have to look at the statistics to see how prevalent osteoarthritis is.
As more and more people choose to have total knee replacement surgery (TKR) at increasingly younger ages, the number of revision surgeries to correct a failed joint replacement is also soaring.
According to a study of more than 2 million knee replacement patients presented at the 2014 American Academy of Orthopaedic Surgeons (AAOS) meeting, there was a:
•120% increase in knee replacements over a 10-year period.
•89% increase in knee replacements among those aged 65 to 84.
•188% increase in knee replacements for 45- to 64-year-olds.
Risks Associated With Revision Surgery
All surgeries come with risks and I am not sure people recognize this whereas exercise comes with very little risk. The main differences are the exercise takes longer to work and requires a lot of effort on your behalf which are the main reasons why people do not choose this option. They are quite prepared to take the surgical risks instead of putting in the hard work to get the instant solution.
Some revision surgeries are fairly simple such as replacing one component of the implant is exchanged for another. But several others require removing and replacing the entire implant device, the ends of which are affixed to the thigh and shin bones. Revisions are long and complex, require special surgical skills and are rarely as successful as the first operation at restoring function and range of motion.
Studies have found that 85% of knees last 20 years, and the AAOS estimates 10% of patients will need a revision at some point. The younger you are when you have the surgery and the longer you live, the more likely it is you will need revision surgery.
You can see more about this in the article by the arthritis foundation.
Prevention Is Better Than A Cure
All these statistics are quite confronting and it leads me to ask several questions such as.
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?
In this article I will try to answer all those questions and more.
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 52 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.
This is not good luck, I had to change the way I move and learn how to make myself stronger and more efficient with movements that I was struggling to do.
A few years ago I met a lady who was only in her early 50’s who already had one knee replacement and was booked to get the other one done. She came to see me to try and strengthen the knee before the surgery to ensure the recovery would be faster. What ended up happening is that after 4 months her knee become so stable and strong she did not need the surgery at all and cancelled the surgery. She just needed to learn how to stabilize, strengthen and move more efficiently.
Osteoarthritis Is Not A Consequence Of Getting Old
Osteoarthritis is often labelled a degenerative condition of the joints, which over time become painfully inflamed leading most people to blame old age as the cause of the problem. 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? They are not lucky they just move better and in most cases have remained active their entire life.
This can even happen to kids, and unfortunately we see a lot of this more these days as kids sit behind screens or glued to their mobile phones. 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.
The Reason For Osteoarthritis Is Poor Movement & Joint Instability
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.
The osteoarthritis is the end result of neglecting to improve how you move. Strength training for older adults is a necessity and the earlier you start the better.
When I say you are moving poorly what exactly do I mean and where you do you start if you want to address the source of the problem? In one of my articles about the causes of knee pain I break down to the source of the problem to four factors.
1.Poor foot stability
2.Lack of hip mobility and poor gluteal strength
3.Poor coordination creating instability & inefficient movement
4.Inactivity – (weight gain and sitting excessively)
You could have one or several of these factors combined together to create the perfect storm that creates stiffness, swelling, weakness and eventually pain. These same factors are relevant to hip problems too.
What prevents osteoarthritis and deterioration of either a hip or knee joint is learning to move efficiently and applying strength training principles to ensure the joint remains stable and strong.
Applying functional movement methods is a great place to start as seen with the video below.
If you already have knee pain or hip pain then you really need to spend more time with single leg stance exercises and gait specific movements as these teach the body how to use the knee and hip joint more efficiently with great stability and strength. I cover more of the specific movements for this towards the end of this article.
What if you have been trying to remain active but still struggle with certain movements? This is where your anatomy may be playing a part.
How Much Influence Does Our Bone Structure & Anatomy Have?
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 a slight 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.
This does not mean they are doomed and should just give up for you can certainly make some great changes with specific exercises to target the mobility of the hips, but it does mean you need to be careful with certain positions.
Interestingly though a person who struggles to squat deep with good form will often demonstrate considerable strength with movements like lunges and step ups and positions that give the hips more freedom and demand more 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 symptoms. If they were to force poor movement however, then the chance of arthritis rises greatly.
Again it comes back to HOW WELL YOU MOVE!
Surgery Should Be A Last Resort
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 or 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.
I have discussed the impact and our over-reliance on surgery before in this article – Do we rely too much on science and surgery for treating chronic pain?
What About Hip Replacements?
I have trained with several older clients who have had knee or hip replacements and they were perfectly fine afterwards, if not better than ever. But I have also met several people who were not better and some much 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 the stiffness went away and pain was a distant memory. They were able to get back to fully functional movement with no problem.
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.
Therefore, 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 Should You Do?
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The very first thing you should ever do is complete an assessment to identify any mobility restrictions, weaknesses, and dysfunctional movement patterns. This gives you clues as to where to start and what movement patterns you need to address.
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.
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 the joint 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 Master The Romanian Deadlift
In the rehab field the Romanian Deadlift (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.
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.
Spending time to develop the strength in the gluteal muscles in this bent over position is critical for improving the joint alignment of the lower limb. This is very important for preventing any joint deterioration when walking or running however the bilateral stance does not demand enough work which is why you need to progress to single leg exercises.
Improve Your Stability & Strength With Single Leg Exercises
Why does the single leg deadlift work so well with hip, back and knee injury?
All people with either hip or knee problems will find the single leg exercises the most difficult to do because they expose the joint instability instantly. It is for this reason that these exercises are the most important to focus on and if you do this you will go a long way to preventing any future knee or hip replacements.
The RDL and especially the single leg RDL work perfectly with hip instability like FAI to realign the femoral back deep into the glutes by releasing the hip and strengthening the glutes.
Watch the video below for a detailed explanation of this.
With knee pain the single leg exercises force the body to align the knee in good alignment or you will fall over.
Knees are exposed to tremendous pain and problems whenever they are forced into a twisting or bend sideways, (eg ACL tear) known as valgus or varus, and lastly if they hyper-extend. This joint is more or less a hinge, it cannot twist and rotate itself, and it cannot bend the other way either.
Once you have gained the stability of the feet and the control of the hip you can add load and use various techinques like the Bulgarian Deadlift below.
Strengthening the glutes is a real part of the problem for both knee and hip pain and you will need to experiment with many exercises to be able to do this correctly. You can read about many other exercises I use to do this in this article – How to strengthen the glutes
Use Exercises That Improve Your Gait
While it is great to have good form and strength with the RDL and the single leg stance you still need to put it all together in the gait cycle to ensure the body moves efficiently. I have covered this in great detail in the article about learning to weight shift before so I won’t repeat myself too much as this is a complex topic to discuss.
One big problem with the muscle and isolated exercise approach is that it often concentrates too heavily on muscle weakness when it may be more to do with neuromuscular weakness. Plus, it also assumes that once your strength is there that your body will automatically know how to use it in complex patterns, which is almost never the case.
In the book “Corrective Exercise Solutions for the Hip and Shoulder” by Dr Evan Osar he states,
“The body does not like to work in isolation and will attempt to distribute forces across as many joints as possible to reduce stress to any one region.”
It is not necessarily a lack of muscle strength that is the problem with gait for many people easily develop adequate strength needed in the muscles of the legs within simple isolated exercises.
This is where I spend a lot of time working on integrated exercises that use the myofascial slings that help connect the upper body and lower body together to create efficient functional movement.
A good example is shown below.
I suggest to read the article about the core slings to see more on this.
Don’t Forget To Work On Hip Mobility
In addition to the strength exercises most people will need to improve their hip mobility. This is due to the fact that so many of us sit too much and not active enough to keep the hips mobile enough.
Some people may have anterior stiffness with the front of the hip and the quadriceps whereas others it is more in the posterior chain of the glutes and hamstrings. Once again spending the time to work on releasing the stiffness in combination with strengthening and learning to move more efficiently will ensure the knee or hip joint remain stable and strong.
You will find tons of ideas about this in the article – 10 exercises to improve hip mobility
Do You Need More Help?
Due to the overwhelming number of questions I have received about our knee pain program and piriformis syndrome 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.
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 go to the online shop.
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 gym complete deadlifts, lunges, farmers walks, 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.
About The Author
Nick Jack is owner of No Regrets Personal Training and has over 20 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes 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
•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