When Less is More

I may be in the minority about this, but the kind of exercise you need for something like knee pain depends on why you have knee pain.

The kind of treatment you receive for heart disease depends on the nature of the disease; the kind of treatment you receive for a loose shoulder joint depends on why the joint is loose. Seems logical to me to conclude that the kinds of treatments (exercises) you receive or do for knee pain would then depend on why your knee hurts.

Like I've said before, pain is not THE problem; it's A problem. So, just because the front of your knee hurts, doesn't always mean that making your muscles stronger will solve the pain. It might, if you're lucky, but the less fit your are, the longer you've had the pain, the less likely that something like the exercises below will help for the long term.

One of the main problems is gravity. Climbing stairs, squatting, kneeling, sometimes walking, or practically anything where you apply force to your leg often turns into a frustrating and painful experience. The force or load of the activity on the tissues of your knee is greater than those tissues can take. The result is that you hurt.

Ok, so you might be thinking, "Well, then if I make my muscles stronger, then I should be able to take the force of gravity; the force of going up a flight of stairs."

Well, here's why just trying to strengthen your muscles often fails to deliver significant functional change; like climbing stairs, squatting, jogging.

One of the main reasons people have knee pain is due to osteoarthritis of the knee. This is a condition that causes a weakening of the cartilage that lines the end of the femur (thigh bone) and tibia (shin bone). The cartilage is weak, thin, frail, and fails to provide sufficient protection for the bone. It's like having lousy shocks on your car.

Now, some people don't believe that you can actually strengthen your joint (cartilage) despite the evidence that you can. What we have suggested for many years, it'll be over 20 for me, is that joints respond best to a load that matches what the joint can tolerate. For joints with osteoarthritis, the concept is No Pain, Gain. So, if squatting down to sit in a chair hurts, it's not the squatting that's the problem. It's the load that your knee joints must carry during the squatting motion. If you weighed less, and I'm not suggesting the solution is weight loss, although sometimes that would be a really good idea, in almost every case, your knees won't hurt. Now, something else that's very cool about joints is that when you perform squats at a level of force that the joints can tolerate and are consistent with the exercise (we like to use a Total Gym for this), the joints respond; they adapt, become stronger, sturdier, and can tolerate more force. Strength training for joints is a different kind of exercise regimen than strength training for muscle. When you try to use a level of resistance that muscles need to get stronger, osteoarthritic joints hurt and don't adapt. Instead, joints want less load, more motion and what you'll get is less pain and more strength and function.

Don't buy it? Well, this idea of reducing load during exercise to reduce knee pain in people with knee osteoarthritis was recently studied in two groups of patients: one group exercised in water while the other exercised on land**.

Care to guess which group had more pain relief and better function?

For osteoarthritis, less load, more motion will usually translate into less pain and more function.

P.S. Guess who else needs to know this.

References:

* Lu, Tung-Wu LU, Chien, Hui-Lien, Chen, Hao-Ling. Joint Loading in the Lower Extremities during Elliptical Exercise. Medicine & Science in Sports & Exercise. 39(9):1651-1658, September 2007.

** Jamtvedt, Gro, Dahm, Kristin Thuve, Christie, Anne, Moe, Rikke H, Haavardsholm, Espen, Holm, Inger, Hagen, Kare B. Physical Therapy Interventions for Patients With Osteoarthritis of the Knee: An Overview of Systematic Reviews PHYS THER 2008 88: 123-136