Knee Joint Pain: It's not the Bee's Knees
Joint health. It's one of those things that becomes of the utmost importance to those who want to remain active into later years, or those who are beginning to experience the signs of joint degeneration. So what do we do? How do we combat joint pain or work to prevent it in the first place? Well, there isn't exactly a straight answer to that.
In my experience dealing with clients living with joint pain, the vast majority of them do not want to jump straight to cortisone injections or prescription medications. As an aside, it is baffling to me how quickly some doctors will prescribe opiates to patients and I will tell you, people are afraid of addiction and end up living with pain, as turning to drugs is not an adequate solution for many. Now the reason that understanding joint pain is tricky, is because prevention and management requires a lot of work in the middle ground. What I mean by this, is that both too much or too little stress on the joints can cause their own set of complications. Today we will talk about development of knee joint pain and degeneration, prevention, and what to do when you are already starting to feel the signs of aging joints.
What causes Joint Pain?
As previously stated, the crazy thing with joints is that they can become painful from either too much or too little activity. I would argue that it is a common misconception that frequent activity will inherently lead to joint pain. Although studies have shown that populations of professional athletes in contact sport typically have a higher incidence rate of osteoarthritis in the knees, there is a lot more going on here than a simple correlation between sport and joint degeneration. When it comes to weight bearing activity, the stress on joints actually creates a reactive development of articular cartilage (cartilage on joint surfaces that glide on one another), improved circulation of joint fluid and blood flow to the joint, and prevents joint capsule contracture. Pro-sports athletes are an extreme example of the physically active, and we have to keep in mind that they typically suffer multiple joint related injuries through the span of their careers. This is where the trouble starts. Although activity with no history of joint trauma is overwhelmingly beneficial to the joints, the body reacts differently when acute injury occurs.
Post-traumatic arthritis can occur between months and years following an acute joint injury. Following injury, we see changes to the make up of bone and cartilage and increases in inflammation. Many times this inflammation resolves on its own, but in some cases following a latency period we see the development of arthritis related to the previous joint injury. In the image below we can see how some people experience spontaneous resolution, and others develop chronic pain and inflammation.
To conclude upon joint issues in the physically active, it is agreed upon that moderate physical activity in those with no hereditary risk factors is beneficial to joint health, and that shear or traumatic stress to the joint is where we see a correlation to development of joint pain.
The next question is, why do we see joint pain and degeneration in sedentary populations? Many things happen when we don't use our bodies. To put things quite simply, when we don't move we see muscle atrophy, joint capsule contracture, decreased synovial fluid movement and blood flow, and thinning of articular cartilage. Muscle atrophy is a concern when it comes to joint health, because muscle weakness leads to poor compensation patterns, changes in posture and gait, and changes in weight distribution in loaded joints. The typical change we see in people with osteoarthritis of the knees, is weakness in the glutes and medial quadriceps muscles. This causes a greater distribution of weight onto the medial surfaces of the tibial plateau and its cartilage leading to further degradation of cartilage, increased boney growth and increased pain. All of these things increase even further if we happen to have a valgus knee posture, as we are predisposed to greater strain on the medial surfaces of the knees. Capsular contracture limits us in a similar way. If the tissues become constrained, we cannot move through a full range of motion, once again creating stress on specific areas of the articular surfaces.
The other contributing factor we often see with joint degradation in sedentary populations, is obesity. Do not get me wrong, this is not a be all end all cause, but rather something that may affect how your joints feel. Research indicates a correlation between BMI >28 and knee joint damage. Yes we can also argue that taller people are heavier and are therefore also more prone to knee joint degradation. But again, the research shows that taller people with normal BMI for their height actually have a larger articular cartilage volume that increases proportionally with height. Even though tall folks tend to have more asymptomatic bone lesions in the joint as compared to average populations, so long as they maintain a recommended body weight, they theoretically should not be predisposed to knee joint issues. All this being said, there is very little research regarding height and related knee issues. I digress, carrying extra weight just as other factors, increases negative joint load and may impact the way the body and joints move, increasing the likelihood of knee pain.
Poor strength, compensation patterns and limited range of motion are only the beginning. Just think of the feeling of damaged tissue gliding on damaged tissue with a limited amount of synovial fluid to provide lubrication. All I can say is YUCK! The more we move, the more lubrication we provide to the joint. But in most cases, the more we move, the more pain we have. Often this becomes a never ending cycle, where pain impacts activity, activity produces pain, and the more sedentary we are, the more the pain increases. So how can we prevent this from happening, or try to stop the cycle in its path?
As previously stated, continuing to move is incredibly important when it comes to joint health. Activities such as walking, cycling and resistance training are excellent ways to apply positive stress on the knees, and making sure to utilize the glutes and quads will only work to improve your longevity. This doesn't mean you should go out and try to get the biggest glutes possible, but rather train them functionally so that you can adequately stabilize the pelvis and knees, and optimize joint movement. Maintaining range of motion is also important, and in the terms of joints, we often see a greater feeling of relief when using a prolonged stretch, where we maintain the stretched position for 1 to 5 minutes. In doing so, we provide more time for the muscles to elongate, adaptation to the new stretched position, and the ability to very lightly stretch the joint capsule. Another incredible option for older folks wanting to prevent joint damage with old age, is something called the GLA:D program. Developed with exercise and education as key parts of its program, GLA:D helps people suffering with hip and knee arthritis regain motion, and reduce pain. You can read more about GLA:D by clicking the link listed above.
Although I am not one to tell people to avoid activities, there are certain activities that have proven to be far more detrimental to the knee joint as compared to others. High impact activities such as running, Crossfit, tennis, gymnastics or anything where you perform jumping or jolting movements creates great amounts of stress upon the joints. Populations who participate in large amounts of these activities are the people who we see developing post-traumatic arthritis or boney lesions within the joint due to repetitive high-impact movements. Of course taking care of your body while participating may help to mitigate the effects of these types of exercise, but there will likely be some type of consequence when it comes to long term participation in these areas. If you're a young person wanting to keep moving for as long as possible, check out some exercises below!
Vastus Medialis Oblique Strengthening
The VMO is segment of the medial quadriceps muscle that aids in comfortable gait.
This muscle may be visible at the inside of the knee when you straighten the knee. To
to strengthen this muscle, place a rolled towel or ball under the knee and turn the toes
outwards. Extend the knee by pushing the lower leg into the towel. Repeat 3x10 1x/day
2. Glute Bridges
Begin with knees bent and feet flat on the ground. Pull heels as close as you can
comfortably towards your bum. Tuck your tailbone under to activate the core, and
press your body upwards by squeezing the glutes. Try to maintain the glute
contraction as long as possible as you return to the ground. Repeat 3x10 1x/day
3. Prolonged Hip Flexor Stretch
Lie on your back on a solid surface where you can hang your leg over the side. Pull
one leg to your chest, and let the other hang freely. The great thing about this
stretch is that we stretch the hip flexors of the hanging leg, while stretching the joint
capsule of the chest leg to improve flexion. Hold this stretch for 1 to 5 minutes as
tolerated and repeat on the other side.
4. Tensor Fascia Latae Ball Release
To locate the TFL, find the bony protrusion at the front of your hip, then move to the
outside of the hip. This muscle will likely be tender to the touch. Using a tennis ball
lacrosse ball or the like, place the ball at the TFL and press gently into a wall. Apply
pressure and roll as tolerated. Perform this movement for 30 to 90 seconds, 2-3x/week
5. Knee Controlled Articular Rotations
This is hard to explain via text, so here's a video for reference. The purpose of this
exercise is to maintain mobility within the joint capsule. Remember to focus more on
the areas where movement does not feel smooth. Repeat as many times as you'd like.
I have pain already, what next?
For those of you who have already entered the world of knee joint pain or degeneration, there are still things that can be done! As previously stated, if you're suffering with osteoarthritis, the GLA:D program is an excellent choice, and if you're located in South Calgary like me, Momentum Health Seton offers GLA:D programming for the knee and hip. Once again, this program is great because participants receive assessments, education and an exercise plan used to strengthen and train cardio in a low impact setting. Another option to help get through the pain, is an osteoarthritis off-loader brace. These braces are designed to apply pressure to the medial knee, reducing pressure and pain in those with medial surface arthritis. They are considered to be a secondary measure to reduce pain following or during rehabilitation, and before surgery becomes an option. It is important to note that if the joint has not been adequately strengthened, and person using the brace still lacks proprioceptive ability, the positive results from such braces is typically low. Other safe low impact activities include walking, swimming, pool walking, cycling, rowing (as tolerated), swim aerobics and others.
In general, I would say that it is safe to seek out some form of physical therapy! Everybody and every body is different, so it is important that you find a qualified practitioner to identify what needs work, and to help build a plan to reach your goals. At the end of the day, if enough damage occurs, the last step is always a full knee joint replacement. But to ensure that you get to live your life as you intend to, prevention and maintenance are key. The other perk of finding a therapist, is that they will likely use some form of manual therapy as well to help ease your pain. I know, the thought of joint pain is not the bee's knees. But with a little motivation, there are many things that can be done to improve the health of your knees.
Kristen Huber CAT(C)
Owner, The Gentle Athletic Therapist
Hunter, D. J., & Eckstein, F. (2009). Exercise and osteoarthritis. Journal of anatomy, 214(2), 197–207. https://doi.org/10.1111/j.1469-7580.2008.01013.x
Hunter, D. J., Niu, J., Zhang, Y., Nevitt, M. C., Xu, L., Lui, L. Y., Yu, W., Aliabadi, P., Buchanan, T. S., & Felson, D. T. (2005). Knee height, knee pain, and knee osteoarthritis: the Beijing Osteoarthritis Study. Arthritis and rheumatism, 52(5), 1418–1423. https://doi.org/10.1002/art.21017
A.J. Teichtahl et al. (2012). The associations between body and knee height measurements and knee joint structure in an asymptomatic cohort. BMC Musculoskeletal Disorders, (19). https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-13-19
I.G. Otterness, et al. (2008). Allometric relationships between knee cartilage volume, thickness, surface area and body dimensions. Osteoarthritis and Cartilage, 16, 34-40. doi:10.1016/j.joca.2007.05.010
Moriyama H. (2017). Effects of exercise on joints. Clinical calcium, 27(1), 87–94. https://pubmed.ncbi.nlm.nih.gov/28017950/
Punzi, L., Galozzi, P., Luisetto, R., Favero, M., Ramonda, R., Oliviero, F., & Scanu, A. (2016). Post-traumatic arthritis: overview on pathogenic mechanisms and role of inflammation. RMD open, 2(2), e000279. https://doi.org/10.1136/rmdopen-2016-000279
Anecdotal information provided by Eli Silva, Momentum Health.