You’ve likely been there before. Running up a flight of stairs and feeling that twinge in your knee. Feeling your knees ache after a long day of walking. Waking up and feeling the stiffness as you put your feet on the floor. Knee pain is everywhere. Most people, at some point in their life, experience it–whether in large amounts or small. As age increases, so does the likelihood that you’ll have knee pain.1 The most common diagnoses of knee pain include arthritis, ACL or meniscal tears, tendonitis, ITB syndrome, and patellofemoral dysfunction.
A Name is just a Name. And so is a Knee Pain Diagnosis.
In general, we tend to overemphasize knee structure and underemphasize function. What I find is that most people have a very static view of how the body works. That means that if something is torn, it’s assumed that the tear is what causes the knee pain. If there is arthritis or degeneration, we think that’s what hurting us. In actuality though, that’s not what we see.
Pain sensors in our body respond to chemical inflammation or abnormal pressures.2 There are a lot of functional changes like abnormal biomechanics or soft tissue density changes (which change pressure distribution) that result in pain signals. Likewise, inflammation, whether from a ligament tear or too much stress on a tissue, will stimulate pain receptors. This means that something like a tear may or may not be causing your knee pain. In fact, 61% of people with meniscus tears in their knee have no pain or stiffness at all.3 While some meniscus tears are painful, we often overlook the effects on the surrounding tissues because of what we see in the picture. Surgery may repair or remove the problematic piece of meniscus, but many patients still have some knee pain, which tells us that we need to look at the clinical picture rather than just at the MRI.
So what treatments address the knee functionally?
Hands-on work like soft tissue release, manual manipulation and active rehabilitation all help.
Knee rehab often looks to strengthen the quads and hamstrings surrounding the knee. Muscular strength is important because muscles stabilize the joint and prevent excess loading of the ligaments. I prefer functional movements like squats. Some therapists will avoid these full body movements because they’re easy to mess up and do with bad form, but they’re important in helping build strength through a whole movement. Naturally we move whole body parts rather than just one joint at a time, so I find it’s important to strengthen the body the same way.
One of the biggest oversights I see in patients with knee pain is the lack of nervous system assessment in the treatment. If we always treat muscle weakness as a lack of conditioning, we miss the impact of the nervous system in healing. When a body part is damaged, pain signals are sent into the spinal cord and brain. Within the spinal cord, these pain signals can alter the way that other muscles function, both in the same body part and even across the body.4 Assessing all the surrounding areas both for strength and neurologically is an important step in full recovery of knee function.
What do I see work best to eliminate knee pain without surgery?
1. Working through the muscles and fascia surrounding the knees.
This helps restore function to the tissue area as well as reducing tension on adjacent joints.5 In my practice, I use manual muscle testing to target the areas I work. It gives me real time assessment of what the root issue is and whether treatment is effective. If you aren’t in Indiana, check this directory for suggestions. Working through the gastrocnemius and soleus (the calf muscles) will be especially important in fixing the knee pain long term. Warning: These muscles will likely be very sensitive. Consider yourself warned.
2. Work on strengthening the full range of motion of the knee and also the joints above and below.
That means the hips, feet, and low back. In my experience, the trend is that hip mobility (strength and range of motion) needs to increase, low back stability needs to improve (build that core!), and the feet and ankles need strengthened. Some practitioners focus a lot on ankle dorsiflexion (the ability to pull your foot toward your head), but I find this usually improves as you work on the other areas. If you have worked on strengthening these areas and find it makes no difference, go back up to number one or check out my article on how chronic stress can affect your ability to heal. Knees tend to be the biggest responder to dietary inflammation.
Like I mentioned earlier, when it comes to strengthening, I prefer whole body exercises if you’re physically able. Exercises like deep squats create flexibility and strength in all parts of the lower body. These whole body exercises also prevent you from developing new poor movement patterns. For example, if you never use your gluts (because you sit all day or you don’t know what gym exercise machine works the gluts), your pelvis tips forward and your hamstrings will tighten. That changes tension on the knees and can cause abnormal wear and tear long term. Better to use your whole body as you move and strengthen it all at once.
3. Work on foot strength and mobility.
If your foot rolls in as you stand, this puts more pressure on the inside of your knee. The inside (medial) part of the knee joint is the most common place to have arthritis in your knee, so it’s ideal to limit the stress you put on that part of your knee. If you aren’t sure how to assess your foot and ankle strength, here’s a quick test: You should be able (1) to stand normally without your feet rolling in, (2) to balance on one foot without falling over, and (3) be able to do a deep squat without falling backward. These are signs that you have both strength and stability in your feet and ankles.
One tool I really like to help build foot strength is the minimalist shoe.
Companies that offer these include Vivobarefoot, Lems, Softstar, Xero, and (my least favorite) Vibram. Most people can’t wear this type of shoe full time fromthe start. Because we spend most of our lives in shoes that keep our toes squished together, our heel above our ankle, and our entire sole comfortably cushioned, our bodies gets used to that. The human body gets very good at doing only what it is asked to do regularly. Using a minimalist shoe can be great for building foot and ankle strength and taking pressure off of your knees, but you need to transition slowly so you don’t ask your body to do too much too fast. Start with a minimalist shoe by wearing them walking for a few hours and build up from there.
I find that most cases of knee pain respond to one of these factors, even the worst cases of knee arthritis. Patients who told me they just have ‘bad knees’ have had full resolution (no pain even running or going up stairs) after 20 years of pain. There are certainly some cases in which surgery should be done on knees, but just because you CAN have your knees replaced doesn’t mean you have to or that shouldn’t care for your knees now.
To schedule an appointment, get in touch with us. For the article sources, see below.
- Nguyen, U. S. D., Zhang, Y., Zhu, Y., Niu, J., Zhang, B., & Felson, D. T. (2011). Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Annals of internal medicine, 155(11), 725-732.
- Dubin, A. E., & Patapoutian, A. (2010). Nociceptors: the sensors of the pain pathway. The Journal of clinical investigation, 120(11), 3760-3772.
- Englund, M., Guermazi, A., Gale, D., Hunter, D. J., Aliabadi, P., Clancy, M., & Felson, D. T. (2008). Incidental meniscal findings on knee MRI in middle-aged and elderly persons. New England Journal of Medicine, 359(11), 1108-1115.
- Chen, L. M., Mishra, A., Yang, P. F., Wang, F., & Gore, J. C. (2015). Injury alters intrinsic functional connectivity within the primate spinal cord. Proceedings of the National Academy of Sciences, 112(19), 5991-5996.
- Roman, M., Chaudhry, H., Bukiet, B., Stecco, A., & Findley, T. W. (2013). Mathematical analysis of the flow of hyaluronic acid around fascia during manual therapy motions. The Journal of the American Osteopathic Association, 113(8), 600-610.b
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