Your knee hurts. Maybe it’s causing you to limp, maybe it feels weak, and maybe it’s not intense, but there’s a constant low-level gnawing feeling there. In any case, you know something’s not right. And you might have received different treatments for it – from physiotherapy to massage, chiropractic, acupuncture, and others, but the progress isn’t quite what you want it to be. Or maybe you experience some pain relief for a few hours or a day or two after your treatments, but then it goes back to the way it used to be. Not good.
So in this article, we’ll cover:
What can go wrong with the knee
The biggest mistakes when it comes to knee rehab
Assessments used to figure out why the knee hurts
WHAT CAN GO WRONG WITH THE KNEE?
The knee is a simple hinge joint. Just opens forward and back. But despite its simplicity, there is a large number of things that can cause knee pain, like:
So when people ask me “what exercises should I do for knee pain?”, I answer “knee pain is a symptom. Not a diagnosis.” All of these different issues that I mentioned will cause knee pain, but the solutions to each one are different. And exercises that may benefit one knee issue may cause significant damage if there’s another issue. For instance, a very good exercise for knee arthritis is what’s called “traction.” That same exercise will make an ACL and MCL tear worse, and slow down recovery.
Hence the need for specificity in exercise selection.
THE BIGGEST MISTAKES WHEN IT COMES TO KNEE REHAB
MISTAKE #1: ONLY SEEKING PASSIVE THERAPIES
As I outline in my article on how to deal with injuries mentally, one predictor of how long an injury will stick around is how active you are in the treatment. If all you do are passive treatments (like chiropractic, massage therapy, lasers, hot packs/cold packs, etc.), you’re used to having stuff done to you. You’re not doing anything. That’s not to say that these therapies are worthless. Far from it. In fact, I often refer my clients to the aforementioned practitioners.
What I am saying, however, is that passive approaches are only part of the approach. They’re not the full approach. You need to be an active participant in your own recovery. How? Exercise!
When you start to combine passive therapies with exercise, you get results much faster, and they’re more long-lasting. Like our client, Carole, whose hip pain from arthritis decreased by 90% in the span of a few months. So much so that she almost completely stopped using her cane, and pain medications. Or Pat, who after years of having arthritis was able to prevent a hip replacement surgery with only a couple months of exercise.
MISTAKE #2: DOING THE SAME EXERCISES FOR DIFFERENT KNEE PROBLEMS
As you can understand from the previous section, different knee problems require different exercises. Doing the same exercises for all these conditions, without precision will make some conditions better… and others, worse. Do you want to take a gamble with your recovery, and see whether the series of exercises that you picked up on the internet will make your pain better or worse? Or do you want a more precise approach?
MISTAKE #3: DOING KNEE EXTENSIONS
If you don’t know what knee extensions are, here’s a picture. Why is this a mistake? Because you don’t know why your knee hurts! If your knee hurts because your quadriceps are weak, then strengthening your quadriceps will certainly help. But what if your quads are already strong, and your knee still hurts? Then additional strengthening will not help. Sometimes, it can actually hurt.
MISTAKE #4: ONLY ADDRESSING THE KNEE
I often tell clients that “the site of pain is not necessarily the source of pain.” What do I mean by that? I mean that the knee may be the victim, not the perpetrator. What is it the victim of? Most typically, it’s a victim of faulty mechanics at the joints above (the hip) and/or below (the ankle).
For example, if the gluteus medius is weak, or can’t control the thigh bone (the femur), it’s a recipe for both a medial meniscus tear, and an MCL tear. The knee suffers, but the hip started it (and to take things a step further, the brain started it. The brain controls all parts of the body, and for some reason decided that it makes sense for the gluteus medius to be weak. We have to investigate what that reason is).
So if all you’re addressing is the knee, it’s a bit of a myopic approach. It’s important to assess the neighboring joints, and address them if deficits are identified.
MISTAKE #5: STRETCHING
Somehow, stretching gained this “halo effect” in our society. That it’s good. For all people. All the time. For every muscle.
Stretching is a tool in a toolbox. Tools aren’t good or bad. It’s how you use them. A hammer is a tool. Is it good or bad? If you use it to hammer in a nail where it’s supposed to go, that’s good. If you use the hammer to break a window, that’s not so good. Did the hammer change? No. The way you use the hammer changed.
Same with stretching. If you stretch the right muscles for the right duration, at the right frequency (number of times per week), you get good results. Stretch the wrong muscles, and you can either slow down your recovery from the injury or make the injury worse.
Stretching is only beneficial if there is a proven need to stretch. How do you prove the need to stretch? You assess the range of motion. No limitations in range of motion, no need to stretch. But how do you know unless you test? You don’t.
MISTAKE #6: NOT ASSESSING
As alluded to earlier, all the previous mistakes really come from one big, fundamental mistake: not assessing. And as you know by now, “if you’re not assessing, you are guessing.” (am I getting repetitive? 😊)
If you’re not measuring what’s wrong, then you don’t know what to “fix.”
Which brings me to the next section, on…
ASSESSMENTS WE USE TO FIGURE OUT WHY THE KNEE HURTS
First, let me say that as fitness professionals, we are not allowed to diagnose. But we certainly can identify muscular imbalances. If we see limitations in range of motion, we’re allowed to correct them, and if we see deficits in strength, we can fix those as well.
So what assessments do I, and my staff use to assess why the knee might be hurting? There are really 5 main categories of tests we use:
CATEGORY #1: HIP RANGE OF MOTION
We assess the different ranges available at the hips:
Why does the hip range of motion matter? Because if the hips aren’t taking their share of the load, the knees have to pick up the slack, and therefore do more work than they were designed to do.
CATEGORY #2: GLUTE ACTIVATION
This is a test of whether your butt works. A lot of activities in daily life involve hip extension. For instance, getting out of your chair involves hip extension. And how many times do you get off your chair/couch/toilet/car seat throughout the day? Dozens.
There are 2 major muscles that can do hip extension: hamstrings and glutes. But if those aren’t working properly, you start to use your quadriceps to substitute. And again, they’re working more than they should be, creating an imbalance of quads (the front of the thighs) to hamstrings (the backs of the thighs). Now, the front of the thigh is pulling on the knee harder than the back of the thigh can counteract.
CATEGORY #3: THIGH STRENGTH
If the ratio of the strength between quads and hamstrings is so important, does it make sense to test it? You bet! The ideal ratio is 4:3. That is, for every 4 pounds that the quads can lift, the hamstrings should be able to do 3. If you can do 50 pounds for the quads, you should be able to do about 38 pounds for the hamstrings. An acceptable ratio is 3:2. If the hamstrings have less than 66% of the strength of the quads, it merits strengthening the hamstrings, without strengthening the quads, until the ratio comes more in the range that we want it to be.
CATEGORY #4: ANKLE MOBILITY
If the hips are the knees’ northern neighbor, the ankle is the hips’ southern neighbor
, so we need to assess ankles as well. We look at:
Similar to the hip, if the ankle is stiff, the muscles surrounding the knee will be forced to work harder than they were designed to. One extremely common cause of stiff ankles is wearing high heels.
CATEGORY #5: MOTOR CONTROL
Motor control is similar to coordination. You see, your brain has a “map” of your body in it (that map is called the “homunculus”). If the map is clear, the brain can move the knee properly, fluidly, and safely. But if that map is “blurry”, there can be pain because of poor coordination around the knee. Certain muscles are contracting when they should be relaxing, and vice versa.
So we test motor control around the knee, by asking clients to perform some movements with precision, and we look at movement quality. If the movement quality is low, poor motor control is a contributing factor to knee pain. If the motor control is good, and there’s still knee pain, we have to look at other factors.
Once we’ve gone through all these assessments (and possibly others), we have a much more direct, clear, and fast path towards speeding up their recovery from the pain, so rather than continuing to struggle, they get better, and get back to the activities they want to do, pain-free. If you’d like to have these assessments done on you, just email me with the words “Knee Pain Help” in the subject line, to see if you qualify.