Is it knee arthritis? Most people with chronic knee pain jump straight to this question without hesitation. People over 40 tend to lean strongly towards 'yes' and just accept this fate as an inevitable part of the aging process. What makes it worse is that many doctors will agree and toss your knee into the "age related arthritis" bin without blinking an eye. The truth is that a lot of chronic knee pain stems from weak musculature and poor movement mechanics.
After lower back pain, knee pain is the second most common form of chronic pain in the body. Almost one in four people are suffering from this major joint condition. It's no wonder that chronic knee pain is handled as if there's nothing that can be done.
I'm here to tell you that before you diagnose yourself with degenerative arthritis, osteoarthritis, knee bursitis, patellofemoral pain syndrome (pfps), or whatever, and hop on the knee surgery bus, you should rule out a few things. Below, I've assembled a sequence for you to investigate your knee health and set the foundation for minimizing pain, improving function, and living your best life again!
Step 1: Assess Your Current Habits
In order to really think about your knee pain objectively, you will need to look in the proverbial mirror. Are you overweight? Are you sedentary? If you answered yes to both of these questions, then it's pretty clear that your health has not been a priority.
Being overweight adds additional stress to the knee joint. Remember, the knee has to support all of the weight above it! If you imagine that for every extra pound you are carrying, your knee will have to manage 3 to 6 additional pounds of force!1 Clearly, reducing your bodyweight will significantly relieve the pressure on the knees during all weight bearing activities.
A sedentary lifestyle does nothing good for the body. Humans are meant to move, and move a lot! (I also think 10,000 steps a day sets the bar much too low for true health & longevity, but I digress.) Movement is not only physically beneficial, but it pushes your mental and emotional state towards balance.
The great news is that if you're both overweight and sedentary, then you've got huge potential for knocking out knee pain provided they are mechanically intact! Take the following steps and incorporate them into your life. Your joints will move more freely, the muscles will adapt quickly, and your body will love you for it! Now is always the best time to improve your health and wellness!
Step 2: Strengthen the Joint
I know that it's easier said than done, but muscular strength will reduce your injuries and increase longevity2. You need muscles to help you move more freely and to prevent injury. Plus, regular muscular work boosts hormone levels.
For strength training, there is one superior exercise that I prefer for the knee joint. That exercise is the beloved squat. If you're out of shape, start with bodyweight squats. It will be enough. You don't need a gym. You don't need spandex. You don't need a weight rack. You just need the earth under your feet.
Start simple. Give yourself a goal of 50-100 full body squats a day. Perform them in the range of motion that doesn't elicit a pain response. (Also note the difference between pain and discomfort. Discomfort doesn't result in swelling, bruising, or injury. Pain does.) When the number of reps gets too easy, increase the number of bodyweight squats as well as the depth of the squat. If you can hit a$$ to grass, congratulations! That's where you want to be! Continue to challenge yourself as your body adapts and your strength increases.
Doing a proper squat is important to reduce the chance of knee injury, but it also provides a proper functional movement that your brain can learn. I suggest that you see a personal trainer, or movement pattern expert, to teach you the principles of a good squat. When I say good squat, I mean hinging at the hip, driving heels into the ground, and activating glutes. If none of this makes sense, then definitely seek out a good athletic trainer. Incorrectly performing the squat will NOT help your knees, and if you're completing 500 of these a day, damage will inevitably occur. Remember, you are trying to improve strength and function. Both are requirements for long term knee health.
Squat every day. Think of daily squats like brushing your teeth. If you don't brush your teeth, your teeth suffer. The same goes for your knees. Right now, how many times do you do a full squat in a day? For most people, the answer is zero. That's why your knee is in pain in the first place. It's crying out for attention and care. Don't wait for motivation to hit you. I mean, are you motivated to brush your teeth? No, you just do it because you know you need to. The same psychology goes for squatting. Squats are absolutely imperative for knee joint health. As the saying goes, "If you don't use it..."
Step 3: Balance the Joint Musculature
Even though this step is somewhat connected to the previous one, it needs significance placed upon it.
To further refine the idea of strengthening muscles surrounding the knee joint, you must also balance them. Both the agonist and antagonist muscles in every joint should be exercised. What does this mean? It means that the muscles moving the joint in one direction, should be balanced by the muscles that move the joint in the other direction.
In my practice, I've found that muscular imbalance has been a major contributor to chronic joint pain. Read that again. In the case of the knee, the weak link is typically the hamstring muscle group. In practically every case of knee pain that I've seen in my practice (not including professional athletes), the hamstring muscles are severely overpowered by the quadriceps group. In addition, the entire posterior chain, which are the muscles comprising the back of the whole body, tends to be weak. In these clinical cases, back pain usually, or eventually accompanies the knee pain. Remember that the hamstrings sit right between the knees and the back, the top two places for chronic pain sufferers in America.
Ask any professional athletic trainer about hamstrings and posterior chain strength and they will tell you that a powerful posterior chain reduces risk of injury in athletes who run in their particular sport.34
How do you strengthen the hamstrings? Squats! You can squat for hamstring health. The focus of the movement is on feeling the burn in the hamstrings and glutes. Again, see a personal trainer and get the movement dialed in properly to reduce your chance of injury and improve your chances of success. But, once you get to a certain level of squat strength, it will be time to add another essential exercise for getting your hamstrings as powerful as your quadriceps.
Enter the Romanian deadlift, or RDL, as it's affectionately known. This exercise is valuable for the hamstring and knees, but it's also world-renowned for it's posterior chain prowess! You'll need a barbell or dumbbells. Add this to your daily exercise routine and supercharge your knee, hip, and back strength! As always, see a personal trainer and learn the correct movement to prevent injury and maximize muscle recruitment.
Step 4: Stretch With Purpose
The jury is out when it comes to stretching and whether or not it is beneficial. I firmly believe in stretching for pain relief. There are many types of stretching, but the one I'd like you to consider has a major purpose, and that is to both provide functional ROM over a wider range of joint operation as well as reset any overactive pain feedback loop in the joint.
Stretching is a complex animal requiring a mix of both mental and physiological input. Since there are so many variations on stretching, it can be confusing to know where to start. But, one form of stretching in particular goes a long way towards pain management and joint mobility. It uses parts of both static and dynamic stretching, but the magic comes from the small bit of resistance to the muscle being lengthened. I call it FROMS and it stands for: Functional ROM Stretching. This type of resistance stretching requires the muscle to function, rather than turn off, at the joint or muscular end ranges of motion. This teaches/retrains/reminds the brain and body that the tested ROM is accessible and safe to use. Here's how it works.
Imagine that you're sitting on the floor with legs straight out in front of you and you bend forward at the hips to reach the hands towards your feet. This seated forward bend (paschimottanasana for the yoga crowd) is a common stretch to mainly lengthen the hamstrings, followed by the lower back and calves. My FROMS technique is one where you would perform the stretch to full ROM, back off the stretch up to 10%. Maintain the position and begin contracting your hamstring muscles using 25% of your maximum contraction strength. Hold the contraction for 5-10 seconds. Relax. Repeat the sequence 10 times. You should notice in the first few repetitions that the stretch becomes less intense. You may also find the joint's end ROM moving further away.
Performing this stretch multiple times a day and throughout the week is extremely beneficial. It resets any overprotective Golgi tendon organs and provide proprioceptive feedback to the brain to signal that the deeper ROM is normal and joint musculature is functional and safe. Although FROMS will fatigue muscles with enough repetitions, it is entirely different from strength training. Eventually, I will have a link to a video and a more detailed explanation of the FROMS technique and how it benefits functional ROM.
Step 5: Learn Proper Movement
As previously stated, the knee joint is pretty simple in function. It's a basic hinge. If it functioned by itself, then control of it would also be simple. Well, the knee tends to work in conjunction with the hip and the ankles, not to even mention the rest of the body. But, you get where I'm going with this.
Most normal body movements that involve the knee are complex, meaning that multiple muscles and joints are moving in conjunction with the knee. For example, standing up from a chair is a complex movement. This action must be masterfully controlled by your brain for efficiency, power, & grace. Or it's a clumsy, difficult, & lumbering movement that can overstress the muscles and joints. Or, you just fall directly on your face.
Since you don't just fall over when you get out of a chair, there's some muscular contraction pattern that stabilizes, forces, and propels you into standing position. Even though you've probably been rising from a chair for years, you may be doing it inefficiently! As your physical body changes throughout your life, your movement patterns should adapt. Obviously, some people have the proprioceptive skills to adapt easily, but not all of us are that aware.
Learn proper movement for basic activities of daily life (ADL). I cannot stress this enough. When I was younger, I didn't care. Now that I'm older, It's a different game. I'm interested in longevity and staying incredibly active over 40.
Park the ego outside. See a personal trainer. Watch a ton of instructional videos. Record yourself and watch how you move. Practice doesn't make perfect. Perfect practice makes perfect. At the very least, learn proper movement for the actions you perform every single day. When you've mastered these, move on to other compound movements. The human body is so incredibly amazing and dynamic! See for yourself!
Step 6: Reduce Inflammatory Foods
Puffy joints don't work well, eh? If you've ever injured yourself, you'll probably notice that. I know that diet is a touchy subject, but it's important to getting the most out of your body. I'm not saying anything new here. Eat clean, natural and organic foods. Stop ingesting artificial garbage. That goes for artificial sweeteners, flavors, & colors. Food is fuel and if your body has a systemic immune response to the food you are eating, your joints will hurt!
I'll tell you that I have a joint in the middle finger of my left hand that swells up when I've eaten something that triggers my gut's immune response. It tells me every time that something is not right. Sure, I could call it arthritis. But I eat the things that keep the swelling down and it works perfectly afterwards. I'm not saying that this is your case, but I know for certain that eating garbage hurts my joints and clean eating fixes them.
Step 7: Try Battle Balm (The Secret Step!)
Battle Balm is a tool for your health. I use it when I need it. I think it's fantastic, but I'm biased, right? Well, let me tell you one very cool way in which Battle Balm can help you understand your knee pain.
Sometimes joint pain is purely muscular. Muscles in spasm due to weakness and/or tightness WILL refer pain to it's attached joint. Read that again. A great way to test if your knee joint pain has a muscular component to it is to perform the above steps daily and use Battle Balm to help you. With Battle Balm alleviating the referred knee joint pain from your leg muscles, you can then separate the referred muscular pain from ACTUAL joint pain.
But don't apply Battle Balm to the knee joint itself!
Apply Battle Balm to the quadriceps and the hamstrings. Perform your strength and stretch exercises. Complete your day and in the evening or night time, apply some Battle Balm to the upper leg muscles again when you've got some time to sit and relax. Take some time to assess the pain in your knees at this point. If the pain is gone, or has changed in nature, there's a huge likelihood that part of the patellofemoral syndrome (PFS is a fancy way of saying chronic knee pain) you experience is from your muscles.
Experiment with this for a week or two and see what happens!
If you are suffering from chronic knee pain, you should be starting your rehabilitation, recovery, & pain relief journey with the information above. This article sets the foundation for every single knee pain condition I see in my clinic and it should be referred to often.
You can work on each of the above steps individually, but the power comes from the summation of all of them. In any case, we all have to start somewhere and one step forward should be lauded as you are moving the needle towards optimizing your health and wellness.
I'm in an age group where many of my peers are experiencing knee pain. Less than half of them run anymore. After an ACL reconstruction at 38 years old, I still have zero knee pain. I perform all of the steps that I've stated above regularly. I wholeheartedly believe in the body's ability to heal itself when given the right environment and opportunity.
Natural pain relief is what I specialize in. I enjoy what I do and my focus is on bringing you information, tips, and tricks for you to maximize your body and minimize your pain. I'm not interested in short term gains. I'm interested in longevity. If you are passionate about the same things, you're in the right place.
Barela, A. M., de Freitas, P. B., Celestino, M. L., Camargo, M. R., & Barela, J. A. (2014). Ground reaction forces during level ground walking with body weight unloading. Brazilian journal of physical therapy, 18(6), 572–579. https://doi.org/10.1590/bjpt-rbf.2014.0058
Fisher, J. P., Steele, J., Gentil, P., Giessing, J., & Westcott, W. L. (2017). A minimal dose approach to resistance training for the older adult; the prophylactic for aging. Experimental gerontology, 99, 80–86. https://doi.org/10.1016/j.exger.2017.09.012
Gronwald, T., Klein, C., Hoenig, T., Pietzonka, M., Bloch, H., Edouard, P., & Hollander, K. (2022). Hamstring injury patterns in professional male football (soccer): a systematic video analysis of 52 cases. British journal of sports medicine, 56(3), 165–171. https://doi.org/10.1136/bjsports-2021-104769
Lopes, T. J. A., Simic, M., Chia, L., Terra, B. S., Alves, D. S., Bunn, P. D. S., Rodrigues, A. I., Lima, M. D. S., Ribeiro, F. M., Vilão, P., & Pappas, E. (2021). Trunk endurance, posterior chain flexibility, and previous history of musculoskeletal pain predict overuse low back and lower extremity injury: a prospective cohort study of 545 Navy Cadets. Journal of science and medicine in sport, 24(6), 555–560. https://doi.org/10.1016/j.jsams.2020.11.020
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