Why Knee Pain Doesn’t Get Fixed
2024-03-18
Jessica Bento, Physical Therapist (Creator DVRT Restoration Certification, DVRT Rx Shoulder, Knees, Pelvic Control, & Gait Courses)
While physical therapy and fitness share a lot in common, especially in our desire to help people, the lenses we often look through and the problems we are trying to solve can be very different. This doesn’t make either side better than the other, however, we can learn a lot by listening to one another. My hope is that by sharing my perspective of being a former athlete, a physical therapist who has been practicing for close to 20 years, and someone who has made a ton of mistakes will help you make problem solving for yourself or those you work with so much better. Especially when it comes to such a common goal of building stronger, more resilient, and healthy knees.
Low back issues tend to dominate the discussion about helping common problems people face, but many would be surprised how the healthy knees are becoming a greater rarity. In a 20 year period knee issues went up by 65% and procedures like knee replacements have TRIPLED in just the time of 1991 to 2006 and the stats keep going up! Whether you are a clinician or fitness professional, building healthy knees is an issue we want to help people achieve. I will say that the type of person that a clinician and a fitness pro may see could be different (being post-surgery for example is a big difference) however, these principles and concepts will help both! When we consider that when people have surgery issues that caused the need for surgery have gone on for years, these principles will still be important.
For many fitness pros, I know you want to help people achieve their fitness goals and when people say they can’t lunge, squat, etc. because of their lack of having healthy knees that can be frustrating and make your job a lot more challenging. I hope these ideas and drills will help you as well because we tend to overlook the root of the issue far too often and place our emphasis on the current problem.
What can we do to help create stronger, more resilient, and healthy knees? Well, here are some keys that will get you going in a very positive direction to making an impact in the quality of people’s lives.
The Knee Is A Victim
The knee is a great example of the saying that the renown neurologist and expert in myoskeletal medicine, Dr. Karl Lewit would offer to help us have a bigger picture view of someone’s issues. The reality being pain is complex and there are MANY reasons that someone could have an issue anywhere in their body, but we are going to focus on the most obvious issues that so many present. When it comes to the knee, the joint is usually a victim of what happens below and above it. The knee itself has most of its movement in the sagittal plane (forward and backwards) so if the joints that have more movement above and below (the foot/lower leg and the hips) aren’t functioning correctly then we aren’t going to be able to address our goal of healthy knees.
Addressing the foot, for example, doesn’t mean just being barefoot or in minimus shoes. While those strategies are great in putting us in better environments, the reality is unless we have people learning HOW to use their feet and to keep their feet active we won’t change a lot in their movement skills. Below is an example of what I love to use in both the half kneeling position (which puts people in a position where the feet become more important) as well as how to give people feedback on how to use their feet.
You may say “I want to do those drills Jessica, but my client can’t be on their knees.” I get it, there are really two strategies I would suggest. The first is simply put a small bit of padding under their knee to see if they are more comfortable (you would be surprised how often this works, but don’t put too big of a padding under where they can’t use their feet). If that doesn’t work, you can use our Sprinter Stance with the same ideas as you see below (keeping the back heel elevated and going about heel to toe gives you some foundational levels of the half kneeling position).
Once we have a good foundation we can put the body in more advanced positions where it needs to create stability by using the feet. While we have discussed a lot about not using unstable surfaces for core training or such, these tools CAN be helpful in building betters stability of the lower leg/foot. The key is not using TOO much instability for the level of the client but this can be a wonderful way of building to healthy knees.
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You may notice in the examples above that I was focusing on our Arc Press. It may seem odd to have a pressing motion relate to building healthy knees, but anyone that has gone through our DVRT courses has realized that in order to press well, you need stability coming from the ground up. The more engaged the feet, the stronger the hips, core, and yes, upper body. The fact the Arc Press amplifies our need to resist movement from side to side is one of the great drills we can use to help teach functional stability of the lower body.
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As you see above though, the Arc Press is far from the only way we teach these concepts. However, you may be thinking “what about ankle mobility though?” Yes, ankle mobility is a key for helping build healthy knees and the correlations coming out to stable/mobile ankles and feet is showing us that this so foundational to the goal of healthy knees. Yet, we often get stuck in a bodybuilding approach to mobility where people just crank on their ankle joint without any real intent or purpose. Yes, you can get the ankle to move better by these passive approaches, but does it last?
Like so many things in movement training, we have to ask ourselves, “why did the ankle get tight?” If we look at the classic “Joint By Joint Approach” we see that the answer can come in what is occurring at the foot (as well as the hip/core).
If we don’t get stability from the areas that are below and above the areas that are built for mostly mobility, guess what the body does in response? If you said get “tight” then you would be correct. That is why I said passively creating mobility in the ankle joint (adjustments for example) won’t hold or be long lasting if we don’t also look at the foot creating stability. Add this to the fact we know that mechanics of the foot have a direct relationship with the glutes, we should be looking to use active forms of mobility training for the ankle (we can include passive as long as we use active to cement patterns)
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When you look at the ankle mobility drills above we are integrating our mobility both from the foot being in positions that build mobility, having the feet being highly active, and working the hip/core relationship. In other words, the key to cementing the mobility we are building for more functional movements like squats.
Glutes & Hamstrings Are Essential
As a young therapist, when someone came in with knee issues I was SO focused on the quads as a way to help build rebuild healthy knees. While the quads definitely play a role, over the years I have gained a greater appreciation to how the whole kinetic chain is important. This is especially true of the glutes and hamstrings. Why? As research shows (you can see below) how the entire chain operates is far more important than any one muscle.
That is why I like to use hip bridges (notice hip and not just glutes) and more importantly, like to build to adding in a supine leg curl into the movement. Unlike the machine version that takes out the core and active hip extension, the supine versions help us integrate the entire chain and build a good foundation to healthy knees. However, we don’t stop with just the ground versions.
Emphasizing performing movements in standing is so much important than people often realize. We think that what we do on the ground automatically makes what we do standing better (it does only as far as building a foundation), but too much emphasis on ground work neglects the complexity of being upright and navigating gravity during motion that requires us constant reaction to all 3 planes of motion. Following ideas like those I present below is how we make it far more beneficial.
This is not just about drills, but concepts and methods. Giving principles, concepts, and systems is far more effective than just a few drills. That is why it will be several posts, not just one, that will help you make a bigger impact on building stronger, more resilient, and better performing knees!
Don’t miss our upcoming Foot & Knee Mechanics Masterclass is having the early bird only for this week, check it out HERE. Also don’t miss 30% off our online certifications and our DVRT Rx courses (like our Healthy Knees course) with code “spring” HERE
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