Fix Your Knees

Fix your knees and avoid having to give up the sports and activities you love. Knee issues have ended far too many amateur athletic endeavours.

Introduction

In 2009, I finally gave up running, I thought forever.

For several years, I had struggled with sore knees, to the point that I would often have to abandon planned runs early on because of knee pain that was crippling. To give you an insight into the level of discomfort: I am no stranger to pain, discomfort and fatigue due to years of long-distance endurance sport. This wasn’t something I could ignore or, trust me, I would have.

I also had pain in my knees and some other joints that was there almost all the time. You wouldn’t know it because I’m one of those annoying people who just tries to “deal with it”.

Whilst I already had my “fitter at 70 than the average 20-year-old” goal, I pretty much accepted that running wouldn’t be part of this. I could still ride a bike and that was fine by me.

I thought I probably had significant osteoarthritis in my knees (and other joints) and that I’d have to manage that for the years to come.

Instead, over the last 11 years, I have fixed my knees. I can run again, and I do run… a lot… pain-free.

I’ve also helped others do the same.

Some of that healing has been the result of simply doing stuff and then realising that my knee pain had lessened. Others have been a result of research and experimentation specifically focused on how to fix your knees.

If you’ve read much of my stuff, it becomes clear that I was a bit of a slow learner when it comes to the damage I did to my body in my younger years. Thankfully, the human body is miraculous at healing itself - given time and appropriate care - and mine has done an amazing job.

The good news is that you can fix your knees. It takes time, effort and a bit of detective work, but you can do it.

Things People Try (and why they usually don’t work)

Because we live in a quick fix world, you could try a lot of shortcuts to fix your knees.

Most of these won’t work long term because they are the equivalent of a crutch. They help you to work around the pain but they both don’t fix the problem and they usually create issues elsewhere.

Softer Shoes

“Cushioned” shoes will supposedly reduce the impact forces of running sufficiently to look after your knees. Apparently, it’s the hard surfaces you’re running on that are causing the knee pain.

The cushioning argument is an interesting one when you consider the impact forces of running, which can be around 10 times your body weight on each foot strike. I haven’t looked at the shoe company research (and keep in mind who paid for that research) but I struggle to believe that adding a little bit more EVA foam to your shoes will do that much to reduce those forces.

What’s more, most of those highly cushioned shoes also come with other features and are referred to as “technical” shoes.

“Technical” Shoes

These shoes include several features that are supposed to control the motion of your foot, to make it move the way a human foot should. Or, at least, the way the designers should a human foot should move.

They include thermoplastic heel cups to keep your heel firmly locked in place in the shoes and variable densities of EVA foam in different parts of the midsole to control how much your foot pronates or not.

Except that there is no such thing as an ideal way for every foot to move. Your feet do not move the same as mine when I run because you have different lengths and shapes of bone in your back, pelvis, legs, ankles and feet. This means your leverages are different and the exact shape of your gait pattern is different.

In fact, it’s not uncommon to find that someone’s left foot moves differently to their right foot. Or that their gait is different when they walk to when they run.

If you put your foot in a highly restrictive splint, then the mobility that you’re meant to have in your ankle and foot is compromised. With the human body being the clever, adaptable machine it is, your nervous system will look for mobility elsewhere.

If it finds that mobility at the knee, over time the knee joint will develop wear-and-tear and, eventually, pain.

Knee Sleeves, Knee Wraps and Patella Straps

Knee sleeves are great for keeping your knees warm and I freely admit to using them occasionally, on cold mornings in the gym, when I’m doing squats and other leg work. But I use them for warmth, not support.

For running, using a compression sleeve risks pushing the kneecap down on top of the joint, causing even more pain if patella-femoral issues are the problem, or causing patella-femoral pain to develop if the original pain is elsewhere.

Certainly, for patella-femoral pain, taping with kinesiology tape seems a far better bet.

As for instability of the joint, in the short term, some kind of taping that avoids placing pressure on the kneecap would be preferable.

Similar to knee sleeves are patella straps. I believe the idea is that they reduce the vibration of the kneecap as the quad muscles contract. As a short-term intervention, they might have value but, in the long term, you want a solution that relies on your body working correctly, not a “medical device”.

Long Term Medication

In the short term, the use of medication to reduce swelling and inflammation can have its place, allowing you to function in everyday life. I say, “can,” because I try to avoid medication wherever possible. But I recognise the role that pain plays in distracting the mind and if you can’t focus on anything else because your knee hurts, you’re better off taking the meds.

In my view, long term medication isn’t a viable solution to any problem. Especially if you’re using those drugs to be able to keep training and competing in the face of an orthopaedic injury. I was aghast to discover that one of the sponsors of the Ironman World Championships is a manufacturer of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). What message does that send?

One of the biggest issues with chronic NSAID (and any medication) use is the risks they pose to our long-term health. These are powerful compounds that have been linked to heart issues, kidney damage etc. These effects are almost certainly magnified when they’re used to mask pain during exercise.

Surgery

Surgery used to be an option that medical specialists went to very early on with many conditions. At least that was my observation. As a young man, I saw a lot of young people who had radical knee surgery which probably meant that any sport would be impossible or at least impaired. This was surgery for wear-and-tear, not trauma, in teenagers.

That doesn’t seem to be the case any more, with more surgeons recommending other interventions before suggesting you go under the knife.

You must remember that as soon as you start cutting bits of your knee joint away, you’re creating a weakness that will probably always be a weakness, even though your knee feels better. Over time, it seems to me there’s a good chance you’ll develop osteoarthritis as a result.

Having said all that, there are situations in which surgery is a good option: athletes having ACL reconstructions comes to mind. Without that reconstruction, they’re probably at more risk of developing osteoarthritis in that knee.

For most of us, it’s more effective to address knee pain by finding a way to fix your knees without surgery.

What Might Be the Problem?

Without having a scan - and there’s no reason not to do so if you’re in crippling pain - it can be hard to figure out what’s going on with your sore knees.

Most of the time it’s not just one thing, but a combination of factors, often nothing to do with your knee directly.

What follows is my list of things that I’ve found to contribute to knee pain.

Catastrophic Damage

This one is obvious and it’s where surgery has the most application.

If you damage your knee in an impact of some sort, which results in long-term pain, there is a good chance that impact was the cause without any other factors interfering.

The problem here is often that the knee pain will cause you to move differently to avoid the pain. This can cause compensation reactions elsewhere and those areas can become painful or the new patterns can cause reoccurrence of the knee pain when you try to return to moving normally. Oh, the body is a wonderful thing!

Tissue Quality and Flexibility

I discovered, after much trial-and-error, that my patella-femoral pain wasn’t caused by anything more than chronically tight quadriceps muscles. A few simple tissue quality and flexibility exercises relieved it every time it appeared and, over time, patella-femoral has become rare.

I have no doubt that other chronically tight leg muscles have the potential to cause knee pain too.

Muscle Activation

It’s not unusual for personal trainers to tell their clients that their glutes aren’t firing properly. I often wonder how they know this without doing any testing, but it’s pretty clear to me that over-active adductors and under active Gluteus Medius muscles have a role to play in sore knees. Correct this and it might be enough to fix your knee pain.

If your adductors are too tight or fire too early, combined with Gluteus Medius that fire too late, your knee will tend to be pulled inward (“knock-knees”, known medically as knee valgus). This isn’t an ideal line for your knees to track and knee pain can result.

The problem with knees is that they repeat the same movement, in the same plane, so many times a day that misalignment makes them especially vulnerable. At least a hip or shoulder gets to move in a different manner from time to time.

Lack of Mobility Elsewhere

I mentioned this earlier in this article.

Because your musculoskeletal system is under the control of your will (to a large extent), your nervous system will do all it can to facilitate what you want to do with it.

The problem this causes is that where there is restriction in one joint, it will seek to borrow mobility elsewhere.

Because we spend so much time sitting, we tend to develop hips that lack the mobility they should have. When we then seek to do something more energetic, our nervous systems often borrow the needed missing mobility at the hip from the knee.

Whereas the hip is a ball-and-socket joint with plenty of potential range of movement in multiple planes, the knee is a hinge joint, designed to move in just one plane. When it tries to act like a ball-and-socket joint, it gets sore.

If you want to fix your knees, chances are you’ll need to do a lot of work on your hips, ankles and feet.

Nutrition

Some knee (and other joint) pain isn’t caused by movement or lack of movement at all, it’s caused by what we eat.

This is a huge subject, worthy of its own article, but it’s worth keeping this in mind if you’re trying to fix your knees.

Sadly, for those who like eating a lot of plant matter, compounds like oxalates, glycoalkaloids, gluten and other chemicals that plants produce as a defence mechanism against being eaten can cause joint pain in some people.

I’m clear that people should eat what works for them. Some folks do really well with lots of veg, others do better without. If you have pain in multiple joints, this is worth investigating.

So, what do you do if you want to fix your knee issues? Here are some things to try.

Lifestyle

Your lifestyle affects your injury risk dramatically.

As mentioned above, nutrition can have a huge impact and sorting out a way of eating that addresses your specific issues can be life changing. I know a lot of people who are no longer fat, sick, in pain and on their way to an early grave because they changed their diet. It’s a group that is growing daily.

Anther lifestyle intervention that can make a big difference is going barefoot as much as possible. Strong feet that move as intended mean happier knees. At the very least, going barefoot around the house and garden should be accessible to most people. Also, unless your gym forbids it, training barefoot will help to strengthen your feet too.

Short Term Fixes

Sometimes we get hurt and a short-term fix is in order.

What’s important with these fixes is that you shouldn’t allow them to drag on and end up as your new normal (Oh, how I hate that phrase!).

Taping

Back in my early days as a coach, I spent a few seasons doing strength and conditioning for a high-level rugby club.

Being the high impact sport that it is, I spent a lot of pre-game time, working with the team physio, taping knees, ankles, shoulders and pretty much any other joint.

Several players had long-term damage, so much so that they probably wouldn’t have been able to play had we not taped those joints. I saw the knee scan for the flyhalf, and to this day, I have no idea how he managed to walk, let alone run for an 80-minute rugby match.

I don’t generally recommend the rigid stability taping we used to do. Instead, the proper use of kinesiology tape - the strips of coloured tape you often see on elite athletes - can make an enormous difference when you first start to fix your knees.

The concept with kinesiology tape is not so much about supporting a joint as about re-educating your fascial and proprioception systems to work as they’re meant to do. If you're going to effectively fix your knees, proprioception - your sense of where you are in space - is really important.

Quite how some of it works still evades me but I once applied tape to my very sore calves after a long run that left me unusually sore. All I did was apply one strip with minimal tension along the length of each calf, nothing fancy. Instant pain relief!

Medication

If you’re in the kind of pain that alters your gait in order to avoid the pain, you need some sort of pain relief.

Short term use of NSAIDs might be effective. If not, it would make sense to visit a doctor to see whether they can provide something better. If you pay for your healthcare, you might be able to get something like a cortisone injection fairly easily. In the UK, your GP is unlikely to get that for you within a reasonable timeframe.

Physiotherapy

Physiotherapy can be very useful but it’s important to see someone who understands that the body is a unit. I say constantly that if you visit a physio for knee pain and all they do is treat the knee; you might want to find a new physio.

(Of course, this is a generalisation and like all such statements, context is important too.)

Exercises

My approach is always to look at what I can do to fix myself, using mobility and strength exercises. Your body is an amazing regenerative machine. Give it the right inputs, be patient and you might be surprised at just how much it heals itself.

When you work to fix your knees it can be a bit more complicated than gaining a bit of mobility or strength in isolation. Instead, you must work on them all.

One simple example, mentioned earlier, is something called knee valgus or valgus collapse. Although most of us don’t demonstrate this to a degree that would be clinically diagnosed, it’s fairly common to have overactive adductors (muscles on the inside of your leg) and underactive abductors (we usually just talk about the Gluteus Medius muscle in this context).

While it definitely helps to strengthen your Gluteus Medius muscles and help them to fire better, your efforts would be far better rewarded by also teaching your adductors to chill out a bit. This is a scenario where simple static stretching does quite a good job.

This is one of the things I addressed when fixing my knees and I did it as follows.

Step 1: Stretch the Adductor Muscles

A simple adductor stretch, like the one pictured will temporarily inhibit the muscle’s firing pattern, meaning it fires a fraction later than it would normally do. Holding the stretch for 20-30 seconds seems to work well, longer isn’t necessary.

How strictly accurate this is in terms of the mechanism doesn’t matter to me because it works and results are what I’m after.

Step 2: Activate the Gluteus Medius

The clam shell exercise as pictured is quite effective, but can be made even more so with the addition of a resistance band around both legs, just above the knee.

I prefer the lying wall angel (pictured) because it forces you to remain in a plane that really hits the Gluteus Medius. It’s important to have both hips and both shoulders against the wall, so that you’re square, as well as keeping the heel of the top foot against the wall.

Aim to accumulate 3 minutes in this position, however you can (6 x 30s, 3 x 1min or, if you have great pain tolerance, 1 x 3min).

Step 3: Integrate the Movement

For this, I like to use one leg touchdowns or split squats, using a technique popularised by Gray Cook called Reactive Neuromuscular Training (RNT). The idea is that by gently pulling the knee into a bad position, your nervous system overreacts to correct the mistake and, over time, learns the new corrected position.

In this case, a band placed just below the knee and pulling the knee inwards should cause greater firing in Gluteus Medius (and other abductors) to make the knee track correctly.

Touchdowns can be done from whatever height you can control pain-free. This might mean starting with a box of only a few inches and that’s OK. Remember, this is about working to fix your knees, it’s not an ego thing.

Split squats are simply a lunge performed without the step element. Again, control the range of movement so that avoid pain.

Other Exercises

Pigeon Pose

My yoga form isn’t that great, but I have a few poses that I’ve adopted and modified to address my issues. The pigeon is one of these and addresses my tight hip joints beautifully. This allows my knees to be more stable.

It’s important to modify this pose however you need in order to avoid excess stress on your knee joint.

Goblet Squats

One much overlooked use for goblet squats is mobility development at the hip, allowing you to achieve the correct bottom position of the squat. In fact, Dan John, the inventor of the goblet squat didn’t come up with it for strength development, but as a way of teaching his students to squat.

Simply descend into the bottom position of the goblet squat and stay there for a minute or so, all the while, pushing your knees outwards and trying to make more space in that position. I also like to visualise making space in my hip joints by moving them out to the side (there’s no movement, it’s just a visualisation).

Fire Hydrants

Fire hydrants are great for activation of the Gluteus Medius but might get you some strange looks in the gym. I use the version with an added band as part of my deadlift warm-up.

Focus on adduction (moving the leg away to the side) and external rotation of the hip (which, confusingly means bringing the foot inwards towards the body).

Lunges

Lunges are actually quite a challenging exercise and should only be performed when you have the control to do them well. Starting with a split squat is a good progression towards lunges.

That said, anything that has to be performed on one leg with a deceleration element is going to be great for your knees in the long run because deceleration forces at the knee are part of walking and running.

Split Squat with Band-Resisted Extension

One of the issues with kneecap tracking can be weakness of the Vastus Medialis (VMO) muscle, the teardrop-shaped muscle on the inside of your knee. Because it generates most of its force in the last few degrees of knee extension, this exercise emphasises strength development in that range.

Just a note: don’t overdo this because an over-developed VMO interferes with efficient running dynamics. I wrote about my weight training mistakes in another article.

Summary

Chronic knee pain has ended many an athletic career, whether professional or recreational. It nearly ended mine and, although he denies it now, my dad told me when I was a teenager that he’d stopped playing sport because his knees hurt.

Fortunately, for most of us, it’s entirely possible to fix your knees, as long as you’re willing to apply a good dose of patience and consistency. Whilst nothing is free, your body is a remarkable self-healing machine, given just a little bit of time and the correct inputs.

Rather than accepting that the physical activities you love are all over because of age, perhaps you could use a little of the time you would have spent on those activities to fix your knees.