With spring in full swing and summer just around the corner, it's that time of year when everyone escapes into the great outdoors and becomes a little more active. For many, this translates to a substantial increase in activity than the previous months have prepared them for; therefore, it should come as no surprise that aches and pains rear their ugly head when the body hasn't been sufficiently prepared. Even if you've been active throughout the winter, that doesn't always translate into healthfully prepared, resilient joints. Today, I'd like to address the knee and provide you some thoughts from a clinical perspective.
Of all the injuries and conditions referred to me and my team, the knee consistently ranks as the most prevalent. This year has proven to be no different as it has accounted for 25% of all joint related issues in the members we have evaluated thus far. The vast majority of these are non-traumatic and the primary complaint is pain or discomfort to the kneecap (or somewhere around it) during activity, after activity or after sitting for long periods of time.
When I evaluate someone with knee pain that has not resulted from an injury or traumatic incident, my job is to be an investigator and attempt to determine if there are underlying dysfunctions present which might have caused the knee to act up. My first priority is to rule out a fracture, tear, strain or sprain. If those are ruled out, then I will look for mobility dysfunctions inherent within either the knee, hip, ankle or beyond. These types of dysfunctions are important to recognize because if you lack mobility somewhere - doesn't matter where - it will subsequently increase the load, torque or stress which is placed on the rest of the musculoskeletal system.
We are a very goal oriented and efficient species and our body will organize itself according to the task placed in front of it and the capacity of our joints and tissues to handle it. If we intend to walk, run, squat or simply move, movement will occur even in the presence of a joint that isn't working the way it should. And just like a bank account, if you drain it to $0, you'll have to beg, borrow or steal from somewhere else to attain what you need. In the body, this ‘borrowing’ equates to overstressed tissues worked in ways they are not prepared for resulting in inflammation, fibrosis, tension or pain. Unless addressed, these cycles of dysfunction repeat over and over.
For the sake of time and the chance of boring you, I'm going to keep this relatively general and outline two of the primary contributing factors leading to knee pain, but I'd encourage you to reach out to me or someone from my team if you have further questions or want us to take a look at your knee.
Joint Position & Negative Adaptation
What angle is your knee positioned in right now? If you're sitting, it's probably somewhere between 0 degrees (completely straight) and 90 degrees (lower leg is perpendicular to the ground). For most people, this is the range of motion they primarily expose their knees to and consequently, this becomes the happy range for them. Over time, the tissues that encapsulate the knee get familiar with this range and adapt accordingly. Certain aspects of the tissues may become more loose while other aspects thicken and become fibrotic and stiff. Of course, if all you're doing is sitting, this isn't usually an issue. However, it becomes problematic when you decide to embark on a new workout regimen that requires a lot of knee bending such as squats, burpees or lunges OR when you take a sudden fall where your knee twists in a weird, unfamiliar way.
Because the joint hasn't regularly been exposed to positions outside of it's ‘norm’, the brain which receives information about joint position will perceive these new ranges as unfamiliar and unsafe. Because the brain has not been receiving much of this information up to this point, it will have trouble registering these new signals and therefore, will have difficulty firing the musculature needed to control the movement.
In order to protect your joint, what the brain will do is create what we call ‘neurological tightness’ in the musculature surrounding the joint. Ever have tight hamstrings that no matter how much stretching you do, remain as tight as ever? That's the brain trying to limit you not because there's anything inherently wrong with the hamstrings but because it's not registering some aspect of your movement as a safe thing for you to do. So if you've gone from sedentary to active within a short amount of time and are struggling with injury after injury, this is probably why.
Distribution of Tissue Stress
Perhaps you're sitting there thinking that this isn't you and that you DO regularly expose the knee to movements like deep squats and lunges. Or perhaps you're a runner or cyclist that only recently has developed knee pain without an injury tied to it. What then? What could possibly be going on with you? Well, despite the fact that you might regularly expose your joints to a greater range of motion compared to the previous example, there still may not be enough VARIABILITY in the motion needed to distribute the stresses evenly across all tissues.
Besides flexion and extension, most people are unaware that rotation is critical to normal function of the knee. It also happens to be a motion least frequently trained. Furthermore, there are a number of motions in the hip and ankle which most people do not consistently train either. When I refer to ‘training’, I'm specifically referring to mobility training which is intentionally and purposefully exposing the joints to a wide range of motion under some internal forces. Unlike stretching, mobility training attempts to stimulate the deep connective tissues of joints in order to remodel tissues along particular lines of stress, provoke joint fluid production and create a better environment for joint resiliency to take place.
Most of the patients I evaluate have not exposed their joints to this type of training. Perhaps you haven't either. If so, even though you are active, there may still be specific lines of tissue untouched by your activity while the remaining tissues are essentially taking on all of the stress. What mobility training can do is create more options which more evenly distributes stresses across ALL tissues adjacent to the joint. For example, if your knee only has about 50% of the rotation available to it, then similar to the example above, 50% of the connective tissues will get 0% of the stress and the other 50% of the connective tissues will get 100% of the stress. That may be simplistic and maybe your percentages look different but you get the point.
So whether your knee is hurting due to joint stiffness or overstressed tissues, the solution really is to incorporate mobility training into your routine every day. These simple exercises can be done anywhere without any equipment. Depending on your particular issue, the level of effort that you might have to put forth will vary but fortunately, they're extremely efficient and only take a couple of minutes to do. Here's a breakdown of what we recommend to do on a daily basis (pdf attached):
- Knee CARs (controlled articular rotations): 3 complete rotations in each direction
- Lower leg CARs: 3 rotations in each direction
- Patellar CARs: 2 minutes
- Hip CARs: 3 rotations in each direction
Perform each rotation SLOWLY and with CONTROL. You want to access the outer limits of your joint's range without compensating or using other parts of your body. If you find that a specific portion of your range is ‘clunky’ or difficult to control, know that this is an area your brain isn't getting much information about. Go slowly and concentrate on these ranges. Popping in the knee that is non-painful is OKAY and something that should decrease over time.
If you find that your knee is too painful to do these exercises, you recall sustaining an injury in which there was a pop or immediate swelling, or you're just unsure as to the nature of your knee condition, please don't hesitate to reach out to me or someone on my team. We are happy to take a look and provide you a more personalized plan of action.