Your Knees – The Perfect (Orthopedic) Storm

hingeWhy do nearly thirty million Americans suffer from pain and loss of function due to osteoarthritis (OA) of the knee? The knee joint is not a simple hinge. Knees exist at the epicenter of the Perfect Storm of orthopedic problems.

They are used with

1.) High frequency – knees undergo thousands of movement cycles every day for decades.

2) Under load – unlike elbows or wrists, knees bear the brunt of your body mass and impact associated with walking, climbing, carrying, running, and jumping.


3. Long levers – the knee joint is the longest lever in the body, which amplifies any

king hippo
Overweight, small glutes, turned-out feet, and high impact activity. King Hippo’s knees don’t stand a chance.

imprecision of movement at the foot, ankle, and hip.


If you run, jump, and accelerate a lot, sooner or later this will probably effect your knees.

If you suffer a traumatic hit, slip, or twist of the leg, it’s probably going to effect your knees.

If you have simple tightness at the foot, ankle, or hip, in time this will effect your knees.

If you have weakness at the foot, ankle, or hip, this will gradually grind your knees.

The research clearly shows that those with knee OA suffer a downward spiral of pain, decreased activity level, and general poor health and fragility. “So you better get moving” say the rehab people. “Lose some weight” order the medical people. But moving hurts. Now what?

Beat Up Your Knees-Save Your Knees

Is exercise a cause of or treatment for knee pain? Both! Well, it depends on what kind of exercise. The role of physical activity in causing and treating osteoarthritis has been extensively studied and reviewed. What we know is what you could have guessed.

We remember the dunks. Jordan’s knees remember the landings.

-Low impact exercise and not being overweight are helpful. Manage your weight and quit doing anything fun.

-Physical therapy (which includes a variety of interventions) is just as effective as surgery in the treatment of meniscal tears and mild to moderate arthritis of the knee.

-If you still have debilitating pain with advanced OA, have stopped doing anything fun, and tried conservative treatments like anti-inflammatory medications and injections of corticosteroids and lubrication, then you’re a good candidate for knee replacement.

-Knee replacements do reliably reduce pain and improve self-reported quality of life in 90% of patients. Yay.

-Knee replacement is a major ordeal. You should expect two or three days in the hospital, unless the new joint gets infected. Then you go home and have at least one month of depression, constipation, restless nights, and increased yelling at your spouse. Oh, and thrice-weekly trips to your physical therapist are always a blast.

New Knee, New You?

Here are a few important pieces of evidence that we probably would NOT have guessed:

-Patients generally plateau in their recovery at nearly six months after surgery. You better have achieved full knee extension (straightening) and flexion (bending) to at least 115 degrees by then.

-Although most patients have much less pain and recover to preoperative levels of strength and range of motion, by about six months after surgery, they exhibit the EXACT same level of functional limitations.

-With or without surgery, those with knee OA function about half as well as people without significant knee pain.

-Two years after surgery, function declines significantly below pre-surgery levels. A new knee won’t keep you from getting older. Sorry.

-“Preoperative level” does not imply good strength. Before surgery, people are painful and weak in the legs. After surgery, they usually have less pain but are still very weak in the legs. It is thought that this strength deficit holds the key to the unfortunate stats below.

-Compared to adults without significant knee pain, those who have had knee replacement surgery exhibit 18% slower walking speed, 51% slower stair-climbing speed, and a 40% leg strength deficit. They report having greater difficulty kneeling, squatting, moving laterally, carrying loads like groceries, exercising and playing light sports, dancing, gardening, and participating in sexual activity.

Don’t ask me! I’m just reporting what the literature says.

What we can gather from all this is that knee replacement surgery helps with pain but not much with function. Some people are content with that. But I work with many people who are considering or have already underwent knee replacement, and are not content to sit on the couch, roll over and die.

The Dark Night of Knee Surgery

Oh, the first weeks after knee surgery. There’s definitely an x factor here, an unknown. The x may have to do with expectations and other deep psychology that’s difficult to quantify. It may have to do with other unmeasurables involving blood chemistry and inflammatory response.

You may be a fit, active, and otherwise healthy adult. But that won’t change how your body handles the pain, swelling, and other miseries due to the controlled trauma of orthopedic surgery. A skilled but mere human subluxed your kneecap, removed the ends of your femur and tibia with a hack saw, jammed a fancy peg into the marrow, added some glue to hold everything together, and stitched it back up.

Despite your neighbors friends uncle who experienced Job level devastation after having his knee replaced, the orthopedic docs are great at selecting appropriate candidates for surgery. The patient satisfaction is above 90%. But knee replacement is a process. In my physical therapy clinic a few weeks after surgery, almost everyone regrets having gone through with it. Their pain rating, on a scale of 1 to 10, is approximately “Go shove that pain scale up your…” By two months from surgery, the same folks are reasonable and tend to forget how difficult the first few weeks were.

Back to….Normal?

How well do you really function after surgery? This depends on number mechanical factors  beyond recovering the knee range of motion. What chewed up your knees to begin with? It is highly likely that the imbalances in strength and flexibility and motor control do not go away when you have a new knee.

Nearly everyone with knee pain has to sit on the sidelines far more than they would like, and this has propitiated poor balance and an “I can’t” mentality. After years of pain and surgery, patients are afraid of falling and have no idea what they *can* accomplish and safely build up to doing.

Typical Rehab is Not Enough.

Long after your insurance benefits have expired, and your orthopedic doctor and physical therapist have discharged you with a good outcome (typically based only on range of motion), you still exhibit weakness, stiffness, and poor movement patterns.

You need more than 2 lb leg raises!

The literature indicates that leg strength correlated with real world function more than anything else. Pushing the strength training is critical, especially in that first six months after surgery. That means pushing 20 pounds instead of 2. That means achieving great control while walking up stairs even before you have recovered sufficient range of motion to descend stairs well. It means challenging your limits in strength and balance with exercises like progressive lunge variations and steps-ups if you can, rather than 3 sets of 100 leg raises and butt squeezes.

Knee to the Future

How much activity can you get away with after having an arthritic or replaced knee? How long will the replacement last? Orthopedic doctors often warn patients about the lifespan of a replaced knee being 15 or 20 years. But I read and hear varying recommendations. The guidelines are definitely anecdotal. I think there’s more to it than that.

How WELL is the knee loaded? Is the replaced joint getting the appropriate support from above and below? Many of those questions depend on the client more than the actual knee hardware. I do not suggest basketball or parachuting, but joint replacement clients can do a lot more than they would think when they have built a fit and generally robust body.


References are available upon request.

Aches and Pains – The Problem is a Verb

Sit Up Tall and I’ll Answer You

The patient sits before me with head slumped and shoulders rolled forward, telling the story of his painful neck. A twenty minute physical therapy examination has shown that the details of his body position do indeed effect his symptoms. A simple correction of the slump in his thoracic spine and tilt of the head greatly improves the pain and neck range of motion.

Still, the patient desires a diagnosis, a label that he is familiar with. He asks whether or not he should get an MRI (Magnetic Resonance Image) of the neck.

under the hood
A great mechanics does more than look under the hood. At some point, he takes it for a drive.

Muscle spasm. Degenerative joint disease. Sciatica. Rattling off a series of typical and likely scenarios is easy. It is far more challenging to find the aberrant movement that is the root of the problem. It’s even more difficult to help some clients understand why a clear-cut diagnosis is unnecessary and more tricky than you would think. Here I will give it a try.

The Problem is a Verb

Herniated disc.
Tennis elbow (or lateral epicondylitis).
Torn meniscus.
Shoulder bursitis.

These diagnoses name an injured part of the body. They are nouns that many people are somewhat familiar with. But it turns out that noun diagnoses are often inaccurate (1,2). For example, it’s nearly impossible to reliably differentiate a shoulder bursitis from tendonitis or a partial rotator cuff tear because they often look and feel similarly.

How you respond to movement matters. Movement is a low cost, highly reliable and relevant diagnostic tool for actually doing something for your aches and pains. At least initially, understanding the noun is less important (3,4). Initial treatment depends on how the symptoms respond to changes in movement and position. Muscle and joint pain almost always has to do with dysfunctional movement. In other words, the real  problem is a verb.


The Limits of Diagnostic Imaging

Why, exactly, does your shoulder ache after volleyball practice? Is your Achilles tendon sore because of poor foot structure or hip inflexibility? Will the back and leg pain require surgery or is it likely to respond to more conservative care? You will need some verbs (movement tests) to answer these types of questions.

Although X-rays and MRIs provide a peek into potential causes of pain associated with injury or “wear and tear,” research has proven that looks are deceiving (6, 7, 8, 15). These images show the internal anatomy while the person holds still like a statue. But they do not show how the muscles and joints move, and the exact tissue at fault remains uncertain(5). Over many years, researchers have repeatedly discovered that people in pain and those who report no pain both usually show degenerative changes and tissue injury under MRI.

Orthopedists and physicians have known of the limits of imaging studies for decades.

For example, many people without shoulder problems have partial and full thickness rotator cuff tears(11). Others with severe shoulder pain and weakness have no tear at all. Concerning back pain, the medical community has generously  invented a diagnostic label that clearly acknowledges the problem of using diagnostic labels.  Nonspecific low back pain has since been diagnosed in over 90% of patients with back pain (9,10). I’m truly not making this up. Search the literature, and you will see countless discussions of nonspecific low back pain.

Experts agree that joint wear and tear is a normal part of aging. Degeneration is not a disease like the diagnosis Degenerative Joint Disease implies. Fifty percent of the MRIs of people in their early twenties show these (13), and the percentage increases each decade! Meniscal tears and osteoarthritis in the knee are almost universal (12), yet not everyone needs a knee replacement.

How much degeneration the body can accommodate varies from person to person. But something other than a structural problem is responsible for causing misery for some people but not others. The difference is in how they move.

The Limits of An Alternative System

So where are we left in our attempts to describe movement related problems with movement-related terminology? Live imaging that allows us to watch internal movement is helpful but very expensive. Some orthopedists and rehabilitation experts have suggested a movement-based classification criteria. It makes sense to healthcare providers who take the time to assess movement quality. But to the rest of the world, these sounds fairly ridiculous.

Lumbar flexion dysfunction.
Scapula upward rotation dyskenesis.
Knee coordination impairment.

In order to be more technically correct in describing movement, we’ve become more vague and silly.  Imagine the scenarios.

“Doctor it hurts when I bend forward, like, flexing my spine.”
“Yeah, it seems to me that you have a lumbar flexion dysfunction.”

Imagine studies are useful!

“Doctor my knee hurts severely and often gives out.”
“Well I’ve determined that you have knee coordination impairment.”

Before laughing, we should recall that we have accepted terms like Restless Legs Syndrome and Halitosis as serious medical terminology. Besides, it’s not so much a label, but a response to movement that we’re after. That’s hard to pin down in just a few words.

The bottom line is that you should never be too intimidated when you hear arthritic this or torn that. Diagnostic imaging is one piece of the puzzle and it really is okay if your doctor didn’t order expensive tests right away. The best thing you can do, at least initially, is to worry less about exactly what’s causing the pain. Instead, seek to find what, if any, movements and positions cause an improvement in pain and function.

I’m willing to admit my biases as a physical therapist. There is absolutely a time and place for surgery and other more invasive procedures. But I would think that sitting with good posture and consistently performing a handful of stretching and strengthening exercise deserves a serious effort.

With the right intervention, changing the details of how your body moves quite often translates into less pain and more verbs.

– – – – –

1. Borenstein DG, O’Mara JW, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, Wiesel SW. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep;83(9):1306-11.

2. Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine. 2002 15;27(22):2538-45.

3. Cook C, Hegedus E, Ramey K. Physical therapy exercise intervention based on classification using the patent response method: a systematic review of the literature. JMPT 2005;13:152-62.

4. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. Spine. 1997; 22:1115-1122.

5. Chou R, Rongwei F, Carrino J, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet. 2009;373 (9662): 463-472.

6. Michael J. DeFranco, MD, and Bernard R. Bach, Jr, MD. A Comprehensive Review of Partial Anterior Cruciate Ligament Tears. In The Journal of Bone and Joint Surgery. January 2009. Vol. 91A. No. 1. Pp. 198-208.

7. Videman T, Battie MC, Gibbons LE, Maravilla K, Kaprio J. Association between back pain history and lumbar MRI findings. Spine 2003;28(6):582-8.

8. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine 2003;3(6):460-5.

9. Koes B. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:2504-2514.

10. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, KlaberMoffett J, Kovacs F. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;4(2):S192-300.

11. Sher JS, Uribe JW, Posarda A. Abnormal findings on magnetic resonance images of asymptomatic shoulders. Journal of Bone and Joint Surgery 1995;77(A): 10-15.

12. Englund M, Guermazi A, Gale D. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108-1115.

13. Takatalo J, Karppinnen J, Niinimaki J et al. Prevalence of disc degeneration and displacement, annular tears, and modic changes in lumbar MRI scans in young adults. Spine. 2009;34(16):1716-21.

14. Hoangmai H. Pham, Bruce E. Landon, James D. Reschovsky, Beny Wu, & Deborah Schrag. Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients. Archives of Internal Medicine 2009, 169 (10), 972-981

15. Connor PM, Banks DM, Tyson AB, Coumas JS and D’Alessandro DF (2003): Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes. A five-year follow-up study. American Journal of Sports Medicine 31, 5, 724-727.

 16. Best Pract Res Clin Rheumatol. 2016 Aug;30(4):766-785. Imaging in Back Pain: Anything New? Epub 2016 Nov 2

The Magic of One Spectacular Thing

If you want to gain or lose weight, develop power or strength, or simply be a more healthy, capable and awesome version of yourself, I suggest that you focus less about body composition, 7-minute abs, or random cardio circuits. These type of interests are fine, but have limited impact. Instead, set a goal to achieve one (physically) Spectacular Thing.

Of course, spectacular is a relative termsquat-11.

What is something that you cannot currently do? Something that you would like to be able to do, and would cause you to commit to a process? If you have never exercised before and need to develop healthy habits, I would NOT suggest a “Big Bench Press” routine. That’s far too easy.



Achieve 5 full range of motion chin-ups

Complete a 5k in under 25 minutes, with no walking breaks

Then you lay it down in small, manageable increments. You work hard at the goal for 12 or 16 weeks and then allow a respite. What happens, IN THE PROCESS, is that you find yourself more interested in following through with many healthy habits. There’s a lot less internal debate on wether or not you’re going to workout on a given day. You have an agenda that fits into a bigger picture. It’s already scheduled and required of you to hit that goal.

The great “side effects” of committing to a process is that, in the mean time, you find yourself stronger, leaner, and healthier, even though you didn’t micromanage every little calorie and step count. And by the time you achieve something physically spectacular, you genuinely quit giving a damn about your small calves or muffin belly because you can DO things!

And for those really into pushing the limits in training and performance?

I do NOT recommend a constant variety of movements performed at high intensity.

I do not recommend muscle confusion.

I do not recommend making each workout a competitive event (with yourself or others).

I do not recommend pushing the limit workout. This is a recipe for getting sick or injured.

I learned some of these intuitively and as a witness of others. But one, in particular, I learned the hard way.


Let’s say that you take my advice and choose a goal of Barbell Squatting 365 for 20 continuous reps. Yes! A brutal, awesome 20-rep squat plan.

Ten years ago I would have went about this by doing 20 rep squats, once or twice per week, and increasing the resistance by just a fraction during every session. Eight or twelve weeks later, I would be pushing some serious resistance, but feel back or knee strain. I would start feeling overall flat and less than enthusiastic about training days. Back then, the squat program would have looked something like this:

Week 1: (All after warm-ups) Squat 275X20

Week 2: 285X20

Week 3: 295 X 20squats-2

Week 4: 305 X 20

Week 5: 310 X 20

Week 6: 315 X 20 (increase in 5 lb increments through week 10)

Week 11: 345 X 20

Week 12: 347.5 X 20 (Yes I have 1 1/4 lb plates)

Week 13: 350 X 20

Week 14: 352.5 X 20

And so on, in ever so small increments, nudging toward 365 X 20. Sure, I would allow a week or two of a slight cut-back if life interfered. But I would quickly get back in the saddle.

Now I go about the actual squat sets/reps quite differently. I also know that in order to really pour myself into a 20-rep squat PR without feeling hung-over, there should be a few other important adjustments.

I will have to cut back on other physical stress, for example keeping a lower intensity in other serious leg work like deadlifts. Toward the end of the Squat cycle, I will significantly cut back on sprints, plyometrics, and any type of grinding workout “finishers” like farmer walks, in order to prioritize recovery. Also, now is not the time to change or get fancy with your diet.

A spectacular 20-rep squat program would look something like this:

Week 1: 285 lbs X20

Week 2: 345 for 3 to 4 sets of 5 rep

Week 3: 305 X 20

Week 4: 355 for 3 to4 sets of 5 rep

Week 5: 315 X 20

Week 6: 370  for 3 to 4 sets of 5

Week 7: Box squats with a pause at the bottom, 315 for 3 to 4 sets of 5 reps

Week 8: 325 X 20

Week 9: 385 for 4 sets of 5 repsimg_4347

Week 10: 335 X 20

Week 11: 395 for 3 sets of 5

Week 12: 345 X 20

Week 13: 405  for 2 sets of 5

Week 14: 365 X 20

Yes! I know there is a 20-lb rather than 10-lb jump at the end. BUT…you would be surprised at how this works. You see, all along, weeks 1 through13, the resistance is set at something challenging, but you KNOW that could handle a little more. Really, you are working hard and heavy, doing much more than the average fitness enthusiast, but not  approaching your maximal effort.

Weeks 1 through 13 are supposed to be TRAINING, not testing. The workload for the day should be something that is hard by most standards. You have to put your “game face” on. But if you show up, warm up, and put some music on, you KNOW that will get the reps in, and go home.

And by the time you arrive at week 14, you will be feeling good, healthy, having recently done a boatload of heavy but not maximal squats, completely ready for an Event. THIS is your test, and if you can find the right Squat Song to put on, I have no doubt that 365 will fall fairly easily!

After you hit your goal, quit while you’re ahead! Relax for a week or two, and pick a new Spectacular Goal to pursue. Maybe it’s 20-rep Squatting 400. Or 5-rep squatting 450. Or deadlift twice your body weight. Or run a sub-6 mile. Or, or, or…do one Spectacular Thing! But don’t try to achieve too many things all at once.

The above 20-rep Squat routine is just an example. Feel free to use it with the resistance adjusted down (or up). Feel free to try other “big bang” exercises. The important lesson here is not any particular sets and reps, but the value of a process of smart, structured and sustainable training rather than any kind of epic berserk high intensity exercises or techniques.

Last spring I used this type of structured programming to be able to squat 315 lbs X 10 reps on the minute, for 10 minutes (100 total reps), and in the summer I used a similar process to achieve a 400 lb farmer walk for 80 yards.

Find a worthwhile goal and stick with it for a while. Keep training as training (not testing), with one goal in mind. Then go ahead and test yourself! Rest and repeat. In the mean time…side effects include feeling good, confident, and being a healthier and more awesome version of you.

Good luck and let me know what’s happening!