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Important ConceptsKneeSit Like A Man

Knee Cap Pain and Crunching

I feel compelled to write about knee cap pain again. Many of you have already read my earlier blog on this subject; “Do Not Do Squats.” http://drbarbarabergin.com/do-not-do-squats/.  Today I saw 6 women in my office with knee cap pain and crunching. All but one had been participating in supervised exercise routines which utilized squats, deep knee bends and lunges as the backbone of the program.

Women have a physical predisposition to having pain under and around their knee caps. It has to do with the shape of our legs. We were put together pretty well for having babies but not so much for running stairs and doing squats. And in the natural world we just didn’t have to get in and out of chairs all day, or go up and down stairs all day, or do squats deep knee bends and lunges with weights in our hands, three times a week. And remember…in the natural world we didn’t live much past 25 years.

When I see a woman with pain around her knee caps, 8 out of 10 times I can get some kind of history of excessive stair climbing or participation in an exercise class involving lunges and squats! Now trainers get very upset when I write about this and often send comments impugning my knowledge. Remember…I’m the orthopedic surgeon. I’ve been doing this for 31 years. And I have this condition. I feel very strongly about this because I see a lot of women and truthfully, this is a big problem, especially since the exercise industry is invested in the squat, the lunge and the deep knee bend.

Trainers would really be doing their female patients a service if they took this information into consideration, and sought out versatile strengthening programs and just try to eliminate the squat and modify the lunge.

But most importantly, just pay attention to clients while they’re doing these exercises. Watch for clients who are “cheating” or making grimaces while squatting. Turn off the music and listen for crunching knee caps. Most of the time the clients just quit, so trainers don’t hear about the problems. Women are embarrassed to complain because they feel they might be accused of just being lazy. Feel their knee caps while they’re doing the exercises. You’ll be able to feel, and sometimes even hear the crunching and grinding! That’s your sign that they shouldn’t be doing this exercise. That symptom often precedes the pain. Let clients know that they should watch for pain, crunching and grinding around their knee caps while on a program of squats, deep knee bends or lunges. And keep in mind that it doesn’t always occur while they’re doing the exercises. Sometimes it starts hurting that night, or even the next day. Sometimes it takes a month for the symptoms to show up!

Okay so you might be getting tired of me telling you to change the way you’re doing things, but I’m going to tell you to change the way you’re doing things that hurt you. If you come to see me with a cut on the end of your finger, you’re not going to question me when I tell you not to rub your finger against things.

Modify Activities

Stairs: The first thing I’m going to tell you to do is to modify the activities that hurt you. If it’s climbing stairs, I’m going to tell you to diminish stair climbing or to somehow lessen the effect of stair climbing on your knees by using the banister. Take elevators and escalators rather than the stairs. Keep a hair brush, deodorant and toothbrush in the downstairs bathroom so you don’t run up and down the stairs for those activities. Yes, stair climbing is exercise, but if you’re having pain, trust me, the benefits don’t outweigh the risks.

Chairs: You can’t stop getting in and out of chairs, but you can use the arms of the chair to help push yourself out of the chair. Your knees will reap the benefits from getting in the habit of decreasing this stress by pushing yourself out of the chair. The toilet is a chair you get in and out of many times a day. And it’s a low chair. Convert your master bath toilet to a handicap or “comfort height” toilet. Use the sink or cabinet next to the toilet to help yourself up. Put in a stainless-steel bar for that purpose. Use the handicap toilet in public places. This is a serious, potentially life altering condition. Do what it takes to make it better!

Squats: I’m going to tell you to stop squats and frankly, my advice is to never do them again! Find another, less stressful way to strengthen your legs. Ride a stationary bike, swim or walk. Do straight leg raises and hip extensions against resistance. These exercises are adequate for strengthening the legs on an average person. Sure, you can do some lesser form of the squat if you must. I’ll go over those a little later. But for me to do that will be like your primary care doc telling you some okay ways to enjoy sugar. Better to tell you not to eat sugar in any form.

SIT LIKE A MAN (S.L.A.M.™) This is an important concept. Basically sit like a man. Please read my extensive post on this. If you’re here, you likely have a problem with knee cap pain, and my S.L.A.M.™ program is critical to your ability to get well.

Strengthening the Muscles Which Control Your Knee Cap

I do want you to strengthen the muscle that helps control the movement of your knee cap. It’s a simple exercise: the straight leg raise (with a twist). I do it almost every day. This exercise strengthens the muscle which controls the position of your knee cap.

Lie down on your bed. Don’t get on the floor because then you’d have to do a squat to get up and down! If you’re exercising your left leg you will bend your right leg in order to take some of the stress off your back (like in the picture). Then turn your left foot to the eleven o’clock position. That way your whole leg will be turned slightly outward. Now raise the leg up off the bed about a foot and hold it there for a count. Then slowly bring it back down. When you’re exercising the right leg you will turn it to 1:00.

Do these 10 times on each leg and do at least 30 of them EVERY DAY! You really can’t do too many of these. You can add ankle weights or heavy shoes to make this more difficult. You can do seated straight leg raises, which will also increase the degree of difficulty a little. You can also try this in a standing position with rubber tubing for resistance.

It’s hard to explain, but the position of your whole femur probably has something to do with the way your knee cap moves. So, this exercise will strengthen the muscles which turn your hip outwards. They’re call the hip external rotators, and you should strength them almost every day too. This is a simple exercise. Hard to mess up.

Lie on your left side. You can start out doing this against a wall if you want to. The wall will help to keep you from rolling backward, which a lot of people just naturally tend to do when they start doing this exercise. Only problem with laying against wall…you might have to get down on the ground. So…lay on your side. Bend your knees and put your legs and feet together. Then…while keeping your feet together…AND YOUR BACK AND SHOULDERS STRAIGHT UP AND DOWN…raise your right knee up about a foot. This is called THE CLAM. It’s pretty self-explanatory. Do this several times every day. You’ll be able to tell when the muscles in your rear end start fatiguing. Now turn over to the other side! Round two.

Bracing

Sometimes I will recommend that you temporarily wear a brace which helps align and support your knee cap. I may ask you to use this for a month or so while you start the exercises and activity modifications. Wear the brace during the day. Don’t wear it to bed.

Keep the brace even after your pain is better. You never know when you’ll need it again. Perhaps you’ll use it specifically for activities you know will irritate your knee cap, like hiking up hills or climbing up and down ladders. You can buy braces like these on-line: You can also get them at places like Academy.

 I started having patellar pain, along with crunching and grinding under my knee caps when I was in my early thirties. Having had the advantage of my training, I knew immediately what was going on. First, I stopped running stairs between surgery cases at the hospital. Then I started the straight leg raises, which I do about 5 days a week. Now, more than 30 years later, I have no knee cap pain. I still have a little crunching there, but no pain. I ride horses competitively, which means I spend hours in that bent knee position…with no pain.

 

IMPORTANT CONCEPT! This condition is kind of like having a disease such as hypertension. One you have it, you’ll always be susceptible to having it again. And much like taking a pill for hypertension, your pain will likely come back if you stop treating the condition. Your exercises and activity modifications are like the anti-hypertensive medication. My recommendation is that you continue to do the exercises and modify as many of the activities which aggravate your knee for the rest of your life, because the shape of your knee and the way it moves aren’t going to change!

 

2 comments
    1. Barbara

      While it’s always good to seek out alternative and legitimate treatment alternatives to conventional treatments, I can’t say that there are many which at this time beats a traditional total knee replacement, when the time is right. Makoplasty is basically a computer guided system for a partial knee replacement. While partial knee replacements definitely have a place among currently accepted modalities for treatment of degenerative joint disease (DJD) of the knee, they are not for everyone. If you have DJD involving any more than one compartment of your knee, you are not a candidate for partial knee arthroplasty. There is no consensus on the benefits of computer assisted arthroplasty over traditional arthroplasty. In my group I have partners using it and others who continue to do it the old fashioned way…which still BTW, is the gold standard. But first you have to be a candidate for partial knee arthroplasty. Then if you believe Makoplasty is what you want and need, you must find a doc who does it. As with all technical systems, the more familiar the surgeon is with the process, the better he/she is at getting it done. All that being said, I never recommend having important operations which are commonly done by good surgeons in your community, done out of town.
      I know nothing about Regenokine, but it sounds like a nutritional program, supplementing some kind of injection (platelet rich plasma?). Proper nutrition, maintaining a healthy weight and good sleep, while important for overall health, will have little effect on improving the knee pain related to arthritis or slowing the process down, to a degree which will diminish your need for TKA, should your disease be progressed to that point. Many of these programs are fancy marketing schemes for already accepted treatment modalities like viscosupplementation. It sounds like it might be some form of stem cell or PRP treatment, which while not prohibited in the U.S., is certainly not currently accepted as a standard treatment for DJD of the knee. I know of no double-blind, prospective studies which indicate that this treatment is beneficial or disease altering. There are anecdotal reports at best. That means someone gets an injection and they report they feel better. That’s the lowest level of evidence. These programs cost thousands of dollars. And there’s usually no guarantee. Hey, but it’s a free country, and as long as it doesn’t “hurt” you, I would say you can do what you want.
      I’ve had a number of patients go to Europe to get these treatments, at a cost of over $10G, and that’s in addition to just getting there. Most of them have come back for hyaluronic acid injections, saying the program didn’t work. Then they eventually get their total knee replacements…which really takes care of it!

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