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. It was my very first post!

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 made squats, deep knee bends and lunges the backbone of the program.

Women have a physical predisposition to having pain around their knee caps. It has to do with the shape of our pelvis. We were put together  for having babies but not so much for running stairs and doing squats. And in the natural world we didn’t have to get in and out of chairs 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 including lunges and squats! Trainers get very upset when I write about this and often send comments impugning my knowledge. Remember…I’m the expert. 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…especially for women! Trainers would be doing their female patients a service if they took this information into consideration, and sought out versatile strengthening programs which didn’t rely on squats and lunges.

But more 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 grinding! That’s your sign that they shouldn’t be doing this exercise. That symptom often precedes the pain. Let clients know they should watch for pain and grinding around their knee caps while participating in a squatting program. 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 tap your finger!

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 handrail. 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 to finish your toilette. 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. But for me to recommend that would be like your primary care doc telling you some alternative 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. Just 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. 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 the 1:00 position.

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.


Sometimes I will recommend 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 or in stores.

 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 happening. First, I stopped running stairs and doing squats for exercise. 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. Your pain will likely come back if you stop treating the condition, just like your high blood pressure will come back if you stop taking the pill your doctor prescribed to lower it. 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!


    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!

  1. Kathy Craig

    I had a total knee replacement 7 months ago and still have knee pain, under the patella. I also hear and feel a grinding… Will these above exercise help?

    Also, I was an avid vinyassa yogi before surgery. Surgeon said I could back to it. I have subsequently found out, I shouldn’t do extensive squats, kneeling…. I am thinking now after reading you article, I should not do warrior (lunge poses) or chair pose. Agree?

    1. Barbara

      The way I see it, is that when you’ve had a total knee replacement, you treat it like a faberge egg. It is delicate and precious, and once you mess it up…a revision is never as good as the original. Depending on your age and weight, you may be headed for revision someday, no matter what. But you should make every attempt to preserve the first total knee replacement. The docs who do the surgery don’t want to introduce an element of doubt regarding the resiliency of your surgery. They say, “sure you can do squats, yoga, run, play tennis.” It’s likely they will be retired by the time you need your revision. They also don’t really think you’ll do all those things. If I ever have a total knee replacement, here’s what I would do: walk, swim, play gold, dance and ride a bike. I would not do squats, run, ski, play tennis or participate in sports. Bottom line. You can do whatever you want to do.
      The components of total knee replacements are HARD. They are not made of the special soft/hardness your cartilage was made of. They click, crunch and grind. The patella is thin. The alignment is never perfect, and you develop a bunch of scar tissue all around it, and that also squishes and crunches.
      I can’t say for sure that you don’t have a problem. Only your surgeon, or another orthopod who can lay hands on your knee, can tell you that. It is likely you will always have some retropatellar discomfort, or just a feeling that it’s just not like the original equipment. That’s good in a way. The original equipment wasn’t too good either.
      Again, not knowing your age, I can tell you that younger patients, and overweight patients, often do not have as good an outcome as older, trimmer patients. That’s just a statistic.
      Hope this information helps. See your surgeon.

  2. Dana

    I have grade 3 chondromalacia patella and have had chodroplasty to smooth down. I still have pain when riding my bike and crackling noise when I bend. In pt but not sure it is getting better. What is the next step? I miss being active.

    1. Barbara

      Unfortunately, you will always have some crunching under your knee cap. The molecular structure of the surface of articular cartilage is very amazing, and very resilient…until it isn’t. Once that surface has been disrupted, the cartilage has no ability to “heal.” Cartilage has no blood supply. So that damaged surface will remain damaged. Your doc has “cleaned” it up, which would be kind of like when there is a pot hole in the asphalt on the street. If you just smooth out the edges, it looks better and for a while it might stop crumbling off, but if you keep driving over it and the rain keeps eroding it, the pot hole will continue to grow. The only way to keep that pot hole from growing and getting deeper is to quit driving on it and protect it from the erosive power of the rain. Likewise your knee cap. There is an alignment problem with your knee. This must be changed by doing certain exercises to strengthen the vastus medialis and the hip external rotators. Then you must diminish the stresses placed on the knee cap, by not doing squats, lunges, stair climbing, leg presses, uphill treadmill, etc. I generally don’t mind the bicycle. Don’t do spin class, where you stand up in a squatted position on the bike. Make sure you set your seat higher so your knees are super bent up, and lower the resistance. You will always have crunching, just hopefully less pain. And give your knee a little grace period. It sometimes takes time for this to get better. NO SQUATS!

  3. Trish

    I am so glad to have stumbled across this as I have been having occasional spurts of pain in my inner right knee & crunchy knees, last few weeks. I am only in my late 30s so has been abit of a concern. Lots of websites advocate squats..which I have been trying to be diligent about(!) Also sometimes do tai chi (in horse stance!) But after reading your own personal experience, it is encouraging to know that through exercise & good habits, hopefully the pain can be overcome.. So would these 2 exercises ie leg raises & clam be sufficient? Guess yoga isn’t really recommended esp when many of it are floor exercises, thus requires squatting? Thanks so much for taking time to share!

    1. Barbara

      Right…no squats in any form. The exercise industry (and this includes yoga) is invested in women doing squats, and body-shaming us about our flat butts. Leg extensions, kicking in the swimming pool, etc., can be used to strengthen the gluteal muscles. Do the leg raises and clams to help keep your knee cap in alignment.

  4. Xenia

    Thank you for a very informative blog!! I guess it’s too late for me because I developed Chondromalacia for doing so many weighted squats and lunges. However, not too late for my daughter to understand SLAM is a good thing. I’m in my mid 50s. What would you recommend for cardio exercises to maintain ideal weight for people who suffers from this condition? Thank you for sharing your professional opinion!

    1. Barbara

      Glad you found my blog helpful, and while my suggestions might only help you and me slow down the progression of arthritis, it might help our daughters prevent it!
      Humans are hunter/gatherers. We walk and lift light weights. We’re put together to walk slowly for long distances, and for dexterity, ergo our long, limber legs and our agile upper extremities!
      Please pass my blog URL on to friends and family so that they can realize the benefits as well! Thanks!

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