I had dinner at a friend’s family home last night with her and her parents, all of whom I’ve known since grade 9, so a year or two. My friend’s dad asked this:
I have arthritis in both knees and will need knee replacements at some point, what would you do with me?
I don’t remember what my answer was, but I remember it was less than inspiring. I’m not sure why. But when I got home I was kicking myself. There’s so much I would do! Then this morning, I received an email from a woman asking what I suggest for her given her goal of trying to stay active while also postponing the need for knee replacements. If I’m getting the same question twice in less than 24 hours, there are others wondering about this as well.
Clearly I need to blog this!
Here’s my response to Mary (is that her real name? ooohhhh the mystery):
Jess will be back in touch to sort out when we can get you into our schedule, but I thought I would step in to provide a little about what we intend to do to help you with your goals.
We start all of our clients off with an assessment that includes a discussion about your goals, any injuries, and your activities; as well as taking a look at how you move using the Functional Movement Screen, or FMS. If you’re at all a geek, you will probably find this post about the FMS interesting.
We put together a custom training program for you based on that and our knowledge of what exercises tend to be beneficial and what exercises should be avoided given a specific injury or problem. In the case of someone who has arthritic knees, or any manner of recurring knee pain, this is the thought process that influences how we set up your program:
1. We look to your FMS results (the quantitative and the qualitative) to see if and where there are movement patterns or dysfunctions that we think may be contributing to your knee troubles. Often we see poor ankle mobility, tight quads, weak hips, and/or a very knee-dominant movement pattern. The latter is particularly common among runners, and is very clear when we watch someone squat (even for a very small range of motion like what you do to sit on a chair or toilet). Basically we see people move forwards and down instead of either straight down or back and down. We include a combination of appropriate stretches, activation exercises, and movement patterning exercises to try to improve these. They typically go in your warm-up (we call it movement prep).
2. We aim to strengthen your hip musculature. Based on our experience, and what we’ve learned from the many great seminars, courses, videos, and textbooks we’ve devoured, the hips are critical for the health of the knees. In fact one of my favourite quotes is “the knee is stupid; it only does what the hips and ankles tell it to do”. Improve your hip muscle function (specifically psoas, glute medius, and glute maximus), and your knee will tend to track better, which allows it to move as it was intended to, and that typically reduces additional wear on your knees that you would be getting without addressing this.
3. We either avoid or tread lightly around squatting or “knee dominant” exercises. Typically this is the category of exercise that is most likely to cause problems for someone with knee damage. In some cases we avoid them altogether, while in other cases, we progress to them, or we incorporate them with a limited range of motion or we use bands to improve the tracking. In all cases, we let pain guide our decisions: if the exercise hurts your knees, we don’t do it. In some cases the knee won’t bother you during the workout, but will be sore later that night or the next day. That’s why we’ll ask you to contact us the day after your workout to let us know if the knee was okay. If it was sore after the fact, then we’ll continue to make further adjustments until we get to the no pain spot. Now, if you are someone whose knees are sore 24/7, then clearly this situation will be a bit different: exercise isn’t going to miraculously make your pain go away. In that case, we make sure that your knee pain level after your training is the same or less than when you came in. If it isn’t, we adjust. We hope that over time, the training will reduce the pain levels, but in cases of severe arthritic damage, our best result may be that your knee pain never increases.
4. We’ll probably give you extra deadlift or “hip dominant” type exercises than normal. This is partly in support of item 2 above (they are great for the glutes!), and partly because they are just a great way to keep your legs strong without straining your knees. People with knee problems tend to be really surprised when they have come to us with the assumption that they can only work their core and upper body and then we say: “Okay, time to deadlift”. This is actually a pretty awesome part of our job. And the special bonus is that the deadlift also helps develop pretty much every other part of your body too. Can you tell it’s my favourite exercise?
5. As much as your knee allows, we include single leg exercises. We believe this is optimal for both developing balance (you’ll see that single leg Romanian Deadlifts done on a two by four are much more effective for developing balance than most traditional balance exercises), and for developing balanced strength – often if we stick to bilateral exercises, the strong leg is able to compensate for the weak one. We want both sides to do their job!
6. We work on the rest of your body without hurting your knees. Yup, it turns out there are loads of ways to get strong without pounding your knees, and we will help find the right ones for you. In addition to the deadlift, we program the rest of your workout to include a balance of pushing and pulling in your upper body, with a little extra focus on the pulling because that is what will help to address the desk-job posture most people have; and to include both rotary (side) and anterior (front) core exercises. The core is crucial to health and performance, but many people forget that the core is more than just abs! We are very aware of this. We also subscribe to the Dr. Stuart McGill-inspired core and low back training philosophy, meaning you won’t see any crunches in our gym, but you will see lots of planks, side planks, bird dogs, glute bridges, leg lowering, stir the pot, chops and lifts, and roll outs. You’ll get a strong core!
I could probably go on, but I’m thinking that’s probably too long of an email already. Hopefully this sounds good. If not, please don’t hesitate to get back in touch!
Note: this person was referred to us by her physiotherapist, so I didn’t ask about whether she is seeing a health care practitioner for her knee pain – I know she is. For anyone else, we will discuss it. I do believe that smart training is integral to helping someone with knee problems, but a trainer is not a health care practitioner, and someone in pain should be under the care of a health care practitioner.
Elsbeth Vaino, B.Sc., CSCS, is a personal trainer in Ottawa who gets a lot of clients referred by athletic therapists, chiropractors, massage therapists, osteopaths and physical therapists.