How To Fix Knee Pain
Sore Knees, Bad Knees, Slouching Knees (Valgus and Knock-Knee), Cartilage and Meniscus, Degenerating Knees and Kneecaps, Patellofemoral Pain, Pain with Bending, Squatting, Stairs, Walking, Running
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© Jolie Bookspan, MEd, PhD, FAWM
Director Neck and Back Pain Sports Medicine
and the Academy of Functional Exercise Medicine - the Fixa U (tm) School of Healthy Medicine
Welcome. This article to FIx Your Knee Pain is one page on my large no-charge web site DrBookspan.com. I am a research scientist and clinician in human physiology and performance in extreme environments. I study why people get specific injuries, and why common treatments don't work. I develop things that work better - evidence-based sports medicine methods that you can use yourself, right away, to fix your knee pain, back pain, neck pain, other injuries, learn smarter stretches, and make your life stronger, faster, smarter, healthier, and sometimes funnier. I also put fun stories on this web site of my years of lab research in environmental medicine and physiology of the human body in extremes of heat, cold, injury states, altitude, underwater, and different nutritional states.
This Page is for Fixing Your Knee Pain. Don't worry, much can be easy to fix. This Get-Started-Right-Now summary shows how to spot and stop common causes of knee pain and injury, right now, today. Don't wait.
These are summaries, with a wealth of knowledge still to give in private appointments, group classes, personal online consults, and my books. For more about me, see the Adventure Medicine page.
SITE MAP. At the bottom of this page (and every page) are main navigation links, plus buttons to SHARE, TWEET, and LIKE.
Now let's go fix your knees!
Answers In A Nutshell
- My work is not alternative medicine. This is evidence-based sports medicine techniques, applied to real life - where you actually need it. I consider it simple standard-of-care.
- Knee pain and most cartilage tears are not a "condition" that once you you have it, you have it for life or need surgery to fix. With changes to healthier movement habits, you stop ongoing damage, and stop abrading and irritating the area. Much can repair.
- You do not need surgery or extended medical treatments or bed rest or yoga to relieve most knee pain or tears. Many times, surgery for tears and damage results in needing more surgery later, or in more degeneration. Some people have to reduce activity so much after surgery that it is not a healthy cure, and their health and happiness suffers over the long term. Sometimes, the yoga itself is the reason for the knee pain - explained here and on the Healthier Yoga page.
- Most people do not need special expensive shoes or rigid inserts to hold their feet in any position. Your own muscles can, and should do that - if you know how. Feet need practice in position sense, and exercise holding themselves in healthy position. You lose that when shoes "support" them so that they never do it for themselves.
- You do not need to give up impact activities like running or martial arts, give up weights or heavy occupational work, or activities you love to do. By changing daily movement habits to healthier ones, you get the built-in exercise you need for health, while you prevent common causes of pain. That means that changing bad knee position while you walk, climb, run, bend, and all movement, to healthy position with good gait, is quicker and more effective than giving up running and hoping yoga poses or reps and sets of exercises will magically change your gait or alignment for you. You can do it yourself in moments.
- Not all knee pain is from what shows on an x-ray or other test or scan. You are not doomed by scan results.
- Knee muscle, cartilage, or joint injury are not causes of the problem - they are RESULTs of what you are doing to hurt your knees - things you can fix yourself. Even when inflammation or immune response are identified, they are results, not causes. Understand and fix causes instead of using drugs, surgery, and exercises for the results.
- You may have several causes of pain. If you fix some of them, you will fix some of your pain. The answer is not to continue on, saying "it just takes time" and allowing the other damaging causes to continue. Check for other causes you may have missed and fix them all. Then you will stop all pain, and instead of alternating feeling better from fixing one thing and hurting from other causes, wondering why you have intermittent results.
- Common medicines and prescription drugs can cause knee pain. Some of the most common shoes, even 'athletic" and podiatrist-prescribed shoes cause much knee and foot pain. Unneeded treatments and surgeries are done - causing more pain and reduction in physical ability. It is a myth that shoes need to "support" or hold you feet in position. Your own muscles do that. Easy changes can stop the need for harmful medicines.
- Study of posture rules, exercises, and devices has shown they have made as much or more pain and damage as slouching, and do not create healthy movement. They are also no fun. First, healthy positioning during movement needs to be learned. Then all daily movement becomes healthy comfortable fun habit.
- This article explains all the above. Make sure you understand the concepts (many highlighted in green). The end of this article (where it says "More fun...") gives several links to pages on this site for more help. The bottom of every page on my web site has main navigation links.
Knee Pain - Why?
Most people know that bending and standing badly can cause a sore back. The same is true for knees.
Legs have posture and position during movement. After years of bad habits allowing knees to slouch or twist, they can begin to ache and wear. Knee pain that seems to begin suddenly is often the result of gradually pressuring and straining over months or years. Much "wear and tear" arthritis is preventable, and pain from it eased, with the healthier movement mechanics summarized in this article.
Instead of doing a bunch of artificial rehab exercises then going back to damaging daily life movement, try living and moving in healthy ways. Instead of wearing shoes that make knee pain, and spending time doing stretches and therapies, then putting on the same pain-producing shoes or orthotics, check for and stop causes. Here is how:
On June 22, 2016, Rita B wrote:
"Your methods work. I went from knee pain to no pain with everyone around me getting knee surgery."
Knee Pain Fix #1 - How To Keep Cartilage Healthy
Two common habits can build up to cause pain and injury: A) letting your knees sag inward, increasing the angle where upper and lower leg meet, and B) letting knees rotate toward each other; knee angle may be straight, but the rotation twists the knee:
A) Increased inward angle (called Q-angle) of the knee. A too-large inward angle is also called "knock-knees" and valgus knee, or genu valgum, because "genu" means "knee" in Latin): An increased inward angle is a slouch and is easily preventable. "Knock-kneed" is often simple bad posture. The knees may sag inward from flattening the ankles, or the ankle and arch may be fine and the slouching motion comes from the knee, or sometimes from the knee and hip together.
Backman! is trademarked and copyright Dr Jolie Bookspan
Like tires that are angled inward too much, knees that tilt inward too much will wear unevenly, and too soon.
The cure for tire wear is not to stop driving (give up activity) or change the tire (wear orthotics or have surgery).
The cure is to check why the tire is crooked and fix that. Learn how to hold your leg in healthy straight position. Then, unlike tires, you can heal.
B) Letting the knees rotate inward - so that the kneecaps face more toward each other than straight ahead. Rotation is sometimes called torsion and other names. The name doesn't matter as much as easily identifying when it happens, and instead, using your thigh and lower leg muscles to comfortably hold kneecaps facing the same as the feet - straight forward.
The above photo shows inward knee rotation. See how the kneecaps face inward of the line of the feet. Rotation is not a "condition" but slouching (poor knee positioning). Rotation can be voluntarily changed to healthy positioning by moving your own knees and thighs into line with your feet.
Knees have posture like your back and shoulders - good and bad and you can control it. Exercises do not fix bad knee habits. You quickly can fix them yourself with instant repositioning, then using that new healthy position during all you do. Then your knee joints don't rub and wear.
Position Is Trainable. Many people are told that turning ankles in and letting arches sag cannot be fixed or that if you try to hold straight you will cause harm. Think of a beginning skater. They let their knees and ankles sag inward until they learn to hold their feet and ankles straight in healthy position. It is simple practice in holding position, not something that cannot be changed.
Letting ankles and knees sway inward, and kneecaps that rotate inward instead of facing straight with the feet, are bad habits that contribute to knee pain. It is not a "condition," it is something you can control using your own muscles to hold your ankles and knees straight.
Allowing knee sagging and rotation are sometimes a hidden contributor to poor kneecap tracking. The kneecap can start to move slightly sideways instead of up and down each time you move your knee to walk. This rubs the cartilage on the inside of your kneecap. The friction can eventually break down and wear away the cartilage. This is called degenerative change.
Many people are told to accept meniscus tears and degeneration as aging, or inevitable from their sports, along with all the pain and disability that accompany it. They may be told they are flat-footed, or have a problem called over-pronation (too much pronation, which roughly means turning inward) or letting the ankles or knees sag inward so that your knees angle toward each other, called "knock-knees." But often, the cause is avoidable. Letting the foot and knee sag, and or rotate, is easily corrected by using your leg muscles to keep comfortable healthy position. It is the same as not letting your shoulders round forward.
How to Check for Knee Pain from Inward Sway and Rotation
Straight legs. Stand with your legs straight and look at your bare legs in a mirror. See if your knees angle greatly or your kneecaps tilt or turn inward instead of facing the same direction as your feet. Notice if it is from letting your body weight sag inward or rotate inward at the knee and/or flattening the arch of that foot. Check both legs. Some people slouch on one side and not as much as the other.
Notice if you hold kneecaps straight ahead when standing still, but sag the moment you put them under load of your body weight. Check standing on both feet and check again when standing on one foot. Check if the knee of that leg starts to rotate inward to face the other leg more. See if you flatten the arch of that foot.
Bent knees. Look in a mirror and do a small crouch, called a partial or half squat. See if both knees are right above your feet (perpendicular to the floor) not inward of the feet. In the photo below, one knee is sagging inward of the foot.
In the photo example above, one of my students demonstrates letting one knee sway inward of the foot and lower leg, and keeping one knee in better position above the foot.
To check yourself without a mirror, look down when you bend and see if your knees are above your feet, or inward in relation to your feet. Also see if you turn your feet outward rather than keeping them facing straight forward. For most moving and bending, keep feet and knees facing straight forward. It gives more healthy stretch to the feet and back of the leg. Obviously, for bending for many things in real life you need to position your feet in different ways. The principle is the same; to keep knees facing in the same direction as the feet, so that there isn't undue twisting at the knee or ankle.
How To Fix Sway and Rotation
Sway. If your knees tilt inward, pull your lower legs to upright position so that the knees are above the feet. If tilted sagging knees are coming from tilted sagging ankles, use your muscles to deliberately lift your weight off your inside arch, gently to the whole foot, without rolling too far to the outside of the soles - don't overcompensate. Use this same repositioning when your knee is straight for standing and when it is bent for crouching, squatting and lunging.
When bending, look down as you bend both knees and see if your knees are above your feet, shown in the first photo below. Use this same check and correction when bending both knees for squatting and crouching, and when bending one knee in front, for lunging. Use the next photo set for reference:
If your knees tilt inward of your feet, it will look more like the photo below. In that case, use your thigh muscles to pull the upper legs outward until your knees line up above the feet, as previously shown in the photo above.
If you find you also turn your feet outward, as in the photo below, that is often another source of pain and problems. Move your feet to face forward also, when you line up your knees above the feet, previously shown.
Rotation. If you let your thighs rotate inward so that the kneecaps face more toward each other than straight ahead, use thigh muscles to rotate your thigh and knee more to the front, so your kneecaps face forward in the same direction as your feet. Don't force or tighten.If it hurts, it's wrong, so stop and assess.
Below, a short gif should load of correcting knee rotation:
This video of fixing knee rotation and others can be accessed directly from my FlickR page: https://www.flickr.com/photos/thefitnessfixer/16874295529/
Practice correcting your knee, foot, and leg position until you can walk with healthy, straight, comfortable leg positioning. Use it when bending both knees for squatting and crouching, and when bending one knee in front, for lunging. Like any new habit it may feel strange at first. It should not hurt to stand straight. Don't force.
This method of healthy functional movement exercise prevents cartilage from wearing away faster than you re-grow it. Your body repairs a certain amount of cartilage with the right exercise. You will stop causes of pain using this healthy movement mechanics method, and stop hurting while your body does normal repairs.
Is knee rotation or increased angle a gender problem? It is popular to state that females have more knee problems due to increased sway or rotation. It seems to be true that slouching is often mistaken for something cute, and is encouraged in females (and many males too), or allowed to continue under the assumption that it is normal. A quick look at clothing catalogs and popular magazines may show how accepted a destructive habit like slouching can be. The essential point is that learning and using healthier position can be done by anyone who wants to improve their health. Using healthy positioning can prevent the knee injuries that occur from forced rotation and angulation with landings from jumps, and the chronic pain from daily life with parts that rub and grind due to allowing this slouch.
Flat Arches, Foot Position and Knee Pain
Orthotics, Supports, and Special Shoes Not Needed
Many people are given orthotics to hold their foot and ankles in level position, and told to never walk barefoot. This is usually unnecessary. Your own muscles can place your feet and ankles as correctly (or more) than using an artificial shim or orthotic.
A short gif of repositioning your own feet and arches from flattened and / or pronated position, to a level and healthy neutral arch should appear below. More on arches is on the Patient Success page, knee pain section.
Engineered shoes also are often a major hidden cause of knee pain. Often, modern engineered, even orthopedic shoes hold you in wrong or rigid positions and lack flexibility to let your legs move in healthy ways, further causing damage and pain. Separately, by relying on a shoe, you can atrophy your muscles, making you less able to stabilize and balance.
Foot positioning problems not from flattened arches. Some people have a well-formed arch of the foot, but they still let their foot, or both feet, turn outward or tilt at the ankle so that the inside edge of the foot presses lower against the ground (or shoe) than the rest of the foot. There may not be knee pain from this, but a lot of mystery foot pain. The person and their practitioners are fooled by the lovely arch, and think it is not an arch problem when the pain does come from compressing the bones of the bottom of the foot against the floor or shoe. Using leg, ankle, and foot muscles to comfortably hold the arch level works well to stop the ongoing pain, and to avoid useless treatments, special expensive shoes and inserts, and arch supports that don't stop the pain because the person continues to compress the ball of the foot and other bony areas downward on the arch support, causing them to rub and hurt.
Stopping Bad Movement Habits During Daily Life is Key. Stop compressing and twisting your joints and cartilage with poor movement habits. You will give your body a chance to rebuild. You will create more joint space. Doing rehab exercises then going back to bad all-day life habits will not help. Surgery removes cartilage that you need, and makes you lose valuable time, health, and needed movement. Many conventional gym exercises, many yoga poses, even exercises given for rehab, are not healthy in themselves, are ineffective, or are done with the same poor movement habits. This and all the other things to check that follow (and more in the books) are part of healthy fix.
The nice note below from Steve Kramer is about using these techniques. Steve's successes fixing back pain, knee pain, and others are featured on the Patient Success page.
Knee Pain Fix #2 Check for Feet Turned Outward - "Duck Feet"
Walking with feet turned outward can contribute to knee pain, tightness of the foot and leg, to hip and heel pain, It also predisposes to bunion, because you push off each step on the side of the big toe, pushing the big toe toward the other toes.
"Duck-foot" can be a bad habit, or from the incorrect belief that is the way to walk. Many people were taught it was normal. "Normal" may be confused with "common" - it may be common but it's not good and creates problems. A cycle may develop that walking turned out (duck-footed) doesn't let you get the built-in stretch your Achilles tendon and foot and leg would get with walking with feet facing straight forward. Tight Achilles tendon further makes walking duck footed seem more comfortable. Also tight side of the leg (ilio-tibial band or IT band), tight bottom of the foot (plantar fascia), even tight big toe (hallux rigidus) that doesn't bend to allow normal foot push-off. All can create a cycle of walking in a manner that doesn't give them the stretch they need and all structures getting tighter leading to more disordered walking.
Turning feet outward when you walk wears on the knees, like tires that are crooked. To fix tire wear, you don't stop driving or change the tires, and you shouldn't keep driving that way. You check why they are crooked and fix that. Learn how to hold your own feet and legs straight by using your muscles, not letting them tilt and sag.
Find the source of your turned out position, sometimes nothing more than bad habit. Use your muscles to walk straight. There are some who say that straightening bad ankle and knee posture will cause pain in the hip. If it is the case that you force feet straight without correcting the source of the problem, the rest of the leg may turn with the foot, making more problems. There is no need for that. Know what you are doing, rather than applying mystery exercises and arbitrary "fixes." Keep your entire leg position healthy and there will be less pain, not more.
Knee Pain Fix #3 How To Keep Knees From Hurting When Bending, Exercising, and On the Stairs
Many people don't "lift with the legs" to prevent back pain, because it hurts their knees. Bending knees properly should not hurt, but help fix and strengthen. A major cause of knee arthritis is weak thighs. Good bending will save your back and exercise your legs in healthy ways at the same time:
Healthy squatting for daily life strengthens legs, hips, and knees. Bad squatting can hurt. It is no mystery. Instead of thinking of squats as an exercise to "do" 10 times, use it for real life. Real built in exercise, both back AND knee pain prevention, and knee strengthening.
Bad bending, with knees forward,
shifts weight to the knees
Good bending with knees back and heels down
shifts weight onto your muscles, and off your knees.
It's good exercise, and healthy for your back and knees.
How to Bend Knees Without Pain Using a Partial Squat
Regardless how low you crouch, keep both heels down on the floor. Don't let your heels come up when squatting. Shift your body weight back towards your heels and feel the weight shift off the knees and onto your thighs.
Keep both knees far enough back when you bend that you can see your toes.
Check if you bend by letting your knees come forward. Body weight is shifted to the knee joint. Instead, whenever you bend or lift, even to pick up a towel, keep heels down and knees back, over the ankle. Shift your weight to the heel, off the front of the foot (ball of the foot) and toes. Feel the difference in thigh and hip muscle use when you shift your weight back to the muscles and less on the knee joints. Done right, feeling of pressure or pain should disappear from your knee. Don't let your back arch; keep hip slightly tucked. Use a mirror to practice healthy knee position. Or put the front of your knees against a bench or other object to train yourself to keep them from slouching forward.
Go up and down gently, a small amount at first. Done properly, it should feel like exercise for the thighs and hips, not pain in the knees. If you do squats in a gym, don't prop up your heels or stand on the ball of the foot (half-toe stance with heels up). Stand flat on your whole foot, rocking weight back more to the heel.
How to Bend Knees Without Pain Using a Full-Squat
Keep both heels down on the ground. Don't let your heels come up when squatting all the way down. Avoid a lot of squatting on the balls of your feet (heels up). Toe-squatting shifts your weight forward onto your knee joint. Instead, to sit or crouch in a full squat to rest, to do chores, or to go to the bathroom in the woods (or wherever else there is no "sit-down" toilet as in much of the world) keep your heels down on the floor. Heel down squatting is a customary sitting posture in much of the world. This shifts effort to the thigh and hip muscles and off the joints of the knees and is a great stretch for your Achilles tendon. Keep your knees inline above the line of your feet, not tilting inward. Keep knees facing in the same direction and your feet so the knee does not twist. That means if your feet face feet outward, keep knees facing to that same direction. If you keep feet straight forward, which is a better Achilles and calf stretch, then keep knees directly forward.
How to Bend for Ordinary Daily Activities Without Pain Using a Lunge Position
Another healthy way to bend for things during real daily life is the lunge, with one leg in front and one in back. With healthy knee position you can bend without knee pain and have a daily habit that strengthens knees rather than hurt them. Keep the front knee over the ankle, with your body weight over the entire foot and heel, not forward to the front of your foot. Shifting forward transfers your body weight through your knee joint, instead of keeping it on your leg muscles.
When bending with one foot in front of the other at any width, keep front knee over the ankle (left) not forward (right). A lunge in healthier position is helpful for all the many dozens of times you bend to reach things every day.
Using the lunge strengthens legs, hip, and knees. Keep your body weight evenly between the front and back leg. Bend both knees to dip straight down, and up again, gently.Use good bending, shown in the left hand drawing above. Done properly, it should feel like exercise for the thighs and hips, not pain in the knees.
Instead of thinking of lunges as an exercise to "do" 10 times, use it for real life. Real, built-in exercise, back and knee pain prevention, and knee strengthening. Imagine how many times you bend for everything during a real day. Imagine doing that many bends in damaging ways. No wonder things hurt. Now bend right and get real exercise and pain prevention. No gyms, therapy, or pills needed.
Retrain your bending habits to help your back and knees at the same time, and give you free leg exercise too. You can become more mobile and strong while reducing your knee pain, by using your muscles instead of throwing your body weight on your knee joint.
Check how you bend for exercise. Use the same good bending - even to get your equipment (mat weights water bottle) to and from the floor. There is junk food, and junk exercise. Bad bending is junk exercise, yet people are mystified when they hurt when they junk exercise.
Good Knee Positioning for Stairs
When going up stairs, keep your weight back toward the heel of the foot that is stepping up. Most people don't step this way because their leg muscles are too weak. They throw their weight forward, stepping up onto the toe. This transmits body weight onto the knee joint in a vicious cycle of weakness and pain. Keep weight back and knee pain will disappear.
When going down stairs, keep the knees back (not shifting or sliding forward) in the same way, stepping down lightly, ball of the foot first (not heel). My books have more. Send your own success videos and photos in so I can post them here on my web site and everyone can benefit - see the Projects page.
Knee Pain Fix #4 Your Own Body's Shock Absorption - Understanding Impact
Many people are told to give up impact activities, however, they may allow more impact during mere walking and using stairs than someone with good movement mechanics will run and jump. Do you walk, run, exercise, jump, and step heavily, letting each foot flop down without muscle use to decelerate? Shock transmits to the joints of your ankle, knee, hip, back and neck, and can strain your calf muscle and Achilles tendon. A certain amount of impact is necessary for body health and bone growth. Impact with poor movement mechanics magnifies damaging forces. I see patients who are instructors of "low-impact activities" such as Pilates, stretch, yoga, rowing, martial arts, and Alexander technique, for degenerating joints. It is simple misuse.
When going down steps or a hill, for example, beside the good knee positioning mechanics shown above, use your leg muscles to step down lightly. Use the leg still on the upper step to decelerate. Instead of banging down onto the lower step, keep weight on the upper leg to lower yourself lightly, then add shock absorption from the leg that steps down. Bend the knee and use thigh muscles as you touch the ground. You will get free leg exercise, burn more calories, and reduce shock and wear on the knee.
Use the same principles for normal walking and running. Use it for exercise classes using a step bench or balance platform. It's no mystery when people hurt "even though they are doing their exercises" when they are slouching, flopping, slamming, and straining knees and Achilles tendons, and calling that an exercise class.
Knee Pain Fix #5 Don't "Lock-out" the Joint with Hyperextension
Some people stand and move while "locking" the knee out straight, or pressing it backward. This hyper-extended joint posture is sometimes called "splay-legs," or "splayed knee" and can even make the leg look more crescent-shaped than straight. Hyperextension can press the joint slightly out of place, putting damaging forces on the cartilage and surrounding tissue.
Many people push their knees into hyperextension when standing and walking. Others "bang" the joint into straight position in exercise and aerobic boxing classes when rising from each crouch or squat, or when kicking. The locked out joint position is sometimes taught in yoga and dance classes. It is unnecessary and injurious over the long run. Sometimes it is given as a PT exercise for people who have such stiffness that they can't fully straighten. Some people continue to force the joint straight or past straight to too much backward angle (hyperextension) long after the need to help it straighten is over. Also there are far better ways to help a stiff joint straighten that use this "pushing the knee backward" maneuver. Pain from hyperextension is commonly felt after long sitting or upon waking. Instead, stand and move without locking the joint straight.
"Locking" the knee out straight, or pushing it back in hyperextension eventually wears at the joint.
Instead, stand, walk, and move without banging the joint straight.
My Academy Student Jennifer Lattouch demonstrates allowing knee hyperextension (#1 left), and correcting to neutral knee (#2 right).
Knee Pain Fix #6 Gait, Walking, Stairs, and Running - Heel First? Toe First?
One way some people hyperextend their knee(s) when walking and running is to raise their toe too high and land too far back on the heel. That is not a healthy heel-strike gait. A heel-strike gait can be one of a few efficient, healthy gaits. The foot-strike lands first on the bottom of the heel (not the very back of it) then quickly shifts weight to the mid-foot and forward. When some people hear the phrase "heel-strike" they think it means they must hit the heel hard and all the way at the back, instead of a soft quick roll from the bottom of the foot. Other people roll inward on the ankle and arch of the foot making two movements (called eversion and pronation) and strike the inside (medial) surface of the heel, making their heel hurt. They may be misdiagnosed with fasciitis or spurs when they are just bashing their heel. Pain stops as soon as you stop landing on it badly and unevenly.
Different gaits work differently for different speeds and purposes of movement. For slower running gaits and for "dog-trots," a mid-foot strike works fine for many. Remember that the word "heel-strike" used in describing movement does not mean to strike hard like a hit or blow, It means the moment of touch. Check if your gait includes bashing your foot hard, or too far back, or unevenly to the sides, instead of evenly on the bottom of the foot, or if you rigidly-straighten or hyperextend your knee.
Next, check if you do the opposite - Many people read articles repeating the "fad-of-the-day" not to run heel first. While it is true that bad heel-first running can hurt, a good heel landing and roll works as described above. A problem comes when people think they must avoid landing at all on any part of the heel, and instead they do too much of the opposite. They either start running only on the ball of the foot, almost tip toe, and lose much of the propulsion, or they "trudge" meaning they slide the knee forward upon each landing. The knee-forward gait transfers body weight, momentum, and shock absorption phase to the joint, when it is better kept on the leg muscles by not landing that way.
The answer is not that heel running or mid-foot running is right or wrong, but that bad heel running and bad mid-foot running can hurt, while there are healthy efficient gaits using both for different kinds and speeds of movement. A bit about barefoot running in #10 below.
For walking down a flight of stairs or stepping down from heights, usually best is to land ball of the foot, quickly following by shock absorbing. That means bend the knee a bit in healthy lined up form, letting thigh muscles decelerate you, not landing on a straight or hyperextended knee. For walking down a slope, in general, it works best to use normal rear-foot to forefoot roll, rather than trying to trudge down toe first.
Knee Pain Fix #7 - Good Range of Motion Without Twisting
Your knee joint is shaped to bend and straighten. Unlike your shoulder or hip it is not supposed to "swivel" or twist much. Check and see if you twist your knees without knowing it. One common way to twist your knee is to plant your foot, then turn your body in a different direction without also moving the foot. People often do this going down stairs where the stairs turn. Or when changing direction in sports and running. Some people even do this walking and running, by stepping down, then letting the heel swing to the side while the foot stays planted on the ground.
Twisting can wear away at the cushiony cartilage in your knee, called the meniscus. You can strain or tear your meniscus (and cruciate ligaments) suddenly from a big twist, or gradually by letting your weight fall inward, or by moving with your feet and knees pointing in different directions. The leg bones twist, step after step, day after day, year after year.
People often injure their knee by twisting deliberately, doing common but bad stretches. They are stretching, but it is not a healthy or needed stretch. Twisting stretches the ligaments that hold the knee together. Overstretched ligaments can make the joint unstable, allowing the bones to rub and grind.
Your knee joint is not shaped to bend and twist to the side at the same time.
That can overstretch the joint and make it too loose, so that it rubs and wears out sooner than it should.
Knee Pain Fix #8 - Ilio-tibial Band or "I.T. Band"
Your I.T. band is a fibrous band that attaches from the side of your hip (your ilium, which is the top of your hip bone) to the side of your knee (tibia bone). That's why it's called "ilio-tibial." Tight I.T. bands can yank on the side of your knee, leading to knee pain, and even change the way you walk. When a tight band pulls and rotates your leg to the outside, it can add to walking "duck-footed" with your feet and legs turned out instead of facing straight forward, which leads to other pain and problems.
A commonly taught stretch for your I.T. band is done standing sideways at arms-length from a wall, crossing the opposite leg in front of the leg nearest the wall and leaning toward the wall. A more effective stretch is done lying down: Lie face up on a floor or bed, or wherever you're comfortable and flat, with legs wide. Cross one ankle on top of the other with both legs far to one side. Keep both legs straight and make sure you lie flat with both hips touching the floor. Hold for a comfortable stretch - at least for a few breaths - then switch sides.
The most common IT band stretch is the standing stretch (left) but a more effective stretch is done lying down (right).
A properly done IT stretch will feel good and help your knee, hip, and other things.
Knee Pain Fix #9 - Knee Pain That Does Not Come From Your Knee - Why Some People Are Told Stretching Fixes Knee Pain When the Pain Was Really Not From A Knee Problem
Your quadriceps muscles, and other thigh muscles, are attached around your knee. (Interesting note - there are four quadriceps muscles, so when talking about the group, the plural is used "quadriceps"). Sometimes, people have tight thigh muscles. When these tight people try to lunge, or stretch their quadriceps, or do activities that need to lengthen the quadriceps like running, the tight muscles pull and yank instead of stretch on the place where they attach - around the knee. People are given stretches in rehab or PT and told that stretching fixes knee pain. They never really had knee pain - there was nothing wrong with their knee, so it is a misleading idea. These same people will often not use the lunge to bend properly because they think it is hurting their knee. It may be that the tight quads were the problem, and lunging (gently and not so hard that it yanks the tight muscles) is what they needed.
Knee Pain Fix #10 - Stop Bad Shoes and Orthotics That Cause Pain - Plus, What About Barefoot Running?
Pain from Your Shoes. Hard, "supportive" shoes and high tech running shoes are a frequent cause of knee pain, documented in studies to contribute to knee and lower limb arthritis. No need for shoe "straight jackets." Soft, flexible shoes that let your feet breathe and stretch when walking are healthier for your feet, knees, and hip. Expensive, engineered shoes are not needed, and may even be causing your pain. Your own muscles can be the support needed, as explained above.
Pain from Your Barefoot Running. When some people hear that engineered shoes are bad, they automatically assume the opposite must be true - that no shoes have to be automatically healthy. Going barefoot will not automatically make you walk and run well. If you run and walk badly barefoot, you can still hurt. It is not true that barefoot running automatically makes or forces a mid-foot strike instead of a heel-strike, or changes you to any specific gait. Make sure your feet get air and light every day for health, and you use good and healthful lower limb mechanics and habits so that you can go barefoot in healthy ways when you want to. A bit more about gait and running in #6 above.
Pain from Orthotics. An extremely common scenario is someone who goes to the doctor with a little pain from bad foot or knee mechanics. They are prescribed foot orthotics, which is a rigid shaped shoe insert, mistakenly believed to "hold" the foot in proper position. However, consider this - some orthotics are molded sitting or lying down, not when the person is standing where they need it and when foot position changes. Other times, the orthotic is "custom shaped to the person's foot" which was in the wrong position to begin with. Often the rigid and hard nature of the orthotic causes new pain in the leg and hip. Then the person is told to further reduce activity, go for physical therapy, or give up and live with pain. Forcing an arch to change, especially over a rigid painful device isn't healthy or correct. A moderately low or high arch may be perfectly healthy with no "support" needed except what you can do yourself using your own muscles. Orthotics are usually not needed in the first place. You can hold your feet and knees in healthy position.
More on shoes, orthotics, bad gait with shoes or bare feet, and other causes of pain is in the books and eBooks.
Knee Pain Fix #11 - Not All Pain is Orthopedic - Pain From Your Medicines
Many medicines cause body aches. Common prescription and non-prescription medicines cause much musculo-skeletal pain - statin drugs, anti-anxiety drugs, cholesterol drugs, stomach acid drugs, and more. The pain is not a rare effect as previously thought. Are you on medicines for lowering cholesterol? Sleeping medicines? Drugs for depression and anxiety? Irritable bowel drugs, stomach acid drugs (a large contributor to osteoporosis and thinning bones, too) drugs to concentrate, to help wake up, to calm you, for allergies. Increasingly, drugs are found to make more pain as side effect, even drugs you are taking for pain. Trying to stop them causes rebound and withdrawal pain - good for drug companies to keep you on them, but bad for you, your bones, your stomach, and your health.
Stop the causes of poor health instead of taking medicines that cause new problems. If your diet is poor so you take cholesterol and heart medicines, it is likely your diet is too poor for you to feel good or be healthy. Use my free web site DrBookspan.com for many articles on getting healthy again, come take classes, plus almost 800 articles on my Fitness Fixer Index.Stretches and exercises do not fix this kind of pain. In a worsening cycle, side effects are "treated" with yet more drugs with effects that lessen and degrade your health. That is not "side effects" and that is not health care. Many of these drugs are not needed. Some, like stomach acid drugs, are associated with rebound, increased symptoms, bone density loss, and other problems.
A top health priority is to stop the need for these drugs so that you can lessen, then stop the need to take them. If you are in pain, so don't exercise, then get cholesterol and other health problems from not moving, can't sleep, then take cholesterol and sleeping medicines that cause dependence and more pain, use the healthy principles in my free summary articles and all my books so that you can move again, and be healthfully tired at the end of the day and sleep well at night. It is not true that all exercise is good medicine. Healthy exercise as healthy medicine will stop the pain and need for medicines that cause more problems.
When you reach for anti-inflammatory medicines and pills (even foods) remember that most knee pain and other pain from bad habits is not inflammatory in nature, and may be why all those pills aren't working. Change the bad habits that are the cause. Reduce inflammatory foods for all the conditions with inflammatory components like heart disease. Unhealthful fad diets are increasingly recognized for joint and muscle pain effects, specifically extreme low carbohydrate diets that restrict fruit rather than junk sugar. Low carbohydrate diets reduce weight, but by reducing needed water in your muscles, making muscles susceptible to pain, weakness, cramping, and other health troubles).Vitamin D is needed for pain free living. Better than taking pills and vitamins, get active again in healthy ways out in the sunshine. More on medicines, orthotics, and other causes of pain is in the books and eBooks.
Body Weight and Knee Pain
Some people are told they have knee pain because they are overweight. When I check them, I often find they stand, bend, and walk with weight poorly distributed on the joint, just like anyone else. When we change that, pain diminishes. I have seen patients, some greatly overweight, who say that retraining gait and stance stopped their knee pain, so that they can go out and walk and exercise for the first time.
People who are not overweight, but walk with poor mechanics, poor positioning, or poor shock absorption can put more weight on their knee joint than a heavier person who walks in a healthy manner. How you bend and walk can matter more than your body weight. Someone with good mechanics can land from a jump with lesser force than most people pound away when they walk, reducing loading on the knees, and especially the damaging forces of twisting and torque that bad movement mechanics cause, and weight loss cannot fix. Light weight people can do huge damage to their knees with awful habits. With good mechanics you can do more exercise for the weight loss you may want and need for the many benefits.
On June 18, 2007,Viki D wrote:
"I have had knee pain for the last two years. I could hardly walk much less bend. All my doctors just kept telling me I was overweight and when I took the weight off the knee wouldn't hurt. Your web site showed me that I was leaning too much weight against my joints instead of holding knee position using my muscles. I feel so much better and the pain is gone. Thank you so much. Viki D"
Why Common Knee Exercises Don't Help Knee Pain
Strengthening alone doesn't fix knee pain that comes from poor mechanics. Plenty of muscular people have pain. They may do knee exercises, but strengthening is not what changes bad knee positioning during all the things you need to do in real life.
The best exercise is functional - how you bend and move all day in real life, not doing sets and reps of artificial knee exercises then going back to the other 24 hours a day of injurious movement habits. Bend properly for all the many dozens of times you bend for things every day. Use good bending described in #3 above. You will strengthen at the same time that you prevent ongoing injury and get free, built-in, real life (functional) exercise all day.
Letting the joints of your knees, hip, or ankles sag and tilt under your weight instead of using supporting muscles to stand and move in healthy position, loses the benefit of rehab exercise, and wears on the joints. Keep knees in healthy positioning during walking, standing, lifting, and bending, as described in this article. You'll get built-in exercise and free knee rehab without going to a gym or PT.
Why Surgery Is Rarely Needed
Much is already known about why knee surgery is usually not needed. Separate well done studies over years by respected researchers collecting results showed that, when looking at long term results, having knee surgery does not improve outcomes more than not having surgery, plus the pain and bills from surgery, and occasional harm from surgery itself. Here is a direct link to a report: "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline" BMJ 2017;357:j1982: http://www.bmj.com/content/357/bmj.j1982.
Other people with less than successful outcomes from physical therapy were left thinking, "it didn't work, and surgery must be the option" usually didn't have all needed info about how to fix daily movement habits, rather thank thinking that doing some exercises ten times a day would fix the pain.
My Fitness Fixer (tm) column ran on Healthline.com for 4 years. Several Fitness Fixer articles documented the studies. When my column ended in 2010, the company kept some of the articles at first, but removed most of my photos and all the movies and reader comments with my replies. In 2016, I found that Healthline replaced my articles on healthy ways to reduce need for knee surgery with their own articles with advertisements for surgery and pain medications. I removed the links to Healthline from the articles, which had previously appeared below. I later found that some of my articles were still intact on the Blogspot archive. Click this link for Fitness Fixer articles grouped on the topic of surgery. Skip the links back to Healthine - NONE of the links to my old articles go to anything by me, only to their own articles. Let me know how the link is working: http://healthlinefitnessfixer.blogspot.com/search/label/surgery It hopefully still contains the following:
Surgery for Knee Arthritis, Meniscus, Unnecessary.
Anterior Cruciate Ligament (ACL) Surgery Unnecessary.
What Works Better Than Knee Surgery?
Surgery For Achilles Tendon May Not Improve Recovery.
Knee Tracking Surgery - Tracking Outcomes.
Knee Surgery - Arthroscopy Results No Better than Pretend Surgery.
Remember that there is a long history of embracing "cures" that sell, before all the evidence of benefit and harm are considered:
Medicine and allied medical fields (including "alternative medicine") have a history of prescribing things that may seem to "work" at first, but are not healthy. Practitioners are not usually scientists; they may only be repeating what they were told by their teachers repeating things that were not so, and by people who sell pills and surgeries.
How Long Does It Take To Stop Knee Pain?
Don't wait. Stop causes of pain starting right now.
If your pain comes from mal-positioning your knees, hips, ankles, and / or feet, you should feel the pain stop or lessen when you reposition to healthier ways. If you're not feeling better right away:
- If it hurts you ARE doing it wrong. Stop and assess. Check what you are doing compared to what is presented above. None of this is "exercises" to "do" but retraining drills to learn to stop doing what hurts and learn healthy movement instead.
- Are you over compensating? Are you pushing too hard the other way? Are you straining to "hold straight" which is just as painful, in many cases, as slouching into poor positioning.
- Are you fixing one segment and leaving others still in painful positions? That does not mean that these methods do not work, just that you have not identified and fixed all needed.
- Are you tightening or clenching muscles?
- Are you doing bad exercises that lean on or twist the knees? Many conventional "knee" exercises are not healthy. Several commonly done yoga poses twist cartilage and grind knee joints. My page on Healthier Yoga tells how many posses were never meant for health, which poses hurt the back, which the knees, what to do, and more. Make sure you can understand the simple basics of healthy movement before using any exercises.
- Are you going back to bad movement habits during the day? Check my free article on Bad Exercises, this one on bad stretches, and this one showing better health and understanding what abdominal muscles really do with The Ab Revolution. All show better movement that helps the whole body including knees.
Make sure there is not something else contributing to your pain
Exercises and good positioning will not stop pain caused by orthotics, medicines, shingles, surgical mistakes, growths, and things unrelated to movement habits and positioning.
Can this hurt? Not if done right. Pain means you must stop and check what you are doing wrong. If anyone, adult or child, has ongoing pain, check other causes. Make sure you don't lose time on fixes for things you don't have. Healthy movement is good for you in general, but don't lose time if infection or other non-movement issues are causes.
Some Lab Research on the Topic
Some of my work in this area is summarized in my Lower Body Revolution Class Syllabus.
For SMARTER PROGRESS Fixing Your Knee Pain and Keeping it Away
- All methods here are intended to decrease pain and improve function starting as soon as you begin using them.
- Each technique should make an obvious positive change right then. If it does not make sense or help, you may not be applying it as intended (you are doing it wrong). See "How Long Does It Take To Stop Knee Pain?" above.
- Do not do anything that makes more or new pain. Don't fix one pain and cause another (that's traditional medicine, not this method).
- Understand each thing presented and why it is done - before using it.
Putting It All Together
For healthy knees during all movement activities:
- Mechanical knee pain can stop, if you let it, by stopping injurious movement habits and using good body mechanics instead (good body mechanics, ergonomics, healthy movement, etc.). Studies show that components of knee cartilage increase in volume with exercise. Doing knee exercises alone won't make sure you use your knees in healthy ways. Bad mechanics can wear at knees and cause pain. Keep knee cartilage, joint, and soft tissue healthy with healthy movement habits. Don't grind your cartilage away with bad exercises and easily preventable bad habits, then wonder why your knees are "bone on bone."
- Watch other peoples gait and movement habits. It helps remind you to avoid unhealthy habits - knees swaying inward unsupported by muscles, feet and knees twisting in opposite directions with each step, stomping without shock absorption. People may move that way because it's easier than using muscular effort, but it is not healthy.
- Notice injurious knee positioning for "fitness and health" moves in fitness magazines.
- Notice your own habits.
- Please don't combine other people's injurious stretches and exercises, then come back to me and say my work isn't fixing that.
- Keep knees and feet facing forward when walking and running, not tilted, sagging, or rotated in or out. Keep the whole leg lined up; don't yank one segment straight, and twist or strain the rest.
- Stop all the bad exercises so common in gyms and yoga studios. Use healthier ones instead. Use this web site to learn how to tell for yourself what is healthy movement. My books tell more, especially Healthy Martial Arts (trains all athletics, and does not teach martial arts but teaches how to make training for body and brain healthier).
- Keep body weight distributed over the sole of your foot, not pressing inward and downward to flatten your arches. Don't overcompensate and roll entirely to the outside of the sole, causing new problems, then wonder why that isn't working either.
- When stepping up stairs or an incline, put your whole foot down, (not stepping on the ball of the foot with heel up). Press through the bottom of your heel and keep your knee back more over the heel than forward toward the front of the foot and toes. Then your thigh and hip muscles lift you, not your knee joint.
- When stepping down stairs, step down on the ball of the foot first (bottom of forefoot), bend your knee gently when making contact with each next step, and lightly on contact for shock absorption. Don't clomp down with a straight knee.
- When stepping down each stair or step, step down lightly keeping your weight supported on the leg on the upper (higher) step. Notice if you let your weight crash down unsupported with each step. Change to using your muscles instead. Better mechanics and better exercise.
- Walk, run, jump, and land lightly with shock absorption, instead of stomping. It's better for balance too. To walk and run lightly, maintain normal heel to toe roll. "Heel-strike" means the bottom of your heel and rear-foot, not striking hard on the very back of the heel. Stepping lightly doesn't mean staying only on your forefoot or ball of the foot.
- Check if you take medicines that cause pain. Many commonly prescribed medicines have joint and muscle pain as effects. Do not take this lightly, or assume you can take more drugs to suppress the new symptoms. This is unhealthy, and often leads to a cascade of unhealthy new side effects and expensive pills and medicalization. Multiple prescriptions are a large and serious health and economic situation. Stop the need for these medicines through healthier habits, rather than harming your health more through more medicines and their unhealthful effects.
- Check for other causes of pain - infection, acute Lyme disease, medical conditions, and so on.
- Don't "do knee exercises" 10 times then go back to harmful use and positioning habits that cause the pain. Fitness as a lifestyle means the healthy ways you move all day.
- Do send me photos and success stories showing the principles in action. Prizes for best ones and best Twitter Tweets of your successes.
- Please do not e-mail saying you are "doing the exercises 10 times" and want me to tell you how to fix your knee pain when you bend, and from bad walking and running. Here is the answer now: If you stop hurting your knees with bad bending and bad movement and standing habits, and bad exercises, then a major source of pain will stop. It is not the exercises that fix things, it's you.
Start feeling better right now and get your life back. Don't wait.
Nice Reader e-Mails
On Aug 19, 2011, at 7:27 AM, PETER L wrote:
"Dear Dr Bookspan, It has been some time since I have contacted you, but I want to thank you firstly for your compassion in that you responded. Secondly, I did purchase 3 of your books and have found them very helpful. My knee is not bothering me very often and the more consistently I use your better movement the less trouble I have. You were right that I did not need surgery. Also the degenerative disc disease i was diagnosed with causes me no problems at all as I practice your advice on good body mechanics. I seem to be able to do just about any physical activity I want.
I work at a desk and lately have been taking breaks and using your exercises during my day and have found that they reduce tension and increase energy and concentration. So, I just wanted to send you a note and say thank you for the help you have been."
On Feb 9, 2012 rob cohan wrote:
"Dear Dr. Bookspan, I am happy to report that after only glancingly reading your chapter on knees and not fully understanding what you intended to express, in less than 24 hours, knee pain which has dogged me for months seems to have vanished. Also gone is a significantly elevated stress level which seems to have come along for the ride. Thank you so much for the work you do and have done and the generosity you show by having put it on paper. Best regards and warmest thanks."
Fixing Knee Pain Story From a Reader
David Schonzeit first wrote describing his knee pain, asking for an appointment:
On June 8, 2016, at 5:29 PM, David Schonzeit wrote:
"Hello Dr. Bookspan, my name is David Schonzeit and I just stumbled upon your web site. I've suffered from patellofemoral chondromalacia for the past six years or so. I've been through four doctors, PT, acupuncture, hyaluronic acid injections (one round in one knee), and a patellar shaving or debridement surgery on my left knee. My issues are bilateral and my pain continued to worsen. I'm only 38 and in chronic pain. I was exited after reading your knee pain page. Please let me know if there is any way I could meet with you. I live in San Diego, but would fly in a heartbeat for some help. Your web site has me exited. I believe I need to change my mechanics, all other treatments have failed me. Please let me know and thank you for listening. In the mean time, I'll get started on my own. Dave."
I wrote back to him with specific questions and things to try. He replied:
"I looked in the mirror and my knees do seem to sag a bit, and I also seem to walk "duck footed." My cartilage defects are on the medial parts of my patellas. Correlates exactly with what you are saying. I am about to make dinner and I'll keep those feet straight and not allow my knees to sag."
Mr. Schonzeit wrote again the next day:
"I have been walking with my feet facing forward rather than turned out, and kneecaps forward, no longer inward. Seems to be making a difference positively. My knees have felt better since yesterday when I started doing this. Today I went fly fishing on my kick boat. I navigate my kick boat with diving fins, which is how I move around. Normally after a day of doing this, my knees are very inflamed from the constant flexion and extension of my leg. After reading your knee article and applying what you said, my knees feel almost normal (less inflammation). Throughout the day, I made sure to keep my knees in line with my forward facing feet while kicking and sitting. For the past twenty four hours, I've been walking, bending, and posturing my feet and knees based on your article. So, to answer your question, yes it is alleviating the pain."
He asked for exercises. I replied reminding that good bending for all you do is good exercise and stops ongoing knee damage that bad bending accumulates. He wrote back shortly after:
"Yes, the bending. After reading about it on your page, I realize I've been doing it wrong for years. Even just getting up from a chair. I feel more powerful when I keep knees aligned with feet and weight on heels. Awesome."
A few hours later he wrote:
"Wow, I also feel less grinding under my patellas when my weight is kept back on my heels."
I wrote back to describe how to keep the knees further back toward the ankles during bending so that there would be NO grinding. Soon after the same day he wrote:
"So amazing, I feel empowered! I wish I could have stumbled onto your page years ago, my kneecaps would be in much better shape. Better late than never. I've been going downhill for so many years, it's exiting to move the other direction. Thank you for your time, care and concern. This is very exiting for me. It's awkward for me to bend this way, but feels much stronger and better. AMAZING, I've been continuing to grind my knees through improper bending! Not because of any reason the 4 orthos gave me (tilted patellas, muscle imbalances, genetic predisposition, my having some extra pounds). Super groundbreaking stuff!!"
Then another mail that day:
"Yes, wow, that is the first time in years I've bent my knees, body weight loaded, and felt little to no grinding. Just like you said, the farther I rest back on heels, the stronger I feel and I virtually eliminate the abrasion. I'm going fly fishing in Jackson WY next month. I'll send a photo hiking, fly rod in hand. I'm better off because you and your web site were realized. You help people in invaluable ways and we are all so grateful. Dave."
He had no legs that practised not his gait;
LADY PERCY. In William Shakespeare's KING HENRY IV, PART II
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Fix Your Own Pain Without Drugs or Surgery
Neck pain, back pain, shoulder and hip pain, knee pain, ankle and foot injuries, wrist pain, and "when everything hurts," featuring actual patient stories in every chapter.
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