Best Way To Approach Hip and Knee Arthritis

[Geoffrey]

I would be most interested in any help and suggestions.

I am 38 years old, a former competitive middle-distance runner, planning on a general workout program as follows: running/swimming; yoga/gymnastics strength training; and, grappling (BJJ/Wrestling).

This will be a humble, well-rounded program, about 2 hours/day 6-7 days/week with an emphasis on the low-impact activities.

Unfortunately, I have injuries to take care of first. These are:

1. Mild OA in both hips, currently stabalized with PT exercises.

2. Chondramalacia + undiagnosed pain in left knee. Injured knee in wrestling drill in 2008 where a big guy landed on me, my leg went out to the side, and a loud pop ensued, but it seemed to heal on its own over a month or two. Pain on excessive weight bearing; aggravated by any cycling, bridging, and even kicking of swimming.

3. Right shoulder supraspinatis partial tendon tear and 7mm separation in AC joint and inflammed bursa. No idea how the injury ocurred, but must be related to a BJJ submission in which my arm was bent behind my back in 2009.

So basically, I'm walking wounded, and quite frankly, I have not had a day without some kind of chronic injury since 2007. Nothing major, just always enough to preclude actual training.

I do have a sports doctor helping me with the knee and shoulder.

But my big concern is how can I best reduce the chance of ongoing injuries as I start this new exercise program in the spring???

For instance, can the Overcome Neck and Back Pain program help me with knee and hip issues? I have no known problems with the rest of my body including neck and back, although mild scholiosis but this rarely presents as problematic.

Any and all suggestions appreciated.

Thanks so much for this great site and forum!

Geoffrey

[Kit_L]

Geoffrey, welcome to the forum.

You wrote:

This will be a humble, well-rounded program, about 2 hours/day 6-7 days/week with an emphasis on the low-impact activities.

In my view, there's nothing humble about a 6 to 7 day/week two-hours per day training program: speaking realistically, I have coached Olympic athletes on significantly lower volumes than that (I am speaking about rowers, here).

The context here is your request for advice in an open forum, so that others can benefit—so the first note I want to make is that diagnosing and offering treatment-specific suggestions is not possible to do by email or in a forum with any accuracy; by necessity, comments will have to be general.

My first comment back to you is that BJJ seems to have been the cause of both the shoulder separation and knee problems, through direct trauma. My advice to any athlete is to strongly recommend against training while in pain, unless those aspects of the training that caused two of the three problems are put aside until you have fully recovered, and until knee and and shoulder not only have returned to 'normal function', but have been bullet-proofed against likely future stresses of the kind that caused the injuries in the first place.

In rehabilitation, 'recovery' or successful treatment is defined as 'return to a pre-injury' state of fitness—this is simply inadequate, because it was this state of fitness that proved inadequate. To return to the demands of your normal daily life, you will need a specific high-level fitness that the evidence suggests you did not have.

Let's look at your specific questions:

1. Mild OA in both hips, currently stabalized with PT exercises

What is thought to be the cause of this osteo-arthritis? How has your hip instability been diagnosed? And precisely what exercises have stabilised your hips?

2. Chondramalacia + undiagnosed pain in left knee. Injured knee in wrestling drill in 2008 where a big guy landed on me, my leg went out to the side, and a loud pop ensued, but it seemed to heal on its own over a month or two. Pain on excessive weight bearing; aggravated by any cycling, bridging, and even kicking of swimming.

You mention "mild scoliosis": is this developmental (where the vertebrae are slightly wedge-shaped, thus fixing a curvature in the spine, or is it adaptive/functional (as in when one leg is physically shorter than the other, as in my own case, or does pronation in one foot contribute to the overall picture? One pronation ankle may have set the scene for that knee injury, and continued pronation might be preventing its healing.

3. Right shoulder supraspinatis partial tendon tear and 7mm separation in AC joint and inflammed bursa. No idea how the injury ocurred, but must be related to a BJJ submission in which my arm was bent behind my back in 2009.

A solid shoulder rehabilitation program can help this, but will not be able to achieve the necessary ligament tightening (which will slowly come with a decent strength program; more below) if other activities like BJJ are working to increase the separation.

The emphasis in your training needs to be rehabilitation (by this I mean ridding the body of pain), then whole-body strengthening (in your case multiple reasons, not the least of which is reducing the shoulder separation, realigning the shoulder girdle on the affected side, because this is the most common pre-disposing cause of supraspinatus tendon tears), and mobilisation, to relearn dysfunctional movement patterns, and to reduce the likelihood of more injuries and to teach you how to apply your strength with reduced risk of injury. There are very few coaches that recognise this approach, in my view.

The big-picture perspective is that you are engaged in these activities to be healthy and functional, I assume. In the state you are in now, my advice is to stop, take a long hard look at what you have been doing, and ask yourself how effective has this strategy been?

If the answer is, 'not so much', then a new trajectory needs to be sought. The material in Overcome neck & back pain will be an excellent starting place (if you will forgive a partisan point of view!).

The last point is addressed to other readers, especially rehab. providers. These questions and comments I have written back to Geoffrey are the minimum set required to even to begin to have real dialogue about his problems.

Happy to discuss.

[[DW]]

Welcome to the forum!

Firstly, I wouldn't call what you have in mind a general program, per se. You're aiming to do a lot of cool, but conflicting physical activities, IMHO. Also, it depends which activity is your main one - what do you want out of your training? You've being doing grappling since 2009; is this your prime activity? IF your primarily a grappler preparing for a comp, then I'd ditch the running and swimming entirely - as well as the gymnastics, and be very specific with what and how much yoga you are doing with those injuries.

Having done a similar schedule (and types of exercises concurrently) in the past I have to say that in my opinion you have very little to no chance of fixing or helping any of those injuries with the proposed work volume. A general program of specific strength training; flexibility and joint mobility (as Kit suggests) based on your own body and its issues would be what I would consider doing. This is probably not what you want to hear, however.

I have been doing just this on my own body for the last 12 months, as I also like grappling and other fun activities of this nature - but don't want to end up crippled by 40 or 50. So I am removing injuries first - then pre-conditioning myself for the activities. I found that being constantly, chronically in pain for years with multiple injuries (whilst only being in my mid-late 20's) was just not healthy; and that being able to move well and pain free when I am 60+ years old is actually, truly what I wanted.

Again, it depends if you are competitive in any of the activities you mentioned. If you really want to win a specific competition before you die and it means an incredible amount to your self-actualization, then I may suggest slightly differently (but would still recommend focusing on those injuries as primary). If you're just doing them for fun I would consider getting those injuries under control first via focusing on specific left/right and back/front imbalances., etc. - before doing any of the others.

Also, with that volume and that schedule (6-7 days, 2hrs) at 38, you'll be struggling to get the bodies restorative systems in a place where they can help you out with those type of injuries - even if you were being paid to just exercise, then rest all day; had 12 plus hrs of quality sleep a night and were taking some A-grade steroids. If you have to work for a living.. well, nothing is impossible but I'd not take that bet..

Not having a day without injury or pain since 2007 is a big sign your body is not entering into a restorative mode enough.. I hope this doesn't sound too condescending; I'm saying this because I myself did not listen to this advice when it was offered in the past; and mixed high intensity strength training; martial arts and conditioning (with no restorative work) to the point where I couldn't train for 6 months, and had to progress to 1 session 30 - 40 minute strength work and 1 stretching session for the next year after that. This was also in 2007, and I am only now getting to a state of being recovered and am still removing old injuries for 2007 and before.

It was actually a really great experience fucking myself up this badly (in hindsight..at the time it was very depressing for someone who loved, and was partially addicted to, exercise - ending up doing no physical exercise for 6 months..) - as I learned so much amount the importance of restorative methods; recovery; fixing my own injuries; health and training for functional longevity in the 5 or so years I took to get back together.. so if you ignore all of this advice and that happens, it still may be something beneficial in the long run. I was in my early 20's however..

I hope there is something of use to you in my post.

D

[Kit_L]

Thanks Dave; excellent advice as always. I should have added that as a 'mature age athlete' myself (middle distance, competing when around age 30) I have experienced most of what you are experiencing—my body was in pain most of the time, and many athletes' bodies are.

The most important question to ask yourself is, 'what do I want my training to do for me'? In my own case, I wanted grace and ease in the body, and to be able to do whatever I feel like doing, physically. Only now can I do this, some 30 years later! It's a long, but interesting, journey.

[Geoffrey]

Wow guys. Thanks for those informative replies. Here are my responses.

I'm definately on board with the suggestions around rest. Maybe I can explain myself better with a brief history. In July 2007 I had a right achiles heal strain during a hilly road race which took about 18-24 months to fully "heal." While "off" from running, I suffered a left groin (adductus magnus) strain in a kickboxing class February 2009, which subjectively healed 95%, but pain stubbornly remained and I quit martial arts around April 2010 (I still had not returned to running). I did nothing but yoga and exercise bike. In February 2011 finally it turned out that my lingering symptom was not the groin tear but left hip osteoarthritis revealed by it. Unfortunately, October-December 2010 in context of Graston Technique treatment (for the supposed groin strain, as referred by sports doctor) I sustained 3 tears to my left rectus femoris muscle. By this time, I had stopped all activities not treatment related. I finally found a PT with a plan in August 2011 and after a few months my left leg was much rehabilitated. But then, while doing nothing but rest and physiotherapy, OA symptoms began in my right hip, and inflammation pain re-emerged in my left knee (subject to wrestling drill injury 2008).

For over 2 years, I have done nothing but physiotherapy and, slowly, added in swimming and walking. I was able to run for a few minutes three times a week but stopped due to the weather. Hips and Quad have been "stabalized". Right shoulder came out last summer; left knee seems to have come back a couple months ago with swimming. Actually was doing one-legged side squat 5 reps and 10 minutes later pain started.

(I believe knee issue related to rectus femoris as well, which now has a lot of scar tissue. Rectus femoris gets sore with exercise. Extra lactic acid and soreness above left knee after leg extensions sometimes.)

So to return to the comments about getting fully recovered before returning to sports. I AGREE!

Kit, to answer your questions:

1. The only answer as to the cause of the OA in my hips came from orthopedic surgeon Koen de Smet from Belgium who told me the shape of my hip joint probably caused it, based on his view of my x-rays. He said I have a "coxa profunda" type of osteoarthritis. No family history of early OA. No hip trauma history. Sorry, I just don't have any more information than that. Original diagnoses was by CT scan Feb 2010 (was to rule out labral tear that was suspected at time).

PT Exercises are as follows. I do these 3-4 days a week, 20-30 reps each. Through experience, I have found this the optimum PT volume and am virtually pain free as a result.

A: lying leg raise (front).

B: lying leg raise (back).

C: Lying adductor exercise. Lie on back, theraband loop around leg above knee and around sofa leg. Knee bent, adduct groin, straighten knee, repeat.

D: Lying glute mede exercise. Lie on side, point top leg toe to ground, push heel towards ceiling while doing reps with the leg. Therband loop around both legs above knee.

E: Standing leg abduction with theraband loop around both legs above knee.

F: Bodyweight squats. Leg extenstions with 10lb weight, 100-120 degree extension only.

G: Once week, back hyperextensions, leg curls, calve raises. Hamstrings strong relative to quads, so do not yet workout more frequently.

H: Pelvic floor, leg raises, and crunches.

I: Leg balancing.

J: Some yoga, but limited due to shoulder injury.

K: Once-twice week, inside and outside of calves, seated foot adduction/abduction, with theraband loop.

2. Both my feet do indeed pronate, confirmed by Podiatrist assessments, and I use orthotics. Far as I can tell, the pronation is worse on the left, and there is the beginnings of a bunion on my left foot. Notably, a new pair of shoes last month radically reduced my hip pain! Do you feel it would be worthwhile spending a long time learning to strengthen the foot arch instead of using orthotics, in my case? I don't feel any more pain walking barefoot at home.

Scholiosis is self-diagnosis only, although confirmed by osteopath. Slightly S-shaped spine. Back when I lifted weights and did grappling, on very rare occassions I would get a "chink" feeling at the S-junction made worse when squating with a bar.

3. Very interesting what you mention about cause of supraspinatus tears. When it occurred last summer, I had just had a couple treatments by an osteopath, who was adressing the back which he felt was related to the hip. Afterwards, my right shoulder was dropped very low. Shortly after that the shoulder pain started. I guess the whole girdle was a bit out of place?

Because the supraspintus tendon tear was missed on all the scans, it did not respond to treatment. Sports doc's tech finallly found it a couple weeks ago, and now start the PRP injections. I have no idea who can provide the rehab once the tendon has healed though. Further to this, I just have no idea where to turn to find someone who can actually bullet-proof my joints and full body from this marathon of injuries. I want it to end, and frankly, and don't have full confidence it will without the best professional help.

Any suggestions on how to find the best person to help in person?

On your word, I will order and try Back and Neck pain as a way to start. Thanks!

4. Thanks Dave, for all your tips too. All this advice from Down Under! It's kind've interesting in that we both have similar stories since 2007.

I do hear from both of you that the training program outlined may be overly ambitious, given the injuries and perhaps, being 38.

By "generalist" program, I mean that I do not intend to compete at anything. I don't believe that my joints can handle serious training like that anymore. My goal is injury prevention while running and grappling to some degree for fun. The gymnastics stuff also a lot for fun.

A: Day One: Cardio: Running just 1-2 miles cross country after a swim. Water is necessary to warm up the hips. Need this for cardio also. Also to use a ski-erg on days family committments require me at home.

B: Day Two: Strength: PT exercises, gymanstics strength, and yoga. I feel this, if arranged properly, can reduce chance of injury not increase it.

C: Day Three: Grappling. This is high risk, even just 2 days a week, but if the strengthening is done properly, should be possible.

This is not literally "day one" etc. Some form of periodization might be best.

The cardio would not be more than an hour total actual exercise. The strength can take 3 hours, given just the PT exercises can take 45 minutes. Grappling just about 90 minutes, but must be preceded with water work and I find just 10 minutes of yoga helps improve recovery afterwards. Intensity on all fronts can be varied by listening to my body. Days off as needed as well.

I AM concerned about being healthy at 40, 50, 60, etc. By cycling training it should be possible to develop in several ways safely over time, no?

Appreciate hearing your stories. Hope some of this was useful.

Geoff

[[DW]]

With proper cycled training I would say it is possible to get some strength & yoga; cardio and grappling in each week. I hear you about doing the grappling for fun, too. It is fun!

I personally found I needed full days of pretty much complete rest during my recovery - often 3 or 4 in a row if I had other stressful things happening in my life. I really had to get over my fear that somehow I was going to waste away if I didn't train.. I actually ended up making great gains in strength during the period where I trained once, for 30 - 40 minutes each week (and it wasn't high intensity - just smart and strategic) - which got rid of this fear. The off days I'd do lying relaxation work (yoga nidra; autogenic training; etc) - which is actually a type of training, and should be viewed as such, IMO. It really helped with my sleep quality and quantity too (which obviously aids into the restoration & regeneration of the body).

I'd also do joint mobility; very slow limbering work (see thread on other page for discussion on mobility, limbering, stretching, etc); self soft-tissue release work (balls; rollers; etc) and walking. Nothing that noticeably raised my heart rate. Later on I increased the intensity of my walking (faster; up and down hills; longer), but never added running.

The proper use of strength training and stretching/yoga on my training days; coupled with mobility, walking and relaxation on my rest days was critical for me, and I think it might be for you too..

It would be really good if you could get someone to put together the whole thing for you; as opposed to seeing so many different people. You sound like you've got a really good knowledge of what is happening in your body. For me, a large part of the recovery process was self-education (50 - 60 non-fiction books a year since 2008; a lot of them quite dense) and then applying this study to pretty much put myself back together on a number of different levels. Like I said, it was actually a fantastic experience and I am truly grateful for having had it. It was not easy, however. I had some great help from Kit and other great practitioners.

I'll let Kit chime in on the other points. Which city are you in?

D

[Geoffrey]

Dave, I hear what you mean with regards to resting making us stronger. So important. Full days off, at least with maybe some light movements, are probably even more important as we age. Who wants to walk around like a beat up garbage can? You're quite right, taking full days off for recovery might be best. I think it's about listening to ones body. .

What is that "autogenic" training? Never heard of that. I use a program called trigger point therapy, an over-priced foam roller program that is really quite good for beginners in this area. Hard to find the motivation for it, though.

Joint mobility seems to me to do much the same thing as yoga and swimming although perhaps more thoroughly.

I wish it was possible to find someone to put it all together for me, but frankly my experience has been of clinicians helping about 25-50% of the time and causing harm 25% of the time. Sometimes they are quite convinced of themselves while being dead-wrong, as it turns out. My sports doctor is very capable but even he has a tendency to trust scans which sometimes prove wrong or incomplete and it takes 3 months between appointments. Unfortunately, the only one I can truly trust to manage my health is me, while gleaning from the best experts I have the good fortune of hearing from.

Are you planning on competing these days? What are your overall goals now?

As I consider Kit's post again, I have to align myself with that goal of " I wanted grace and ease in the body, and to be able to do whatever I feel like doing, physically." When you look at Kit's on video, it's evident he has an exceptionally balanced and healthy body. Being healthy and able to approach a variety of activities safely is my goal.

I live in Toronto, by the way.

[[DW]]

It most definitely is about listening to the body. Also, the more you practice listening the more interesting things you hear..

Autogenic training (http://en.wikipedia....ogenic_training) is basically what I call the lying progressive muscle relaxation work I do that isn't specifically a yoga nidra practice. Sometimes I'll incorporate tensing and releasing different patterns and combinations of muscles during it. Kit's ONBP book has a great chapter on this (the final chapter that many people gloss over!). The Relaxation Response by Benson has a good general intro to this type of stuff.

The self-massaging with rollers and balls (we call it RollStretch) does take a fair degree of motivation - but if you practice properly it becomes extremely effective (or it did in my body) and is cheap (I prefer single ball over roller, so I mainly use a weighted tennis ball that cost me $2). The best benefits come when you go much slower, longer and with more awareness than most videos on the net show, I've found.. I would spend 20 minutes traveling 8 inches up one side of my back - working all types of angles and using different breathing techniques to augment the release. I also like to do it in the dark, to cut out visual stimulus so I can focus on the kinesthesia more.

One of the most useful parts of this is cultivating the willpower to motivate oneself to do what could be very boring, if you let your mind make it so. I find it really fascinating and fun to explore the bodymind in this way - and I get the added bonus of feeling fantastic afterwards, and getting a lot of time in the rejuvenating parasympathetic nervous system state (besides the specific therapeutics of the tension; trigger point and soft tissue adhesion release).

Whilst yoga and swimming do keep you mobile generally, what I meant was systematically running through a whole host of joint mobility exercises to find out where your own personal restrictions of motion are - then working on those. Your body will find a way to do yoga and swimming that evades opening these specific restrictions (if not cued properly by the teacher/instructor) - everyone's does until they become aware of their movement patterns more deeply (and then still when they are tired/sick/not paying attention/etc.). It also depends a fair bit on what style of yoga you do, and more importantly who is teaching it. A lot of the people lurking around on this forum know far more about yoga than I, so they can answer any specifics in that regard.

This might sound odd, but for people of a certain capacity and intelligence the way out of a chronically injured (or ill health) state is very often self-education and re-assuming responsibility for their own health (IMHO). So, as you said; 'the only one I can truly trust to manage my health is me' - but I would remove the 'unfortunate' prefix. If anything, I would say this is very fortunate. Look at all the research you've already done, too!

It does help a lot if you have supportive people around; sorry, I don't know anybody in Toronto (maybe Kit or another board member will).

No goal or desire to compete. Even with myself. I do physical activities that I find fun and enjoyable, and love to explore all different types of things related to movement and health. My goals.. well long-term, for the bodymind, things like full mobility in every joint that allows movement; to be able to sense all my organs and viscera clearly; a complete Bodymap (sensory & motor homunculi); 15 inch forearms; radiant health; to embody Joy - you know, things like that. ..shorter term I want to increase my horizontal broad jump from 8ft to 9ft, and get over 20 reps in dead-hang full range chin-ups by the end of the year. I've also got a couple of imbalances in my legs I'm working on, too.

Thank you for starting this thread, btw. It's great to get people from around the world posting here!

D

[Geoffrey]

Thanks for answering my questions...

To be honest, I'm not really into a lot of the "soft" side of training, yoga, joint mobility, foam rolling etc. For me, if it's necessary to prevent injury, I'll do it and have done it.. But it's just not a goal in and of itself. I can do the trigger point roller and it does feel good doing it, but as you say, it can feel better to spend a long time on a single area. Just doing a basic overview of the body takes an hour!. One could probably spend all day on it and and still miss something! I found roller program also was not necessarily helping my problems, although not doing any harm either, as far as I could tell.

This isn't to suggest that it's not "deep water" with lots to it..I respect it a great deal...but for me, it's ultimately about how it will help my knee..

It is possible that some of my knee pain is referred from the hip and that some form of mobility, strength, and targeted stretching could deal with this. I don't believe this is the core issue, though, because the hips are visibly very flexible in all directions as are the knees. Doing yoga with DVDs helps me feel more balanced, but, it doesn't ameliorate the knee much. Yoga instructors in my area, whom I called last year, didn't have much of a game plan for injury, but I am looking forward to going when I'm better.

I honestly think the issue is that there is damage inside the knee joint itself, chondramaclacia and something else not properly diagnosed. A tendon that is weak, tight, or pulling. Most likely a syndrome of little things internal. The rectus femoris might have changed since the tears, despite having healed, no longer provided knee stability in tiny ways. Doubtful that surgery can help, apparently, but at least understanding it better would help and maybe allow me to squat again, bike again, swim without issues. MRI, ultrasound, haven't shown much new. Am considering an arthrogram MRI which might show more detail. I'm still not willing to give up on troubleshooting this. I'd be happy to provide details of the initial injury and symptoms.

Well, it is fortunate that some of us have the capacity to take charge of our injuries and illnesses. But I have to say that the conduct of many in healthcare is not fortunate. Far too many tend to provide enthusiastic and hopeful assessments but quickly drop off into ambivalence and vagueness once their cookie cutter solutions don't work out. Meanwhile, pts loose valuable time, money, and even their long-term health. I've witnessed and experienced this multiple times. Patients need to advocate publicly for change. We need clinicians who are A) sincere and honest about their mistakes and limitations--B-- motivated to innovate and C) truly collaborative with their clients, recognizing that both are "experts" within certain realms of the problem. Let's not let them off the hook. Professionals are accountable for their side of the bargain. Dave, if you've had the misfortune of injury and needed expert help, then you know just how valuable a truly innovative and up front clinician is. Because they are fairly rare, they are in very high demand and don't have a lot of time. So the solution has to be a more systemic change, probably within the training schools, insurance companies, and publicly funded institutuions. Good luck.

Totally not disagreeing with you, by the way, that there are not positives in becoming educated. Absolutely. Learning how the body functions and finding new ways to work with it are a silver lining indeed. I've found that too. I've also learned the value of tapping sooner! My side of the bargain.

Interesting goals. Seems like you are coming at it from a very internal-focus, or an Eastern approach? For lack of better terms. Ultimately, isn't that what we all want, to experience positive states? I appreciate your goals, and the depth of thought that preceded them.

[[DW]]

I think I may in a very small minority who actually likes doing the foam roller and ball work.. It's definitely not a panacea, either - and won't help much if the issue is inside the knee joint as you mention (and it should be able finding the things that work for the knee, as you say). I hear you re: system change, too. I used to hate all the soft style training (especially stretching!) back in the day.

I should also say I used a lot of strength training work in my rehab from various injuries, too (not just soft stuff, though you wouldn't know from the posts above!); which was crucial to my recovery. I still have a lot of strength training goals, but have added in the more internal-focused stuff, as before it was purely hard training style goals. I like the combination of soft and hard training methods in balance, I guess.

[Geoffrey]

So, what were your injuries? If you're in your 20s, it must especially suck to have these issues.

This morning because of sleep positions I walk out of the parking lot after dropping my son of at school and that right hip just starts biting. Not enough to cause any real discomfort, but just enough to remind me I'm not a strong and healthy like I used to be. It sucks. I can cope with it. But it sucks.u

Interestingly, standing on the other leg and putting the right knee at 90 degrees while doing windshield wipers fixes the pain after just 15 reps.

But isn't that reflective of injuries, even chronic injuries? The key to relief can be the smallest intervention.

I had but pain almost every day for a year that turned out to be a tight glute that, once stretched just a couple times in the right way, vanished permanently. Same thing for a left rectus femoris pain, standing lunge stretch with arms overhead from yoga did that one.

[Geoffrey]

Kit's YouTube One-legged squat video is interesting.

When there is a problem with the knee, as in my case, it is so important to strengthen the legs. With a problem in the hip, this becomes important again. But that isn't always easy when there's an injury or problem.

Personally, if I do leg press or squats in the gym, I start to get this pain coming up from the bottom of the hip joint towards the femur. I don't believe this is the chondramalacia . No idea why MRI does not show meniscus damage or joint space narrowing. I can only assume it is OA, however.

One-legged squats are an excellent exercise, and Kit posts this one.

Does anyone know if someone should do this exercise with knee arthritis? I can only assume the best modification is to not go too deep into the squat...

[Kit_L]

Hey Geoffrey,

I have to teach this morning so need to be leaving here very shortly and so I can only make a brief reply now. The article I wrote was for a magazine called The Retiree, and hence we were expecting an audience of 60 years of age or older. The exercises that I focused on were more concerned with balance than with strength; accordingly we only use a modest depth in the single leg squat exercise.

However it is essential to understand that the first half of the squat (from the top position to the halfway mark) actually stresses the knee joint more than the bottom half, because that part of the movement is control almost primarily by quadriceps, and quadriceps decelerates the body weight via the patella. One of the most perniciousness myths in the fitness industry is that full squats are bad for the knees. Nothing could be further from the truth and the fact is among all track and field athletes, Olympic athletes have the lowest incidence of the problems and they only ever do full squats.

The secret is that to do a full squat effectively, you must have active and strong glutes. Most people's knee arthritis comes from a combination of two factors: quadriceps dominance coupled pronation. Accordingly I recommend strongly that you practice the Building the Gymnastic Body (BtGB) single leg squat protocol, making sure that you do not miss any of the preparatory elements. This protocol is the most in-depth one that I have seen so far. Notice to that these are bodyweight exercises and can be scaled infinitely. And the secret to the squat, without any doubt, is mastering the negative element to the full depth position, and this is a very low stress activity as far as the knee joint is concerned.

As an aside, a knee replacement surgeon friend of mine told me that he has never replaced a knee due to lateral condyle wear: it is always wear on the medial side and pronation is the main reason for that.

I have to go off and teach now so must leave you here with this thought: I believe that the single leg squat, taking account of balance and knee tracking (you simply cannot balance if the ankle is pronating) is simply the number one rehab exercise on the planet.

Edited March 21, 2013 by Kit_L

[Geoffrey]

Alright, the past 3 weeks, I've been practicing single leg squats for my left hip OA and left knee Chondramalacia and here is what I have to report:

1. I am only able to get to about 90 degrees, no deeper, and finish just 10-12 reps per leg safely before failure, using something for support.

2. Amazingly, the knee typically has no pain after this exercise, although sometimes for 10 minutes or so I might get some knee pain.

3. I tried doing negative deck squats but frankly do not have the flexibilty to land without falling over. I didn't even bother trying negative SLS's down to the floor. Question: What stretches help one to complete SLS negatives falling past 90 degrees? I find my lower back gets in the way.

4. Also woundering if it's safe for a knee with Chondramalacia to allow the knee to "go over" the toes during the second half of the SLS?

5. Positively, I have found this exercise to be absolutely outstanding for developing strength and balance in a very short time. I do only 2 sets per leg, twice a week, and after just 2 weeks found radical improvement experienced walking up hills, etc. I'm really excited to see what changes this exercise brings over time, following the BtGB protocol.

Related to the Chondramalacia, I have a couple other questions:

1. I was wondering what hip exercises or stretches, in addition to those already in my PT formula posted above, can help to protect the knee?

2. A couple weeks ago I started the calve-raise exercise Kit posted to address pronating. I find I can only manage 2-3 reps, and frankly, my calves are incredibly weak on the left side at the upper end of the raise, especially on the weak left side where I pronate most. In fact, I can only manage 2 reps on the second set! Is there any way to make the process complete faster than 2-3 years? Will the exercise work if one uses orthotic insoles, which are necessary to stop pronating in the meantime?

Related to my left rectus femoris scar tissue/old tears. Kit mentioned I should be careful stretching this. Well, in doing the heel to but stretch in "Overcoming Neck and Back Pain" I added the detail of curling the pevis foward to take out some of the curve in the lumbar spine and found the rectus femoris is far less flexible than I had thought. In fact, even with a very careful "light" stretch, the rectus was sore for the rest of the day. Keep in mind these tears occurred over two years ago!

1. My question is: should I avoid any project to increase the flexibility of this damaged muscle, or, should I seek to improve the muscles "health" and flexibility?

[Kit_L]

Geoffrey wrote:

. I am only able to get to about 90 degrees, no deeper, and finish just 10-12 reps per leg safely before failure, using something for support.

2. Amazingly, the knee typically has no pain after this exercise, although sometimes for 10 minutes or so I might get some knee pain.

3. I tried doing negative deck squats but frankly do not have the flexibilty to land without falling over. I didn't even bother trying negative SLS's down to the floor. Question: What stretches help one to complete SLS negatives falling past 90 degrees? I find my lower back gets in the way.

I hope this gives you deeper insight as to the root causes of the problems you have been having. Re. negative deck squats: they reveal two critical things here: one, your ankle flexibility is not sufficient (this is why you feel the effects in the lower back: if the ankles do not allow your mass to stay sufficiently forwards of your balance point, then you must flex strongly at the hips; we see this on a daily basis! To test this assertion, try squatting down with a 1" support under your heels: you will be abel to go deeper under control, as this support tips you forward of the balance point—illustrating the fundamental need for this ROM.

And there is zero problem in falling over backwards in the process of learning this movement: have a mat behind you, and simply fall in as controlled a way as possible, and roll back. Get up any way that feels comfortable. Working negatively like this will strengthen all the muscles involved and improve both your coordination and balance further.

4. Also woundering if it's safe for a knee with Chondramalacia to allow the knee to "go over" the toes during the second half of the SLS?

Did you not read the post immediately above? I wrote:

However it is essential to understand that the first half of the squat (from the top position to the halfway mark) actually stresses the knee joint more than the bottom half, because that part of the movement is control almost primarily by quadriceps, and quadriceps decelerates the body weight via the patella. One of the most perniciousness myths in the fitness industry is that full squats are bad for the knees. Nothing could be further from the truth and the fact is among all track and field athletes, Olympic athletes have the lowest incidence of knee problems and they only ever do full squats.

The biomechanical facts are it is simply not possible to squat down fully without the knees travelling forward of the toes if you want to keep your heels on the ground. When you can it will be instructive for you to visit an Olympic weightlifting gym: there you will see people who can all do full backs squats and in all cases their knees travel forwards of their toes, as noted above. And I note from a recent workshop run in Hong Kong that the vast majority of Asian people can squat down perfectly and the reason is that their ankles are flexible compared to Westerners.

5. Positively, I have found this exercise to be absolutely outstanding for developing strength and balance in a very short time. I do only 2 sets per leg, twice a week, and after just 2 weeks found radical improvement experienced walking up hills, etc. I'm really excited to see what changes this exercise brings over time, following the BtGB protocol.

The protocol we are discussing is mine, not BtGB's, just for the record.

1. I was wondering what hip exercises or stretches, in addition to those already in my PT formula posted above, can help to protect the knee?

Refer to the books: hip flexors and quadriceps, and soleus/ankles. Please search the Youtube channel if you do not have the books; solo and partner versions of exercises for these parts of the body will be found there.

2. A couple weeks ago I started the calve-raise exercise Kit posted to address pronating. I find I can only manage 2-3 reps, and frankly, my calves are incredibly weak on the left side at the upper end of the raise, especially on the weak left side where I pronate most. In fact, I can only manage 2 reps on the second set! Is there any way to make the process complete faster than 2-3 years? Will the exercise work if one uses orthotic insoles, which are necessary to stop pronating in the meantime?

You have been doing these exercises for two weeks, Geoffrey. And the fact that you are so weak in these exercises, especialy the anti-pronation one above, should tell you at least part of the reasons you have been having the problem that brought you here in the first place. Stick with it, please. The point is you have already seen improvement in this very brief period of time. No one can estimate how long it will take before you have overcome this problem completely. Once you have though, you will know for sure.

Related to my left rectus femoris scar tissue/old tears. Kit mentioned I should be careful stretching this. Well, in doing the heel to but stretch in "Overcoming Neck and Back Pain" I added the detail of curling the pevis foward to take out some of the curve in the lumbar spine and found the rectus femoris is far less flexible than I had thought. In fact, even with a very careful "light" stretch, the rectus was sore for the rest of the day. Keep in mind these tears occurred over two years ago!

This is hardly surprising—you have not stretched this area for at least two years and, realistically, probably for a long time before that too. Please continue and go gently.

1. My question is: should I avoid any project to increase the flexibility of this damaged muscle, or, should I seek to improve the muscles "health" and flexibility?

You very definitely do need to stretch muscle, but you have to be extremely mindful of the reaction of applying this new stress to it, and modify the intensity accordingly. Please re-read all the posts above, and make sure you understand what has been written; if anything is unclear, please ask for clarification.

[Geoffrey]

Hi Kit. Once again, thanks for all your help.

Okay, I'm not good with the technology so I'm just going to number some responses.

1. My ankles ARE inflexible, so you're right on there, but I'm not sure there is anything to be done about it. You see, I've long done calf and soleus stretches, but what happens is that it seems the bone of my foot and a bottom of my shin bone connect, disallowing much flexibility. I know this from the standing stretch where one pushes ones knee forward over a planted foot and one crouches down. Always seems that, in my case, the limiting factor is bone connection not really soleus or soft tissue. What to do?

2. Regarding knees over toes squating effects on knee Chondramalacia, I now get that the knees over the toes in the bottom half is not a problem, and I DID read all the posts above. However, it's clear from the comment that full squats are not bad for knees, and that many elite athletes do them all the time and have low incidents of Chondro, but this doesn't mean that full squats are not bad for people once they DO have chondramalacia. . . . it's not the bottom half of the squat that worries me, but that middle quarter of the movement where the knee cap is put under the most pressure. Are the long term benefits of doing the full squat protective of the cartilage for people who already have Chondro, in your opinion? Why would this be the case?

3. Thank you and yes I WILL continue with the anti-pronation calf raises, executing the technique as best I can. I'm concerned for my hip though so it would be good to get results as fast as I can. I will continue using orthotics though while outside in the meantime.

4. So if I should continue stretching the rectus femoris with the old "healed" tears, will this help prevent reinjury? What has reinjured it in the past, is any standing or balancing work. I can do squats without much problem, but, stepping up on a 8 inch block sideways or balancing on that leg for long periods has caused problems. It's as though the muscle is harmed when forced to balance the leg/body from a standing position...does this make any sense? Even doing the SLS with less than perfect balance upsets the rectus. Of course, be careful. Any idea what can be done about this vulnerability or what causes it?

I understand that any advice has to be general given no opportunity to examine me physically. Still, I'd be fascinated to hear your view.

[Kit_L]

Geoffrey wrote:

1. My ankles ARE inflexible, so you're right on there, but I'm not sure there is anything to be done about it. You see, I've long done calf and soleus stretches, but what happens is that it seems the bone of my foot and a bottom of my shin bone connect, disallowing much flexibility. I know this from the standing stretch where one pushes ones knee forward over a planted foot and one crouches down. Always seems that, in my case, the limiting factor is bone connection not really soleus or soft tissue. What to do?

"Nothing to be done about it?" That's simply not accurate. Persevere! The reason you feel compression at the front of the ankle is because that is where the stretching force in soleus is actually resolved. When soleus is loose enough, that compression sensation will disappear completely. At least half the beginners in a beginners class feel exactly the same sensation and there is no negative aspects to it—it's just part of the deal of getting looser.

it's not the bottom half of the squat that worries me, but that middle quarter of the movement where the knee cap is put under the most pressure.

I understand your concern—why not just try these suggestions and see what happens. You are not going to make the problem any worse by simply experimenting with these things and you may learn something very useful in the process. Worrying about what could happen will never change what actually does happen. Try carefully and see. Your worrying about what might happen is definitely part of the problem, and it's both understandable because of your injuries and also very common.

A second and tremendously important point is that you must build up your glute strength. This is best achieved firstly by stretching hip flexors and secondly by following the various glute activation exercises you will find on my channel and elsewhere. The reason is that if the glutes are inactive (which is very likely if the hip flexors are tight) there is much more force on the patella in any squatting movement. Once the glutes have been woken up and strengthened, they literally pull the upper leg down and behind the body and take all the strain of the knee. It is very likely in my experience that inactive glutes were a major contributor to the problems that you now have.

And now, addressing your point 4:

Geoffrey, this is all fascinating: please re-read your first post to see what Dave and I were commenting on. You wrote, immediately above:

4. So if I should continue stretching the rectus femoris with the old "healed" tears, will this help prevent reinjury? What has reinjured it in the past, is any standing or balancing work.

Is what you wrote here true? How could you even contemplate the two-hours-per-day hard training that you wrote about in your first post if balancing work is enough to re-injure rectus femoris? Can you see why we reacted the way we did? There seems to be a huge mismatch between what you can do, and what you think you want to do.

And to answer the question, yes, of course: stretch it as much as you can without reinjuring it and strengthen it, too. It is absolutely necessary, in my view, to go through the earliest and simplest rehabilitation exercises in either book and get your body functioning properly again, before you contemplate anything more strenuous. You have all the tools now, I believe, so check in from time to time and let us know how you are doing.

[Geoffrey]

Hi Kit,

Just a quick post. The rectus femoris may be a limiting factor but I think it is far too soon to conclude that my proposed training plan is unrealistic. Already after 6 SLS workouts over 3-4 weeks I have noticed a significant increase in overall leg stability which, combined with the leg curls I was doing before, has eliminated my knee pain with the exception of the chondramalcia, and, at least in the last couple of workouts, the SLS balancing has not caused any rectus femoris pain. I am certainly concerned the Rectus may never return to "normal", but, still think it quite possible that with the right total build-up safe functionality consistant with 6-7 days a week of impact-low impact workouts will be possible and safe. Understanding and build up is key to success.

I certainly understand why you and Dave reacted as you did. It tells me you "get it" with respect to the severity of these issues plus that I explained them properly. I don't take anything for granted. It's just that I am not going to give up on recovering these issues easily. Exercise is a way of life for me, after family and making a living.

Added to that, your ideas have really helped me, already, so all of this is meant as a rather somber and impassioned compliment. Today I again, for perhaps the 3rd time, stretched the rectus femoris by first curling the pelvis forward to straighten out the lumbar spine, then slowly pulling the heel to butt, and this time, no pain at all. I had found before that the knee can get sore from doing this. So I curl the pelvis first, then gradually bring the heel to butt, while keeping the knee pointed directly to the floor the whole time. The bad news is that I find it necessary to hollow the whole upper body and shoulders in the effort to pull the ankle. Probably wrong. Anyway, the early sensation is one of improvement.

I am going to try to assess leg length discrepancy, pelvic tilt, and this tight right hamstring and "tight" right hip joint (although ROM is v ery good). Slowly, I am working through the Overcoming Neck and Back pain and thank you I will check in from time to time. No rush here. We want long and healthy lives with improvement over the years.

Thanks for the comment with respect to the glutes firing and thereby protecting the knee during squatting movements. In my case, glutes have a fair buildup from theraband exercises for glute mede and hip muscles plus lying leg back kicks over the past year and a half. They certainly seem to be firing to me, walking, doing the SLS. However, may well not be optimized. It is imperative, for me, that that left knee in particular be protected during these SLS -- which pay such huge dividends overall and would be such a loss to give up -- so I'm going to take some steps to evaluate and increase activation.

A side note, my sports doctor, who is rather well known and has worked with Tiger Woods, Dara Torres, and many others, has advised me the following for the knee. Three injections of Synvisc over 3 consecutive Thursdays (about 15 days) followed by a period of cycling (inside, outside). I had thought that endurance training would be important to rehabing a serious Chondro situation and he says that usually after a period of sufficient biking the Synvisc is no longer needed because the tissues and tracking are sufficiently rebuilt by the biking. He has Chondro himself, quite advanced but stabalized for decades now, and apparently biking has worked for him also. So my fingres are crossed that I'll be able to return to cardiovascular workouts again, biking and swimming.

I understand that broader biomechanical aspects are at work including some relationship between the hip and knee problems and weak outside calve muscles and pronating. Maybe the curved spine is involved too. Frankly it's all way above my pay grade. But yes, I am starting to understand how these kintetic chain factors are impacting each other. Certainly pronating and anterior knee movements can cause me some Chondro pain and Vastus Medialis strength helps.

Hope some of this is useful to anyone out there with similar problems!

Geoff

[Geoffrey]

Hello,

It's been a while so I thought I'd give an update.

As previously mentioned, I had synvisc injections for the left knee chondramalacia scheduled for late April (18th April to May 2nd). This was 3 injections of 2 weeks. My sports doct suggested I use a bike at that time because he believed the chondramalacia was because of the Vasust Medialus not firing at the right time. He said no single leg squats for 6 weeks after the last injection. Not sure why.

Well, it has now been over 2 weeks since the last injection. I can go up to 20 or 30 minutes on the bike and a stationary bike and there is LESS inflammation the next day but still SOME. Before I had the injections, I had NO knee inflammation during regular dailty activities except if I biked or swam vigourously. Since the injections if I even swim for a couple of minutes I end up with inflammation in the knee. In short, since the injections, inflammation has decreased after biking, but I don't swim at all because it made the knee much worse for that activity. I can only assume the new and current presence of inflammation from daily activities (ie walking) is a result of the biking from the previous day. Not sure if all this is a temporary effect of the Synvisc anyway.

I don't really know if my doctor has put a lot of thought into any of this as he is always so busy. He's hard to reach for follow up.

I'm not sure if I should keep biking or stop altogether. Should I re-start SLS or not. Should I seek out yet another PT or a Muscle Activation Technique guy to help with targeted strengthening? I just don't know where to turn with this.

Reading posts above by Kit, I do wonder whether my glutes are activating appropriately during cycling and if perhaps a problem of that sort could be causing my knee pain/degeneration. But glutes can't be why there's a problem swimming.

Anyway, would appreciate any advice. Hopefully it's not just a fact that the cartilage is worn and nothing can stop that process or the inflammation. If that is the case, what does one do for exercise then?

[Kit_L]

Geoff, I can't really offer any more advice; sorry. One of the problems you are having is that you are getting too much advice, and some of it is conflicting.

Others may wish to offer their views.