Knee Pain - A Survival Guide

IMovement helps, if not solves, most musculoskeletal issues and the knee is no different with respect to this axiom. If we also consider that it sits between the ankle and the hip, a strong knee capable of moving throughout its full range of motion seems necessary for the health of both of those joints. A telltale sign that your knee is not able to move through its full range of motion is the presence of a painful condition called patellofemoral pain syndrome. This stubborn injury is responsible for almost 30 percent of all knee pain across all age groups. Treating this injury early and moving the knee purposefully throughout its full range of motion can save your summer sports season.

The knee is a hinge that bends one direction, then straightens. However, the knee is actually two joints. First, we have the interaction between the femur (the big bone of the thigh) and the tibia (the big bone of the lower leg). This part of the joint gets all of the attention as it houses the meniscus, the ACL, PCL and a host of other structural components. When there is a major “blow-out” of the knee, it is generally one or more of these structural components that is involved. However, most knee pain involves the other, less glamorous part of the knee. This is the interaction of the patella (knee cap) and the end of the femur. Every time we bend our knee, the patella slides down a bit. The more you bend your knee, the further it slides down the femur, eventually sliding down and partially around the end of the femur when the knee is fully bent. The patella slides up and down the femur in a groove. If it stays in that groove, everything is just fine. However, if it moves just a bit outside of the groove, the pain can become debilitating. Most knee pain that I see clinically is in the patellofemoral interaction.

When the patella begins to move outside of its groove, the surrounding tissue becomes inflamed, causing pain. This is called patellofemoral pain syndrome. While structurally it is not a dramatic injury, there can be a lot of pain associated with it, and consequently it can sideline you. The quadriceps muscle group at the front of the thigh ends in a tendon that envelopes the knee cap and inserts below the knee on the shin. Its role at this end is to control the bend of the knee, and as such, the position of the knee cap. Because of its tendon and function, the quadriceps is quite often, but not always, the culprit with dysfunctional movement of the patella. The quads are then the logical place to begin when treating and preventing this painful and stubborn condition.

If the quadriceps muscle group is tight or holding excessive tension, it will cause the patella to track a bit off center, out of its groove. If you are experiencing knee pain, begin by improving the mobility of this muscle group. Once you feel knee pain, stretching this muscle is often too painful and not an option. It can be more effective to begin with relieving the tension in the muscle by foam-rolling your quad. Begin by placing the foam roller on the ground. Lay on top of the foam roller, positioning it on the front of your thighs. Begin rolling up and down seeking out any areas that are particularly sensitive. Once you find a sensitive area, keep your weight centered over that area and repeatedly bend and straighten your knee for 10-20 seconds.

Then, move on to the next area. Once the sensitivity of the knee starts to subside, in 2-3 weeks generally, begin to stretch the quadriceps muscle group after you foam roll. Both the foam rolling and the stretching can and should be done on a daily basis thereafter. Should you also suffer from arthritis, torn meniscus, torn ACL, etc., foam-rolling will benefit these injuries as it improves the quality of movement of the knee.

Preventing patellofemoral pain involves strengthening the knee throughout its entire range of motion. While I never recommend just one exercise when strengthening around a joint, the lunge is a great place to start. However, the lunge should only be performed if you are pain-free, as it will exacerbate a patellofemoral joint that has yet to heal. Begin by standing with your feet together. Step backward a couple feet with your right foot, keeping most of your weight biased on your left foot. Now bend both knees dropping your right knee toward the ground and pushing your left knee forward beyond your toes. Yes, beyond your toes. Continue dropping your right knee until it is an inch or so from the ground, and driving your left knee as far forward as your ankle will allow it to go. When returning to a standing position, keep your weight biased on your left leg driving your force through the balls of your feet. Try this for 30 seconds, then switch legs. Accumulate a couple minutes per leg on a daily basis

A quick note about why you should let your knees go past your toes while lunging. If you lie on your back, bend your knee and pull it up to your chest, you have just expressed the full range of motion of this joint, and yes your knee is past your toes. There is no reason that you cannot express that same knee range of motion while standing. If it were dangerous or bad for your knees to move out past your toes, your body would not have that range of motion available to it. Furthermore, I would argue that to have a functional and healthy joint, you need to strengthen throughout the full range of the joint. If you perform this lunge and your knees are sore the next day, you need to give the joint more time to heal. While this was not an exhaustive examination of the cause of knee pain or causes of patellofemoral pain syndrome, the information above is a good start.


The Four Letter Word

Chronic low back pain prevalence increases linearly in the adult population from the age of 30 on. At any given time, 20% of the over 30 crowd has low back pain. Sciatica is one type of low back pain that can be very painful, debilitating and difficult to live with. This is a condition that involves an impingement (compression) of the sciatic nerve due to either a vertebral disc anomaly, a spinal column anomaly, a muscle spasm or a combination of all three. While the causes of sciatic pain can sound scary and daunting, they are generally just a symptom of chronic and bad spinal mechanics. Thus, the underlying cause of sciatic pain is movement dysfunction. Acute injuries like fractures, and chronic degeneration based on predisposition are obvious exceptions to this hypothesis. That withstanding, even injuries or conditions that have persisted too long and require surgery and/or medication, often underscore an a priori movement dysfunction. That being said, after the short-term goal of pain reduction has been set in motion, restoring proper movement spine become the focus of treating sciatica.

The sciatic nerve is the longest nerve in the human body and is formed from 5 individual nerve roots that emerge from the 4th lumbar vertebrae down to the 3rd sacral segment. The nerve roots emerge from the spinal column, combine to form the sciatic nerve and descend through the pelvis emerging posterior to the thigh and traveling all the way to the foot. As the sciatic nerve emerges from the spinal column and course throughout the pelvis and lower body, it can become impinged by a herniated disc and/or the accompanying inflammation. Either of these conditions can cause pain or paresthesias locally at the point of insult or downstream anywhere from the posterior hip, the calf or the foot. Certain muscles can indirectly cause sciatica as well. The psoas is a powerful hip flexor that originates at your lumbar spine(low back), passes through the pelvis and attaches to your femur (thigh). If the psoas gets too tight, and this happens quite frequently, it can begin to pull on the lumbar spine, altering spinal mechanics and ultimately irritating one of the nerve roots that feed into the sciatic nerve. Another muscle that can cause sciatic pain is the pirifomis. The piriformis is a deep hip stabilizer, whose path intersects with the sciatic nerve. In fact, a significant portion of the population has their piriformis bisected by the sciatic nerve. The piriformis, when tight and irritable, can impinge the sciatic nerve at the hip. 

The literature says that most back pain SYMPTOMS begin to move in a positive direction, with decreased pain and disability within a month. For 3 months after that acute pain, chronic pain generally persists, but becomes less frequent and intense. Then sometime around the 1 year mark, give or take a few months, patients report their back is all better. Unfortunately most people will have a reoccurrence within one year. Either chronic back pain is an immutable characteristic of being human or we are just treating the symptoms not the underlying problem of movement dysfunction. In fact, restoring proper spinal mechanics is both a treatment and a prevention of future occurrence of back pain. The following exercises are your starting point when experiencing sciatic pain.

Down Regulation

Try this exercise if you are in acute 10/10 pain. This position and the associated breathwork will calm your nervous system and help to relax your back musculature. Begin on your back, with your calves resting on something like a couch or a bench, knees bent to 90 degrees or so. Gently push into the surface of the couch with your calves such that you are able to flatten your low back against the ground. Hold this position throughout. Now take a slow nasal inhale for 6 seconds, then a slow nasal exhale for 6 seconds. Perform this exercise for at least 5 minutes or up to 20 minutes. If your hamstrings get tired, either rest a bit and return to the exercise or lessen the amount of downward force you are applying.

These next two exercises are stretches that address the most common points of muscular impingement of the sciatic nerve.

Couch Stretch

Begin on your right knee with your right foot propped up on your couch and your left foot on the ground in front of you. Now engage your abdominals and tuck your pelvis underneath you. Hold this position for 1 minute. Then drop both hand down onto the ground, inside of your left foot, and drop your pelvis towards the ground. Hold this position for another minute. Then switch leg position and repeat.

Seated Pigeon

Sit on couch or bench such that both knees are bent to 90 degrees. Cross the right leg over the left , resting your right ankle on the left knee. If you feel a stretch in the outer part of the right hip, hold this position for 1-3 minutes. You don’t feel the stretch yet, lean forward until you do and then hold for 1-3 minutes.

These next two exercises are motions that address either a flexion or extension movement dysfunction in the spine.

Sphynx Pose

Lay on you stomach and gently prop yourself up by placing your elbows directly under your shoulders. Push you shoulder down and slightly back away from your ears. Now begin to gently inhale (6 seconds) and exhale (6 seconds) through your nose, allowing you stomach to sink into the floor. Slowly allow your upper and low back to arch into extension. Hold the position for at least a minute. If you low back starts to get sore in this position slowly back out of it and try again.

Jefferson Curl

Stand with your feet, hip width apart. Begin by nodding your chin down to your chest. Continue bending forward one vertebrae at a time, allowing your arms to hang freely forward. Continue bending forward until you have reached down as far as you can comfortably go. Then reverse your motion and slowly stand up, stacking one vertebrae at a time until your are standing up straight.

A Pain in The Neck

Find the area of pain, then look above and below it to find the problem. This axiom is one of the guiding principals I use when restoring proper biomechanics and eliminating musculoskeletal pain. When treating neck pain, it is often quite easy to identify the painful structures and observe the dysfunctional movement. A sore neck presents with irritable musculature and obvious movement compensations in almost all cases. If I focus my treatments on releasing those irritable muscle and restoring healthy neck (cervical spine) movement I can make quick and noticeable improvements, but those benefits are often short-lived. However, when I look below the neck, at the ribs and thoracic spine, the underlying problem becomes painfully obvious. A stiff and immobile mid/upper back (thoracic spine) and ribs forces movement compensations at the neck, that ultimately lead to pain and dysfunction. 

It is hard to overstate the importance of rib cage and thoracic spine mobility when considering how to deal with your neck pain. A stiff thoracic spine will necessarily stress the cervical spinal structures in compensation for that loss in thoracic range of motion. Moreover, stiff and immobile ribs force us to alter our breathing patterns leading to overused and irritable neck musculature.

The most common thoracic spine dysfunction is excessive flexion. We slump forward when we sit, run, walk etc. I am a world class slumper myself. Truth be told there is nothing wrong with slumping so long as we maintain our ability to fully extend the thoracic spine and back out of that posture. When we do slump so much that we take on that position as our go to posture and we can’t effectively back out it, our neck suffers. Our brains always want us to maintain the ability to keep our eyes on the horizon. When we slump forward our gaze is down at the ground. To compensate we extend our cervical spine (neck) and hold it there. This posture upsets the length-tension relationship of our neck musculature eventually leading to pain and vertebral disc degradation. To add insult to dysfunction, our slumped posture limits our ability to rotate the thoracic spine. This loss of rotational range of motion has to be compensated for at the neck when turning your head to look laterally, further degrading the vertebral discs and upsetting the cervical musculature.

Daily foam rolling on the thoracic spine is effective at relieving neck pain. Rolling on a foam roller helps neck tension in two ways. One, the pressure from the foam roller releases our thoracic spine musculature. These muscle are often full of tension from supporting the head and shoulder girdle in a slumped position, limiting our cervical spine range of motion. Two, the foam roller gently pushes our thoracic spine out of excessive flexion, and into a functional slightly flexed to neutral posture, allowing us to relax our hyper-extended neck.

Foam Roll Thoracic Spine

To improve thoracic extension lay on the ground on with the foam roller underneath your upper back, positioned perpendicular to your spine. Cross your arms across your chest as if giving yourself a hug, and lift your hips off the ground. Now use your legs to roll your spine up and down on the foam roller. Spend 2-3 minutes with this. Now position the foam roller at your mid-back, lift your hips off the ground and engage your abdominals. Bend backwards conforming your spine to the shape of the foam roller, holding your lower ribs in place with your abdominals. Reposition the foam roller and inch or two lower on your spine and repeat. Spend another 2-3 minutes playing with this motion.

Deliberately rotating the thoracic spine relieves tension on the neck. Rotating the thoracic spine promotes rotation of the mid/upper back and expansion of the space in between our ribs (elongation and flexibility of intercostal muscles). If we can get more range of motion from the ribs and thoracic spine we require less excessive rotation of the neck.

Threading The Needle

To improve your thoracic rotation position yourself on the ground on your hands and knees. Lift your right hand off the ground and place on the back of your head. Now rotate to the right pointing your right elbow up towards the ceiling. Drive this rotational motion with the muscle of your core, do not reach with the shoulder. Hold the position briefly then rotate to the left, reaching your right hand as far as you can underneath your torso, such that your right shoulder is now pointing towards the ground. Again, drive this motion with your core. Repeat this motion for 1 minute per side.

A daily breathing practice helps prevent and eliminate neck pain by reducing our reliance on secondary respiratory muscles. Secondary respiratory muscle run from our cervical spine to our ribs. When we are exercising or really stressed out, we use these muscles to lift the ribs upward, providing more room for our lungs to inflate. This becomes a problem when our rib cage is tight and we overwork the secondary respiratory muscles even for our breathing at rest. Moreover, a daily breathing practice helps us learn how to use our breath to relax, even during stressful situations, thus reducing our reliance on our neck musculature.

Side-Lying Rib Expansion

To reduce your reliance on your secondary respiratory muscles, lay on your left side on the ground across 1-2 two pillows positioned underneath your ribs. Reach up with your right arm positioning it next to your ear. Take a deep nasal inhale for 5-6 seconds. As you inhale, reaching with your right arm and bend over the pillows. Feel the air stretching your right-sided rib cage. Then slowly nasal exhale for 5-6 seconds. Repeat for 1 minute on each side.

As I continue to write these monthly articles about my clinical observations, one on the conclusions I consistently arrive at is that the treatments for pain and dysfunction, anywhere on the body, are often the most beneficial preventive interventions that I recommend to patients. The three exercises I outlined above, while not a completely comprehensive approach to treating existing neck pain, will improve your spinal range of motion and help prevent neck pain.