Knee Pain - By: michael russell

We bend them, kneel on them, run and jump on them daily, yet few of us give them a second thought. Knees. They're one of the most complex and most injury prone joints in your body. Why? Blame the knee's design. Unlike the more stable hip joint, which is a ball in a deeply cushioned pocket, the knee joint is more exposed and more vulnerable. Essentially, the knee is a rounded bone that rests on a relatively flat one. The thighbone (femur) ends in two rounded knobs (condyles), which sit on the relatively flat shinbone (tibia). The kneecap is a small, rounded bone that sits in a groove between the thighbone and the knobby ends and gives strength to the joint. As the knee bends and straightens, the kneecap slides up and down in the groove. A tendon attaches the kneecap to the thigh muscles above, and a ligament connects it to the shinbone below. The kneecap acts like a pulley, increasing the power of the muscles attached to it.

The knee flexes and extends, but it has little lateral rotation, says board certified foot surgeon Elliot Michael, D. PM., director of the residency program for Podiatric Medicine at Holladay Park Hospital in Portland, Oregon. The upper and lower leg bones act like long levers on the joint, increasing power and force. A small change in the levers is magnified many times over in the knee, says Michael. This intricate design can cause problems, especially for the kneecap, which accounts for about 20 percent of all knee pain, say knee experts. Proper functioning of the knee and its kneecap doesn't depend on the alignment of the bones themselves, but on the alignment of the surrounding structures. Think about the kneecap as a puppet controlled by string muscles, tendons and ligaments. As long as all of the strings pull in just the right way, the kneecap moves back and forth smoothly in its track. But if any string pulls too strongly or not hard enough, the kneecap is pulled out of its track and can no longer glide easily against the thighbone, which can cause pain and may even damage the kneecap.

Because women have wider hips, the upper-leg bone of a woman enters the knee at a greater angle, which twists the knee. This makes women more vulnerable to certain types of kneecap injuries, such as chondromalacia, in which the smooth layer of cartilage that undercoats the thighbone becomes roughened or cracked, according to orthopedic surgeon Michael Baskin, M.D., an assistant clinical professor in the department of Orthopedics at Oregon Health Sciences University in Portland. If the large muscles in the thigh (quadriceps) are inflexible due to disuse or lack of stretching before exercise or if these muscles are overused, they can cause inflammation of the knee tendons (patellar tendinitis), sometimes called jumper's knee. Muscle imbalances, in which one group of muscles is stronger than another and pulls harder, can cause knee problems, too.

While knee problems can result from trauma due to falls, automobile accidents, and athletic injuries or from diseases like arthritis, the vast majority of knee problems are caused from over stressing the knee, according to Michael. When there isn't an acute injury, most knee pain comes from doing too much too soon or from putting the wrong type of force on the knee, he says. Often, people who start a running program develop knee problems early on. They don't realize they're subjecting their knees to four to five times their body weight with every running step. Physical therapist Ellen Nona Hoyven, PT., owner and director of Ortho Sport Physical Therapy Pc. in Clackamas, Oregon, says most of the knee problems she sees are caused by deconditioned muscles. People put a high demand on their knees and their muscles without the proper conditioning, she says. Or they overuse their knees by doing only one type of activity over and over like kneeling, running or climbing. Of course, you can't always prevent injuries from occurring, and any serious knee injury should be evaluated and treated by a physician. However, if your knee problems are caused from overuse, disuse, or improper training, you can use the following strategies to keep your knees healthy and if you do develop pain, to help ease the hurt and speed healing.

Stay Trim : Being over normal weight stresses all the joints of the body, but those extra pounds are particularly tough on the knees. Because of the way the knee is structured, every time you take a step, you're putting one and a half times your body weight on your knee, says Michael. If you run, you're putting up to five times your body weight on the knees. Twenty, thirty, forty or more pounds of extra weight can really stress the knees. For example, if you're only 20 pounds over weight and you jog, you're putting 100 pounds extra force on each knee with every step. If you're overweight, says Baskin, it can really add to knee pain. Being over weight means you're going to need greater muscle strength to prevent injuries. Keep your weight with in normal limits with a low fat diet and regular exercise.

Look at Your Feet : There's an old saying. When your knee hurts, look to your feet. Hoyven agrees. When the feet hit the ground, everything changes, she says. Think of the body much like a slinky. If one part of the skeleton is out of balance, it will throw off the other parts. When the feet are not supporting the body properly, it can cause problems all over the body, including the knees. A common cause of knee problems is overpronatlon or rolling inward of the foot. A certain amount of pronation is normal, but too much can cause knee problems. When the foot pronates, it rotates inward and flattens out, explains Michael. At the same time, it rotates the lower leg, which malaligns the knee. This malalignment can cause the kneecap to track abnormally and grind, causing pain. You can correct overpronation with supportive shoes designed to prevent pronation or with orthotics, which are special shoe inserts. You can buy ready made, over the counter orthotics or you can get custom made ones from a podiatrist. orthopedist, chiropractor or sports medicine specialist.

Buy The Right Shoes : The right shoe can prevent all kinds of knee problems, says Kathleen Galligan. D.C., who specializes in sports injuries in Lake Oswego, Oregon. Wear the lowest heel possible. Galligan says the' body can tolerate a heel of about one inch. Higher heels throw the body forward and stress the knees. If you tend to pronate, buy a shoe that has antipronation devices. You can buy athletic shoes that have higher density materials on the inside of the shoe sole and cushioning material on the outside edge of the sole, says Michael. The higher density material doesn't allow the shoe to give on the inside and helps prevent pronation. Michael says you should also look for shoes that have a stiff heel counter, the part of the shoe that cups the heel. A stiffer heel counter will stabilize the heel and help prevent overpronation, he says.

Then Replace Them : Often, knee problems are simply caused from running shoes that are worn out, says Louisa Silva, M.D., who sees plenty of knee problems in her private practice in Salem. Oregon. Even if the sole of your shoe looks fine. the structure of the shoe may be worn out, she says. Then the shoe isn't giving your foot the support it needs. Shoe experts estimate that running shoes are good for 400 to 600 miles walking shoes for 600 miles or more before they need to be replaced.

Check Your Alignment : If you're bowlegged or knock kneed, you may be at greater risk for knee problems, according to Baskin. To check your alignment, stand with your ankles touching. If you're in alignment, both your ankle bones and your knees should touch. If your knees touch. but there's a large space between your ankles, you're knock kneed. If your ankles touch, but there's space between your knees, you're bowlegged. If you're out of alignment, says Baskin, you may need to avoid certain activities, like running, that stress the knees. Substitute activities like swimming, biking or working out on a cross country ski machine.

Don't Rely on Over the Counter Braces : Often, you see people wearing knee braces or bandages they've purchased at the pharmacy. An over the counter knee brace may make you aware of the knee and remind you to avoid overtraining, but it doesn't really correct or prevent problems, says Michael Martindale, L.P.T., a physical therapist at the Sports Medicine Center at Portland Adventist Medical Center in Oregon who specializes in sports injuries. Know that over the counter braces don't take the place of exercises you should be doing to strengthen your knees, says Baskin. He says if you do use a knee brace, opt for the one piece neoprene or elastic braces rather than the elastic wraps, which make it difficult to apply pressure evenly to the knee. Michael warns against becoming dependent upon a knee brace. If you've got pain that is persistent enough to buy a knee brace, you need to see a doctor, he says.

Avoid Knee Busting Activities : Deep knee bends may feel healthful, but they're too hard on the knees. Knee bends put way too much pressure on the knees, says Michael. I tell people to take squats and deep knee bends out of their exercise routine and to avoid kneeling whenever possible, especially on hard surfaces. Silva says one of the most common causes of knee pain among her patients is weight training. People can literally wear out their knees by lifting too much weight and putting the knee through its full range of motion, she explains. There are tremendous forces on the knee in the fully flexed position. Silva's recommendations to weight lifters. Never fully, flex the knee, and keep the amount of weight you ask the knees to lift to a minimum. If you're gardening or doing some other activity that requires kneeling, Michael says to use foam kneeling pads and to give your knees frequent rest periods.

Don't Run Through Knee Pain : Many people, especially athletes, believe that it's best to run through knee pain. However, they may be doing more harm than good. Pain is an indicator that something is wrong, says Martindale. If you're having pain, you may have biomechanical problems like overpronation, or you may be overtraining, training incorrectly, or wearing the wrong footwear. Michael agrees. You don't have pain in your body if everything is right, he says. The body is sending you a signal if it's hurting. Don't keep going. Stop stressing the part that hurts. The body heals it self with rest.

Change Surfaces : Michael, who was a national collegiate running champion, says running on the wrong surface can cause knee problems. Roads are canted, or slanted from the center, Michael explains. Runners who run only on one side of the road often overstress the knees. He recommends running or walking on the flattest part of the road. Switch sides of the road frequently if it is safe to do so. Hard surfaces such as concrete or asphalt can increase the beating the knees take, too. Michael recommends running or walking on a soft surface, such as a forest pathway. Be careful of too soft sand, however, which can stress the knees. Running or walking downhill can cause knee problems as well. The natural tendency is to brake with the knees downhill, which can overstress them. Slow down and, whenever possible, traverse down hills. If you're already having knee problems, avoid training downhill.

Mix it up : Martindale says he's seen an increase in knee problems with activities like step aerobics. Anytime you overstress the knee with too much squatting or stepping, the knee is vulnerable, he says. Michael recommends cross-training, or doing a variety of physical activities rather than just one or two. Any repetitive routine strengthens specific muscles, he explains. Cross-training helps balance out the imbalances caused by training only particular muscle groups. It helps counteract the stress and strain caused from repetitive activities. He suggests combining running or walking with biking, swimming, dancing, aerobics, weight training or any other activity you might enjoy. He says if you choose biking as one of your crosstraining activities, be sure to raise the seat up so that the leg is almost fully extended on the downward stroke to prevent knee strain.

R.I.C.E. it : Ok despite all the good advice, you've overdone it and your knee hurts. Give it R.I.C.E. rest, ice, compression, and elevation. Take the weight off the knee. During the first 24 to 48 hours, use an ice pack (20 minutes on, 20 minutes oft) to keep the swelling down. Wrap the knee (not too tightly) in an elastic bandage to reduce swelling, and keep the knee elevated.

Take Anti Inflammatories : Aspirin or ibuprofen can reduce the pain, inflammation, and swelling, says Silva. Don't use anti-inflammatories, however, if you have an ulcer, a bleeding condition, or a sensitive stomach, warns Baskin. The only thing worse than a sore knee, he says, is a sore knee and a bleeding ulcer. Acetaminophen can help with the pain and may be easier on your stomach, but it won't do much for inflammation.

Avoid Heat : Ice prevents fluid buildup, but heat can promote it, says Michael. For the first 48 to 72 hours after a knee injury, avoid hot tubs or hot packs.

Massage It : While massage won't affect the bony structures of the knee, it does increase circulation and can loosen tight hamstrings or other structures around the knee, says Martindale. If you've already developed knee pain, says Michael, see a professional massage therapist or physical therapist, not just a friend, for a professional massage.

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