PDFQ: Your book, “The Knee ”, has been a great help to me in the past ten years in managing the various difficulties I have had with my right knee. Those difficulties started in my early sixties. I was playing competitive tennis two/three times a week as well as running and swimming. On the advice of a consultant surgeon, I started a regime of remedial exercise which was helpful in reducing pain and maintaining reasonable mobility. This regime was greatly helped by your book but recently - I am now 75- I have had to seek medical advice because of recurring bouts of extreme pain and inflexibility.
The consultant said in his view that I was a candidate for knee replacement but if I felt I could manage with a combination of Ibuprofen and appropriate exercise - which I do already- I should avoid replacement as long as possible. Would it be possible for you to help me with a continuation programme?
Male, 75, UK
A: Thank you for your kind e-mail, and I'm very glad my "Knee" book has been useful to you.
Presumably your surgeon has identified osteoarthritis in your knee, as he is recommending knee replacement surgery. However, it sounds as though your symptoms are not constant, so it's important to identify the cause of your bouts of extreme pain and inflexibility, to give yourself a chance of improving the situation.
If your symptoms are specifically related to weightbearing activities like running, then of course you should cut down or eliminate that. With tennis, it's vital to have the right shoes for each surface you play on. Carpet surfaces and some synthetic hard courts require smooth soled shoes, as any grip at all can cause damaging jarring in the knee. If you play on surfaces which require non-marking shoes, you must use smooth soled shoes, although they’re surprisingly hard to find nowadays. Always choose sports shoes which are as flexible as possible, and avoid shoes which offer too much support, as they limit normal foot and ankle movement. If you need more cushioning, put in a shock-absorbing insole.
If the pain is not directly related to activities or sports, the most likely cause is food intolerance . It can also be linked to relative dehydration , so you should make sure you are drinking water (not in large quantities, but little and often) throughout the day. You should also ensure that your mineral balance is good, as a salt-free diet combined with adequate water-drinking can lead to a deficiency of sodium , which is potentially very damaging. If you are taking any medication for any reason, you should check the side-effects, as many medicines can affect your fluid balance, or affect the joints through the immune system.
Keeping the knee mobile and stable is a must. I would recommend using a muscle stimulator for the vastus medialis obliquus muscle, as this can make a huge difference to the stability of the knee, and the specific strength effect is difficult to achieve through exercises alone. The single most important exercise for mobility, is lying on your stomach and gently stretching the front-thigh . Incidentally, if bending your knee quickly two or three times as you lie on your stomach causes cramp in your hamstrings, it's a sign you are relatively dehydrated.
It's also important to try to strengthen and stretch the hip adductors and abductors, plus the calf muscles, to protect the knee.
I don’t recommend taking Ibuprofen or other NSAIDs, as they have known unwanted side-effects, and mask the pain, creating the risk that you might overdo things without being aware of the damage. It’s also the case that if you are suffering from food intolerance, the fact that most medicines work through the liver can make you more sensitive, rather than truly eliminating or reducing your symptoms.
I certainly think you're right to try to avoid the knee replacement surgery, as it is a big intervention, and not yet foolproof. If you do eventually have to have the operation, you need to make sure of your surgeon's track record of results (including incidence of complications such as infections and blood clots). If you were to have the operation on the NHS, you should try to ensure that the consultant will do the operation himself.
But I think the first priority is to assess the symptoms to try to identify cause and effect. It would be helpful is you keep a diary, which should include the episodes of pain and stiffness, activities, food and drink intake within the previous 1/2-day period, and any other symptoms, such as pain elsewhere or symptoms of illness such as sore throat, stomach upset and so on. To make it easier for a practitioner to analyse a problem, it’s always helpful to make a brief record of any previous injuries to this knee or elsewhere, and any significant illnesses. I presume you're right-handed and right-legged.
Q2: Thank you for your quick reply. I shall do as you suggest with the record.
I have had bouts of pain and severe stiffness for many years but they come and go. The pain location also changes. For some years I could not sit or drive a car or sit in the theatre for more than 30-40 minutes without extending the leg when the relief would be immediate. That doesn't happen now. Instead I get a shooting pain when walking or lifting a heavy object and pain across the kneecap. The pain persists if I straighten the leg or if I lie down in bed- sleeping is difficult when this happens. Yes it is the right leg- I also ruptured my achilles tendon in this leg about five years ago. It was a long recovery and a consequence of using the left leg all the time during recovery was the need for a left side hip replacement which I had three years ago. That has been successful.
Am I right in supposing that the knee is simply worn out, to put it in layman's language?
I am very familiar with the exercises described in your book and do them two or three times a week as required. I am not familiar with a muscle stimulator but would certainly give it a try if you could give me the details.
A2: Thank you for the further details. They give rise to a few further questions:
1. Was there ever a known injury to the right knee? The previous pain you describe sounds like kneecap pain syndrome (patellofemoral pain), but it seems that has passed.
2. How much plain water do you drink per day?
3. How often do you experience the right knee pain now? Is it every time you walk or lift an object?
4. What is your balance like when you stand on the right leg? On the left?
5. Can you stand on the right leg and go up and down on your toes keeping your leg absolutely straight? On the left leg?
6. If you stand on one leg and lift the other sideways, do you have equal strength and balance on either side?
7. Can you squat down, keeping on your toes: not at all, to quarter-squat, to half-squat, or to full-squat?
8. If you sit on the floor and stretch your legs out sideways, how far can you go? Are you limited on either side?
9. Can you do bent-knee sit-ups, without fixing your feet?
10. How far can you bend your knees (one at a time) when you lie on your stomach?
The pain you describe now sounds as though it might be a combination, with some referred pain from the hip or back. The kneecap is obviously stiff, so it would be good to sit with your leg relaxed now and then, and gently press the kneecap from side to side, especially towards the inner side. That is much easier to do in a warm bath, or after a warm shower.
Q3: Thanks for the questions-the answers are as follows.
1. No injury to knee-a torn calf muscle about 8 years ago- achilles tendon rupture 5 years ago.
2. 4 to 5 cups a day.
3. Irregular - a long walk or lifting heavy things can start it but sometimes there is no reason.
4. Balance on both legs is OK-easier with shoes on. I do Yoga twice week which helps.
5. Right leg lift is poor since the achilles tendon damage. Left leg OK.
6. Yes but I need to be close to a wall for balance.
7. Half squat.
8. About 30 degrees each leg.
9. Yes.
10. Left leg no restriction-right leg 90 degrees to the floor, no further because of severe pain and stiffness.
My current bout of pain has taken a new turn. During the day the pain is across the patellar and I limp. I can relieve it by sitting down with leg extended and supported. But at night when lying down I have a new pain which is located on the inside of the knee around the cartilage area. I can relieve it by getting up and walking around for a few minutes but it returns when lying down again.
I had an x-ray of the knee last October. Follows the report. "Compared to the film of August 2005 there has been severe degenerative change throughout all compartments. The osteophyte formation is most severe in the patellofemoral and medial aspect with subchondral sclerosis. There is decreased joint space in all compartments. No loose bodies identified."
I continue with the exercises and have done on and off ever since the first signs of stiffness and pain some 12 years ago. Over that period I have used supports to good effect and occasionally sticking plaster across the patella. I will also follow the advice you have given me to press the kneecap side to side.
A3: Thank you for the answers to the questions. It's excellent that you can do the bent-knee sit-up, that means your trunk stability must be very good, and it's also a sign of good body condition.
The yoga is obviously a good thing. However, wearing supports is not recommended if they are tubular and enclose the knee, as this restricts the circulation and has a profoundly weakening effect on the vastus medialis muscle.
It would be good if you could alter your water-drinking pattern, to try to drink a little from first thing in the morning at regular (eg half-hour) intervals, up to the early evening. Your intake does seem low, and this can have a very bad effect on your joints. For instance, the pain you have that is relieved by getting out of bed and moving around could be due to sluggish circulation, which is strongly influenced by poor fluid intake, in my experience.
Another thing which can cause that type of (arbitrary) pain is the food intolerance that I mentioned previously.
There's no doubt in my mind that electrical muscle stimulation for the vastus medialis obliquus muscle would be beneficial, now and in the future, especially if you did ever decide to have the knee replacement operation.
You would also do well to do a programme of specific exercises - but take care never do exercises which cause or increase undue pain.
A) Exercises to improve your balance:
1. Balance on each leg in turn, barefoot, trying to hold your balance for as long as possible; 2-3 times a day;
2. Standing on one leg, go up and down on your toes slowly 3-5 times. Do more sets on the right leg.
3. Stand on one leg, and lift the other sideways 3-5 times, with full control. Repeat about 5 times on each side. You probably need to use a chair-back to steady yourself at first, but try not to hold on.
B) Exercises to improve your knee mobility: try to do the patellar mobilizing (pressing the kneecap to each side with the knee straight and relaxed) before you do these:
1. Lie on your stomach and bend one knee; press it gently further back, using the other leg. Hold the bent position for a count of 3, then relax. (Do not force this movement at all, as the muscles won't hold the stretch if you do) Repeat 3-5 times, as often as possible each day, doing more reps for the right leg. If lying on your stomach cause knee pain, place a folded towel under your thigh to lift the knee clear.
2. Sitting on an upright chair, with your knees bent to a right angle: keep you heel on the floor and turn your foot inwards and outwards gently, 3-5 times, as often as possible. Mainly for the right leg, but also the left.
3. In the bath or in a swimming pool, gently bend and straighten your knee as much as possible, without forcing the movement.
C) Exercises to improve your hip range and strength:
1. Lie on one side and lift the uppermost leg vertically, keeping the knee locked straight. Repeat 10 times on each side.
2. If you can, do the side-raise exercise: lie on one side and rest on your elbow so that your shoulder is lifted off the floor/bed. Lift your hips up vertically to balance on your elbow and outer side of your foot, keeping your body and legs straight. Repeat 3 times each side.
3. Lying on your back, lift one leg and describe circles in the air, keeping your knee locked straight. Repeat three times on each leg.
4. Sitting on the floor, put the soles of your feet together and try to press your knees downwards gently with your forearms. You may well have done this exercise in yoga. Repeat 3 times.
The X-ray report sounds gloomy, but it's fairly common to find that a knee which looks terrible when filmed does not necessarily cause pain. If one can get enough movement, stability and blood flow going, an arthritic knee with even apparently severe degenerative changes can often be surprisingly painfree. As you say, your pain is a bit arbitrary, so I would not be surprised if you could make quite a difference to your symptoms if you work out a good rehabilitation programme.
Q4: Thank you so much for your help. It really has encouraged me to carry on with exercise. This latest bout of pain was quite severe and demoralising particularly when I laid down in bed at night. This was a new pain which I hadn’t experienced before - lying down usually brought relief but not this time. The pain was located on the inside of the knee and down the shin. However I have manipulated the patella as you described and carried out the other exercises with some distinct benefit.
You did ask about diet so I have kept a record over the past four days.
Breakfast is always the same-Two slices of multiseed toast with honey or jam. Choice of fruit/apple/orange/ pear/plum and peach. Coffee or tea.
Lunch-usually home-made soup/tomato/onion/vegetable.
Multiseed bread, sausage/ham/anchovy. Water. Also various salads/ham /anchovy/cheese.
Dinner- this week I have had stir fried lamb and vegetables with rice. Glass of red wine. The next night I had spinach and ricotta ravioli,followed by prunes and yoghourt. Glass of sparkling wine. Next night I had fish pie followed by gluten free fruit cake and yoghourt. The next evening I had fish and chips followed by a fruit yoghourt. and a glass of sparkling wine. Last night I had a salsa with organic hamburger and rye bread followed by prunes and creme fraiche.
As you suggested I have increased my water intake. As to salt I have never added salt to food on the plate but I do add pepper sometimes. I do drink two or three cups of tea during the day and a coffee in the morning. I also snack occasionally on wholemeal biscuits. I don't eat sweets except for dark chocolate occasionally. I eat out once or twice a week.
Once again many thanks for your help. I shall progress the stimulator and if I need help I'll contact you if I may. If my diet is unremarkable please don't go to the trouble of replying.
A4: Your diet sounds perfectly reasonable and healthy enough, provided you make sure you are drinking water regularly through the day.
However, food intolerance can happen as a reaction to perfectly healthy seeming foods. The idea of keeping a symptom diary is to note down your symptoms in the context of activities, foods and drinks. That way you can identify if pain is caused by a movement or possibly posture, or if it comes as a reaction following a meal. Things like tomatoes, tomato sauce, spices, flavourings, fizzy drinks and white wine are particularly likely to cause intolerance reactions, but they are very individual, and that's why you have to do detective work to see if that is what is happening.
The night pain you describe sounds as though it's circulatory, and therefore should be eased, as I said before, by increased water-drinking, stretching the leg muscles as recommended, and moving around. But food intolerance could also play a part in it. Another possibility might be referred pain from the hip or lower back, so it's important to keep the hips mobile, and to avoid putting too much strain on the lower back, either through heavy lifting or by sitting in awkward, curled or crooked postures.
Q5: Thank you so much for your e-mails earlier this year on managing my knee pain and flexibility. Now it’s six months on, I thought you would like to know that your exercises have been very effective. On the plus side I rarely get pain now unless I walk a long distance-five miles or more, or stand around too long, ie watching an event where you can't sit. On the minus side the knee is still swollen across its width. The swelling appears to be the bony area on the inside of the knee joint facing my left knee. It is not painful just hard. Do bones get bigger? Also the knee joint will not flex enough to let me squat on my haunches. Altogether a pretty good result so far. I have not obtained the stimulator yet because I seemed to be doing well without it. On a good day I can flex the vastus medialis with great ease and move the patella freely.
As to surgery I think not as you said. I do know people in my age group who have had part or complete replacement and most of them are relieved that the pain has gone but are not happy about their knee movement. Will knee replacement ever become as reliable as hip replacement.?
Once again, thanks for your kind and effective advice.
A5: I am delighted that you have made a difference to your knee pain through doing remedial exercises.
The "hard swelling" that you mention on the inner side of the knee is probably linked to the limitation of movement which prevents you from squatting fully. It is usually simply a distortion of the joint, rather than actual bone enlargement. You certainly need to concentrate especially on stretching the knee - very gently - by bending it in the stomach-lying position. Remember, if you force this movement, the muscles will not pay out properly, so you will not gain the desired increase in muscle length / flexibility.
Knee replacement surgery is improving all the time, but replacing the knee joint is technically more complicated than hip replacement. Whether it will ever be a completely routine operation, with the high success rate of hip replacement, is impossible to tell. From the rehabilitation point of view, the wise course is to do as much specific rehabilitation exercise work as possible, in the hope that surgery won’t be necessary. At the very least, if it turned out that surgery was unavoidable, recovery would be much easier and more complete because of the careful preparation.
There is still a very strong case for using a muscle stimulator for the vastus medialis obliquus, as I suggested previously. If you can find a practitioner to show you how to use it correctly, or if you can work it out from the instructions on my website, you would probably be surprised at the difference it can make.
Q6: I have now set the muscle stimulation machine up following your instructions and had my first session. One thing I am not clear about is the length of the session and how often should I do it. In the meantime the knee is doing fine thanks to you- I cannot bend it much further than 90 degrees but there is absolutely no pain whatsoever. Also I can do most of my Yoga movements apart from squatting.
A6: It's good to start with about 5 or 10 minutes of work with the muscle stimulator, and gradually build up. Do perhaps a couple of times a week at first, but if you're comfortable with it and have the time, you can build up to daily sessions, up to an hour at a time if that suits you. Once your are fully familiar with it, you can use the muscle stimulator while doing other things, such as watching television, reading or listening to music. It will take about three months at least for the stimulation and combined exercises to have an effect, so be patient. And do remember never to persist with any kind of exercise which causes or increases pain or adverse effects. In the final count, you must be guided by the practitioner treating you.
