How to Treat Knee Pain: Causes, Myths and Management

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show is for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. So, we're going to cover knee pain today, and I'm going to cover this from a few different thought processes today and a few different problems because the hard thing first is to understand is that knee pain is, it encompasses a lot of different problems, a lot of different problems.

And I'll cover the four diagnostic categories today, just general categories that you guys should be aware of. If you're not aware of them, it's sometimes very hard to understand what to do with your knee and how to treat it. And manage it and manage it and do you need surgery and injections and so on. And understanding the basic category that it's in can help you understand a little bit more about what to do with it. So, in this one, we're going to cover what current research says about some types of knee pain, as well as some things that can and can't work and so on. Also, how knee pain happens.

The seven myths about knee pain that you may not be familiar with, and you may still be thinking that it's actually true. We're going to cover the four diagnostic categories, like I mentioned, and we're going to cover the five treatments or five stretches and exercises that actually do work. And that's going to be the YouTube link that I'm going to supply you guys with. It's in the description. And there's five simple prevention tools as well, prevention tips. Now, the first topic we're going to cover is knee osteoarthritis today and what some of the current research says about it. The first thing to realize about osteoarthritis of the knee is there are some preventable aspects to it, at least I believe.

And this paper that I'm going to show you guys, which is in the slideshow, if you haven't seen it already, is from 2015. And it mentions a few things that are generally related to having an onset of osteoarthritis of the knee. Osteoarthritis of the knee, number one, we should cover it, that it does not always hurt. It can hurt, but it doesn't always hurt. And it doesn't happen overnight. Like there's things that are happening over the course of years to months, even decades, they are creating osteoarthritis of the knee and changing the severity of it, maybe in your case. And so osteoarthritis of the knee is, they say this is the leading cause of pain and disability, and it leads to a reduction of quality of life.

Like you can't do certain things that you want to do, it hurts, and then you feel physically disabled or you're clinically disabled. Like you're not able to work or do certain things and so on. This was taken from a meta-analysis and systematic review. And so they included 46 papers, but they screened out over 6,000 papers, but they only included 46. And they found that knee pain, onset of knee pain, was related to being overweight or obese. By the way, it's important to note that there's different categories of being overweight or obese. It's the clinical category for BMI. So it's related to both.

Also, another risk factor is being female. Who'd have thought, right? The other risk factor is previous knee injury. They thought that actually hand osteoarthritis was going to be related as well, but it was found to not, and actually smoking was not either. They found that new onset of knee pain was 5% related to previous injury. 25% roughly was related to being overweight or obese. So in this paper, they were talking about how can we help manage people with knee osteoarthritis if we know some of the risk factors. And so this is saying clinicians can use the identified risk factors to identify and manage patients at risk of developing an increase in knee pain.

Obesity, I think this is one of the easiest takeaways today if you are catching on already. Obesity and being overweight puts more load on your knees. And so it's going to be related to knee pain. All right, if you have knee pain and you're overweight, one of the easiest things that you can do is attempt to lose weight. Okay, there's losing weight is obviously it's not going to be something we're going to focus on really diligently in this podcast. But generally speaking, it's a nutritional problem. It's an eating issue. Normally, people lose weight because they are eating better versus exercising more.

And the reason I'm bringing this up is because a lot of people with knee pain, because it's painful, but knee osteoarthritis is painful. It creates disability and so on. How do you exercise to lose weight if you have knee pain? It's very hard. It's just vicious cycle. And so managing the intake of food is one of the most appropriate things you can probably do in this case. Now, the next paper we're going to cover is can exercise help with knee pain with osteoarthritis? As we mentioned before, it would be nice to say we can just simply eat better and exercise. But it's very challenging sometimes to actually incorporate exercise when you have knee or joint pain.

This is a paper from 2021. In this type of research, they pulled a bunch of different types of research and they interpreted it to figure out what are the most common themes surrounding exercise and osteoarthritis. And so they found that 44 of the trials indicated that exercise significantly reduced pain and improved physical function to a moderate degree immediately after treatment. Well, evidence from 13 studies revealed that exercise significantly improved quality of life immediately after treatment with small effect. In addition, 12 studies provided two months to six months post-treatment sustainability data, which showed significantly reduced knee pain.

And 10 studies showed improved physical function. Now, the conclusion was that amongst people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment. Isn't that amazing? Exercise can make you feel better and make you function better for two to six months after you stopped. And I think here's the interesting part in this paper was that they said that there was a moderate degree of pain reduction and improved physical function immediately after treatment. Immediately, meaning the same session.

Exercise when programmed well and coached well can really help. The next one is about osteoarthritis after a knee injury. As I mentioned before, in the prior paper, the first one that we discussed a little bit was that a past knee injury can oftentimes create things like osteoarthritis. And so in this one, it said the odds of developing knee osteoarthritis following an ACL injury are approximately four times higher compared to non-injured knee. A meniscal injury and a combined injury affecting both the ACL and meniscus are associated with six times higher odds when compared to a non-injured knee.

So as a takeaway, when you have a knee injury, there is a higher probability, generally speaking, that you will have osteoarthritis of the knee. But the good news is, is as you go back one paper, you can see that exercise can help you with function, it can help you with pain, and it can help you with disability. So I think we need to relate a few things together here is that osteoarthritis, again, does not always hurt and does not always disable. But it can hurt and it can disable and it can limit how much enjoyment you get in your life and so on. And so usually management of it, I think immediately after the injury and realizing that rehabilitation and exercise, a good formal exercise program, being physically active and having good hygiene skills about your knees can really, really help with, I believe, decreasing the onset of osteoarthritis.

Because there's something that happens after the knee injury that creates the osteoarthritis. Now, the last one I'll cover with research is patellar tendinopathy. This is one that a lot of you are going to be told that you have. Whether you've had an ACL or meniscus, then at some point you may be told you have a patellar tendinopathy. And it's not wrong, it's not wrong, but a lot of people who have this will just take months and months off or they treat the area where the tendinopathy is located within the tendon, like the degenerative zone. And so what this tends to do is it creates months and months and months of deloading, okay?

There's a time and place for deloading and taking some rest, but as this paper shows in 2015, this says that the cornerstone and patellar tendon management and rehabilitation remains highly specific. And it includes progressive loading of the lower extremity, kinetic chain, muscle tendon unit, and the tendon itself. And so you can take some time off, but if you are taking excessive time off by probably, I'm going to say excessive by two to three weeks, you are missing some very easy ones you can do. And we need to make sure that we do load patellar tendinopathies and tendinopathies in general as soon as humanly possible.

Now, the mechanism of injury with general knee stuff is obviously there's trauma, but most of them are non-traumatic. A lot of them, even ACLs and meniscus with things like soccer, change of direction and jumping and landing and so on, a lot of them are non-traumatic injuries. But some of you will have traumatic injuries, and that's not anything that you really could have prevented that I can think of. It's just someone slid tackled you, or you hit your knee on something, or you fell, or I know that my dog just bashed me in the side of the knee, and that's just what she did. Most of them are non-traumatic, all right?

And most of them, they include repetitive stress on the knee structures, which creates the knee pain. A lot of times, the dysfunction happens from above or below the region, i.e. the hip or the ankle-foot region are not working well, which will subject the knee to repetitive stress in whatever structure ends up being your symptom generator. And so, the meniscus can be a little irritated with rotational forces when that could be absorbed in the ankle-foot region or can be absorbed in the hip. Now, I should probably back up a second, because I know a lot of you with knee problems have probably said, well, I've done hip mobility and it didn't help.

Right, but if your hips are generally mobile and they're working well, you don't need more. And so, you need to figure out the area which is the outlier. And some people tend to only work in one region because that's what they've told is going to be helpful, but really, maybe the foot and ankle is a better starting point. I tend to find that the hip is the easiest starting point for most people, or you find an area between two areas where they have problems. Let's just say if you have knee pain and back pain, I'd say the hip is probably a really good starting point. Now, let's say you have foot or ankle pain and knee pain, then I think we probably start at the ankle, possibly.

Or you've had a past ankle injury, ankle turns, fractures in the ankle, maybe the ankle's a better starting point. If you had a past hip dislocation or a AI or past injuries in the hip, whether they be traumatic or not, maybe the hip's a good starting point. So, you kind of take like an overall view, like don't go too microscopic in the beginning when you're starting with a mechanism of injury and how to reverse engineer the process of a knee problem. Now, past injuries do tend to come back. As I mentioned before with the research, injuries will come back. And this happens with every single area of the body.

The only way to predict future problem is identifying that you've had a past problem. And again, the first problem may be traumatic or it may not be. But if you've had problems over the years with your knee, generally, you're probably going to have it again. And it's not a bad thing. And just, I think if you know ahead of time, if people know ahead of time what may come to be, they have a chance to intercept and decrease the probability. I tend to think that people have a, they have the complete control over how long their knee pain stays around, how fast it goes away, and how much time passes between knee flare-ups.

I mean, you can choose for it to flare up every week, or you can choose to have it flare up once every five years. It's really dependent upon what you want. And this really comes down to how well your hygiene is of your body. Not like how you smell, but it's, do you treat your musculoskeletal system well? And do you have some general physical activity? And do you see anybody to help you out of the flare-ups when you have it? You know, because the longer you have it, the harder it becomes, generally. Also, there's a mechanism of injury that tends to be pretty common. It's too much too soon, or the volume is too much.

And that can be acute volume or acute workload or chronic workload. Acute workload is like, I haven't worked out all year, but it's January 1st, and I'm going to do 30 million jumping jacks. That's acute workload issues. That's a volume issue. It's just too much too soon on the joint when a joint or the tendon or the muscle or the ligament or whatever of the knee is too much on the knee when you haven't subjected to anything in the past where it's not prepared. It's just basically it's not prepared. Chronic workload is just too much over time. We see this a lot oftentimes with people who are training for a marathon in the beginning of the year.

They pick up a program that's like a 16-week running marathon program or half marathon program. And the time to build up is not enough, especially if they don't have a good base. And so those are the general things that we tend to find in regards to the mechanism of injury. Now, here's some myths. The first one is don't let your knees pass your toes. I think this is more been debunked over the last few years, thank God, because this is something that is, I don't know who made this thing up. I really don't know. And it's so prevalent. Even people who come in who don't have knee pain and we tell them we do a physical exam when we're looking at them actually squat and they stop sometimes.

And it's like, what's stopping you from going lower? Well, if I go lower, my knee's going to pass my toes. Who the heck, who made this up? You know, now I'm not sure there's a time and a place for your knees not passing your toes. I'm really sure there's a time and place. And I'm pretty sure it has to do with, are you in pain? But also it has to do with how much weight is on your back, right? If your knees pass your toes when you're back squatting or front squatting or doing some type of squat, you're going to take, you're probably going to take load away, away from your, your posterior chain or your heels, and you're going to shove it into your, into your chain, your knees.

And so it's just going to work a lot at the knee. And so it's going to produce a lot of sheer force, they say at the name with too much bend. But generally speaking, let's just say from a, a movement standpoint, because once you throw a weight into the equation, like the whole thing changes, like conversation changes, like you, there's certain movements you wouldn't do if you had 500 pounds in your back or a hundred pounds in your back. While if you just have your body weight, you can certainly do them. Attempt to walk up and downstairs while not letting your knees pass your toes. It's literally impossible, completely impossible.

So that is something that I think you guys should just write it off for now. Don't worry about your knees passing your toes. For some of you who are dealing with back pain and knee problems, this may be the easiest way to manage your problem than you ever thought possible. Just let your knees pass your toes every once in a while. Like it didn't have to be all the time. Just because I'm telling you to go to Vegas doesn't mean go to the beach or don't go to Vegas. I'm not telling you to go to the beach. I'm not saying go, don't go one direction. So go the other. All right. I'm not saying pass your knees over your toes all the time, but don't stop it.

Just allow it to happen, especially if you don't have any weight on your back. The second myth is knee pain is an inevitable part of aging. This is something I think that has come from the old age type of thing, runs in my family type of thing, the hereditary or just age-related aspect of it. I disagree. I've met so many people of various ages who have knee pain while I've met people of various ages who don't have knee pain. I met people in their 80s and 90s who don't have any knee pain. And now is it they're the lucky ones? No, I think it's just they just happen to live their life well. They had good physical hygiene.

I remember this one gentleman I talked to, he was an interesting guy and he was, I think he was about 85 or so. He was an older guy. And so he moved so well. He squatted well. He hip hinged well. He walked well. He was just in good physical condition. And I said, what's your secret? And he said, I go outside and I pick up the leaves every morning. I said, with a rake? He said, no, one by one. He physically bends over and picks up the leaves. He squats down and picks up the leaves. He uses his leg. All right. I've noticed people sometimes when they have past history of knee pain or they just get older, sometimes they don't actually get on and off the floor.

Even getting off the toilet or out of a wheelchair is sometimes really hard for them because their legs are weaker. And it's not because they're old. It's because they just haven't used them in a while. I mean, you don't use it, you lose it. I mean, I love to say that, you know, that grandma's wrong on some things, but grandma's right on this one. You don't use it, you lose it. But I wish you listened to her own advice. If you don't get down on the floor, you're going to lose it. Your quads will get weaker. Your leg will get weaker. And then it's harder to use it when you need it. All right. Now, with that being said, I know that some of you, when you get on the floor, like the thing is like, I don't know, I don't know if I can get back up.

Right. That is the exercise. You put a chair by you somewhere, get on the floor and attempt to get back up. You can get up any way that you want to. You can make it knee over toe version. You can do that one where I know everyone kind of rolls on their belly and then pushes their hips to the air and they kind of stiffen out their legs and use their hands to push themselves up into a standing position. That's okay at this point. That's actually a hip hinge. Those are useful ways to build, I think, preventative type of model, especially if you're, if you notice now in your forties and fifties, you don't get down and off the floor.

Just try it. You know, 25 times a day is enough. You got kids or you got a dog get up and down off the floor. It'll really help you. Myth number three is running can increase the risk of developing knee osteoarthritis. I don't know many ways to put this, but this is wrong. A lot of seasoned runners who are dedicated runners actually have less knee problems than people who don't run. Now, I'm not telling you to run, but I think where this roots out of is that people who don't run start to run and they end up having a too much too soon phenomenon and they go to their doctor and they say, my knee hurts from running and, and they say, yeah, don't run.

It's a spike of activity, you know, but if you had, as I mentioned in the last myth, if you had a little bit more of, of expose it every once in a while to running, then I think you'll be okay. If you ran, you know, half a mile every day, or if you walked half a mile or a mile or two miles every day, I think you'd be less susceptible to having knee pain when you start running. All right. But just like, just like eating cake, eat a little bit every once in a while. Don't eat the whole cake. You know, you're going to have a bellyache. Myth number four, my scan shows exactly my, my scan will show exactly why I'm having knee pain.

Yeah, this is, so x-rays and MRIs and ultrasounds, all of them can be very, very helpful. And I'm not a naysayer and a hater on imaging whatsoever. I do love imaging. I think there's a time and place for it, but there's a time and place for it. It will not show how you use your knees. It will, it will show osteoarthritis. It will show meniscal frays and meniscal tears. It'll show signs of, or actually will, all these images will show ACLs and PCLs and MCLs and LCLs and tendinopathies. They'll show all this stuff, but is it the generator of your pain? No, not always. I remember I had this one girl that I saw when she was in college.

She had a condition of her foot and ankle area, actually of her foot. And so I was mainly concerned of if she had a stress fracture in her bone. And that was the reason why I was taking an image. When we took a couple images, we saw that the stress fracture was, was not apparent. It wasn't, it was not there. And she eventually recovered from that pinpoint bone pain. But also on the image, there was all these tendinopathies and all these other findings on the x-ray. You know, there was arthritis, this, and, you know, osis, that, and so on. On the x-ray and the MRI and the CT and so on. And so she, I asked her, I said, do you have any, do you have any foot pain here or there?

And she said, no. Over the course of the next two, three months, she, she ended up having it there. Now, was it that the findings in, on the imaging was dormant and it was going to at some point pop up? Well, I would take it the other way. It doesn't mean that you have to have pain. She was a very high level runner. She was running a hundred miles a week. Like she wasn't having any problems there, but her image will show that she has normal. I hate the words wear and tear, you know, but wear and tear doesn't always hurt. I have this old car. I have a really old car. And it's not, it's not like it was when it was new, but man, it runs.

It's dependable. There's no problems with it. There's no leaks. It runs very dependable. And so think about the imaging kind of like that car dependable. And if you find these little dings and who cares, you know, it's not really part of the picture. It just shows that you've had a life and you've used your body. Number five myths, a steroid injection will fix my knee pain. Well, so this actually helps out sometimes when there's swelling in the knee. And sometimes the injection will reduce that swelling and it'll make it so your knee can actually move better. But I would take this a different route.

And I actually chose personally to do a steroid injection of my knee. I did SYNVIS injections as well. I was having some knee pain from some trauma onto the knee and it was direct impact. And so I, the SYNVIS wasn't really working well. I did three shots of it. You know, it's the lubricant type of thing. They say, oh, this is going to lubricate the joint. And I thought, hey, this is a good theory. I'm going to try this. And so I was still not able to bend my knee fully. It still felt like a balloon in there. You know, I'd move my leg when I was in bed and my ankle, my foot would get caught on the sheet and I'd feel like it's kind of tweaky as well.

And so nothing really decreased that until I got the steroid injection. Now, the steroid injection over the course of about two days made it so I had full knee bend, which was fantastic. So I took the opportunity to actually rehabilitate my knee at that point because there's no physical limitations anymore. Now, generally what was causing the problem was probably still there, but I was looking to support it. I was looking to create some support system. As you mentioned in the second paper, we were talking about how exercise and therapeutic exercise, corrective exercises and stretches can really help out with supporting the knee and helping out with what you're doing day to day, helps out with pain levels and so on.

And so that's the approach I was taking. Now, a steroid injection, it won't fix your knee. It will just be a part of the puzzle if it's needed. So if you need to deswell the knee, by all means, you can do that. If it doesn't do it with simple rehabilitation and some exercises that actually can work out really well for decreasing the swelling of the knee. But I didn't know those at the time. I'll cover them a little later. But if you need to actually have something to deswell it, by all means, you know, I haven't had to send anyone out this year for that, but I know there's a time and place. Number six, all meniscus tears and ligament tears need surgery.

No. If your knee is physically locked in a certain position, meaning you can't flex it, can't extend it, it will not move. It's like someone put duct tape and glue on your knee and you cannot physically move it, then probably, maybe. All right. There's people walking around all over the place with meniscus tears and ligaments that are frayed and have damage shown and so on. And go back into that number I talked about, the MRI and the x-ray and the CT and like ultrasound. Can they be helpful? Yes, they can. But also people tend to sometimes fuss about these things. Meniscus are managed really, really well with exercise, not just jumping jacks, but, you know, a specific program, a specific exercise program and guidelines of what you can and can't do for a little bit of time until your knee is prepared.

And then you can go further. Ligaments, the same thing. They just take a little bit longer. Both of these have really low vascularity in the structures themselves. I think in the NFL, they're saying, you know, that accelerated ACL program was, that's an ACL is a ligament, anterior cruciate ligament. They're saying about a year. Some people are saying that that's a little too quickly because the ligament is still healing itself. And so you have to give the body some support. You have to, if you get the right exercise and guidance and right coaching and good acknowledgement of what's safe and what's not safe for you, you can certainly do this without surgery.

And it's actually, it's advised. Surgery will not change how you're using your body. It will not change the fact that you had a current injury and then you'll may have a future one. But again, learning the skill sets of how to manage it and decrease the probability is, I think, where the money's at. Number seven, you have to push through knee pain to get rid of it. No pain, no gain, baby. Yeah, this is incorrect. So most exercises should not really hurt. There's only a few that may hurt a little bit. The first few reps with things like pushing through movement a little bit or even some of the tendinopathy exercises.

But the tendinopathy exercises generally should produce a pain reduction effect later. Like you shouldn't leave a rehabilitation program or a physical therapist's office or a chiropractor's office or a physical therapist's office and say, I feel worse afterwards. If that's the case, you may have the wrong program or the wrong coaching. Now for a quick pause before we keep going. Hey everybody, it's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working, and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity.

The link's in the description. It only takes a few minutes to fill out the form. Okay, back to the show. Negative MRIs. Sorry, generally negative MRIs. Negative ults, channels, negative x-rays, negative CTs. You name it. All negative. Generally speaking. Other than the things that are normal dings and stuff that is on your car because it's not a brand new car. Internally structures, you'll find things like types of arthritis like osteoarthritis. Also ACLs, PCLs, meniscus, baker cysts, osteochondral defects, even infections I'd probably put in this category too. Although some of these things are more, they do need more urgent management like an infection.

You're not going to exercise this thing away. Osteochondral defect, like there's going to be, like there's a chunk of bone like in there that came from a donor site and it's just hanging out and they're like floating around. Like that may need to be removed. Baker cyst, I've seen these things get reduced with some of the simple exercises I'll talk about later. Meniscus, normally very simple unless it's locking into a certain position. ACLs, PCLs, like this is something that may be a little bit more surgically related. I know there's been things thrown around about non-surgical ACL, PCL. I think it depends upon what you're going to do with your life later.

I certainly know people who didn't have them repaired, but they're also, they're very careful of their knee because there is laxity in there. And generally speaking, the laxity, I think will be a proponent of osteoarthritis to come. Not to say they won't get it anyways, but the more movement in the knee, I think the more issues with the bone and body trying to stabilize the area over time. So these are internal knee structures. Again, some of them can be managed with a good rehabilitation program. Other ones can't. External knee issues. This is your tendonitis, tendinosis, tendinopathy, bursitis, jumper's knee, musculoskeletal tendinitis, tears, muscle strains, and so on.

Think about all these softer tissues would be outside or external of the knee. It's outside of the knee joint. And so these things are really, really manageable with therapeutic exercise. Sometimes they'll require things that will decrease the pain in order to go through the corrective exercises. But if you pick the right corrective exercises and loading patterns, corrective movement patterns, like a lot of times people don't need a pain management strategy, but sometimes they do. Pain management strategies that may work for these things is like your soft tissue work, your cupping, your needling, massage, things like that.

Like, but I think it's going to be important that everybody realizes that a knee is generally an issue that can be resolved or managed with physical activity. Anything that somebody does to you, like stretching you, mobilizing the joint, in my personal opinion, these things can help, but they're a smaller percentage of what you need to do. You need to do something that challenges and repairs the knee, stabilizes the knee, and offloads the knee, which I'll talk about later, which involves hip, ankle, foot, limb, and core. It requires all of it. Like your whole body is a quarter, that quarter unit, like it's important.

Then there's referred to knee issues, which is things like a hip referral. Some kids will have a problem with the femoral head, which I think a 12-year-old or so. They'll report things like knee pain. They won't have any hip pain, but they'll report the knee pain, and it ends up they have something called a slip femoral capital epiphysis. Not a really fun thing to have. They might need surgical intervention for that. But this shows how the hip may refer to the knee. Also, there's spine referral. A spine referral pattern would be something like a L3, L4, maybe an L5, S1, depending upon where in the knee we're talking about.

So there's certain sections of the low back which can refer into the region. And there's a nerve, which you look it up online, called the infrapatellar nerve. It's a branch of the saphenous nerve, which comes right around. It sits right on top of the patellar tendon. So for some of you out there who are having patellar tendon pain, but your image is generally negative, this may be something where you're like, maybe there's more to it. The cool thing is, at least when it's referred to the knee, like a spine referral or a local nerve entrapment, like the infrapatellar nerve, the branch of the saphenous nerve, these things are way easier to manage, in my opinion.

I think they are the easier ones to manage. They don't require surgery or injections or medications of any type. I think they respond really, really well. But when you have a hip referral, like if you have something of a hip referral to the knee, like the slip femoral capital epiphysis or avascular necrosis to the femoral head or something like that, like we might need to have an image of the knee just to make sure nothing's going on there. And that's going to be based upon the patient's presentation, their age, their gender, their activity level, and things like that. So that's why having someone on your medical staff who really understands knees and hips and ankles and the whole limb, the whole body, not just a knee specialist is going to be really important.

And then there's category four, which is too much too soon. On the slideshow, I put the New Year's Eve workout and I wrote down and I have another picture of the six month couch to marathon training program. How do we know the status or the physical state of somebody who's starting on the couch? I mean, there's like, I'm, I'm five, seven, one 65. There's me who I don't run marathons, but then there's also a, maybe a five, seven, 300 pound person. We already know obesity has something to do with knee pain. So is this the right thing to do with somebody? You know, the New Year's Eve workout is pushups, squats, jumping jacks, sit-ups, lunges, and so on.

And so these, it, I'm not saying these aren't safe for people. Neither one of them, I'm not saying they're unsafe for people, but it comes down to, is it, is it appropriate for your body at that time? Do we need to slow things down? Do we need to set the goals a little bit more appropriately too? So six month couch to a 5k training for someone who's five, five, seven, 300 pounds, maybe more appropriate. And it's not that they won't ever get to a marathon. It's this, they need more time. You guys need more time to build up some adaptation and tolerance within the joint, within the limb, within the body.

So you can actually attain the goal that you want. I'd love to say everybody coming out of high school can graduate college with, as a valedictorian, like within six months, but it's not realistic. Now, if they want to graduate within four years as a valedictorian, I think this is more attainable. You see what I mean? Like there's, there's a timeframe, which is going to be important. Like you need to make sure that your, your goals are appropriate for your timeframe and your starting point. Now, some knees are some treatments that really, really work for us at Performance Place are number one is McKinsey knee extension.

It's really, really helpful. Some of these things are going to be things that you guys can YouTube and check out, but really, I think you can probably, it's, it's best just to see somebody who can help you through that. I don't know how many people I've, I know personally who I've sent a video to, because we have videos on all these things. We have videos for our clients or our patients who we send to them as reminders of how to do it. The coaching on the exercises are not specific to the person because the way we coach each person is different. Okay. The, the amount of range of motion we go through with each person is different and the considerations of what's safe and what's not safe for the person is different.

Now, the videos we send them are general because we're trying to send them to everybody's a reminder. I kind of have a saying where I think we've talked about doing these videos more intricately, you know, coaching more specifically to each, each type of person. There's endless types of people, but the hard thing is, is, is now we have like 30 different videos of, of one exercise, which my opinion, I think the person probably is going to recall really well. If we coach them well, all they have to be done, all that has to be done is their refreshers. These videos are refreshers. So McKenzie knee extension, you can go on YouTube and look up a refresher exercise, but I think if you're attempting to get better, you might as well see somebody who knows what they're doing.

Okay. The second thing is skin rolling. Both of these things, skin rolling is describing the skin rolling. We have a video online on YouTube for it. It's one of our most popular videos. If you look up performance placement, skin rolling of the knee, or just look up performance placement knee, you'll see that these, uh, this video is super, super popular. And if you look in the comments is actually the more important part read through it's, it's people saying, Oh my gosh, I've had knee pain for 10 years and I did this and it's gone. Thanks. You know? And then there's other people who say, what kind of sorcery is this?

You know, I can't believe this is so stupid, but it worked. And so on. My point is that these two top things really, really work super well to reduce pain, but they don't restore function. I'm going to say it again. I paused dramatically. So hopefully you guys get that. They reduce pain, but they don't restore function. The problem is, is we go back into the early reference. We said the physical exercise, challenging the limb through the whole kinetics chain, which is the core, the pelvis, the hip, the quad, the calf, the foot, the ankle, all of it, literally the whole limb is important. And that's what helps out to reduce pain and restoring function for months at a time.

These two things don't do that. These things are ways to manage pain and there's nothing wrong with that, but that is a, that is one part, which I'll talk about a little bit later. The third thing I wish I really like people to do is force your hip to take the workload. Okay. We have a few exercises we'd like to do with this. Taking a hip dominant approach is really easy way to do it. Something like a hip thruster, banded glute bridge, even a regular glute bridge may work well. Or for those of you who are scared of going knees over toes, even going knees over toes can make so the hip has to work.

If you get all the way to the bottom without having any problems. So forcing your hips to take some of the workload can really, really, really, really, really, really, really help. So number four core work, I specifically, I think side planks is a good one to do with this side planks is there. I remember there was a paper I read years and years ago, which I cannot get the reference anymore just because it's been years since I read it and I didn't write it down, but you guys can certainly look it up if you want to. So there it was, I want to say it was about almost 400 female college runners. And so they surveyed them all and said, what's going on?

And they, they did some core testing on them. They did a frontal plane, which is kind of like a side plank that did forward, backward and so on. And so they tried to eliminate the hips and the pelvis as a part of it because they want to see how the trunk really worked. What was related to something like a knee problem. And so they released them all, collect the data and they said, look, come back. If you ever have knee pain, unless it's traumatic, if it's traumatic, we don't want to see back. And so they came back one by one. And what they found out was, I want to say it was about 90% of them had deficiency when they were first tested and something like a side plank, a frontal plane resiliency.

And so a side plank is a really, really easy way to reduce things like hip drop when you're running, uh, it, it helps out to support the side of the hip, the glute med, the glute backs a little bit. And so it helps out with stability in that plane of motion, which is really important. The fifth thing is a single leg patterning exercise or a single leg stance exercise. Now, some of you may be familiar with single leg RDLs. I'm not telling you to do that because there's a weight in your hand. And a lot of times when I bring up RDL or a single leg RDL, people just stiffen the heck out of their knee and they rotate about their hip, like they're kind of like a flamingo.

It should be almost like a skater. And we have a certain way of teaching it at performance place where we show people on a wall, this incorporates some of that side plank because we have them lean on the wall and it's like they're holding up the wall and then they go through a single leg patterning. Now this comes down to, this is where the unique coaching comes into play. Some people don't need, don't, don't need to be coached very much on this. They do really, really well with it. You have them reach forward. Like they're going to touch a, touch a, like a foam roller in front of them or like maybe a chair or a desk or further on the wall.

And they, they just move in like butter and they feel their hip working well, you know, they don't have any knee pain and so on. Like it, it really works well. Other people, they tend to take their foot off the ground and put all their weight onto the inner part of their foot. Cause the inner leg is the one that's supporting. There's only one support leg. Other people will tend to squat down really excessively. Other people will stiffen their back up. Like they don't want to round their back. They're afraid because they heard their back in the past. So there's different ways where we may coach somebody through this.

And again, this is, is important because a specific coaching of those exercise programs are important. Now I made a little note on this is successful knee rehabilitation is about removing demand from the knee, but then also returning demand as soon as possible. So there's certain things that you will want to take away possibly if they're triggers for your problem. Like if putting the knee past the toe bothers your knee, then don't do it for a week, but then put it back. If you don't put it back, you'll end up having an unprepared knee. And so successful rehabilitation comes down to removing something.

And then putting it back if need be. All right. I know some of you have probably had things like low back pain before. Rounding your back, sitting like a bad posture was really probably not good. And so you put a lumbar support behind your back and all of a sudden things felt better. Then you felt better after a couple of weeks and you got rid of the lumbar support. Now you sit sloppy again, which is not a bad thing. It's just reintroducing of the rounds, right? It's probably not the, uh, the way I would pick to do it, but it essentially is what it is. Now, as I mentioned in one of the, uh, in the, in the second paper, which I think is the most important one of all of them so far is realizing how quickly something like an exercise can help you.

Um, I go to the optometrist every year and every year she checks my eyesight and she says, you know, is a better or be better? And I say, well, be, and she says, okay, how about a and B now? And I say, A, and you say A and B now, well, A again, it's immediate. And so this same thing can happen if you pick the right exercises coached the right way. It's a misconception. I think a lot of people have about using exercise as a way to recover from something like knee problems and jumper's knee and osteoarthritis of the knee. Like they think it's going to take months to get stronger. It's not about strength.

It's about giving your body a new movement pattern. It's about giving your body a new movement opportunity and finding a new way to do something. Okay. So with that being said, I just, just realize that the strength is important. Endurance is important, but the way corrective exercises can be used if done in a medicative approach can make you feel better almost immediately. I mean, halfway better, maybe like what would that paper say? For those of you on YouTube, you can go backwards and read that paper. There's references right there. It says immediate. Okay. And so I cannot stress that enough.

If you're not having the results with having immediate, then you may need to find something a little bit better. Now, the way we manage knee pain at performance place, we use something called the MAPALOAD framework. I've talked about this with things like sciatica and low back pain before, but it really carries over to different parts of the body too. And so I mentioned earlier that you can M modify pain and MAPALOAD is an acronym. There's MAP and then L is load. M is going to be modified pain. A is going to be activate the support systems. P is pattern new movement habits. And four is load the limb.

So M, modify pain. I mentioned number one and number two, the McKenzie knee extension and skin rolling are really, really great ways to modify pain, but they're not the whole picture. It's not the whole program. It's just part. It's a really important part, but it's only part. The next is we have to get the support systems back. And this is going to be coming with things like, I mentioned a side plank is really, really easy one to do. Or I said hip function. So a glute bridge, maybe something like that. These are basic, really basic suggestions with it, but these are important. The hip and core are very, very important for the knee because we have to take load away from the knee.

And this is activating the support systems of the knee. Then we get into P, which is patterning new movement habits. Previously, it may have hurt to run. And so we're repatterning in single leg stance on the wall with what I mentioned just previously. This is patterning movement and sometimes new movement habits need coaching. That's just the fact of the matter. And then lastly, number four is going to be L, which is load the limb, which is what everybody's been waiting for is get the quad and VMO working and the hamstring and the adductors and all that stuff. And again, that is important, but I really think the reason why some people have ongoing knee pain is because they're not taking the necessary precursor steps like M, A, and P.

They just load the limb and then they end up having a problem. Because it's too much too soon and they end up having a fallout and they get frustrated. And there is a way to, there are ways to make it so you can reintroduce your activities again. But having recurrent flare-ups and problems over months to years is, it really, really wears on the mind and it makes it so the body sometimes, we'll call it an allergy against that activity, like it doesn't like it. You can get it back in, but it just, sometimes it just has a disdain for it, you know? So it's going to take a little, it sometimes gets a little harder to put it back in.

Now, the preventative model that I would suggest is walking daily, ideally barefoot if possible. If you can't walk outside barefoot because it's too cold where you're at, walk around barefoot in your house, even walking barefoot on surfaces that have rocks and pebbles, and this is all good. Even if you found a little area where someone did desert landscaping around your house, walk in there. This may be one of the easiest things you can do to prevent ongoing knee pain. Number two, let your knees go over your toes. We talked about this earlier. This helps out for a variety of different reasons.

It helps out with the hip function, helps out with the core function, helps out with deloading the possible regions for referred pain there, and also gets strength in the entire limb. And if you don't have current knee pain, maybe going knees over your toes every once in a while can really, really help. Number three, challenge your body weakly. This doesn't have to be like, I'm throwing up on the floor because it's so hard challenge. It's just challenge your body a little bit. This can be some moderate weight training. It could be going on a hike. It can be something like holding a squat position for 30 seconds, which is hard for some people.

Doing a wall sit, do something challenging. If you're finding that time is an issue, remove one of any shows that you may be watching or possibly one of your meals, just make two of them and freeze it and then eat it the next night. And then that will give you a little time that you can actually challenge your body a little bit. So a weekly challenge is important because once you challenge it again, when you have a goal of something that you want to do, like you have a better floor, you have a better, you have a better foundation to go off of versus starting from like a couch. Number four is squat and hip dominant exercises that are challenging.

Do them, find them. I suggested a few of them. If you have a personal trainer, talk to them about that. If you have a strength coach, they should know these as well. If you have a chiropractor or physical therapist, they may know these as well. It's important to note that not all people will know these, but just ask them and listen to how they say it. Joe, what do you think about what's a hip dominant exercise you think I could do based upon your history of working with me? Well, I, in that case, maybe ask somebody else. But if they go right to it, you know what? You can do probably a bridge or you can probably just pick up something off the ground or long jumps.

Maybe more confidence the way they answer it, mainly because I want to make sure that you guys, I'm not talking bad about these other people, but the fact of the matter is, if you ask me about blood work, I really don't know. Like, I don't know much about a lot of things in life, but there's people who are really, really good at suggesting knee and hip dominant exercises that can really help you, that are specific to you and what you can do today, not just a generalized program. Number five is don't stress that about the knee structures, the things that you find on the image, if somebody's already told you, don't worry about it.

All right, dings on the car, as you mentioned earlier, if it really works well, don't worry about it. The last thing we'll cover in the slides is actually general physical preparedness or GPP as wellness. General physical preparedness is being generally physically able. And this is important because you need to have a baseline. I have a friend who, he has a good saying. He says, I don't want to be a human liability, meaning if there's a tornado that hits the airport that he's in, he wants to be able to get out himself or save people, not someone he needs to, someone, not that someone needs to save him.

So his goal of life for physical activity is to be generally physically able. And so again, this is not talking bad about people who have disabilities at all, but in regards to making yourself physically able, I think if you make this a goal versus having like an aesthetic look or a six pack or muscles or a thin waistline or like things like that, like general physical preparedness is really an easy way to program in things that you should be doing, but also not extremely focused on the things that you can't do. The slide I have in here is over the course of six months, the amount of physical strength gain that people had that in this case, it was females over the course of six months.

And you can see that they, you know, went up. My point is not to show you the basic numbers of like, you should be here. It's more that it takes time. Dan John, who's a strength coach, he has a good saying. He says that physical activity, strength and things like that, like physical abilities, it's like a college education. It's built day in, day in or day in and day out, brick by brick. It's not like it's all of a sudden you snap your fingers and it's there. It's something you really need to make as a habit. And so I know, I know somebody who they, their mother recently had a surgery on their ankle.

And so the general physical preparedness is a problem with her, mainly because I know, although we, we acknowledge at this point that she can't use her ankle because it's in a cast. She can't get out of the wheelchair because her arms are not strong enough. She can't, she can't walk around and, or hop or use crutches. She can't use a walker because the other leg isn't strong enough. It doesn't have the physical ability. So let's just say if we scale this thing back, because I know that people sometimes know that they're going to have a surgery or have something performed, you know, in a year, your, your goal may be to make the rest of you physically able.

So it can compensate in a good way for the one that, you know, you're going to lose for a little bit of time. So general physical preparedness is something that everybody I think should strive for, no matter if they have one leg or two, one arm or one arm or two arms, it doesn't matter. Gender doesn't matter. Age doesn't matter. You know, it's just being able to move yourself about and perform general physical abilities, walking, standing for 10 minutes, you know, getting yourself off of a toilet. Like these are things that I think are attainable for any age group. And the reason why I bring this up is because beyond when we're talking about things like knee treatments and so on, like where do you go from there?

Well, you can go back into trying to deadlift 500 pounds or, you know, run a marathon or perhaps general physical preparedness might be another goal. It's way less stressful to do it this way. And also it's a very attainable goal for most people. Now, for all of you who are looking for the link of the YouTube video where I cover some of my favorite exercises, I have it. It is in the, it is going to be in the description for the podcast. If you're watching this on YouTube already, then I will supply it in the description of the video as well. If anything in today's episode resonated with you, visit the link in your podcast player.

There you'll find any free resource that we mentioned in the show, any guest links and a link for a free discovery call with us. We're licensed to work with our outdoor active people via telehealth across many states in the U.S. at this point. In fact, we cover almost half of the population in the U.S. and we add more states every year. Thanks for listening. Subscribe to the show and we'll see you in the next one.