Overcoming Inner Knee Pain to Run Again at 50

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, it is your co-host Sebastian with the Restoring Human Movement podcast. Thanks for joining the show with me today. Again, you're on the right show if you're an active individual and you've been dealing with some groin, lower back, leg, knee, foot stuff. We specialize in helping people with lower quarter conditions, especially via telehealth. But we do have in-person services too. I'm going to tell you a case presentation today of someone that I worked with.

I saw him, I saw this person in person, but there is ways to do it via telehealth. And I'll tell you a couple of things that are, that can be done. But he was dealing with some knee pain. He's about 50 years old. His goal is to be able to run again in some form. He's okay with jogging, doesn't need to sprint, but he wants to be able to run with friends. And so at this point, he doesn't feel like he can really do so without bothering the knee. And quite honestly, he's pretty afraid of using the knee. He was told by his surgeon that he should never squat below parallel again. And I think that is bad information.

After I did an assessment with him, I deemed it was actually okay to go down that low. Now, I'll give you some context with him. He did have an old, old surgery to the knee. And it was about, I think it was about six, seven years ago, if I recall. So there's a chance that the information given by the surgeon was not qualified in regards to timeline. Or at least maybe this person heard it differently than it was intended. Because a lot of people do get information from their surgeon or doctor that says, you shouldn't be doing that. But really, I think what they're meaning to say is don't do that right now.

Or don't do that within certain pretenses. So if I were to say this person can squat with 500 pounds on his back again below parallel, let's probably not. But I think it's very reasonable that he should be able to squat with a nominal weight or what we would deem as kind of lifestyle-based weights. So if he was going to pick up a child, what, 40, 50 pounds? You know, that's kind of squatting down and picking them up. If you're going to sit on a toilet seat, especially if you're a taller person, yeah, those are all below parallel squats. So calling it a squat as a movement and a squat as an exercise are very different things and giving it the context of loaded heavily or just nominal weights.

So what I like to do with people with knee conditions, and he was experiencing inner knee pain kind of around, not around the kneecap necessarily, kind of around the inner part. Some of you may call it pezanserine type of pain or MCL, menial meniscus type of area. I like to assess people to figure out what is their risk? Do they have any real problems with loading this knee or is it completely clean to load to some degree? And so in order to do that, I do stress testing and try to figure out if I have this person do something, is their knee just going to just explode? You know, I say that in a joking way.

No one's knee really just explodes. But there are certain assessments we would do with a knee where it's like, you know what, this knee is not really able to take full load just yet. A lot of swelling is probably one of those qualifiers, especially load through variable ranges. You can probably still do isometrics. Knees with recent instabilities or ACL injuries. Like, I think we have to be careful of saying that they're cleared for all activity because they're probably not. But meniscal injuries, they don't like twisting. ACL injuries don't like shear force. So there's a lot of ways that we can manipulate an exercise program or give them context to what movements they should be doing and not doing.

So for him, I did stress test all the structures of the knee. And actually, they look really good. His surgical site looked like it was old and resolved. I had him squat down below parallel and asked if it hurt. He said no. And I actually had him sit with his knees on the ground and his heels to, butt to his heels. And I said, do you have any pain? And he said, well, it feels a little tight. I checked his range of motion. In fact, that knee did have limitations in full flexion, which would make sense with being tight with sitting in that position. I had him sit cross-legged. He didn't really have any pain with that, which means that we're looking at rotational intolerance at the knee.

And I had him lock his knee fully, just stand and gradually, aggressively extend the knee like he's contracting his quad. And that didn't bother him either, testing extension tolerance of the knee. Now, there's many other orthopedic tests that we can do, like your McMurray's and your Thistle's and et cetera, and so on. But I think from a logical perspective, if we're looking to see if a knee is really internally irritated, it's going to appear swollen. You may not actually see the knee cap. It may look different from the side. There may be some difference of feeling or squishiness around the knee.

You may actually feel that it is full like a balloon, but it doesn't really hurt. And then there's people who actually don't have any real internal swelling at all. It just hurts to move their knee, which is what this person was. He did have a limitation in full range of motion, but it didn't visibly look swollen. It wasn't sloppy with stability testing. All the ligaments that I loaded didn't bother him. He twisted about a little bit. It didn't really hurt. And so this is more of a scenario where it's probably safe to load the knee, and it's advised to do so, because everything is resolved that should have been deloaded, such as surgical sites or surgical structures.

So he was very hesitant of doing exercise, so I gave him some ideas of what's safe and what's not. I told him that full range of motion all the way down right now with heavy load would probably not be a good idea. And if he was worried about it, we could actually expose the knee to different ranges of motion with isometric load or non-movement exercise, which are very, very hard. And they can get a lot of contraction from the quads and the hamstrings and so on if you do them well. And those actually provide a lot of stability to the knee. They make a lot of people with knee pain feel stronger, like the knee is in more tact.

And for those people who feel like they are not physically able because their knee is quote-unquote damaged, it collects a big ol' win. Like these exercises like wall sits or what we call door jam squats or low bears, which are all over our YouTube channel, are really hard on the quads. They're really hard. And man, it's to the point where the quads are about to completely go to failure and the person stands up, they say, man, that was hard. Yeah, it was, right? How does your knee feel? It feels good. You want to do it again? Yeah, let's try it again. Like they get excited, which I don't think it's fully appreciated that people have mental aspects of their problems.

Sometimes their ongoing problem is a result of them being fearful of movement, either rightfully so, or being told to never do something again, feeling that their knee is just going to keep going downhill and they should never do X, Y, and Z again with their knee, or jogging is a young man's game. There are plenty of things that we can do to build up tolerance to that. And so what our plan with this gentleman is we're going to build some tissue tolerance around the knee. Clearly, he hasn't bent it under load for that long. So I would like to do isometrics with hamstring isometrics, as well as quad ones.

We're going to build his frontal plane stability, which is side to side, which is going to be more with glute exercises. I really like a single leg stance drill, almost like a baller or a single leg RDL that doesn't move. It's an isometric version. I really like doing those because the glute max attaches into the IT band. The IT band attaches in the side of the knee and that creates lateral stability. So we can stabilize the knee in that regard and use isometrics really aggressively in the beginning to do so. The next thing is we want to make sure that we clear all activity, which is not destructive.

So he is going to the gym and I said, how do you feel about doing deadlifting? He's like, I haven't done that in a long time. I said, does it hurt to do? He said, I don't know. I haven't done it in a long time. I said, well, let's watch you do it. And so I watched him do it and he said, that feels pretty good. I said, great. You want to go a little heavier? Yeah, sure. And so we went up about 60 pounds or so. He's easily over 200 pounds on his own. And so he felt good doing that. And so we left it at that. I just gave him deadlift or kettlebell deadlifting or hip hinging to do. Also, we end up using a isometric squatting pattern, which you just mentioned.

And I took away walking lunges for him because he was doing those already and then he bothered his knee. There's a lot more impact on those than step back lunges. And so we incorporated step back lunges instead. And I had him kneel to a plate. That way it took some of the full range out of the knee because we already know in the exam that full knee range he wasn't super happy with. I mean, not to say we can't get it later, but it looked like something that if we added it too soon, it may aggravate it a little bit. So let's just challenge a lunging pattern, but in a step back with the knee on something to limit the range.

I asked him if he's doing pushups. He said, he said, yeah, they feel good. And I said, do you pull up? He's like, no, I don't do pull ups. I said, so what do you, what do you, can you do a pull up? And he says, I can try. And so we try to pull up. It was very hard to do. We did a couple struggling. So, and I said, do those. And he said, why? I said, well, because it helps your core. And also, do you notice that when you're doing a pull up that you actually feel your back extend? He said, yeah. I said, well, part of keeping good form in a pull up is actually core activity. So I can give you a bunch of different core exercises if you want, or we can just do strength conditioning to help out with some of the core function.

And so we know for a fact that if people are active, especially around the area, that they actually respond a lot better. As we're starting to build capacity to those tissues around the knee, it doesn't mean we need to deload the rest of the body. And so he's allowed to do any pushing thing that he wants to, any pulling thing, as long as it doesn't hurt. He can do carries if he feels good about it. We tested suitcase carries, rack carries. They all feel good. Now, I'd be hesitant to give him too much sled pushing, but I do think that would be something in the future we'd do. Squatting, we regressed that a little bit, but we kept hip hinge or deadlifting around.

So I think those are good starting points, at least for a strength conditioning realm. And I certainly think they'll help out with tissue capacity. Now, the last thing, which is something more specific to the person's goals, if he wants to be able to jog again, we should probably get him to be able to hop on one leg. And so we did not start yet, because we had other fish to fry, is that we were going to have him do 20 hops per side, times three sets, a couple times a week. And if he's not able to do that, we'll probably start him off with something called a soleus calf raise. If you're wondering why the soleus, it's because the soleus actually does 70% of the stability against shear force in the knee.

70%, it's a lot. So getting the soleus to really become more active is a really big win, and it can help out with knee stability. So at this point in time, we are going to see him once a week for about four weeks. And a lot of it is going to be building a program with him and making sure he understands reps and sets and how much weight is needed and so on. Now, I'm not going to say that people can't do stuff on their own. I certainly believe that. But I feel like people get this way sometimes because of trauma, which he did. But sometimes people get this way because of the past things they've been doing.

So they default back to a lot of their things. So I would rather keep them under supervision. If they have a flare-up, I want to teach them how to manage it. Now, I remember there was one person that I worked with that I said, with his knee, I said, look, I want you to do full-depth squats with a nominal weight or body weight for the movement of it. We're greasing up the hips and the knees. But if you're doing heavy squats, I want you to do them above parallel. And so what he heard was, guilty words are one stone. He did heavy squats below parallel. And the next time I saw him, he says, well, my knee really hurts this time.

I said, what did you do? And he told me that. I said, remember, those are for different purposes. He said, ah, that's right. Right? And so part of our job here is to be a coach to people, to help them navigate their own problems. But also, let's be realistic. You can't just teach someone good exercise programming or good habit or good pain management in a day. It's not going to happen. Like, there's a reason we went, I went to school for this for a long time. And there's a reason why I've gone to continual, continue to add workshops. And I still am improving my skill set. So there's a lot to learn, and it does take time to get there.

But earlier, I mentioned that some of this can be done via telehealth. So let me just point out the things that would have gave us the scenario that it's okay to load this person, especially isometrically. Number one, isometrically is generally safe anyways. If people do it post-op, then they're usually okay. Last time I tore my hamstring, I started literally the next day. So you can do it very quickly. The second thing is, visually, I didn't see any signs of internal joint issues that I did not want to load the knee. And when I had him sit onto his haunches, he reported only minimal discomfort or fullness.

And when I had him fully extend the knee under repeated higher loads, like with the quad extensions, he did not report any problems. And then when he twisted a little bit, standing twist, he had no problems either. So these are all showing me what his problem is probably is going to be not internal joint problems. So that leads me to believe I can load the knee a little bit more aggressively. And also his movements show me that too. His tolerances show me that I can actually do a lot more with him than he thinks. So if you guys are looking for help and you want telehealth options for this, just reach out to us.

We see tons of people telehealth and we love to help them and show them exactly what to do. 714-502-4243. Subscribe to the show. We'll see you next time.