Saturday, July 3, 2010

Dangerous Knee Myth #1: To Heal Bad Knees, Focus on Strengthening the Quads

My former physical therapist designed a treatment program around this belief, that the key to controlling my knee pain lay in strengthening the quads (the large muscles on the front of the thigh). I dutifully followed his advice and did the exercises he suggested. I made no progress for months in my battle with achy, painful knees, then eventually succeeded in damaging the joints further.

I started getting better when I rejected the "strengthen the quads" approach to beating knee pain, realizing that it didn't make sense.

It seems almost heretical to say that. If you search the Web for treatments for "chondromalacia patella" or "patellofemoral pain syndrome," you'll find the "strengthen the quads" advice doled out repeatedly.

Which is pretty remarkable, considering it fails the common-sense test. Here's why:

Just imagine you bang your elbow against something, really hard, and it begins to ache. After many weeks, your elbow still bothers you. So you go to see a doctor.

He takes X-rays and examines the joint. It's capable of moving through a normal range of motion. You tell him about the ache: low-grade and chronic, though sometimes it's worse than other times. There's nothing broken in there, he reassures you, and the joint pretty much behaves as a normal elbow would ... he sort of shrugs and sends you to physical therapy.

The physical therapist, after inspecting your elbow, recommends exercises to build up your shoulders and biceps. Having a strong shoulder and biceps will ease the load on the joint, he says. You leave his clinic with several sheets of diagrammed exercises that you are instructed to do 20 to 30 repetitions of, once daily.

What's wrong with this picture?

The problem isn't with your shoulders and biceps. It's with your elbow.

Likewise, I realized my problem wasn't with my quads, it was with my knee joints. Why not directly treat the problem? Why not focus on strengthening my joints, not my quads? Once my joints were strong enough, THEN I could worry about building up my quads. Sure, strong quads help protect knees, but their weakness isn't what's making you miserable.

Of course this raises some intriguing questions (that I'll return to in future posts): If this is such an obvious application of common sense, why don't orthopedists and physical therapists try to strengthen joints, first and foremost? Why do so many think the route to saving your knees goes through your quads? The answers are a bit complex, and I thought about them on many days during my recovery, as I focused on joint-strengthening exercises.

Some physical therapists do know better, like Doug Kelsey of Sports Center, whose writings were a beacon of hope to me during my bleakest days. Here's an excerpt from one of his blog essays:
Most of the medical profession believes that there is nothing that can be done, conservatively, for a joint with degenerative changes. The medical options are to quit doing things that make your knee hurt, use medications to control inflammation and pain and / or perform surgery - partial or total knee replacement ... Sometimes people will get sent to a physical therapist with instructions to strengthen their quadriceps muscles. Of course that often fails or is ineffective because the force needed to strengthen the muscle is beyond what the joint can withstand ... I've seen thousands of people with damaged cartilage over my career and a large percentage of them recover.
He's absolutely correct: people do recover. I did, and my crackly cartilage improved too. But I didn't get where I am now with a muscle-first approach to vanquishing knee pain. I realized it had to be joint-first. And that was a big first step.


  1. Have you seen the gym? I need to pump up my quads... =)

  2. Do your knees crackle at all today? Mine make some noises but they don't cause much pain. I have a broken foot now so I can't try to be active but I'll try to test my limits when I get back.

    Hopefully the knee issue won't continue to bother me but if it does I know where to search for tips. Thanks for your hope :)

    1. You're quite welcome for the hope! There should be more hope spread around for people suffering from knee pain. Yes, my knees still crackle, but a lot less than they did before.

  3. Hi! I found your blog by accident but it looks very helpful and I may say illuminative. My knee suffers for 3 years now and gets me to limited activity because of pain. But according to my OS opinion not the cartilage is the problem but the Hoffa's fat pad underneath my patella. But the problem with therapy and quads excercises seems exactly the same...