Saturday, March 23, 2013

A Deeper Look at Hip Strength and Knee Pain (Part II)

Last week, in Part I, we looked at shortcomings in the structuralist explanation of how hip weakness causes knee pain.

This week, we get down to brass tacks.

If studies have shown hip strengthening reduces knee pain (and let’s assume for now that many studies have shown this, though I don’t know if that’s necessarily true), one attitude might be:

Who cares why it works? I’ve got bad knee pain. I’ll try anything that works, especially if it’s gone through the crucible of rigorous scientific testing.

So this week we’ll look at that argument, but in an unusual way. The first half of the post will be simple and visual (Cool! Pictures!).

Hey, why not have a little fun? :)

So, in other words, we’re going to start with a:

Now then, if you’re a carpenter, you’re familiar with the image below. Even if you’re not a carpenter, I bet you know what it is:

That’s right. A nut and bolt. There are many, many things in this world joined by nuts and bolts. But what if, at some point, you need to remove that nut? Hmm. How are you going to do that.

Now I know everyone knows what this is:

Praise be to opposable thumbs! Using your fingers, if the nut isn’t screwed on too tightly, you can remove it.

Let’s be charitable and say FINGERS are OKAY for removing nuts from bolts. (Actually, if we’re honest, we’d rank them as short of OKAY. But at least they’re better than nothing.)

“OKAY” isn’t very good though.

What about this instead:

A pair of pliers! That will certainly work fine -- for most nuts tightened to bolts. So let’s say PLIERS are BETTER at removing the nuts. We’re making progress!

But, alas, you’re going to run into that really-tightly-screwed-on nut or that rusting nut or that difficult-to-remove-for-whatever-reason nut. Sweat will break out on your forehead as your trusty pliers succeed only in stripping metal off the fastener’s edges.

Hmm. What works better than pliers?

How about these:

Yup. Socket wrenches. The mouth of the wrench fits snugly over the six-sided nut. It’s the perfect tool for the job. This is what the socket wrench was designed to do, tighten and remove metal hexagonal-sided nuts.

That doesn’t mean it will always work. There are times it will fail. Still, it does the best job.

So let’s say SOCKET WRENCHES are BEST at removing nuts from bolts.

Okay, we’ve reached the end of the picture book session. :)

What does all this have to do with rehabilitating bad knees by strengthening your hips? Well, actually it has more to do with the Big Picture: finding the best way to rehab your knees.

Imagine a one-year study broken into the following groups of chronic knee pain sufferers:
(1) 100 people who do nothing but live their ordinary, rather sedentary lives (our control group).
(2) 100 people who go through a program of hip strengthening.
(3) 100 people who go through a program of quad strengthening.
(4) 100 people who go through a program of high-repetition, low-load activity that only gradually increases in intensity (basically, the kind of program that saved my knees).

Say that in the original 100 people, the knees of 5 spontaneously get better after one year. Not many, but a few. So that’s our benchmark.

Now the 100 people who go through hip strengthening will potentially get several benefits. They should gain from getting in at least some activity (by doing exercises related to hip strengthening, which is certainly better than sitting around on the couch). They may benefit too from the placebo effect -- the mere fact that a physical therapist is working with them will encourage some to think they’re getting better. (Note: One problem with such an experiment is that it can never be truly blind for participating subjects; it’s impossible to disguise who’s getting the physical therapy attention and who’s not).

Still, I would guess that many will not get better.

Say in the hip strengthening group, the knees of 20 subjects appear to improve. If you just compare hip strengthening with doing nothing, then you have to conclude: strengthening the hips is a winner!

But what if we look at the quad-strengthening group -- there have been studies showing that quad strengthening helps bad knees. Strong quads arguably have a more direct effect on the joints and can help cushion them from harmful impacts. While the quad exercises will probably be too strenuous for some knees, others will tolerate them fine.

Say in this quad strengthening group, the knees of 35 subjects improve. Once again, if you just compare strengthening the quads to doing nothing, bulking up the quads wins the day!

But what if, in the last 100 people, who are trying to heal the joint itself, there is even more success? Say in this group, the knees of 80 subjects improve. Now where are you?

Well, the analysis would be something like this:

HIP STRENGTHENING is OKAY for beating knee pain.
QUAD STRENGTHENING is BETTER for beating knee pain.
JOINT STRENGTHENING is BEST for beating knee pain.

Naturally, this is what I expect such a study would show. It’s a shame no one has done one, so we don’t know.

If this is the case, the fact that quad strengthening shows some success, as does hip strengthening, tends to muddy the waters. They work okay for treating patellofemoral pain syndrome, but not great. In fact, where we’re at today in terms of standard treatments for managing PFPS can be summed up like this: Nothing works very well, but a number of things work better than nothing. (If you doubt this point, just review the literature about this condition -- I have -- and see how often medical professionals complain that PFPS is a mysterious problem that’s hard to solve. That's the best indictment I know of the standard treatments.)

But the fact they sometimes work means people keep using and trying to modify them. Unfortunately, no one seems prepared to make the radical (yet simple) leap: Why not just try joint strengthening? It’s an injured knee. Maybe it just needs to be healed, just as other injured structures do?

Closing note: I can imagine a structuralist type fuming about the statements “hip strengthening is okay” and “quad strengthening is better” with the remark, “Well, it depends on what’s causing the knee pain in the first place! Maybe hip strengthening is great for weak hips and quad strengthening the best approach for problems related to weak quads!”

But let’s get real for a moment. The fact is, right now, the mass of patellofemoral pain syndrome sufferers are basically like those in the hip strength study I began this series by looking at: They suffer “diffuse peripatellar and retropatellar pain of an insidious onset” and there’s no clear sense of what’s going on. Six different medical specialists may say six different things. A LOT of confusion surrounds PFPS. So in my hypothetical study above, I’m just assuming we round up a lot of PFPS patients with diffuse knee pain that appears to have an unclear origin -- because that’s what the real world looks like.

Maybe someday, in another 10 or 20 years, we’ll be at the point where we can focus on comparing hip strengthening to knee joint strengthening for specific subsets of patients, who fit certain criteria that leads some to believe their hip weakness is the essential contributor to their knee pain. But even so, I’m betting that, if put side by side, joint strengthening would prove superior as a treatment. Hopefully, someday we’ll see.


  1. I really liked the way you explain the good, better, and best using the images and the hand/pliers/socket wrench analogy.

    As for me, I had a second orthopedic surgeon take a look at my knee for a second opinion since I've been having a really hard time since January even progressing from a state of "very very very painful" to merely "painful."

    The good news is that the second opinion doctor said exactly the same thing as my first opinion doctor. Same diagnoses (PFPS & chondromalica). Same recommended treatment: both of them say that they really think my knee is not a candidate for surgery and that I should be able to get better via physical therapy by strengthening my quads and hips. Wow! That's wonderful that TWO respected surgeons looked at my knee and rejected surgery (for now.) But, on the other hand, I've done physical therapy over and over and over and I just haven't been able to get back to a normal life.

    BUT! I have a solid plan of action now. So, my solid plan is not go back to the official physical therapist (because I already know all those exercises and I think that they tend to push me into things that might work for many people but that my knee joint is not ready for yet). Instead, I will re-invoke my exercise plan from last year which had worked very very well.... all the way up until I had the giant relapse. Except, this year I'm NOT going to have a giant relapse because I am going to be even MORE patient than last year. I'm NOT going to be tricked into thinking "I'm healed" just because I'm able to bike 10 miles including hills and not have any pain. I'm not going to start relying on biking as my main form of exercise before I can even jump or trot or waltz yet. I will be patient patient patient. I should probably just plunk down the $$ for Doug Kelsey's book about the Runner's Knee Bible and his plan for healing in stages. I think that I was probably acting like I was in stage 3 when I was really still in stage 1 or 2.

    I wrote a commentary on this blog about patience last year which was something like this. At first it's like painting a white wall with off-white paint with a tiny tiny paint brush. It's hard to see any progress at all. You have to really really look closely and pay attention from one day to the next to see where you've already painted. Then, after a while you upgrade to a slightly larger paintbrush. Then, after a while, you upgrade to light beige paint. Wow, now it's getting a little easier to see where you've painted and slightly more interesting as well. Then you upgrade to using a slightly larger paint brush again. Then, after you've finished that wall... you realize you're not just painting a wall, you actually have to paint the whole room. Yikes. So you move onto the next wall with a slightly more colorful paint. Maybe a light blue now. So... now it's getting easier to see your progress as well as more interesting and encouraging. etc. etc. Until you finish the room. Then... you realize.... it's not just one room you have to paint, but... the whole house! Yikes!

    Of course the temptation is to want to hurry up and upgrade to using dark blue paint with a large paint roller! But! If you upgrade too quickly... you find yourself suddenly and painfully downgraded to painting that first white wall AGAIN, with the tiny tiny paint brush AGAIN, and using that off-white paint AGAIN. Painful And Discouraging And Boring.

    1. Knee Pain, I hear your frustration. If it helps any, even if you tell people that healing knees is slow, and they fully expect as much, one reaction after their knees finally heal is: "My God, I never expected it to be THAT slow." It is extremely slow, and the worse your knees are, the slower it will be.

      With my knees, I recall people at work thinking my recovery would be slow (they were willing to give me three months medical leave, if I could get a doctor to sign off, which I couldn't). I thought though it would be very slow, needing more like 9 months. It turned out to be very, very slow, requiring closer to a year and a half.

    2. Hello! Ok. Year and a half. Or longer. Of course that sounds daunting, but, it just is what it is. And luckily the treatment includes things I enjoy like walking and biking. When I start getting better I start getting more enthusiastic and then I re-injure myself. So. Just need to stay the course. Slow & steady.

      Guess this means I'll be posting on this blog for two more years. ;)

  2. Geez Knee Pain, I could have written that same post.

    My diagnosis is the same as yours (plus some damage in medial meniscus compartment post menisectomy). My OS and Sports Dr also rejected surgery.

    I got back on my bike this week and was able to bike 20kms at moderate intensity without too much pain (still some discomfort/tightness, mostly afterwards not during). It felt so good to be out in the wind again, & I thought I was finally on the road to cure after 10 months of frustration.

    Then y'day I went for my 30min walk, and decided to walk fast and even threw in 4x30 secs of jogging. No real pain while jogging, but Hell did my knees burn and sting and get stiff a few hours after & that remained for the entire day. What a @#$%^&* idiot !

    I've also been contemplating buying the Runners Knee Bible.

    For now, if I can just ride 20kms a few times a week without going backwards, I'll take it !

    cheers, TriAgain

  3. Good luck, TriAgain!


    Well. Not just patience. It's "strategic patience" as compared to "passive patience."

    I say "strategic patience" because sometimes it feels like I'm being lazy if I'm not trying 110%. But. With this problem giving 110% can result in a giant setback. So. In this case the BEST thing I can do for myself is be "strategically patient" or "purposefully patient." so. I'm bring patient on purpose as part of my carefully planned stratedgy. Which, is a lot harder than it sounds day in and day out day after day after day after day. Being patient for weeks and weeks and months and months is not easy.


  4. Knee Pain

    What was your exercise plan last year?

    And what caused the giant re-lapse?

    cheers, Tri Again

  5. Hi TriAgain,
    Here is my plan which I had cobbled together last year before I read Richard's book but which includes many elements of what Richard says. My exercise therapy I'm doing is a mix of movement and strengthening and stretching -- with the caveat that I refuse to do any well-meaning strengthening which aggravates my knee after multiple bad experiences.

    1) water therapy. this is NOT the same as swimming or walking in water. I'm talking about wearing a floatation belt and doing gentle leg motions while suspended in the deep end. I'm talking about holding on the sides and doing slow gentle bicycle motions. I'm following a book that I purchased that has a whole section about rehabilitating knees. wow!

    2) stretching. This seems to help my condition. To me it sometimes feels as if I have all these raw pools of pain inside my knee and my knee cap is being yanked into the pools by tight muscles. Ouch. But, when the muscles are more relaxed and flexible then they stretch and do not tug the kneecap into pools and let them heal up.

    3) all-over muscle strengthening as long as it is not aggravating my knee joint. Overall, my muscles have atrophied, so, seems like a good idea to get them moving and working and growing as long as it's not aggravating my knee joint. I instinctively STOPPED doing exercises prescribed by well-meaning people which never-the-less seemed to eventually HURT my knee joint and send me into a flare up which would take weeks to recover from. And, now after reading Richard's book I can see that this was very similar to Richard's idea of don't put on the shoe before the sock. So.... don't focus on the quads until after the knee joint can handle it. Although at that time I didn't realize that the knee joint itself could "heal."

    4) walking. I actually love walking but I have to be careful not to over do it.

    5) bicycling. start by stationary biking indoors. Do not push myself to add tension! This is key. It's just about the motion for the knee joint and not about strengthening the quads.
    But.......... then I had a giant flare up in October and was back to having screamingly stabbing pains. I'm still not sure what exactly went wrong. Neither do my doctors. But, my thinking is

    1) I had been starting to feel so great and so confident that I stopped journaling, thus, I don't even have my journal to review and help me identify the problem. And, this to me means I was losing focus. I was thinking that I was more healed than I really was.

    2) I was starting to get excited and do steeper and steeper hills on my bike on the weekends.... and probably my knee joint was not yet ready for that.

    3) Also, I started focusing on biking on the weekend as my main form of knee therapy (which is the most FUN) and stopped doing the other stuff during the weekdays.

    4) I should have realized that I was doing too much too soon because even though my knee was doing so well, I was still not at the place where I could Jump. Hop. Or Run. Or Dance. So, it's not as if I was a person with a regular problem-free knee.

    The plan is to do what I did last year and then when I start to feel better... realized that I'm NOT actually out of the woods, but that I still need to be careful and very patient. Don't push myself to do steeper and steeper hills. Just, let that grow more organically. Also, keep up with the other forms of exercise during the weekdays instead of falling into a lazier schedule of just biking on the weekends. Maybe at that point I will get Doug Kelsey's book. he talks about the three stages 1) recovery 2) restoration and 3) re-training. So. I was probably just leaving "recovery" when i thought I was in "re-training"

  6. Thanks Knee Pain, good info.

    I suspect I'm still doing too much as my knees still have some level of discomfort all the time. They seem to be best on moving a bit after waking, then gradually get worse during the day. They are not getting progressively worse however, perhaps getting a little better. But I probably should be doing a level of activity that makes the pain & tightness as close to zero as possible.

    I tried to get back on my bike, but it wasn't helping. I really miss riding.

    My symptoms are almost identical to Richards.

    cheers, TriAgain

  7. Hi TriAgain. I miss biking, too. :(

    That is interesting your symptoms are the same as Richards. I think most people's are. I don't know why mine are so different -- which is another reason why I got a second opinion just to see if maybe I had a different diagnosis. But. Nope! PFPS chondromalacia.

    Good news is yesterday I walked 2.5 miles including a hill. Today, so far, no flare up. So, will see how things develop over the next 24 hours, but, I'm hopeful. (I've been building up my walking ability slowly. So. Last week did 2.1 miles and I've been doing 1.8 miles for a couple weeks. My low was January when I had pain with literally every step and thus was just doing 1-3 blocks just to get around for daily life. So, I think my recovery is going great!)

    After reading the comment about taking small steps by another reader, yesterday during my walk I made an effort to take shorter strides and lessen the impact on the heel strike. Did that help? I'm not sure. I'll play around with it. But, at the very least doesn't seem to do harm.

  8. How does joint strengthening happen? I can strengthen/stretch hip and quad muscles no problem. But how does one strengthen a damaged joint? I've read Richard's book, and he talks about rest and gradual reintroduction of exercise. But if I can strengthen and strech my hip/quads, without aggravating my knee, what's the harm?

    1. Good question on joint strengthening. I thought I made that clear in the book (thousands of gentle, low-load repetitions), but maybe not. For more, check out this blog post:

      If you can strengthen your hip and quad muscles, and you're sure that that's not aggravating your knee (remember it's not only immediate pain you have to watch out for, but delayed symptoms too), go for it. I couldn't. Many others can't too.

      I agree with Doug Kelsey though, that the emphasis on strengthening muscles when you have bad knees is simply misplaced. Doug (a really smart guy) said: "Having stronger muscles is helpful but weak muscles are not the primary problem." So why not try to fix the primary problem? :)

  9. Also, there are some knee braces on the market. People, if you're having patella pain, please consider. I won't mention brands for spam reasons, but I will recommend if someone asks.

    Here's my experience: I bought a knee brace 5 days ago. I wore it all day every day since I bought it. The pain almost vanished. It went from a 4-8 range on the pain scale to a 0-2. I think it will be an indispensable tool to allow the knee cartilage to heal while I address the underlying causes (weak joint caused by misalignment and muscle weakness/imbalance).

    1. I'd be keen to know what brand/type of knee brace it was.

      In the past, a knee brace which warmed my knee for a few days was all i needed, but not anymore.

      But i've not tried one where there is a cut-out for the kneecap. Have been wondering if that might work?