The aging athletic knee can feel like a dumpster fire at times. One day you can run 3 miles pain free, the next day you howl walking down the stairs. You can play pickleball for hours at a time, but sitting in the car for 45 minutes will have your knee barking for the rest of the day. Old knees are funny like that. Two of the most common sources of knee pain that tend to give the aging athlete the most trouble are the meniscus under the femur and the cartilage underneath the kneecap(patella).
The role of the meniscus in knees is that of shock absorber and stabilizer. The meniscus attenuates that ground reaction force with every step you take and keeps the tibia from sliding forward and backwards excessively, on the femur. The cartilage underneath the patella reduces friction as it slides over the femur each time you bend and straighten your knee. The majority of the injuries to these two areas do not require surgery, although they feel like they do. When you irritate or injure either of these areas, the pain is often disproportionate to any injury that has taken place. Furthermore, the rehabilitation of these areas can be straight forward and easy to do at home. When your knee begins to push back against your active lifestyle, reduce your activity level a bit, or a lot, and follow the three steps below.
Step 1 - Get out of pain and improve knee joint mechanics. Pain changes the way we move, so you cannot layer fitness or strength on top of an injury without adverse movement compensations. After a knee injury, know that your quadriceps muscle is not firing to its full potential. This decrease is strength whether below your level of awareness or not, puts additional stress on the meniscus and/or patella cartilage. In this context, all the strength training in the world is not going to compel the body to reactivate the quadriceps to its full potential, until you are no longer in pain. With your quadriceps in a weakened state, the knee joint is more vulnerable and prone to further injury. Adding insult to that knee injury, without a fully functioning quadriceps, compensatory movements will begin to potentially injure/irritate your back, hip and or ankles.
So how do get rid of your knee pain? Begin by reducing the pathological tension in your quadriceps muscle with foam rolling and stretching. Foam rolling will reduce excessive tension in the quadriceps as physical pressure on this tight muscle will compel the individual muscle cells to release from each other. Stretching this muscle after foam rolling will elongate it and help prevent the muscle cells from contracting and shortening back to its pathological state. With reduced tension in the quadriceps, we improve the mechanics of the knee joint. Your patella will slide correctly over the joint, reducing the irritation of the cartilage underneath the kneecap. Additionally, movement of your femur (thigh) relative to the tibia (shin) will improve, taking stress off the meniscus. Frequency is the key here, as stretching and foam rolling the quadriceps needs to be done on a daily basis. Once you have the pain moving in the correct direction, the next step is to strengthen the quadriceps.
Step 2 - Strengthen the quadriceps to stabilize the knee joint. Initially you want to start with, “open-chain,” knee extensions. Open-chain in this context just means that your foot is not on the floor. Straight leg raises and knee extensions are two simple exercise that both reactivate and coordinate the quadriceps muscles with minimal tension on the knee joint. Begin with straight leg raises as they allow strengthening without movement of the patella. Next, move on to knee extensions to restore functional bending and extending of the knee joint.
If you can preform both straight leg raises and knee extensions on daily basis for 1-2 weeks without any pain, move to closed-chain exercises, like the squat and its various renditions. I start patients with short range of motions squats, bending the knees to no more than 45 degrees. When you can perform these pain-free, we progress to full range of motion squats. My preference on full range of motion squats is to have my patients descend in the squat until their hips are below the level of the knee. I prefer this depth of squat because it indicates the patient has good range of motion not only in their knees but also in their hips and ankles. After that I add different types of squat progressions to emphasize work on the quadriceps muscle and scale up the difficulty of the movement.
Phase 3 - Strengthen the hip and ankles to support the knee. Once the knee can tolerate some squat progressions like goblet squats and elevated heel squats, it is time to work on movements for the entire lower extremity. A lunge, because of its narrow base of support, challenges the hip and ankle musculature. Furthermore, a lunge progression advances a patient towards single limb exercises. Once those lunges are dialed in, I add bodyweight single leg strengthening exercises like a single leg deadlift. The single leg deadlift really challenges the hamstring and glutes preparing patients for a return to running, hiking or any dynamic sport.
If knee pain is has robbed you of your sport, slowed you down or is getting in the way of your daily life, it is time to make a plan. As I stated above, the majority of knee pain can initially be addressed at home. To give you guidance, I have developed an online knee treatment program. My online program will take you through discrete steps, which I described generally above, drilling down on specific exercises, cues, sets, frequency and repetitions. Each phase of the program outlines criteria need to safely progress to the next phase. The program is designed with just a few exercises and stretches in each phase so as not to dominate all of your free time. You can find my online knee program at: https://www.returntosportphysio.com/the-aging-athletic-knee/.