The most frequent cause of knee pain in walkers

I have written about this topic some time ago; but the cases continue to roll in, so its time for an update.

I could not count the number of times a walker has come to see me for help with their sore knees following a long hike in the hills, or following an event like the Oxfam Trailwalker 100km.  They may hobble up the path to my office and describe suffering a tightness and diffuse pain in one, or both knees.  It is typical that their knees have been troubling them for several weeks or months and they have had many physiotherapy treatments without relief.

Although they may be complaining of knee pain and although they may have had a diagnosis of, say, wear under the knee cap, or the kneecap not tracking correctly, these often turn out to be "red herrings".  

Swelling and pain affecting the lower inside of the knee

More often than not we will find swelling and pain around about the lower inside of the knee, skirting around to the back of the joint.  The knee joint itself, may be fine.  This kind of injury is most common in walkers but also found in distance runners and cyclists.

The cause of this pain is excessive rubbing of the tendons of the inner thigh at the point where they wrap around the inside of the knee bone.  There may also be pain and swelling at the point of attachment of the tendons to the tibia just below and to the inside of the knee.  In some people, especially women, this may appear as a swollen and soggy mass just below and to the inside and rear of the knee.  

It is quite surprising just how swollen and painful this region can be and even more surprising how long it can go without prior detection.

Knee pain of this kind is more common in women than men, possibly because of their having softer collagen.

Walking seems to be particularly conducive to this injury, although it is present in runners and walkers.  The repetitive straightening of the knee may inflame the inner knee tendons and they consequently swell.  With this swelling, the tendons rub more than ever, causing further swelling.  Its a vicious cycle.  As time passes there is progressive scarring and thickening of the tendons and surrounding tissues.  Rest, on its own, gives little more than temporary relief.

Treatment of knee pain

Treatment consists of deep tissue massage of the inside and front of the knee where the affected tendons slide and where they insert into the tibia and form the knee joint capsule. This must be done by a trained and experienced therapist.

It may also be helpful to give dietary supplements such as vitamin C, zinc, magnesium, manganese and silica which aid tissue healing.

Look for areas that are tender and swollen and concentrate on massaging these. Where there is visible swelling, the massage technique used is "effleurage" to shift the fluid out and towards the heart.

Massage the affected areas firmly but gently for several minutes using a quality massage oil.  Stay within pain limits - you are not setting out to hurt - only to heal.  Repeat the therapy at seven day intervals for as many sessions it takes to be completely recovered. Do not massage hard in between: Stick to gentle effleurage which will assist healing.  

Exercise as per normal, using pain and discomfort to guide just how much to do at a time. While there may be pain when touching the massaged areas, there will be improved function, such as being able walk more freely.  There is usually marked relief by about the fourth session and complete recovery by about eight or nine sessions (weeks).

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The advice in these articles is given freely without promise or obligation.  Its all about giving you and your family the tools and information to take control of your health and fitness.

I have been diagnosed with water on the knee with mild degenerative changes

What has sparked me to contact you is an article I read by you in the Walking magazine issue 128.

The thing is I have recently been diagnosed with water on the knee with X-rays reporting arthritis (mild degenerative changes) so I’ve stopped all my usual exercise high impact classes – as knee has been too sore anyway and I’m seeing a physio, and also started taking glucosamine tabs.

However, I was interested to read the advice you had given a reader in your article with a knee arthritic condition also, that he shouldn’t walk or cycle but swim. 

Having been an exercise addict for 23 years I would find it hard to give up walking, cycling etc and my knee seems to be a lot better now than even a week ago (has only been troublesome for a few month though).  Although I have discussed cycling etc with my physio and he seemed to think it should be ok as long as I don’t over do it.  I do intend to gradually go back to Pump classes, Zumba, cycle classes and aqua jogging, and I’m already doing an hour or so walking per day plus upper body Pilates and weights with one of our PT’s

what is the best glucosamine supplement for our worn knees?

Hi Gary
Which supplement(s) do you think would be best for us:

Active couple, in mid 40's. Keen trampers/MTB and try to keep running but our getting sore
knees...pain under patella and some swelling at times.

We both suffer on downhills, doctors say we're worn....

In my case I've additionally got some bone damage in my ankle (Talar dome) for which I'm
trying to avoid an Op. Can just see it in MRI.

We do still run offroad but I suspect it makes things worse. Usually 2 runs a week. I've found
leg extension exercises help the knee.

Kind regards
John
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Gary responds:
John, if your knees hurt and swell during a form of exercise such as running and hiking, then it is advisable to modify, restrict or cease the offending activity. The pain and swelling tell you that damage is being done and the arthritic processes are being needlessly accelerated. Of course, I am not about to tell you both to stop hiking and running; but you may need to back off for a year or so while you get your joints into better shape. You have a lifetime to go, so what's a year or so spent getting the body set up for the long haul?

Glucosamine, chondriotin and MSM
Gluosamine, chondroitin with MSM (methylsulfonylmethane) is definitely beneficial for even advanced cases of joint arthritis. I have been prescribing various formulations for well over 10 years now and I can tell you that these supplements do work when applied with patience and combined with other supplements and sensible approaches to exercise.

The best formulation for older joints with arthritic changes is Nutra-Life Joint Factors 4500. Take 2-3 servings per day for 3 months then ongoing once a day.

Other supplements depends on the individual with the most useful usually being coenzyme Q-10. (These products are available from this website store)

Reduce the impact and strain on joints
Formthotics Shock Stop for athletes should be fitted to all your hiking, walking and running shoes. These support the foot and ankle and reduce impact on all the joints of the legs. The other measure is to get a pair of Nordic walking poles and use these when walking and hiking. These poles are especially effective for reducing knee strain when walking downhill.

Give the knees a break
It is a sure recipe for disaster to be a one trick pony when it comes to exercise and recreation. Running, hiking and walking are too similar. Introduce other activities such as cycling, canoeing, swimming and aquajogging. Do upper body workouts. This is particularly important for women as they get older to ensure the thoracic spine is kept strong, supple and straight.

If your knees need a rest at any time, you have plenty of other exercise options sitting there in the wings that you can switch to in an instant. Spend more time exploring on your mountain bikes (When a bike is set up properly, there should be no wear of significance on the knees).

If the knees are sore - give them a break!

If you apply these suggestions and give the knees time, they will settle with time and they will give you many years of faithfull service, including running and hiking the Great NZ Outdoors.

Smash them continuously and you will be facing expensive plastic replacements by 60 years and the rest of your years restricted in your activities. While the plastic knee technology is getting pretty damn good, it is still a poor second to the real ones.

Look after your genuine pins - Love them.

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I am training for a marathon and I have problems with my knees swelling

Hi Gary I am currently into week 10 of an 18 week marathon training program and am experiencing problems with knee swelling.

...I had a successful knee reconstruction 6 years ago which has enabled me to go on and run several marathons as well as the Keppler challenge and other off road events, all without knee swelling and stiffness. I am 40years old.

What I would like to know is, should I be taking the Joint Factors supplement that you are advertising on your website. Or is it too late to start to be of any benefit? Looking forward to your reply. Regards
"L"
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Gary Moller responds:
I am assuming that you had an anterior cruciate repair. There is often damage to the knee cartilages and there may be some unwanted ongoing joint laxity which causes some slipping and sliding within the joint. That you are now getting some swelling is not unexpected.

Unfortunately, these injuries come back on us as we age and the repair processes are less able to keep abreast of the wear processes. As somebody who is a wee bit older, who has had two operations on the same knee and who remains obsessively hyperactive, let me give you a few words of wisdom. Before I do so, I would like to point out that my knee is functioning better today than it was when I was 40. Credit for this goes to being a stickler for ensuring no further damage is done to that dodgy joint:

If it causes joint pain or swelling - stop immediately
Pain and swelling mean that you are causing serious damage to joint surfaces which are literally a millimeter or less in thickness. Do not harm these delicate surfaces unless you plan to spend your latter years in a wheel chair. According to Tower Insurance knee replacements are up 268% from 2001. This is a shocking indictment on the way we treat (sorry - abuse) our knees. Look after those knees folks if you want to get through airport security without being frisked every time!

Nourish your joints while there is still something there to repair
You can never be too early (or too late) in supplying the nutritional substrate that those hard-working cells need to rebuild healthy joint tissue. This means trace minerals, glucosamine, chondroitin and several other nutrients, including plenty of vitamin C. When it comes to joint nutrition, the sooner one starts the better.

Exercise; but not in a way that causes harm
I was pretty good at marathon running. Did over a dozen with several at a brisk pace. That was over 20 years ago. Although I think I am fit enough, I will never do another because I want to have knees when I hit the ton. I simply made the decision to quit doing marathons and never, ever regretted that decision. Nowadays, most of my running is off road and no longer than about 1.5 hours. I can still chop out a 5km race in about 20 minutes which is satisfying for a chap now in his mid 50's. Nowadays, I do the grueling endurance work on a mountain bike. I can still do a 2-3 hour off-road running race without too much distress. All this is carefully chosen and executed to prevent ruining my knees.

Mountain bike riding is very hard work while being easy on the knees. A ride can last 3-4 hours with no joint pain of note. The other fitness activity that my knees love me for is kayaking.

So the advice is to choose activities that are good for your knees. Pounding the pavements is not one of them and marathon running sure is not on the menu either. And yes, I would recommend the joint foods of glucosamine and chondroitin; but not if the rest of the advice in this article is ignored.

Please help! I have injured my knee!

"Hi Gary Me again! My old knee injury (sprained or damage to the anterior cruciate ligament & medial collateral ligament) appears to have flared up so was wondering if you could recommend anything to help with the inflammation? and whether you think i should go back to physio?

It is pretty minor compared to what i experienced years ago & was at its worst on Monday but has calmed down a bit thanks to wearing a stocking all day/night. The inside of my knee seems a little swollen & it feels tight at the back to the point that it is hard to completely straighten or kneel. I could still run quite happily on Tuesday but after realising my knee was a bit swollen have decided to stop until its back to normal. In terms of the cause I am not sure as have not had a sprain as such. However, my knee did start to 'click' a lot more (& is clicking quite a bit now) when I started to do single leg extensions where my leg/knee is at a 90degree (sitting on a gym machine) & I lift a 5kg weight with toe slightly pointed out.

This exercise is part of the program that my trainer at the gym (Chek Practitioner with Diplomas in Rehabilitation & in Sports Medicine from Otago Uni) designed & apparently works to strengthen the inside of my knee. She also just started me on a new exercise with the swiss ball where my torso is on the ground but lifted up in the 'bridging' position & my calves are on the swiss ball & i have to lift one leg up at a time & hold it for 5 seconds so as to apparently strengthen my core, butt & hamstring. i have found this exercise really hard & pretty much strain the balancing leg so i can keep the lifted leg up in the air.

The trainer is convinced that these exercises could not have caused my knee to flare up unless i was incorrect in my technique & suggested it might be a hamstring insertion (whatever that is!)& thought i should try antiflam cream & seeing a physio in a few days if it had not self-corrected. but as she has overrided my old physio exercises & your advice to do 1/4 squats (she got me doing full squats with minimal weight)

I'm now confused as don't know if i can trust that she knows what she's talking about or who i should ask....except you! all i know is that my knee has been fine for the past 5 years & now its not!

Pretty gutted as i ran 9k for the first time in 5 1/2 years last week! any suggestions would be greatly appreciated."
"R"
Gary Moller comments:
"R", The swelling is telling you that your knee has been injured somehow and the swelling is your body's way of restricting movement.

Knowing your history of knee injury, it is possible that the damage to your knee ligaments previously and possibly to the knee cartilage makes the joint vulnerable to further damage.

It is possible that some of the exercises that you describe doing could have irritated the knee joint.

Your anterior cruciate prevents forwardsliding of the tibia on the femur, especially when the large quadriceps contract. The medial ligament prevents the knee from buckling inwards. Between all of them, the ligaments hold the knee joint snug and secure. The articular cartilages form a shock absorbing dish between the bones of the knee joint (tibia and the femur). It is possible that you damaged one or two of these cartilages when you sprained your ligaments.

When you are doing any kind of strengthening exercises using the big thigh muscles you should be weight bearing. This is because the knee bones are held firmly in place in the dished cartilages. If you do leg exercises such as leg extensions on a leg extension weight machine, the lower leg will be hanging free, gapping the joint and throwing stress on already damaged or stretched ligaments. The joint cartilage is vulnerable to further damage as the joint is gapped and twisted.

I would be very careful of the Swiss Ball bridging exercise that you describe because the knee could gap and twist. If you want to work the hamstring and butt, do standing dead-lifts with a barbell or dumbells; but make sure you get expert instruction in safe technique, lest you do your back in!

Stick to weight-bearing exercises such as squats and never go beyond right angle knee bends when under pressure. Deep knee bends may strain the ligaments and pinch the cartilages. The best machine in the gym for you for strengthening the quads is the incline leg press. Avoid the hack squat, including wall squats with a Swiss Ball behind your back. These throw excess strain on the front portions of the knee, including the undersides of the kneecaps. You don't need this.

Always get professional instruction by a weights expert and review your technique regularly.

Ice may help with the swelling but I am not a fan of it. Elevation, plus rhythmic exercise is best. Massage the knee, thigh and calf.

Exercise in warm water to manage swelling and to maintain strength, endurance and flexibility.

Take a glucosamine and chondroitin formulation and MSM and take generous doses for as long as there is pain and swelling. Use these in preference to pain killers and anti-inflammatories. Add 2,000mg of vitamin C per day. Copious amounts of fish and flax oil and especially Evening Primrose Oil have natural anti inflammatory qualities while not compromising healing. These natural supplements will assist healing. Continue normal doses for at least three months after the knee has settled.

Contact me if the knee does not settle significantly by next week.