Patient Education

Orthopaedics Patient Education

Shoulder rotator cuff tendonitis exercise program
Shoulder stiffness exercise program

Dr. Crawford's home exercise programs

Knee pain

Knee pain is often caused by an increase, or simply a change, in pressure under the kneecap (patella) bone. This may happen even without a specific injury, although it may happen after you change your activity level. The patella is a "V" shaped bone that sits in a groove (trochlea) at the end of the thighbone (femur). The kneecap (patella) bone is part of the tendon of the quadriceps muscle (thigh). Normally, the patella stays within the groove in the thighbone as we flex and extend our knees, because of a balance among muscle strength of the leg, ligament-like restraints called (retinaculum), and flexibility of our joint.

Weak quadriceps (front of thigh) muscles, after knee swelling, injury, or simply because of lack of use, can result in poor tracking of the kneecap. Poor tracking also occurs in people with mal-alignment of the leg. This poor tracking can cause pressure under the kneecap to be unevenly distributed on the cartilage of the kneecap. In addition, the ligament-like tissue (retinaculum) on the inner part of the knee often stretches, while the one on the outer part of the knee shortens simply as a result of our knee anatomy and daily use.

Pain is often worse when you bend your knee or when the quadriceps muscles are active, because each causes more force on the patella. This kneecap pain is not only associated with weakened, unbalanced muscles, but may also result from tight hamstring (back of the thigh) and/or calf muscles, as well as flat feet.

Other factors associated with kneecap pain are excessive knock-knees (kneecaps that point toward each other when the feet point straight ahead) and malformed trochlea groove (which some people have at birth). Many of the factors that cause kneecap pain are treatable. The large majority can be treated without surgery, if you do the recommended exercises. Healing and pain reduction is generally quickest when you rest from the activity that caused the pain. However, if you continue sports or work activity that aggravates the knee, this does not usually lead to irreversible problems or damage.

Knee pain solutions
Avoid squatting, stairs, and hills, if possible. At the gym, do not use the leg extension machine (where you sit with the knee bent and straighten the knee with weight at the lower leg). Do not do deep squats,and lunges.

If you want to ride a bicycle or exercise bike, raise the seat so that your knee is fully straight when the pedal is all the way down. This helps to reprevent the knee bending when the pedal is up. Continuing your normal activity while doing these exercises is possible. It is unlikely that you will cause more harm to your knee. However, it may take you longer to get better if you continue to jog, run, jump, and climb stairs or hills during your rehabilitation.

Knee pain treatments
Your first treatment will be ice to relieve pain and reduce inflammation. You may also take medication. Stretching and strengthening exercises and changing the activity that produces symptoms are also very important. This program is designed to be done at home, although occasionally physical therapists or athletic trainers may be helpful. It will often take up to six weeks before you will notice improvement in your knee pain. These problems often took years to develop, so be patient.

Icing the knee after your exercise is helpful. Your physician may also recommend bracing with a knee sleeve to help the kneecap track properly. Arch supports (orthotics) are helpful for people with flat feet. If you still feel pain after you have tried these conservative exercises at least daily, surgery may be required. Other strategies include using an arthroscope (a video monitor that looks inside your knee joint) to help release the tight retinaculum. Occasionally, bigger surgery to re-align the knee cap can involve cutting the tibia bone near the attachment of the patella tendon.

Knee pain medications
Non-steroidal anti-inflammatory medications, such as aspirin, acetominophen, and ibuprofen can help with pain, but they may upset your stomach. Take them with food. Newer research suggests glucosamine alone, or with chondroitin sulfate, can help with pain and inflammation in these conditions and may help fight arthritis. Injections of steroids or potentially hyluranate derivatives may help but are not commonly used.

IMPORTANT: Do not take aspirin or ibuprofen-like medications if you are having surgery in seven days or less.

Ice for knee pain
Cold therapy is terrific for relieving pain and inflammation after activity and for flare-ups. Apply cold for 20 minutes on, then 10 mintes off, after any activity that aggravates your symptoms. You can do this about two or three times each day. A bag of frozen corn or peas works great, too.

Arch supports for knee pain?
Yes! If you have flat feet, arch supports can help your knee alignment and possibly your patella tracking. Off-the-shelf arch supports, particularly ones without plastic, work well in most cases. Plastic or rigid arch supports transmit shock to the leg and may cause excessive stress in the leg, particularly in athletes. Several brands (Spenco Arch Supports, Superfeet) are available inexpensively at sporting goods, drug, or shoe stores. Another option is the "1 Stop EVP," which you can order by calling toll-free 1-800-HOT-FOOT (Foot Management, Pittsville, MD).

Rehabilitation for knee pain
You can easily do this exercise program at home without gym facilities, although certain exercises may be easier in a gym. Stretching exercises are desoigned to relax tight hamstring and calf muscles that both cross your knee and fight your quadriceps tendon. When these muscles are tight, they can pull the patella backwards causing increased and/or altered forces under the knee and, often, pain and swelling.

STRETCHING

IMPORTANT: Do all exercises for each leg for maximum recovery and prevention!

Hamstrings
You can stretch the muscles in the back of your thigh as shown below.

Keep your knee straight and bring your chin toward your foot (not toward the knee). You should feel a gentle pull in the back of your thigh.
Hold this stretch for 20 seconds. Repeat the stretch three 3 times for each leg.
Do this at least once a day. Doing it more often will not hurt you, and may help you gain flexibility faster. Always do it before exercise! Doing it afterwards and at other times helps, too.

hamstrings: start

hamstrings: finish

Calf Muscles
There are two sets of calf muscles. The gastrocnemius and soleus (calf) muscles also cross behind the knee joint. If they are tight, they act together with the hamstrings to keep your knee bent.

IMPORTANT: When you do these stretches, keep your knee straight, your heel down, and your foot pointed straight ahead to lengthen your calf muscles.

You can stretch your calf muscles as shown below.

The photos below show the leg of the calf to be stretched behind you, with the knee straight, while the other leg has the knee bent. Both feet are pointed straight ahead and both heels stay firmly on the ground.
Hold this stretch for 20 seconds and repeat 3 times.
Complete this series at least once a day. More often is better.

calf muscles 1: start

calf muscles 1: finish

Here's another exercise to stretch your calf muscles.

Stand on a step, curb, or stair. Hold on to something so you do not fall.
Place the front or ball of your foot on the curb or step. Slowly lower your heal down until it is below the level of your toes. Keep your knee straight!
Hold this stretch for 20 seconds. Repeat 3 times.
Complete this series at least once a day. Did I say that more often is better?

calf muscles 2: start

calf muscles 2: finish

Runners' stretch: the ilio-tibial band
Runners often have problems with patello-femoral joint pain in the outside part of the knee. A tight iliotibial band can pull the kneecap outward and make knee pain worse. We call this "runners' knee." This area often gets better with stretching, but the exact area is difficult to isolate. A good stretch is shown below.

Lie on your side that doesn't hurt. Bend your painful knee and its hip so the thigh is at a right angle to your central body.
Hold on to the ankle of the bent leg and pull your ankle and leg back, straightening the hip as your legs are apart.
Keep your hip straight and knee bent as you slowly try to bring your injured knee toward the ground. Use your good leg to help pull your knee.
Hold this stretch for 20 seconds. Repeat the stretch three times.
Do this series of three stretches at least once a day. Did I mention that more often is better?

runners' stretch: start

runners' stretch: finish

STRENGTHENING

Strengthening exercises are designed to help restore balance to your quadriceps muscles and improve kneecap tracking. Remember that strengthening exercises and bending your knee can put more pressure on your kneecaps and cause pain. Therefore, most of these exercises are performed with your knee straight or only slightly bent. As your pain subsides, you may be able to do more knee bending or increase the resistance with these exercises. Be patient and be careful.

Quadriceps

Sit on the floor. Straighten your knee and tighten your thigh muscles. Feel your muscles pushing the back of your knee toward the floor.
Hold the contraction for 5 seconds. Do three sets of 20 contractions (60 total). Stop if you have pain.

quadriceps: start

quadriceps: finish

Straight leg raises

Sit on the floor. Raise your injured leg, with your knee straight, so your foot is about 12 inches off the ground.
Hold for 20 seconds, then lower the leg slowly to the ground. Repeat 20 times. Do three sets of 20 leg raises.
If this is too easy for you, hold for a count of 5 seconds at the 6 inch- and 12 inch-positions while you raise and lower your leg. As you get stronger, hold it for as long as 20 seconds. Move slowly between positions and rest the leg on the ground for no longer than a second. If this is still easy, add heavy shoes or ankle weights. Start light and work up to more strenuous activity.

straight leg raise: start

straight leg raise: mid-point

Wall slides

With your back against a wall, place your feet about 24 inches away from the wall.
Start with your knees straight. This is called zero degrees of knee flexion. Bend your knees 30 degrees. Hold that position for 20 seconds. Straighten your knees. Repeat this for three sets of 20 repetitions.
When this exercise is no longer painful, bend your knees more with each dip to 45 degrees. Hold this for 20 seconds. Do three sets of 20 repetitions until it is not painful.
When this is comfortable, try 60 degrees of knee bending. Hold for 20 seconds and complete three sets of 20 repetitions.

Don't worry if it takes a few months to advance to 60 degrees. Do not bend more than 60 degrees of knee flexion!

wall slide: start

wall slide: mid-point
30 degrees

Single leg knee bends

Stand on your painful leg with your knee straight and foot pointed straight ahead.
Bend the knee of your painful leg 20-30 degrees. Hold this position for five seconds.
Straighten your knee as shown in the third picture below. Repeat this for three sets of 20 repititions. Hold on to a stable object to help you keep your balance if you feel wobbly.
When you can do this exercise without pain, hold the knee bent position for 10 seconds for three sets of 20 repetitions. As you gain strength, add 5 seconds to the bent position. Do not bend more than 30 degrees of knee flexion!

single leg knee bend: start

single leg knee bend: mid-point
30 degrees

single leg knee bend: front view
30 degrees

Step-ups

You may not be able to do this exercise during the early part of your recovery.

Place a hardcover book or aerobic step (no more than 2 or 3 inches high) in front of you. Step up onto this platform with your painful leg as shown below. Step up with the other leg so you are standing on the platform.
Step back off the platform with your non-painful leg first. Then lower your painful leg off the step onto the floor. Do three sets of 20 repetitions.
When you can do this without pain, add 2 or 3 inches to the platform height. Do three sets of 20 at this height.
When you can do this on a 6-inch platform with no pain, try the exercise on a regular stair step.

step-up: start

step-up: mid-point

We hope this program is easy for you to understand and carry out. If you have any questions about your shoulder or my recommended treatment, please let me know.

Dennis C. Crawford, M.D., Ph.D.
Assistant Professor
Sports Orthopedic and Arthroscopic Surgery
Department of Orthopedics and Rehabilitation
Oregon Health & Science University
3181 SW Sam Jackson Park Road
Portland OR 97239-3098
503.494.6400
crawfden@ohsu.edu