Knee Osteoarthritis

Do you, or someone you know, have knee osteoarthritis? If the answer is yes, you’re not alone. Knee osteoarthritis affects about 1 in 10 adults of 60 years of age (Zhang & Jordan 2011), but also affects many younger people too, so it is not surprising that many members of the Be Mobile community suffer from this condition. 

At Be Mobile, one of our big goals is to reduce the barriers to exercise for as many people as we can. Now, knee pain can be a significant barrier to many forms of exercise and people with knee osteoarthritis tend to be less physically active (Wallis et al. 2013). Unfortunately, there are many misconceptions around knee osteoarthritis that can further limit people’s engaging in physical activity. So, this article will take a look at some of the common misconceptions around knee osteoarthritis and make some recommendations about what you can do about your knee pain.

What is Osteoarthritis?

There is a prevalent idea that osteoarthritis is a “wear and tear” or “degenerative” condition, whereby after years of work or physical activity, the joint cartilage thins, until the joint may even become “bone on bone”. This is an overly simplistic way of thinking about osteoarthritis, as there are many other factors that are involved. 

Knee osteoarthritis is a condition in which a person usually experiences pain and stiffness around the knee joint. People may also feel or hear crepitus (noises) around the knee or have a feeling of instability. These are the symptoms of knee OA, but also the main diagnostic criteria. You might wonder “but what about X-Rays and MRI’s - surely they should be used to tell if you have knee osteoarthritis?”. Whilst imaging has its place, it’s not that useful for diagnosing knee OA because many people with knee pain have no signs of OA on imaging, and many people without knee pain have signs of joint changes on imaging (Culvenor et al. 2019). So, you can see it’s not always useful. Let’s look at some of the other factors that contribute to knee pain.

Factors contributing to knee pain

Age related changes like cartilage thinning can certainly play a role in someone’s pain experience but joint change is just one biological factor. There are other physical factors that can influence pain such as carrying excess body weight, previous injury, or doing too much too soon when it comes to exercise. In addition to these biological factors, there are psychosocial factors. Psychological factors that can mediate pain include mental illness, poor sleep, unhealthy lifestyle, negative beliefs and a lack of control over your health (otherwise known as self efficacy). We know that pain is incredibly complex and a result of many factors, not just tissue damage. If this is a new idea for you, then I strongly recommend reading this article.

What can be done about knee osteoarthritis?

As we have seen, there are many more factors involved than just the loss of cartilage in knee OA. So addressing the factors that can be changed are important. This includes, but is not limited to, adopting healthy behaviours such as getting adequate sleep, maintaining positive relationships, and looking after one’s mental health. These are all important steps in addressing knee osteoarthritis from a whole person perspective - instead of a joint focused view. 

While we are on the topic of the whole person and health… Increasing physical activity and exercise is one of, if not, the MOST beneficial thing you can do for your health.

In 2018, the Royal Australian College of General Practitioners published their guidelines for the management of knee and hip osteoarthritis. They made two strong recommendations based on the scientific evidence:

•  Land Based Exercise
•  Such as walking, muscle strengthening and Tai Chi
• Dosage should be progressed over time

•  Weight Management 

• People who are overweight or obese should aim for a minimum of 5% weight loss, but greater weight loss is associated with greater symptom improvements.
• Weight Loss should be combined with exercise for maximum benefit.
  

If you have knee pain you might ask the question: “If exercise is painful, doesn’t that mean I am causing more damage to my knees?”. This is where it is important to understand that HURT DOES NOT EQUAL HARM. We discussed earlier how osteoarthritis is not a ‘wear and tear’ condition. This idea comes from the analogy that joints are like those in an automobile that need regular oiling, maintenance and eventual replacement. The fact is, the human body is an adaptable organism. Just like muscles become stronger with gradually increasing stress, we can improve the health and load tolerance of the joints with exercise. In fact, in one study examining the cartilage in elite weightlifters (who regularly load their knees with high amounts of force) they found that the weightlifters had thicker knee cartilage than non-weightlifters (Grzelak 2014) - an impressive adaptation!

But this isn’t to say you need to become an elite weightlifter to benefit from exercise... The key is finding a starting point that you can tolerate. From there we can gradually build up the load and the capacity of your knees. Notice the key word here - tolerate. If we said to everyone with osteoarthritis “Don’t exercise when you feel pain”, almost nobody would exercise. Remember that when you load a sensitive joint, your body tries to protect that area by giving you a pain response. Whilst pain can be a useful marker of threats to our body, it is an overprotective system and a manageable amount of pain is not a sign you are doing more damage.

“What about squats? I heard they were bad for my knees”

The reality is that any form of exercise will be beneficial for your overall health and your knees, so you don’t HAVE to squat. That said… squats are a very useful exercise for building strength in the lower body, especially because they resemble the action of getting out of a chair - something that a lot of people with knee pain struggle with. This is why they are a regular inclusion in our online and in person exercise programs. Now squats can certainly cause pain for some people but we shouldn’t throw the baby out with the bathwater - the squat can be modified to make it more tolerable. Here are some strategies if you experience pain during or after squatting.

1. Weight - Reduce the weight or try no weight at all.
2. Range of motion - if a bodyweight squat is still intolerable, you can reduce the depth. Even a very shallow squat, whilst it may not feel like much, is still beneficial, and represents a perfect starting point for a lot of people.
3. Substitute a similar exercise - If squats just aren’t working for you, a sit-to-stand from a comfortable height chair can be more tolerable for some people. And if even that is too sore, don’t worry! You can leave squats for the moment and try different exercises like pick up exercises which require less knee loading.

For some more information about how to modify painful exercises, check out THIS VIDEO.

If you would like an example of how to incorporate resistance training into your schedule, check out our free strength workout when you sign up for a free account on our website. In the workout we give different difficulty levels and show tips on how to make movements more tolerable.

 

Takeaways

If you’ve made it this far, we hope we have been able to change your mind about knee osteoarthritis. Here are the key points you should remember:

1. Knee osteoarthritis is diagnosed based on your presentation. Your scans don’t tell us much - there are many other facts that contribute to why your knee has become sore including your general health and your mental wellbeing.
2. Knee osteoarthritis is not a ‘wear and tear’ condition. Joints of the human body are different to the joints in a car that need oiling and replacing. Human knees adapt to load.
3. If you experience pain when exercising, that doesn’t mean you are causing harm, only that you are loading a sensitive structure - and if you start low and go slow with your exercise, the joint will become less sensitive!
4. Appropriately dosed exercise makes joint health BETTER, not worse. Getting moving will also help with weight loss and this can further improve your health.
5. There are no bad exercises, but care needs to be taken when exercising not to over do it! Thankfully, there are ways of modifying exercise to make it more suitable. These include reducing the weight, the range of motion or trying a different movement.

If you would like more information on knee osteoarthritis and exercise, check out this video!

References

Baraki, A., & Dickson, C. (2021). The Barbell Medicine Guide to Osteoarthritis | Barbell Medicine. Retrieved 23 July 2021, from https://www.barbellmedicine.com/blog/the-barbell-medicine-guide-to-osteoarthritis/

Culvenor, A., Øiestad, B., Hart, H., Stefanik, J., Guermazi, A., & Crossley, K. (2018). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British Journal Of Sports Medicine, 53(20), 1268-1278. doi: 10.1136/bjsports-2018-099257

Grzelak, P., Domzalski, M., Majos, A., Podgórski, M., Stefanczyk, L., Krochmalski, M., & Polguj, M. (2014). Thickening of the knee joint cartilage in elite weightlifters as a potential adaptation mechanism. Clinical Anatomy, 27(6), 920-928. doi: 10.1002/ca.22393

Guideline for the management of knee and hip osteoarthritis. (2018). [Ebook] (2nd ed.). Melbourne.

Trost, S., Blair, S., & Khan, K. (2014). Physical inactivity remains the greatest public health problem of the 21st century: evidence, improved methods and solutions using the ‘7 investments that work’ as a framework. British Journal Of Sports Medicine, 48(3), 169-170. doi: 10.1136/bjsports-2013-093372

Wallis, J., Webster, K., Levinger, P., & Taylor, N. (2013). What proportion of people with hip and knee osteoarthritis meet physical activity guidelines? A systematic review and meta-analysis. Osteoarthritis And Cartilage, 21(11), 1648-1659. doi: 10.1016/j.joca.2013.08.003

Zhang, Y., & Jordan, J. (2010). Epidemiology of Osteoarthritis. Clinics In Geriatric Medicine, 26(3), 355-369. doi: 10.1016/j.cger.2010.03.001