KNEE ARTHRITIS - General principles of managing Osteoarthritis of the knee :
New research about Knee OA and muscle strength.... - - Posted by hmaxwell (Heather M.), 16 April 2003
I know that doctors love to turn conventional wisdom on it's head, but the following article really floored me...it came out in today's New York Times. The study was done at Northwestern Universtiy--both are highly respected and responsible institutions here in the US. Check out what the article says--I'd be interested in anyone else's take on this:
Quote:April 15, 2003
Regimens: A Warning for Arthritic Knees
By ERIC NAGOURNEY
People with arthritis of the knee are often advised to exercise the muscle on the front upper part of the leg, the quadricep.
But in a study released yesterday, researchers warned that such exercises did not seem to help and might even hasten the course of the disease. The report appears in Annals of Internal Medicine.
Researchers led by Dr. Leena Sharma of Northwestern University found that strengthening the quadriceps appears to pose a risk to those whose knees are misaligned and those whose knees are unusually loose, or lax.
When the researchers followed the conditions of about 230 arthritis patients over 18 months, they found an association in those two groups between quadricep strength and a worsening of the disease. One explanation is that lax and misaligned knees do not properly distribute the load in exercise, putting too much pressure on vulnerable parts.
"Our results raise questions about the use of quadriceps strengthening," the researchers wrote. The warning is especially important, they said, because many patients are sent off to exercise on their own.
"The availability of resistance exercise equipment in fitness clubs creates opportunities for additional unsupervised strengthening exercise," the study said, "and contributes to assumptions that such exercise is without risk and that `more' must be better."
The researchers cautioned that they were not advising arthritis patients to avoid physical activity. They suggested that patients with misaligned or lax knees be taught exercises tailored to specific muscles so that the benefits would outweigh the harm.
Dr. Sharma said the focus should be on maintaining muscle strength, not on building it.
As some with both lax and mal-tracking knees...well, it does make one wonder. Maybe the last sentence is about the importance of supervised PT vs hitting the stairmast and aerobics class at the gym?? Any comments
Heather
Posted by Janet (Janet), 16 April 2003
My last OS said that my weak quads were what was causing most of my knee pain. She said any time you have weak quads, even with a normal knee, you will have knee pain. Well, my new OS says that's true to a point. But in my case, quad strengthening causes knee pain, which means damage is occuring, which is worse than the weak quads. So my gut reaction was correct....if it's causing me pain, I shouldn't be doing it because it is causing more damage. I wish my PM&R doctor could hear this. He kept telling me it was in my head, that there wasn't really anything wrong but my brain didn't know it, and that the only way to get a "breakthrough" was to increase exercise gradually. But that only caused more pain! Right now, I am doing only a very little quad work just to keep what I have. But I hope that following my upcoming surgery, the pain will be less and I will be able to strengthen my quads more.
Anyway, interesting article. I guess it's just another example that there is a lot more to learn about knees and how they function. I really do think doctors try to do the best thing for their patients, but often they just don't know what it is.
Janet
Posted by cm (cm), 16 April 2003
I've always been told that the bigger problem is weak hamstrings, and that overtrained quads (in relation to your hamstrings) can cause knee injury because of the imbalance.
Posted by enuff81020 (enuff81020), 16 April 2003
Oh my,
I've been doing quad strengthening exercises for qa long time--my pt was absolutely insistent on my need for this. I really think they helped me before my tkr, I was pretty capable pretty fast. but I am particularly wondering about doing all of that after the LR's I had done. My life was such a nightmare--particulaqrly after the second one and maybe, just maybe, all of that work helped to keep it that way.
Does anybody have a link or source for that research and info? I think I'd like to print out a hard copy of that and ask some questions. Thanks, Sylvia
Posted by Rich_NYC (Rich_NYC), 17 April 2003
When I was younger I was into weight training, and I was always taught that it was important not to overdo anything, in particular not to concentrate on a muscle or muscle group without training the surrounding muscles (unbalanced training) as it can lead to damage. Moderation and common sense often seem to be ignored nowadays. Try explaining any of this to somebody who thinks that "a bit of excercise and that arthritis of yours would be put right"!!!! 
Very frustrating.
Rich
Posted by violin1 (mj/usa), 17 April 2003
Hmmm.....
This is a very interesting article and gives one food for thought. I think (since I haven't read the whole article) that the main point is the reference to malaligned and/or lax knees. It makes sense to me that if your knee isn't properly aligned, then you would need special exercises--tailored to your knee and its own special mechanics--to stenghten your quads.
From my personal experience: after the oats op, my kneecap was subluxing because my quads were sooo weak and the vmo had disappeared. It took a long while to get them back, now they have come back and the subluxing has stopped. My kneecap is back on track. I also remember that both my pts were very attuned to which exercises I should or shouldn't do. If one set proved too painful, my pt found another way of getting the same result. I guess I was lucky to have such good therapists.
The VERY frustrating part of all this, is that not all pts and/or os seem tomake the necessary differentiation and that seems to have caused a lot of people grief....Perhaps now more will become aware of how vital it is to make sure that the exercises you are given at pt are really to ones you need!!!
Thanks for bringing the article to our attention.
Mary Jane
Posted by Kimby (Kimby), 16 November 2003
In response to both Janet and Heather - thanks, Heather, for posting the article. Had not seen it previously and was feeling pretty vindicated by it. As with Janet, I first went to a PM&R for my knee pain. I was hoping that he would help with the pain management as I tried ALL of the arthritis meds on the market and none of them worked. The PM&R ordered a full series of x-rays - then proceeded to tell me that they looked fantastic and that the pain was all in my head, despite the fact that when I walk there is an audible crunching noise and my knees were dislocating.
I finally broke down and went to an ortho who told me that I needed a TTT and he didn't do them. He sent me to his mentor who proceeded to obtain bilateral arthrograms. The arthrograms showed that I had degerative changes, loss of more than 50% of my cartilidge, under the kneecap. The cartilidge was erroding from the inside out and looked like a doughnut - which explained why my xrays looked so good.
My R TTT was a success and I'm having the L one done next year.
I'm glad that people put info out there - it's good to know others are going through this stuff too.
Thanks!
Kim
Posted by rideforever (rideforever), 9 December 2003
(I may be new but) it seems to me that exercise is good because you feel that you can actually do something positive about your knees ... and you can also lose weight and keep your mind busy and not think about your knees which is also good.
Static (isometric) exercises which don't put too much pressure on the soft tissues.
Posted by Darvin_Hansen (Darvin_Hansen), 18 August 2004
I think mj/usa is on the right track here.
I had been lifting weights for about 6 months, enough to get both my quads and my hamstrings super strong. I had patello-femoral pain the whole time, and it just got worse.
After a misdiagnosis with a meniscal tear by my local gp, I got the correct diagnosis via a doctor who works with professional athletes all the time. And the patello-femoral pain is a very common thing, so this may apply to you.
If you are familiar with your musculature, you may be able to notice that your VMO (the tear drop muscle on the inside of the thigh near the knee) is undeveloped. If you have relatively large other three muscles in the quads, this difference is most probably NOT genetic - it's something you need to work on. After I went on PT, I realized that the whole time I had been not firing my VMO at all when I was lifting before! It was tiny and pathetic in the leg that was getting all the pain - and the rest of my quads were wasting too.
Also, getting orthotics has been an absolute godsend. If you have flat feet - you really should try orthotics. It makes a big difference in being able to fire that VMO and in so doing, strengthen it.
So the plan of the doctor has been:
1. Get the inflamation down by stopping the weight lifting and taking NSAIDS.
2. Get the VMO strong as hell, the hip stabilizers strong so as to enable the legs to run in the same plane and not exert unecessary pressure on the knees, get orthotics so as to get proper biomechanics, ease of pressure on medial compartment in knee, and stretch the fascia on the VL side of the leg.
3. Do the same exercises, and add in weight as the muscles grow stronger - i.e. typical progressive resistance training.
It is a month later, and the pain that used to send me wincing from being in a lunge position is gone, so long as I flex my VMO at the same time as the rest of the quads. It used to feel as though my kneecap was going to pop out of the skin at any moment! The VMO is getting bigger, too. This is my third day without taking Voltaren, and the pain has not returned anywhere near to where it once was.
Soon I plan to get back into the squatting and deadlifting I used to do, but this time with orthotics and this time focusing on using the VMO at all times. I will be building up from fairly low weights, as of course there is no point to keep exercising past the point of individual muscle fatigue (in this case VMO).
(Note I am also wearing several pairs of long underwear and socks so as to stop the arthritic pain from the cold that has developed in that knee.)
Posted by River525 (River525), 18 August 2004
Wow, what an interesting article.
I was just at my OS today to see what the Next plan of action would be for my knees after agressive PT. He told me that I needed to put in three more months of agressive PT and injected both of my knees with cortisone.
My OS said I really need to concentrate on strengthening my VMO and quads and to work through the pain. UGHHHHHHH
Lord I wish there was an easy solution to this. 
Posted by HK_Aubie (HK_Aubie), 13 December 2004
Wow. My first thought was, this article is amazing! My second thought, upon seeing the date, was I wish had seen it sooner! Knee dislocations had worsened for me in the past year, I've had surgery before but never done PT, so I found a doc and asked if PT would help. I started PT, doing lots of quad strengthening, and was getting told it would help both my stability and with my arthritis. Even after I had a dislocation at PT, and although my arthritis had worsened since beginning PT (in my whole body though, not just the knees) both my PT and doc still insisted that PT was helping, even if I didn't feel like it was. After 6months of throwing much of my free time into PT and seeing no difference, and feeling like my concerns were not being taken seriously, I quit. I was left frustrated and wondering if there really was any benefit at all. As I child I did quad exercises at home for my knees and after years of worsening, not improving, knees, quit due to my childlike deduction that it was not helping.
Thank you so much to the poster. Now I don't feel so ridiculous thinking that those quad exercises seemed to make things worse than better.
Posted by shadehawk (shadehawk), 13 December 2004
River, I am surprised that your OS would tell you to work through your pain because I have been told that your body (through pain) is telling you that this is wrong. Guess this is like everything else in life, no two people give the same advice. It is awful hard to know what to do.
I had exercises taken away because they were causing me pain and the OS said they were causing more damage to my knee. The step exercises and the wall squats.
Posted by Jax33 (Jax33), 18 January 2005
Thanks Heather for this article, I have just been told by my PT that there is nothing more she can do for me and to stop exercises as they are just increasing the pain. I find I can walk fine as long as it is not too far and this is her recommendation for my fitness. I felt really down after this thinking I was a failure and all that had been stressed about the importance of building the Quads to slow down the wear and tear. I am due to see my OS next week but after this last LR I don't know what my option are.
Jax
Updated Sat Nov 21 2009
