How to Fix Knee Pain: The Plan I Give My Patients

Does your knee hurt going down stairs, or getting up out of a chair? Did somebody tell you it’s arthritis, or just tell you to rest it and take some ibuprofen? Most knee pain gets better without surgery, so let me show you how to fix knee pain the way I’d walk you through it in my office: what the spot that hurts is telling you, the biggest mistake I see, the five exercises I start with, and the signs that mean you need to get it looked at this week.

I’m Dr. Stephen Daquino, a board-certified family and sports medicine physician. For over 20 years I’ve been taking care of athletes at all levels, from high school all the way up to Olympians and professionals, and now I do that here at Revivify Restorative Medicine in San Diego.

If you’d rather watch than read, the whole plan is in this video, and you can see each exercise being done.

Where does your knee hurt?

When somebody comes in with a sore knee, I have them point to it with one finger, because the spot tells me a lot. A lot of times patients will point with their whole hand, it hurts somewhere around here, Doc. So I make them pinpoint it.

• Front of the knee, around or under the kneecap. That’s usually the joint behind the kneecap, what we call patellofemoral pain, or it’s the patellar tendon right below it. These are the people who hate stairs and squats and sitting through a long movie.
• Inside of the knee. This is a common spot for wear and tear arthritis. It could also be a meniscus irritation, an MCL sprain, or the pes anserine tendons, which attach on the inside of your shin.
• Outside of the knee. Think IT band, that long band of tissue down the outside of your thigh, or the lateral meniscus.
• Behind the knee. That can be a Baker’s cyst, which is a pocket of joint fluid, or your hamstring tendons.

For a lot of this, especially kneecap pain and earlier arthritis, the first treatment is usually the same thing: exercise. That’s what the orthopedic and rheumatology guidelines recommend. So wherever your pain is, this plan should be where you start, as long as you don’t have any of the red flags below.

A tear on your MRI may not be why you hurt

People get scared reading their MRI reports. There’s a study in the New England Journal of Medicine that looked at people 50 to 90 years old, and about 35 percent of them had meniscus damage on MRI. Of the people with tears, 61 percent had no pain, aching or stiffness in the month before.

So a tear on your report doesn’t automatically mean that’s why you hurt. Same kind of thing with X-rays and arthritis, where the picture and the pain don’t always match. Remember, we treat the person, not the report.

When to see a doctor instead

Before you try any of this at home, let me make sure you shouldn’t be in somebody’s office sooner rather than later. Go see a doctor if:

• You can’t put weight on it.
• It swelled up big within a few hours of an injury, especially with a twist or a pop. That can be a ligament like your ACL.
• It locks, catches or won’t straighten all the way. That can be a piece of meniscus getting caught in the joint.
• It gives way under you.
• It’s hot and red and you have a fever. That could be an infection, which is an emergency, so go get seen today.
• Your calf is swollen, tender or warm. That needs to be checked for a blood clot.

The biggest knee pain mistake: complete rest

The number one mistake I see is complete rest. And I get it. Your knee hurts, so you want to stay off of it, and that’s what anybody would want to do. But the muscles protecting that knee get weaker when you stop using them, and a weaker knee hurts more, so you rest it more, and you can see where it goes from there. A lot of patients come in and tell me they’ve been doing nothing but resting for six months and it’s not getting better. Now you know why.

So think of exercise like a medication. It has a dose. Too little doesn’t help much, and too much at once flares it back up. The rule I use is a pain scale from zero to ten during the activity:

• Zero to three: you’re fine, keep going.
• Four or five: back off a bit. Go shorter distances, at a slower pace, on flatter terrain.
• Six or more, or it’s worse the next morning: that was too much. Cut the dose next time, but don’t quit.

A little discomfort is okay as long as it’s settled by the next morning.

You can use the same idea with whatever you like to do. If running hurts, try walking or a stationary bike. If deep squats hurt, squat down to a chair so you don’t get so deep. If stairs are rough, take them one at a time for a few weeks. You’re still using the knee, you’re just turning down the volume a bit.

The five knee pain exercises I start with

This is the part that does the most for most knees. Your quads, the big muscles on the front of your thigh, are the shock absorbers for your knee, and when they’re weak, the joint takes the hit. Your hip muscles control whether your knee caves in with each step.

Here’s what I have people do, two or three days a week, with a day off in between.

1. Wall sit. Put your back flat against the wall, with your feet shoulder width apart and a little out in front of you. Slide down only as low as is comfortable, then tighten your quads. Do five holds of 30 to 45 seconds each. You’re holding still, so it works the quad hard without a lot of joint motion, and a lot of people find it eases the pain right afterward. This is where I start almost everyone.

2. Straight leg raise. Lie on your back with your other knee bent and that foot flat on the ground. Tighten your thigh, lock the knee straight, and lift to the height of the other knee. Hold it there for 5 to 10 seconds, then lower it slowly. These are great when bending still hurts.

3. Step up. Start low, because a few inches is plenty. Step up with the sore leg, push through your whole foot, then bring the other foot up and step down slowly. Watch that your knee stays over your second toe and doesn’t cave inward.

4. Clamshell. Lie on your side with your hips and knees bent and your heels together. Keep your feet touching, lift the top knee, and don’t let your hips roll back. That’s working the glute muscle on the side of your hip. The research on kneecap pain says to work the hips along with the knees, even though the hip isn’t what hurts.

5. Glute bridge. Lie on your back with your knees bent and feet flat. Squeeze your glutes and lift your hips until you’ve got a straight line from your shoulders to your knees. Hold it a few seconds, then lower slowly. That builds the back side and takes stress off the front of the knee.

Everything except the wall sit is two or three sets of 8 to 12. When 12 starts feeling easy, make it a little harder with a longer hold, a higher step, or a light resistance band.

And give it time, because strength takes six to twelve weeks to build. A lot of people do this for a week or two, don’t see results, and quit. This probably didn’t happen to you in less than a week, so don’t expect it to get better in just a week.

What helps everything else

Weight is a huge one. In a study of overweight older adults with knee arthritis, each pound they lost took about four pounds of force off the knee with every step, and you take a lot of steps in a day.

For shoes, you want something supportive and comfortable. You don’t need anything fancy. And a knee sleeve? If it makes you feel better, go ahead and wear it. It’s not going to fix anything, but it doesn’t hurt anything either.

When exercise isn’t enough

Let’s say you’ve really done the work for eight to twelve weeks and you’re still hurting. That’s when you get a doctor involved. That starts with an exam and usually an ultrasound or an X-ray, with an MRI only if it’s going to change the plan.

Physical therapy is a guided version of what I just showed you, and sometimes you need that. A good physical therapist can tailor an exercise program to the way you move and the way you hurt.

Then there are injections. Cortisone can calm down a flare, but it’s a short-term tool. In a two-year study in JAMA, people got a shot every 12 weeks or a saline injection, and the cortisone group had more cartilage loss and their pain was no better.

PRP uses your own platelets, which put out a bunch of signals saying hey, we’ve got damage here, come help me fix it. I use this in my practice. It isn’t magic and the research is still mixed, but it may help more than a cortisone shot at six months to a year, and in a large trial it didn’t cause any more cartilage loss than saline. Talk to your physician about whether it makes sense for you.

Knee surgery vs. fake surgery

Fine, I’m being a bit dramatic, but there really are studies looking at what is basically fake surgery.

There’s a procedure where they scope the knee to clean it out. In one trial of people with knee arthritis, some got the real surgery and some got just the incisions, and the real surgery never beat the fake one on pain or function. Another trial did the same thing for worn meniscus tears and found the same result after a year.

When researchers compared surgery to physical therapy for a meniscus tear with arthritis, function came out about the same at six months. About 30 percent of the therapy group did end up having surgery within those six months, so about 70 percent didn’t.

Sometimes surgery is the right call, like a knee that’s truly locked or a real structural problem. It just shouldn’t be the first call.

Who this plan is for

If your knee aches on stairs, stiffens up when you sit, or keeps you from the things you like to do, and you don’t have any of the red flags above, this is a good place to start. That goes for the weekend warrior who wants to get back on the trail and for the person who’s been told it’s arthritis and just wants to walk the dog without thinking about it.

Next steps

Start with the wall sit today. Do it for 30 seconds and see how your knee feels tomorrow morning.

Here at Revivify, I want to get to the source of your knee pain and start with the least invasive option that makes sense. If you’re in San Diego and want somebody to take a look, you can schedule at revivifymed.com or call 858-429-0099.

The full plan is in the video on YouTube. Tell me in the comments there where your knee hurts: front, inside, outside or back.

Sources

• Englund M, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008.
• McAlindon TE, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis. JAMA. 2017.
• Messier SP, et al. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 2005.
• McLarnon M, Heron N. Intra-articular platelet-rich plasma injections versus intra-articular corticosteroid injections for symptomatic management of knee osteoarthritis: systematic review and meta-analysis. BMC Musculoskelet Disord. 2021.
• Bennell KL, et al. Effect of intra-articular platelet-rich plasma vs placebo injection on pain and medial tibial cartilage volume in patients with knee osteoarthritis. JAMA. 2021.
• Moseley JB, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002.
• Sihvonen R, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013.
• Katz JN, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013.
• Collins NJ, et al. 2018 consensus statement on exercise therapy and physical interventions for patellofemoral pain. Br J Sports Med. 2018.

Please remember, I make these videos for educational purposes only. Although I am a doctor, I’m not your doctor, and you should definitely check with your personal physician before making any changes or beginning any medical treatments.

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