What’s Making Your Knee Pain Worse

Our knee joints bear the weight of our bodies almost every day of our lives. As a result, many of us suffer from knee pain of varying degrees. In this interview with Jeff Greenwald, Dr. Stone shares how to assess your knee pain, which sports to enjoy or avoid, and how to make lifestyle choices that can help your knees last a lifetime.  

Habits to Avoid Knee Pain

Minor knee pain is a chronic issue for many people. How can they work to reduce this pain in their daily lives? 

Dr. Stone: Start by getting an accurate diagnosis. So have a physical exam, X-ray, and an MRI if necessary to be sure of the cause of the knee pain. Once you know the cause, the treatment plan can be instituted. That can include anything from soft tissue massage and exercise to injections of lubrication and growth factors to surgical repair of the damaged tissue. 

But it's really important not to ignore these minor pains, and hope they go away—because sometimes, unfortunately, minor pains are indicators of significant joint injury. And some of these injuries don't present with a lot of pain until it's too late, and severe arthritis has set in. 

So my counsel is: Pay attention to pain. Pain is a red flag. While you can start with easy things of ice and massage and stretching to see if they go away. Changing the activity that you might be doing that might be irritating it. Optimizing your gait, optimizing your seat on a bicycle, bike fit, and all the usual things that can produce minor pain. But if the pain is persistent, I overwhelmingly encourage people to get an accurate diagnosis and treat the problem early. Even if it seems minor—because pain is not necessarily proportionate to damage.

Can you elaborate on how our daily movement, gait, and posture influence knee pain?

Dr. Stone: Those are three totally different topics. Let’s address movement first. Most people's knees feel better with movement. If they're sitting on an airplane for a long time, or in a car, many people develop joint stiffness. That stiffness can be diminished by glucosamine as a supplement, with chondroitin—but it can also be diminished by moving around, because movement increases joint lubrication, and stimulates the production of hyaluronic acid. It also increases blood flow, which loosens the muscles and is generally healthy for all the joints. So, immobility leads to stiffness. If your knee is stiff, or limited in the motion, it's like a car tire that's out of alignment. It wears only on one part of the joint rather than across the full joint. While improving your range of motion and flexibility decreases knee pain in general.

The second part of your question was about gait. If you notice people who have one stiff joint or another, or one arthritic part or another—whether it's their back, their hips, their knees, or their ankles—all tend to develop abnormal gait patterns. That abnormal gait wears on different parts of the joints, and will often create pain, wear and tear, and arthritis. Optimizing your gait with muscle balance, proprioception, and exercise helps diminish joint pain and mobilize the entire body.

Now to posture. Most people walk badly, with their shoulders ahead of their knees, and with a curvature in their spine that looks abnormal, or is shifted one way or the other. And so listening to what your mother said—which was to stand up straight, square your shoulders, try to walk with your shoulders behind your hips, and free your hip motion—will improve your posture. By improving your posture, you load the spine, hips, knees, and ankles in a more vertical, balanced, biomechanically advantageous way. Abnormally loading them leads to a stiff, immobile gait, incomplete range of motion, bad posture, and the early appearance of aging.

Are there any sports activities or exercises that should be avoided or changed to manage knee pain?

Dr. Stone: In general, we counsel people that impact exercises increase knee pain, while exercises like cycling and swimming tend to be good for almost every knee problem. It's hard to hurt your knees on a bike and in the pool. So, without a specific diagnosis, we would say generally avoiding impact sports.  

Can the shoes you wear make knee pain better or worse?

Dr. Stone: Yes – because the softer the landing, the less peak force is going through the joints. Whenever you use soles and shoes that have good cushioning, you're going to decrease the amount of force going through the knee joints—and thus decrease the knee pain. 

When we counsel people about running, we focus on the techniques of Chi running: short strides, high frequency, mid-foot landing, soft soles, and soft surfaces. That philosophy also applies to walking. Walk on soft surfaces on grass versus concrete, whenever you can. And optimize your gait so that you're landing smoothly. 

Simultaneously, the more you increase your muscle development, the more your muscles, rather than your bones, are absorbing the force. So building muscles can help protect the knee, and diminish knee pain.

It’s clear that lifestyle choices—like diet, nutrition, weight management, smoking, sleeping, hydration—must also have an impact on knee pain.

Dr. Stone: The biggest impact on knee pain is weight. For every 10 pounds you increase your weight, you dramatically increase the force in the knee joint—up to 50 pounds. That's because, in a year of normal walking, you take one to three million steps, loading up to five times your body weight with each step. So as you land on one foot—coming down from a jump, or a high step—it can be the equivalent of five times your body weight transferred to that single joint. Conversely, if you lose or optimize your weight by 10 pounds, you decrease dramatically the total amount of force going through that joint over the course of a year. That is the single most effective way to diminish joint pain.

What can people add to their pre or post-exercise routines to help mitigate knee pain?

Dr. Stone: Stretching before and after exercise helps people quite a bit. People tend to forget that if you warm up, your tissues are a little bit more elastic, and therefore less likely to be stiff and get injured. Warming up before exercise and icing or cooling down afterward also diminishes swelling and inflammation. 

Final question: What should people do if they hear strange popping or crackling sounds in their knee?

Dr. Stone: Some knees are harmonious, and make beautiful sounds, while other knees are discordant and make ugly sounds. But sounds themselves are not necessarily a predictor of injury. Some people— just from the biomechanics of their knee, or the way they walk—will pinch on some scar tissue or snap their patella a little bit, and cause sound. So we don't pay too much attention to sounds in general—unless they're associated with pain and swelling.

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Medically authored by
Kevin R. Stone, MD
Orthopaedic surgeon, clinician, scientist, inventor, and founder of multiple companies. Dr. Stone was trained at Harvard University in internal medicine and orthopaedic surgery and at Stanford University in general surgery.

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Learn about procedures that can help you return to sports & delay or avoid an artificial knee replacement.