From telegraph.co.uk
From diet and exercises to supplements and footwear, three experts reveals how to rescue your knees
When it comes to osteoarthritis (OA), our knees are most vulnerable; the most complex joints in the body, constructed with four bones and an extensive network of ligaments and muscles, carrying our full body weight. An estimated 5.4 million people in the UK are living with knee OA, but we still don’t know the cause. It’s not a simple case of ‘wear and tear’. Genetics play a role, as well as gender – it’s more common and severe in women – and injuries, such as sports injuries earlier in life or hard physical labour.
“At its base level, OA is inflammation of a joint, a cycle of wear and failure of repair,” explains Mr Saket Tibrewal, a consultant trauma and orthopaedic surgeon at the Cromwell Hospital, who specialises in the knee. “Any joint damage causes inflammation, then you get the release of fluid which carries enzymes which damage the cartilage itself.” Cartilage is the smooth, slippery tissue that cushions the end of our bones to allow them to move freely against each other. The more damaged it becomes, the greater the reaction to further damage – the more fluid, the more enzymes. “Over time, these cycles get progressively worse.”
How can we halt it? Anyone concerned by OA knee pain should first get a diagnosis to establish the state of the joint and, if it is OA, how much cartilage is left. When it comes to self-management, it won’t be possible to reverse, but there are steps that might prevent further deterioration and certainly control symptoms. “If you get it right, you might be able to get through all your active life with a little bit of pain but avoiding surgery,” says David Vaux, the head of therapies and exercise at Arthritis Action and author of Stronger. “If you get it wrong, and especially if you do too much, you potentially accelerate your journey towards a knee replacement.” So what might help?
The best supplements for knee pain
Turmeric
“Turmeric is a natural anti-inflammatory,” says Tibrewal. “I tell my patients to take it and for some, it really works.” Curcumin, one of its active components, has anti-inflammatory properties similar to that of non-steroidal anti-inflammatories and a BMJ review of studies of turmeric or curcumin on knee OA found that all recorded improvements in pain and function.
Glucosamine
“This plays a role in building cartilage and might delay it’s breakdown,” says Tibrewal. “Again, not everybody is going to feel a benefit, but some do.” While some research has found that glucosamine reduces OA knee pain, other studies showed little improvement.
Chondroitin
“This can nourish the joint and improve cartilage health,” Tibrewal explains. According to the charity Versus Arthritis, chondroitin has been tested in more than 20 randomised controlled trials and many have shown significant clinical benefits in pain reduction. Although, again, evidence is mixed.
Vitamin D
“Vitamin D supplements are important for general bone health,” notes Tibrewal. It may also have anti-inflammatory effects and help maintain the immune system.
Get the right footwear
“Your knee is affected by everything around it,” says Tibrewal. “The ankles, hips, back and spine all feed into it. It’s one whole chain and little imbalances anywhere can affect the knee. People who are flat-footed, or have an incorrect gait, for example will get good symptom relief by addressing that.”
A doctor, occupational therapist, physiotherapist or podiatrist can all give advice here. For those with advanced knee arthritis, Nice guidelines recommend Apos, a foot worn device which looks like a trainer and redistributes pressure in order to reduce pain. (It’s also available privately, often covered by medical insurance.) “Insoles can make a big difference,” says Tibrewal. “I also use a lot of knee bracing. For people who have a lot of wear in one part of the knee, special braces can push the leg straight and take away the pressure.”
Finding the correct footwear is essential. Shoes should have thick soles, enough toe room, and good arch support. “There should be enough cushioning to reduce the impact when you walk,” says Vaux.
Listen to your knees
“Exercise is so important to strengthen the joint but if you feel pain doing something, it’s a request for change,” says Vaux. “Either you did it for too long or it’s the wrong exercise for you. Anyone with OA needs to listen to their body and pace themselves far more than the person on the next treadmill or climbing the escalator in front of you who doesn’t have OA. It’s not fair but it’s important to understand that. Exercise, like medicine, requires the correct dose and for that, you need a diagnosis first, and then a schedule where you ‘train clever’, not hard, doing less exercises but precise ones. We need a little bit of impact for strong bodies, but prolonged impact is detrimental.”
How do you know if pain is ‘healthy’ post-exercise ache or a sign of damage? “It’s normal to have aches after training, but if the knee swells, if you’re losing mobility, if it’s pain that persists, you need to rest the knee,” Vaux continues. When it comes to training muscles around the knee, Vaux suggests twice a week is enough. “But that’s not a golden rule,” he adds. “If you train on Monday and by Thursday, your knee is not feeling great, opt for something non-weight bearing, like cycling, or work on your core and upper body.”
Lose weight
“Offloading the knee through weight reduction is first and foremost the most effective way to alleviate symptoms,” says Mr Rej Bhumbra, a consultant orthopaedic surgeon on the Knee Team at The London Orthopaedic Clinic. “Four times our body weight goes through the knee joint, so even if a patient can lose 5kg, that means 20kg less on the knees. That slight change in weight makes a huge difference.”
However, it isn’t just about weight. “It’s the type of weight you have,” says Bhumbra. “Is your body distribution more fat-based or muscle-based? Muscle bulk around the knee – good quads and hamstrings – offloads the knee.” Research by the Radiological Society of North America (RSNA) has shown that people with strong quads are less likely to need knee replacements.
Sleep well and manage stress
“Sleep is when your body makes its repairs, so prioritise sleep and find ways to manage stress, whether it’s breathing protocols or talking therapies or anything else,” says Vaux. Chronic stress and lack of sleep triggers inflammation and potentially exacerbates pain and the cycle of joint damage. “If you’re always in a state of arousal, our sympathetic nervous system keeps us on alert and the counterbalance, our parasympathetic nervous system, doesn’t have a chance to help our body relax, recover and repair.” A review of 54 studies on the impact of chronic stress on arthritis, found that 41 showed it to be a risk factor for worsening pain and disease progression.
Tailor your diet
“Eat your anti-inflammatories,” says Tibrewal. “Get your omega-3 from oily fish.” The Mediterranean diet is anti-inflammatory while processed meats, sweets and sugary drinks are linked to higher inflammation. Protein is also important. “As we age, our ability to absorb protein is reduced so we should be eating a little bit of protein with every meal,” says Vaux. “The amino acids stored in our skeletal muscular tissue are the repository on which the body draws when recovering from injury and repairing.
Stay flexible
Synovial fluid, also known as joint fluid, is a thick, lubricating liquid found within the knee joint that reduces friction during movement and nourishes the cartilage and surrounding tissue. “Joint health depends on a full range of motion in order to get synovial fluid feeding the surface of our articular cartilage,” says Vaux. “If you lose 10 or 20 per cent of movement, you’ve lost 10 or 20 per cent of that nourishing fluid getting to those areas and that will accelerate wear and tear. Build in a simple night-time and morning stretch routine – you can do them when you’re lying in bed.”
These include:
Knee rotations
Lying on your back with your legs together and knees bent, slowly lower your knees to one side, staying within a comfortable range and not allowing your back to raise up. Bring your knees back to the middle, repeat to the opposite side. Doing so for 2 minutes, this should be slow and rhythmic.
Crossover knee push
Then cross your right ankle over your left knee. Using your right hand to gently press on your right knee, push your knee away from your body until you feel a slight stretch in your right hip and lower back. Then, gently pull your knee toward your belly button before pushing it away again. Continue this movement for one minute before swapping to the left side and repeat the movement.
The best exercises for arthritic knees
When it comes to exercise, low impact is important, such as swimming, cycling, cross-training, and rowing machines. “If you really want to run, if you love to run, I’d recommend grass, not tarmac or treadmill and to limit it, mixing it up with other non-weight bearing cardio,” says Vaux. “Brisk walking is excellent.”
“For strength training, you want to build all the muscles around your knees as a natural brace for that corseting effect, but you also want to strengthen the connective tissue, your ligaments, and tendons that stabilise the knee joint. Isometric exercises – which involve contracting muscles without moving the joint – are ideal for people with knee OA. They give you a really nice contraction without the impact that we want to avoid.”
Static wall sit
“These are great for stabilising our knee joints,” says Vaux. “Depending on your level, start with a slight bend in the knee leaning against the wall, then hold for 30 seconds. Over time, build up to a minute. When that becomes easier, bend your knees a further five degrees and so on. Build this habit into the dead times of your day, like waiting for the kettle or when you’re on hold on your phone. Remember, if it hurts, go higher, or try another exercise.”
Static hip bridge
“This is another great isometric exercise that builds tolerance in the muscle and ligaments of the knee,” says Vaux. “It is also a good alternative if wall-sits make your knees sore.” Lie flat on the floor with your legs bent. Drive through your heels to push your hips upwards as far as you can go.
Slow motion sit down
“When you have got to sit down during the day, do it in slow motion every time to the count of 5 or 6,” says Vaux. “This is an eccentric contraction and it’s gold dust for building stability and preventing knee injuries and the kind of knee pain you experience when walking downstairs.”
Alternate single leg box step-ups
“Build up to four sets of 10 on each leg and when that feels easy, put some bottled water into a pack on your back and build up to four sets of 10 again,” says Vaux. Using the staircase is also fine.
Walking lunge
“Start with own body weight, building up to four lots of 10 lunges for each leg and when this is too easy, add some water bottles to your backpack and start again,” says Vaux.
Single leg balance
“Balancing on one leg can be done anywhere, including waiting for a train or queuing at a check out,” says Vaux. “Use a sink or table if you need a little more support.”
Bouncing
“These are great for balance, muscle and bone health and without the knee impact of jumping,” says Vaux. Facing a desk, a table, kitchen top or sink, hold the surface in front of you with your hands shoulder width apart, bend your knees slightly, with feet shoulder width apart and gently bounce. Keep your back straight and looking up, letting your heels raise up but not letting your toes leave the floor. Start out with 20 bounces and build up to 50 bounces 3-4 times a week.
Stronger:10 exercises for a longer healthier life by David Vaux is available now
