THE 90 DAY

KNEE
ARTHRITIS
REMEDY

AN UNCOMMON GUIDE
TO SWITCHING ON YOUR
BODY’S NATURAL
HEALING POWER
DOUG KELSEY, PT,
PHD
Copyright © 2010 to present by Doug
Kelsey. All rights reserved, including
the right of reproduction in whole or in
part in any form. No parts of this book
may be reproduced in any form
without written permission of the
copyright owner.
The author and publisher have used
their best efforts in preparing this book
and the instructions contained herein.
However, the author and the publisher
make no warranties of any kind,
express or implied, with the regard to
the information contained in this book,
and specially disclaim, without
limitation, any implied warranties of
merchantability and fitness for any
particular purpose.
Notice of Liability
In no event shall the author or the
publisher be responsible or liable for
any loss of profits or other commercial
or personal damages, including but not
limited to special incidental,
consequential, or any other damages, in
connection with or arising out of
furnishing, performance, or use of this
book.
Trademarks
Throughout this book trademarks are
used. Rather than put a trademark
symbol in every occurrence of a
trademarked name, we state that we
are using the names in an editorial
fashion only and to the benefit of the
trademark owner with no intention of
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Thus, copyrights on individual
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 TABLE OF CONTENTS

1. Thank You
2. Note to Readers
3. Introduction
4. How to Use this Book
5. What You Need to Be
Successful
6. Three Sets of Ten
7. Not All Pain Is The Same
8. Most Common Painful
Conditions of the Knee
9. A Primer on the Knee Joint
10. A Primer on Articular Cartilage
11. A Primer on Tendon
12. The Suspension System
13. Biomechanics and Knee Pain
14. Knee Pain and Bending the
Narrative
15. The Loss of Equilibrium
16. A Primer on Pain
17. What I’ve Learned About Pain
18. Benchmarking
19. Gravity is King
20. Demand, Capability, and Pain
21. Common Treatments for Knee
Pain
22. The Myth of Stretching
23. Common Exercises Used for
Knee Pain
24. Beating Knee Pain is an Inside
Job
25. How to Improve Joint Health
Without Exercise
26. When a Good Knee Goes Bad
27. Joints Are Not Muscles
28. Choices Are Everything
29. Guidance Glitches
30. A Primer on Strength
31. A New Kind of Cross Training
32. Core Strength
33. Test Leg Strength (Weight
Bearing Capacity)
34. How to Get the Most Out of
Exercise
35. Suspension System
Strengthening
36. Strengthening Quadriceps
37. Joint Strengthening Laws
38. Core Exercises
39. Leg Exercises
40. How to Know if You Need a
Coach
41. The Routine
42. The Routine Addendum:
Athletic Preparation
43. Return to Running
44. Tools and Equipment
45. Forms and Videos
46. About the Author
Spread the Word
Notes
Chapter 1
THANK YOU

T o say thank you for purchasing

The 90 Day Knee Arthritis
Remedy, I’ve created an additional
video series via email that you can
get for free.

Click the image to get the video

series
Click here to enter your email
and get the exclusive video
content.
Chapter 2
NOTE TO
READERS

T he material in this book is for

informational purposes only
and is not intended to serve as a
replacement for the advice of your
medical doctor or therapist.
Please discuss all aspects of the
The 90 Day Knee Arthritis Remedy
with your physician or therapist
before using any of the information
in the book. If you have any medical
conditions, or are taking any
prescription or nonprescription
medications, see your physician
before beginning the program or
altering or discontinuing your use of
medications.
I suggest certain web sites and other
sources as potential resources of
information, however, this does not
mean that I endorse any of the
information it may provide or
recommendations it may make.
Likewise, the fact that my own Web
site is listed does not mean that I
endorse any of the information it
may provide or recommendations it
may make.
Nothing in the title or content of this
book is intended to suggest that the
use of the recommended
supplements or programming will
fully eliminate osteoarthritis.
The evidence, which is carefully
presented in this book, supports that
the information and
recommendations are frequently
effective, even for long periods of
time. Even so, I offer no guarantee
that every individual will benefit
from the information in this book.
Chapter 3
INTRODUCTION

T his book provides an in depth

analysis of one of the most
common problems people face,
especially over the age of 40 - knee
pain.
When you can’t move the way you
need to or want to because your
knee hurts, life is a lot less
enjoyable.
But there’s no such thing as perfect.
Neither perfect knees nor a perfect
life.
As you will discover in this book,
there is a lot you can do to improve
the health of your knees which, in
turn, will improve the quality of
your life.
Over my career as a physical
therapist, clients tend to ask certain
questions about knee pain.

Why does my knee hurt?

Why am I not getting
better?
What should I be doing to
get better?
How do I know I am
getting better and how long
 will it take?
How do I maintain my new
condition?

We’ll explore the answer to these

questions and help you get on the
best path to improve your knee but
keep in mind that a book can never
replace working directly with a
practitioner who understands how
joints heal and strengthen.
There are several conditions that
can cause knee pain. This book
covers the most common ones:
osteoarthritis, chondromalacia
patella, and patellofemoral pain
syndrome.
I’ll explain how these problems
develop, how they present
themselves to you, and what to do
about it.
The approach I developed is based
on the science of “mechanobiology”
- how the application of external
force alters the internal
biochemistry of injured tissues.
Bone, tendon, ligament, cartilage,
muscle, fascia all respond to
external stress or load. Too much
load, more than what the tissue(s)
can withstand, you end up injured.
Too little load over too long of a
time, your body gets weaker.
Leading an active lifestyle requires
your body to be strong enough to
withstand the forces produced by
the various activities you enjoy. For
example, if you like to run or
engage in a sport, your knee will be
exposed to forces produced by your
feet striking the ground over and
over. If either during or after the
activity, you notice that your knee
hurts, aches, or is swollen, you can
conclude that your body is unable to
withstand those forces.
Notice I said body and not just
knee.
This is because your knee does not
work by itself. Your whole leg and
trunk is involved in any activity that
requires your foot to strike the
ground or what is often referred to
as weight bearing or closed chain:
hiking, walking, running, tennis,
going up and down stairs, squatting,
jumping and more.
Most of life involves weight
bearing or closed chain activities.
Using the principles of
mechanobiology, we can design
exercises to help the various tissues
- muscle, bone, cartilage, tendon,
etc - improve their strength.
Strengthening your knee is more
than just strengthening the muscles
around you knee.
While this is helpful and often
needed, it’s only a part of a
complete strengthening program.
By integrating the concepts of
mechanobiology with optimal
nutrition, you will unlock your
body’s natural healing power.
You’ll feel better and increase your
physical ability so you can enjoy
life again.
Chapter 4
HOW TO USE THIS
BOOK

A void jumping immediately to

the section on the exercise
regimen. I know that’s tempting but
for long term success you need the
knowledge and principles that
support the routines.
There are various physical tests in
the book. These are not difficult to
do. To record your results, please
use the included test data sheet.
Also track your exercise routine
details on the included data
collection sheet.
Proceed through the book one
section at a time.
If you would like personal guidance
and coaching, we offer this service
through The Kelsey Group.
Contact my colleague Laurie Kertz
Kelly for a free 20 minute Strategy
Session. To learn more about
Laurie, visit her website by clicking
here or visiting www.
kertzcoaching.com.

Forms and Videos

The forms and instructional videos
are located in the Forms and Videos
chapter near the end of the book.
Chapter 5
WHAT YOU NEED
TO BE
SUCCESSFUL

T he person who will benefit the

most from this book will have
these characteristics:

A diagnosis of
osteoarthritis, tendonitis
/ tendonosis,
chondromalacia patella,
or patellofemoral pain
syndrome. If you know
you have a meniscus tear, a
subluxing patella, or a
condition other than those
listed above, the solutions
for these conditions are
different than what I
present in this book.
No more than mild to
moderate wear or loss of
the joint cartilage (Stages
1 - 3). Severe loss of joint
cartilage is a much more
difficult problem to solve
and often requires a
personalized program and
sometimes an invasive or
surgical procedure.
Intermittent knee pain. If
you have constant knee
pain, knee pain at rest,
pain that doesn’t improve
or go away, you should see
a physician to determine
the nature and cause of
your pain.
A strong desire to be
active with a clear
objective. This is
important because you
must have a long term goal
beyond, “I just don’t want
to hurt” in order to fully
upgrade your knee.
A self-starter and a
desire to learn. Much of
what I present in this book
 will be new to you. In
order to get the full benefit
of the material, you must
want to learn and be
comfortable applying what
you learn independently.
The necessary exercise
tools. I list suggestions in
the chapter “Tools and
Equipment”. The
recommended tools are
inexpensive and readily
available (and we have no
financial interest in any of
the equipment we suggest).

I strongly advise against mixing

other exercise approaches or
regimens with this material. Doing
so could easily over load your body
and make it more difficult to
determine the cause.
Plan on committing at least six
months of time to the book material.
Chapter 6
THREE SETS OF
TEN

W hen you can’t move the

way you need to or want to
because your knee hurts, life is a lot
less enjoyable.
However, the most common non-
surgical solution practitioners use
is a muscle first approach -
strengthening the leg muscles of the
affected knee.
The theory is that if you have
stronger muscles, you can protect
the painful knee.
The prescription is often something
like straight leg raises, quad sets,
wall slides, hip raises, stretching.
And the dosage, or the number of
repetitions and sets, is almost
always three sets of ten repetitions.
Why is that?
Good question.
The story behind Three Sets of Ten
dates back a long time.

In the 1940’s, from polio and World

War II (WWII), there were a large
number of young men in need of
physical rehabilitation.
The physical therapy approach at
the time was “light exercise” since
many of the patients treated up to
and through WWII had
poliomyelitis.
Poliomyelitis is an infectious
disease caused by the poliovirus.
The disease attacks nerve cells in
the spinal cord and destroys the
connection to the associated
muscles.
The muscles then permanently
weaken and shrink.
As a result, physicians and
therapists believed that post-polio
patients could not withstand heavy
loads or resistance exercise. The
muscles had wasted away and no
longer worked properly. The
common techniques at that time
included assisted exercise with a
pulley system or exercise in water
with an emphasis on high volume of
repetitions.
As injured soldiers returned home
for care, the approach used with
post-polio patients carried over to
patients injured in the war.
Dr. Thomas Delorme had rheumatic
fever as a child. Rheumatic fever,
now rare, was caused by a bacterial
infection and often damaged the
heart.
The treatment for this condition, in
the 1920’s, was rest.
While Delorme spent four months in
bed recovering from the disease, he
read a lot. He read about Medicine
and various magazines on exercise
and conditioning.
Once he was out of bed, Delorme
began weight lifting. Over the
course of about 11 years, he
transformed himself from a skinny,
frail boy to a strong, well-
conditioned young man.
By the time Delorme was 28, he
could deadlift over 500 pounds.
He went on to medical
school, first in
Alabama and later in
New York.
But in 1944 he was
Todd JS,
called for duty and Shurley JP,
reported to Gardiner Todd TC.
General Army Thomas L.
DeLorme
Hospital. While he and the
science of
was there, he met progressive
Sargent Walter Easley resistance
who had sustained a exercise. J
Strength
knee injury from a Cond Res.
parachute jump. 2012
Nov;26(11):29
Easley had been in 23.
rehabilitation for six
months by the time he
met Delorme and was frustrated
with his lack of improvement and
that his doctors told him he would
always have to wear a knee brace.
The treatment of the day was rest,
heat, and light exercise.
He wanted Delorme’s opinion.
Delorme examined Easley and
concluded that the problem was
significant muscle atrophy and
weakness of Easley’s injured leg.
Easley followed Delorme’s
protocol which was 7 sets of 10
repetitions using as much weight as
could be managed.
Four weeks later, Delorme’s
protocol had transformed Easley’s
knee. Easley threw away the knee
brace. His function was normal.
Word spread about Delorme’s
success which lead to a clinical
trial of his protocol. The results of
the trial changed the world of
physical rehabilitation.
In subsequent work, Delorme found
that 3 sets of 10 repetitions worked
as well as 7 sets.
In 1945, the Surgeon General
ordered the therapists of the U.S.
Army to follow Delorme’s strength
program which he later renamed
“Progressive Resistive Exercise”.
I learned the Delorme protocol
when I was in PT school. It was the
gold standard for physical
rehabilitation.
The problem with the program
however is in how it’s used and
with what kinds of physical
ailments.
Delorme worked mostly with
younger people (remember it was
WWII) and at that time
osteoarthritis was not as prevalent
as it is today.
If your problem is muscle
weakness, the Delorme program
will work but you have to follow
the rules.
Delorme’s three sets of ten were
based on something called a “10
repetition maximum” or “10RM”.
This is the amount of weight you
can lift (or push, pull, etc.) no more
than 10 times.
The first set is 50% of the 10RM,
the second set is 75% and the third
set is 100% of the 10RM.
The challenge is determining the
10RM especially if your knee hurts.
The test must not elicit pain in order
to determine the proper amount of
weight.
For example, let’s say you sit on the
edge of a table and strap a 10lb
weight to your right lower leg just
above the ankle.

Knee extension exercise

And let’s assume it’s your right

knee that hurts.
Now, straighten your knee, lifting
the foot upward over a four second
count until the knee is straight and
then lower it over a four second
count.
This is one repetition. Do as many
repetitions as you can.
Let’s say you could do 5 and then
you noticed knee pain.
With the opposite leg, you could do
20.
Because your knee hurt, we don’t
know the true strength of the
muscle. We could assume it’s equal
to or close to the left leg but that
doesn’t help us much in designing
an exercise regimen.
We could lower the weight to 5
pounds and repeat the test. Perhaps
this time you can do 10 repetitions
before your knee hurts.
Again, it’s not muscle fatigue that
is stopping you. It’s pain.
As a muscle test, the results are
invalid.
What happens in practice is
clinicians will often not test for the
10RM because it’s too time
consuming and the test results are
often invalid.
Instead, they use a random amount
of weight, instruct the patient to
perform 10 repetitions, 3 sets and
then ask the patient if that exercise
was tiring.
Sometimes they don’t ask either.
They just assume it is.
I’ve seen this happen over and over
with students who interned with me.
With this kind of scenario, not much
therapy is happening. Because the
load is so low, no muscle
strengthening takes place. And, as
you’ll discover later, because there
is so little motion, no joint
strengthening takes place either.
It’s a waste of time for both parties.
The Delorme protocol works well
if the problem is muscle weakness.
It doesn’t work so well if the
problem is joint weakness.
Chapter 7
NOT ALL PAIN IS
THE SAME

E ven though the pain may be in

your knee and yes, your pain
may be from a combination of
weaknesses, you could have pain
from a source elsewhere in the
body. So if you notice any of the
following, get medical help quickly
for an assessment:

Pain during the night

Unexplained weight gain
or weight loss within six
months
 Pain at rest
Pain that fails to improve
after 6 weeks
Bowel or bladder
disturbances
Fever
Pain that doesn’t go away
with a change in position

There are a number of pathologies

or medical diagnoses that can lead
to anterior knee pain. Below is a
partial list:

Articular Cartilage Injury

Bone Tumors
Chondromalacia Patellae
Hoffa's Disease
Iliotibial (IT) Band
Syndrome
Loose Bodies
Neuromas
Osgood-Schlatter Disease
Osteochondritis Dissecans
Patellar
Instability/Subluxation
Patellar Stress Fracture
Patellar Tendinopathy
Patellofemoral Arthritis
Pes Anserine Bursitis
Plica Synovitis
Prepatellar Bursitis
Previous Surgery
 Quadriceps Tendinopathy
Referred Pain from
Lumbar Spine or Hip Joint
Pathology
Saphenous Neuritis
Sinding-Larsen-Johansson
Syndrome
Symptomatic Bipartite
Patella

Knee pain can be referred from the

lumbar spine (lower back) or hip.
You can also have knee pain from a
stress reaction (an overload of the
bone), a stress fracture, or complete
fracture.
If you have any doubts about your
condition, seek the advice and
medical opinion of a trusted health
care provider.
Chapter 8
MOST COMMON
PAINFUL
CONDITIONS OF
THE KNEE

A s I listed in Chapter 4, there

are a number of conditions
that can cause pain in the knee but
most orthopedic knee pain is from a
few sources.

Osteoarthritis
Osteoarthritis (OA) is the most
common form of arthritis affecting
over 30 million Americans. The
roots of the word, osteo = bone,
arth = joint, and itis = inflammation
and when combined mean
inflammation of a bone joint. It is
sometimes called Degenerative
Joint Disease or Osteoarthrosis
(because more often than not the
joint is not inflamed), is most often
found in the hip and knee joints
(although it can affect any synovial
joint) and more often in women than
men.
The condition results from a
weakening and deterioration of the
articular cartilage lining the bones
of the joint.
Chondromalacia Patella and
Patellofemoral Pain Syndrome are
also conditions in which the
articular cartilage is weak or
injured.
Articular cartilage is a tough,
rubbery and slick substance that
covers the end your bones. Its job is
to provide a nearly friction free
environment while also protecting
the bones from excessive force
(more about cartilage in a later
chapter).
The primary symptoms of OA are
pain, aching, stiffness, swelling and
weakness. These symptoms often
interfere or prevent weight bearing
activities - walking, squatting,
certain kinds of exercise for
example.
The diagnosis of OA is based on
signs and symptoms (a sign is
something a practitioner can detect
while a symptom is what you feel
or experience) and is divided into
four stages.
 Stages of Osteoarthritis

Stage One is minor. Symptoms are

few and infrequent. The most
common symptom is a sense of
stiffness or fullness in the knee with
occasional aching. Weight bearing
activities - certain kinds of
exercise, running, walking, hiking -
can cause the symptoms which can
be delayed a day or more from the
activity. Most people at this stage
do not seek medical care.
Stage Two is mild. X-rays will not
show any loss of space between the
bones but there may be some small
bone spurs. Symptoms are more
often and more noticeable. You
might feel stiffness or pain in your
knee after sitting for a period of
time or near the end or after an
exercise session.
Stage Three is moderate. At this
stage there is evidence of loss of
space between the bones on x-ray.
Your knee joint is more apt to be
inflamed, you tend to hurt more with
weight bearing activities and it
takes longer for the symptoms to
subside. You may also hear
snapping sounds or popping kinds
of noises in your knee.
Stage Four is severe. On x-ray
there is considerable loss of joint
space along with much larger bone
spurs. The bone under some parts of
the cartilage may be exposed. There
is much more pain, aching, stiffness
even at rest.
General consensus is that OA is a
progressive disease which means it
gets worse over time if nothing is
done about it.
Your chances of slowing the
progression of the disease and
maintaining an active lifestyle are
much better if you take action at
Stage One or Two. Stage Three is a
more difficult road but not
impossible. Stage Four most often
results in surgery, usually a Total
Knee Replacement.
How does OA evolve?
The first signs of OA include a
sense of stiffness and / or aching in
the joint. The articular cartilage,
normally a tough and slick
substance, develops tiny defects on
the surface that can cause
microscopic slivers of cartilage to
slip into the joint fluid. The
presence of these flakes of cartilage
in the fluid sets off an inflammatory
reaction in the joint - hence, the
feeling of fullness (swelling)
aching, stiffness.
Gradually, over many years, the
cartilage breaks down progressing
through the four stages of the
disease unless something is done to
slow the progression.
Risk Factors
The one known risk factor for
Primary OA is being overweight
(this means carrying excess body fat
not weighing more because of
added muscle mass). Genetics
likely also plays a role but thus far
science has not demonstrated a link
(OA does tend to appear in families
but no specific gene has been
found).
People who carry extra weight
place an increased load and stress
on the joint which can hasten the
development of OA. Women who
are overweight have four times the
risk of knee OA and overweight
men carry five times the risk than
their counter parts who are not
overweight. 1
By reducing body fat, you can
dramatically reduce your risk of OA
(and if you have OA, losing weight
can greatly help your joints). If you
can lose weight to move from the
overweight to healthy weight range,
you can lower your risk of OA by
almost 25%.
There are other factors that many
professionals place in the general
category of “causation”. I go over
those later in the book.
 Source: World Health Organization

Tendinopathy
A tendon is a form of connective
tissue that transmits force from
muscle to bone. The tissue blends
from the muscle fascia into a
distinct structure which then inserts
into the bone. It helps stabilize
joints in some instances, while in
others, it helps move joints.
Tendons have both a blood supply
and a nerve supply. Because of this,
the healing rate of tendon is faster
than cartilage although is still
considered to be slow overall
(when compared to, for example,
muscle).
But tendons respond to mechanical
load (such as exercise) which can
alter their metabolism and structure.
Tendons will get thicker and
stronger with appropriate physical
conditioning training. A healthy
tendon will be twice as strong as
the muscle it attaches to.

Knee tendons

​But, excessive force or even

aggressive stretching leads to
overuse injuries which can cause
tendinitis or tendinosis - both are
types of tendon injuries.
Tendinopathy is a general heading
for two types of tendon overuse
injuries.
Tendinitis is an inflammatory
condition of the tissue. In most
cases, it comes from performing a
new activity or an activity you’re
used to but with greater duration or
force.
The area will be tender to touch or
pressure and anytime the tendon is
used, you will hurt.
Tendinitis however is generally
short lived and often resolves on its
own. There’s some evidence that
tendinitis can convert to tendinosis.
In fact, most of the problems people
struggle with in everyday life or
sports stem from tendinosis and not
tendonitis. 2 The difference with
tendinosis is the tissue is not
inflamed.
If you look at the injured tendinitis
tendon under a microscope, you
won’t find any evidence of
inflammation. The tendon tissue
will however appear disorganized
which means it’s weak. The
disorganization comes from tiny
tears that have not healed or have
healed but the result leaves the
tissue in a weakened state. The
injured area may or may not be
tender and you may not always feel
pain when you use the body area or
the pain might be delayed 24-48
hours.
Because the tendon has a lower
metabolism than muscle (which I
discuss in more detail later in the
book), the way you exercise to help
it heal is not the same as exercising
a weak muscle. For now, just make
a mental note that muscle and
tendon are not the same kind of
problem and therefore need
different approaches.
What Causes Tendinosis?
In most cases, tendinosis is caused
by overuse (there are other factors
that many professionals place in the
general category of “causation”. I
cover those later in the book).
What does “overuse” mean?
For someone who exercises / trains
regularly, it means increasing the
training intensity too fast or training
too long with insufficient rest or
recovery.
For a person who is new to
exercise, overuse generally is doing
too much, too fast (this can also
happen in the well-trained group).
Ben, 46 years of age, knew he was
overweight. He was healthy
otherwise, no aches or pains, and
all of his medical measurements
(heart rate, blood pressure, etc)
were in line.
Because of his busy schedule, Ben
decided to start running as a way to
lose weight.
He started out four days a week
running about two miles per day at
a pace, in his estimation, of a ten
minute mile.
After about six weeks, he had lost a
few pounds, was feeling good and
optimistic so he increased the runs
to five miles per day at roughly the
same pace.
A month later he noticed pain in the
front of his right knee. It only
seemed to bother him after he ran so
he didn’t think much of it.
He continued running.
But, two weeks later, his knee now
bothered him when he wasn’t
running and it also hurt to ascend /
descend stairs.
Ben’s situation is quite common.
You could use a different activity,
for example, an exercise class, but
if you use the same kind of dosage -
too much, too often - the result will
be similar to Ben’s.
The repeated stresses produced by
his foot hitting the ground, called
micro-stresses, gradually wore
down the tendon creating small
tears in the tissue. The tendon grew
weaker and weaker and its method
of “talking” to Ben was the brief
periods of pain he noticed after
running.
If the tendon could speak, it might
have said, “Hey Ben buddy! This
running stuff is too much for me.
Could you take it a little easier? I’m
feelin’ it down here!”
Since tendons are inherently
stronger than the muscle they attach
to, the tendon acts as a kind of
spring storing a considerable
amount of elastic energy to be used
when the foot hits the ground. If the
tendon is weak, then it loses its
protective elastic element and the
force cannot be dissipated
adequately. 3

The signal from Ben’s body, the

first appearance of pain, was when
Ben should have stopped, re-
evaluated what he was doing and
even sought guidance. But his
reaction, to ignore the pain or think
he was just “doing too much” is
quite normal.

PatelloFemoral Pain Syndrome

Patellofemoral Pain Syndrome
(PFPS) describes the pain
emanating from the interaction
between your kneecap and your
thigh bone. It is also called
Runner’s Knee Syndrome (RKS). In
addition to PFPS and RKS, another
term frequently used to describe it
is Chondromalacia Patella or
softening and fissuring of the
cartilage that covers the underside
of the kneecap.
In medicine, when we don’t know
the exact nature or basis of a
problem, we call it a SYNDROME
(by the way, the word “syndrome”
comes from the Greek word
SUNDROMOS which means “run
together”). A syndrome is a
collection of signs (physical
expressions) and symptoms
(complaints) that appear together
with sufficient frequency to become
a recognizable pattern. In most
syndromes, there is no clear
anatomic or physiologic cause. A
syndrome characterizes an
abnormality but cannot explain it.
For example, perhaps you have
heard of Chronic Fatigue Syndrome
(CFS), a disorder characterized by
exceptional fatigue that worsens
with either mental or physical
activity and does not improve with
rest. Frequently, there are other
symptoms that run together with the
fatigue such as weakness, memory
loss, sore throat, muscle pain, and
headache. There is no known cause
for CFS and consequently no clear
treatment path.
For a lot of people with PFPS,
there isn’t a specific injury or a
easily identified event that
preceded the discomfort. It just
seems to sneak up on you. This can
leave you wondering what
happened, why your knee hurts and
what to do about it.
I cover the commonly thought
causes of PFPS in the chapter
“Biomechanics and Knee Pain”
Chapter 9
A PRIMER ON THE
KNEE JOINT

T he knee joint is comprised of

three joints with four bones.
One joint is between the femur
(thigh bone) and tibia (shin bone).
Another one is between the patella
(knee cap) and the femur and the
third is between the tibia and fibula
(the small, thin, long bone on the
outside of the lower leg).
 Knee Joint Anatomy

A lining on top of the bones and on

underside of the patella is a special
tissue called hyaline cartilage
(articular cartilage). This cartilage
is exceptionally strong, slick, and
only about 1.5 to 2.0 millimeters
thick (about equal to two stacked
credit cards). Its job is to provide a
nearly friction-free gliding surface
while also protecting the underlying
bone by reducing the transmission
of force.
Your knee joint is held together
partly by a “joint capsule” - a
ligamentous sac that connects to the
bones. On the inside of this sac is a
thin membrane - the synovial
membrane.
The joint capsule is water tight so it
can hold fluid. The synovium
(synovial membrane) produces the
fluid - synovial fluid - which
provides a source of nutrition to the
cartilage, lubrication for the joint,
and even acts as a load bearing
aide. 1

Inside the knee - lateral view

The synovial fluid not only helps

keep your knees moving easily but
also serves as a source of nutrients
for the articular cartilage since
cartilage has no direct blood
supply.
Ligaments connect the bones to each
other and tendons connect muscles
to bones. Fascia, a kind of
biological fabric, surrounds the
muscles connecting the muscles to
tendons, bones and other muscles.

Cross section of thigh

The muscle enveloped in the fascia
is often referred to as myofascia.
This tensile system is responsible
for controlling how joints move and
how the forces are distributed
through the body.
The knee joint is what’s called a
“hinge” joint. It’s movements are
primarily a bending motion
(although technically there is some
movement side to side and a tiny
amount of rotation).
The knee joint however rarely
moves in isolation of other parts of
the body especially the hip, above
it, and the ankle & foot below it.
The hip, knee, and ankle/foot could
be considered a three joint system
with each influencing what happens
at the other. Consequently, keeping
your knee healthy and strong means
also having a healthy, strong hip and
ankle/foot joint.
Chapter 10
A PRIMER ON
ARTICULAR
CARTILAGE

A rticular cartilage (for our

purposes, we’ll use the word
“cartilage”), is a slick, tough
connective tissue that covers then
ends of bones that form joints. This
tissue is considered by many in the
medical world, once injured or
worn down, unable to heal without
an invasive procedure such as
surgery.
In Physical Therapy school, I was
taught that cartilage was
“biologically inert” or “bioinert”.
Something that is bioinert means
that it has no life, does not interact
with the body. In other words, it
would have no metabolism.
Metabolism or metabolic rate refers
to the chemical processes that occur
within a living organism in order to
maintain life. The material used in
joint replacements, for example, is
bioinert (you wouldn’t want the
material to cause a negative
reaction with the body). Contact
lenses are another example of
bioinert substances.
So, why would cartilage, located in
the body and developed by the
body, be bioinert and have no way
of maintaining its existence? And if
that’s true, how did it get there?
The consensus in my orthopedics
class was that because cartilage had
no direct blood supply, it couldn’t
heal. If it couldn’t heal then it must
be bioinert.
I raised my hand in class and asked,
“So, how does something survive in
the body if it’s bioinert?”
Some professors object to pointed
questions and mine did. His
response was that you get one dose
of good cartilage and once you
injure it, too bad.
Since then, science has shown that
my professor was wrong. Cartilage
is not bioinert. It has a metabolism
but it’s slow. 1The slowest
metabolism in the body along with
intervertebral disc.
Cartilage is a tough, fibrous, elastic
tissue with no direct blood supply
and no nerve supply.
 Articular cartilage lines ends of
bones

Healthy cartilage is both stiff and

slippery and protects your joint
from every day impact forces. It
provides a nearly friction free
surface - slicker than a skate on ice.
The impact protection comes from
corralling water molecules into
small groups and binding them
together creating a cushion similar
to taking a large piece of foam and
wrapping rope around it from all
directions which enhances the
stability of the cushion.
Cartilage has an unusual make up.
Once fully developed, the cells
isolate themselves from each other
unlike other tissues of the body
which have direct cell to cell
contact (skin cells for example).
Cell to cell contact greatly aids in
responding to injury, as the cells
can send signals to other cells
recruiting certain ones to clean up
debris and others to begin forming
new tissue.
The result of isolation is a longer
healing time. The lack of blood and
nerve to cartilage makes both the
recognition of injury and recovery
difficult and prolonged.
Cartilage cells only talk to each
other through what is known as the
extra-cellular matrix. This matrix is
a complex mixture of proteins and
sugars that act like a three-
dimensional spider web. The matrix
is responsible for making cartilage
stiff by attracting and binding water.
The pressure from physical loading
and unloading (for example, placing
weight on your foot and removing
the weight) exerted on and within
the matrix is transferred to the
cartilage cells.
The pressure applied to the joint
and the cartilage serves as the
communication highway for
cartilage cells.

….human cartilage responds

to physiologic loading in a
way similar to that exhibited
by muscle and bone, and
that previously established
positive symptomatic effects
of exercise in patients with
OA may occur in parallel or
 even be caused by improved
cartilage properties.

This is how cartilage cells know

what to do. If the loading pressure
is too great, the matrix begins to
come apart, water escapes, the
internal pressure drops, and the
cartilage cells have little
stimulation (and remember,
mechanical stimulation is what
makes all tissues stronger which
means you must use it or lose it).
However, proper magnitude and
duration of the pressure alter gene
expression and metabolism leading
to a stiffening of the matrix and a
stronger joint.
But, there’s a limit to what the body
can overcome when cartilage is
weak or injured.
If the damage is great enough,
especially if the underlying bone is
exposed, the cartilage cell
communication is impaired and any
healing or strengthening is nearly
impossible.
The process of toughening up the
cartilage can take a long time, many
months or in some cases years.
Some people may experience relief
of symptoms within a few months
but the cartilage likely still needs to
be stimulated.
A client of mine, Roger (not his real
name), was 35 and had right knee
pain for a few years. He had seen
an orthopedic surgeon who told him
his problem was chondromalacia or
softening of the cartilage.
When I started working with Roger,
he found daily activity painfully
difficult - walking up his driveway,
squatting down to pick something
up, playing with his two young
children. He couldn’t snow ski - a
passion of his - and couldn’t
exercise intensely enough to get in
condition for it either.
I worked with Roger in the clinic
for three months at the end of which
he was no longer symptomatic but I
told him he had another several
months before his knee would be
sturdy enough to exercise intensely
or try snow skiing.
Because he felt okay, my words
didn’t stick. I saw him again four
months later after he had gone snow
skiing. His knee couldn’t handle
that much load day after day. It
didn’t take long for him to get
control of his symptoms and this
time, he followed my advice and
kept working on his knee.
The following year, he resumed
snow skiing and had no problems.
Cartilage injuries force you to be
disciplined, patient, persistent and
that is the most difficult part of
strengthening the joint.
Chapter 11
A PRIMER ON
TENDON

A tendon is a form of
connective tissue that
connects a muscle to bone. In the
knee, the patellar tendon connects
the patella (knee cap) to the tibia
(shin bone). Some texts will also
describe tendons in the same family
as ligaments but for our purposes,
we will keep them separate.
 Patellar Tendon

Tendon’s are remarkably sturdy. For

example, the tensile strength of
tendon - the force at which the
tissue breaks - is over 13,000
pounds per square inch. 1 For
comparison, the breaking point of a
1” bar of steel is close to 60,000
pounds per square inch.
By nature, tendon is much stronger
than muscle. You can run, jump, lift,
throw and do all sorts of physically
demanding things and the tendon
says, “Is that all you’ve got?”
The load the Achilles tendon
receives during running, for
example, can be to 12.5 times
bodyweight. 23
Strong indeed.
Injuries can range from tiny,
microscopic tears to rupture.
Tendon injuries are one of the more
common activity related problems
people face.
Runners, for example, are often
plagued with knee tendon problems
accounting for 30% of all running
related injures. 4
Because a tendon’s blood supply
isn’t as ample as muscle, the tissue
takes much longer to heal. A lower
blood supply means less oxygen,
less oxygen means a lower
metabolism. For tendon, that means
7.5 times less oxygen than that of
muscle. 5
One of the benefits of the low
metabolic rate and lower oxygen
consumption is that tendons can
withstand loads for a long time. But
the downside is the slower healing
rate. 6
Tendons heal best by applying some
degree of tension force to the tissue
rather than immobilizing the joint.
This is true for nearly all soft
tissue, non-rupture injuries. Moving
the area in a controlled way is a key
component of healing.
Chapter 12
THE SUSPENSION
SYSTEM

I f your quadriceps muscle has

atrophied and you have
difficulty making it contract, there’s
a very good chance that the entire
Suspension System is weak.
Your Suspension System consists of
muscle, connective tissue (fascia,
tendons) and the joint surface
(cartilage).
You need a strong quadriceps no
doubt. Strengthening your
quadriceps muscles (thigh) can help
your fight against knee pain.
But there's another aspect to
strengthening that you may not know
about.
Muscles are wrapped in a tough yet
pliable connective tissue referred to
as fascia. It’s a sort of biologic
fabric. The term "fascia" comes
from the Latin for "band" or
"bandage". This connective tissue
sheath envelopes the different
layers of muscles and connects, for
example, muscles in the lower leg,
to muscles in the hip and trunk.
The fascial sheaths connecting
muscles to each other as well as to
tendons and bones is often referred
to as a "myofascial sling".
When a muscle contracts, it
produces a force within that muscle
but the force spreads beyond the
local attachments via the myofascial
sling.
These muscular forces produced far
from the original muscle create a
force vector - a line of force with a
magnitude and direction.
Overlapping myofascial slings can
interconnect with other slings
creating complex vector
arrangements that cross multiple
joints.
Depending on the activity, the
balance of forces delivered via the
myofascial sling vectors provides
controlled, balanced movement and
distribution of loads. When the
vectors become imbalanced due to
weakness, disuse of certain
muscles, or injury, the tension
within a myofascial sling drops
which creates a disturbance within
the force vectors.
A well developed biologic
Suspension System is a tensegrity
structure.
Tensegrity refers to the balanced
tension among various members to
create structural integrity. The
tensegrity concept is used in
architecture for bridges and
buildings. The combined tension
among cables and beams makes the
structure remarkably strong yet
lighter weight than steel beams.

Source: https://www.fenner-
esler.com

When you climb a flight of stairs,

the lower leg muscles contract
creating tension in the fascial
sheaths which in turn add tension to
the trunk and hip muscles creating
greater stability.
Inadequate muscle strength creates
an inadequate and imbalanced
myofascial sling network and in
turn can overload the knee joint.
For example, hip weakness is
linked with knee pain. 1
Back to you, your quadriceps
strength will be a critical factor for
recovery but the quadriceps
functions within the myofascial
sling of the hip and trunk. If your
hip and trunk muscles are weak,
then even if you can develop
quadriceps strength, you may still
be at risk of re-injury or have a long
road to recovery.

Example of Myofascial Sling on

Function
The impact of myofascial force
vectors on function occurred in one
of my clients.
He had persistent cramping and
pain just below and behind his right
knee extending into the right calf.
He didn’t recall injuring the knee
and noted that the pain and
cramping would come and go. We
couldn’t find any activity that
seemed to consistently provoke his
symptoms and his examination was
mostly unremarkable.
I referred him to an orthopedist who
sent him for an MRI which was
negative. I then sent him to a
neurologist. His exam was negative
so the neurologist referred him for a
Doppler ultrasound (a test used to
detect abnormalities with the
vascular system). This test was
negative too.
After all of these evaluations, we
were right where we started.
On a hunch, I gave my client a pair
of compression shorts. I thought that
if he had some type of myofascial
injury, then perhaps the extra
compression from the shorts might
be enough to act like an artificial
fascia.
As soon as he put on the shorts, he
noticed improvement. And as long
as he wore the shorts, he had no
symptoms.
I knew of a physician who used an
innovative ultrasound technique to
visualize the integrity of the
myofascial connections. I referred
him for a consult.
The result of the consultation was
that my client had tears in the
myofascial network on the inside of
the thigh directly above the knee.
This is where a large bundle of
nerve and blood vessels run down
into the lower leg. The area through
which they traverse is like a tunnel
of connective tissue and, in my
clients case, the tunnel had
collapsed.
With enough movement and load,
the nerve would become irritated
from the loss of freedom within the
connective tissue tunnel which in
turn would cause the calf cramp and
knee / lower leg pain. With rest, the
irritation would subside and his
symptoms would as well.
We resolved his problems with a
special kind of injection, Platelet
Rich Plasma (PRP), followed by
physical rehabilitation. After about
four months of rehab, he no longer
had any of the original symptoms
and could function at an athletic
level.
My client’s case is uncommon.
Most people with knee pain do not
have a tear in the connective tissue.
It’s more often that the suspension
system is weak but his case
demonstrates the importance of the
myofascial slings’ role in physical
function.

1 Boling, M. C., Padua, D. A., &

Alexander Creighton, R. (2009).
Concentric and eccentric torque of
the hip musculature in individuals
with and without patellofemoral
pain. J Athl Train, 44(1), 7-13.
Chapter 13
BIOMECHANICS
AND KNEE PAIN

B iomechanics is the study of

how forces from muscles,
movements and gravity affect the
human body.
I was teaching a class about knee
pain to a group physical therapists
several years ago. The subject of
biomechanics always comes up
when discussing joint pain.
One of the students said he thought
the answer to solving knee pain was
making sure clients had flexible
hamstrings and quadriceps muscles.
The muscles are too tight in his
opinion. Another person was
convinced that there was too much
pronation of the foot - a flat foot.
Someone argued that the main issue
was weakness of the quadriceps
while someone else believed it was
a poorly tracking patella.
Variations from the “norm” in
biomechanics is often referred to as
“imbalance” or “abnormal
biomechanics”.
For knee pain, abnormal mechanics
would also include any or all of the
following:
 laterally tracking patella
weak medial quadriceps
tight hamstrings
tight iliotibial band
tight calf muscles
weak or tight hip rotator
muscles
over pronation of the foot.

So, who is right? Which problem is

the cause? What if a person has
several biomechanics
abnormalities?
Most people without knee pain will
have one or more of the
biomechanics abnormalities listed
above.
In one study, 50 people who had
kneecap pain were compared with
47 people who had never had
kneecap pain. The painful group
had better kneecap position and
motion than the non-painful group
as revealed by MRI. 1
In another study of 80 patients with
a diagnosis of PFPS, with all other
likely diagnoses already eliminated,
signs of pathology were found in
only 17 of 75 patients, and the
authors conclude that even these
“cannot be detected from ...
commonly used clinical tests.” 2
In other words, we can’t say for
certain that because someone has a
patella that seems to move
unusually, that it is the cause of the
knee pain.
To further complicate things, some
runners have less than ideal running
form (altered or abnormal
mechanics), yet perform at a high
level without symptoms.
Priscah Jeptoo won a silver medal
in the 2012 Olympic Marathon,
finishing in 2:23:12. She’s a world
class runner with more than one
running mechanical problem:

Priscah Jeptoo running form

Notice how her right and left knee

each lean to the inside. Her right
foot is turned outward and the left
side is similar.
Keep in mind that Priscah is a
world class runner who could not
compete at such a high level if her
mechanical problems caused
persistent knee pain.
So what's the explanation for knee
pain, if it's not mechanics?
Perhaps you’ve heard of Occam’s
Razor? Occam’s Razor is a
principle used in solving problems
that is attributed to a 14th century
logician and Franciscan friar
William of Ockham. In it’s simplest
form, the principle is -
 “When you have two
competing theories that
make exactly the same
predictions, the simpler one
is the better."

If you have several mechanical

abnormalities, which one causes the
symptoms? And if it’s more than
one, will you have to correct all of
them - assuming that all mechanical
abnormalities are correctable?
It’s not unusual to find weakness of
the hip abductors, an overly
pronating foot, an abnormal
position of the patella, tight
iliotibial band, weak quadriceps,
and inflexible hamstrings all in the
same person with knee pain.
Or in a person without knee pain.
Finding the answer and solving the
various mechanical problems is a
complex process at best.
My theory is this: the force your
knee is exposed to is too great for
the soft tissues of your knee and
that’s why you hurt.
My students would often ask why
some people with abnormal
mechanics have knee pain while
other people who have normal
mechanics also have knee pain.
My answer:

Abnormal mechanics +
strong tissue = no pain
Normal mechanics + weak
tissue = pain

Here’s an example.
The force that goes into your knee
to climb stairs is about two times
your body weight.
If you weigh 150 pounds, that’s 300
pounds of force. If your knee tissues
(tendon, bone, synovium, ligament,
muscle, cartilage) cannot withstand
that level of force, you’ll hurt.
If your tissues are strong and you
have abnormal mechanics, you
won’t hurt because the force of the
activity does not exceed the
capacity of the soft tissues.
The problem of knee pain for many
people is not primarily the result of
abnormal mechanics.
The problem is the result of the
weakness of the joint, the muscles
and soft tissue plus the interplay of
mechanics.
In some people, like Priscah
Jeptoo, the soft tissues have
adapted or strengthened so the way
she moves works for her.
Remember that the simpler solution
is the way to go first. Strengthen
your joint tissues, muscles and
improve your ability to move and
see what happens. In many cases,
the pain resolves and mechanics
also tend to improve.
Chapter 14
KNEE PAIN AND
BENDING THE
NARRATIVE

S everal years ago, a friend of

mine said to me, "I'm really
concerned about you."
"Yeah? Why is that? What are you
concerned about?" I replied.
"Because you have hair in your
ears," she said.
I paused, tilted my head, and said,
"Why would that concern you?"
Without hesitation she said,
"Because men with hair in their
ears have heart attacks."
"Really? How do you know that?
Where did you learn that?" I asked.
"Because my father had hair in his
ears and he had a heart attack and I
know other men like that too," she
said with care woven into her
voice.
I explained that I didn't think she
had anything to be concerned about.
Whatever hair was there was
normal, served a good purpose and
until I could braid it, I believed I
was okay. She remained convinced
of her position though (interestingly,
in 1984, a couple of doctors in New
York proclaimed that men with ear
hair were more susceptible to heart
disease. The next year, having been
accused of misinterpreting the data
in a major way, they recanted).
We all bend the narrative from time
to time to fit our perspective--to
make sense of things that don't make
sense to us.

Knee Caps and Knee Pain

If you have knee pain, especially
around the front of your knee,
there's a good chance that someone
along the way has suggested that
your pain is caused by a poorly
positioned patella (knee cap). It's
either tilted, rotated, tipped, or too
far to one side or the other.
Because certain muscles
(quadriceps) attach your knee cap
to your thigh bone (femur),
clinicians logically conclude that
these muscles must be weak; that
the muscles are unable to keep your
knee cap where it's supposed to be
so when you do something like
climb stairs, your knee cap ends up
in the wrong position, tissues get
stretched, squished or twisted too
much and the result is you hurt.
Treatments may include
strengthening exercises for the
muscles or taping of the knee cap
(in an attempt to reposition it), knee
braces, stretching of tissues that
seem tight around the knee cap or
electrical stimulation of the thigh
muscles, or stretching of the IT
Band. Sometimes these things help;
sometimes they don't.
And even if these types of
treatments help, what I've found,
more often than not, was that people
felt better for a day or so but very
few could really do much on their
leg.
As soon as they started climbing
stairs or had to squat down to pick
up something or tried to jog, the
symptoms returned.
This belief, that your knee pain
comes from a poorly positioned
knee cap, is very firmly entrenched
in the medical community even
though the assessment process, how
you figure out that the patella isn't
where it should be, is a completely
unreliable one.
For something to be reliable, from a
scientific perspective, it means that
the results are consistent upon
repeated measurements. So, if your
assessment process isn't reliable, it
means that one time you get one
result and another time you get a
different result. If you plan a course
of action based on unreliable
information, you often end up with
at least a poor result, and
sometimes a disaster (think
weapons of mass destruction in
Iraq.
Ok, so now what? I think of it like
this. The problem of anterior knee
pain (patellofemoral pain
syndrome, chondromalacia) is not
primarily the result of an
abnormally positioned knee cap but
the result of poorly conditioned
tissues which is then exacerbated
by patellar mechanics.
Injured tissue is weak tissue. When
you climb stairs, the force that goes
into your knee cap is about two
times your body weight. If you
weigh 150 pounds, that's 300
pounds of force. If your knee cap
tissues (tendon, bone, synovium,
ligament, muscle) cannot withstand
that level of force, you'll hurt.
It's about that simple.
So, the answer is to somehow
increase the strength of your knee
joint tissues and not just your
muscles while encouraging as
normal movement as possible of the
kneecap or patella.
What I tried first though, back in
1984-85, was conventional muscle
strengthening.
The logic I used - because this is
what I was taught in PT school -
was that if I could make the
quadriceps muscles stronger, the
muscles would take up more of the
force sort of like biological shock
absorbers and they would pull the
kneecap back over or at least act
like a super strong bungee cord and
keep it from sliding around.
It seemed to make sense at the time.
But, in practice, it was a disaster. In
order to increase my client's muscle
strength, I had to increase the
amount of weight used in the
exercise because otherwise, she
didn't feel any muscle fatigue or
effect from the exercise. But, when I
increased the weight, her knee hurt.
Decrease the weight, knee pain was
ok but the muscles never really got
tired.
To make things worse, the knee pain
showed up with weight bearing
activity so exercises such as squats
were out. And, this is when I would
pull out whatever else I had in the
toolbox, like heat or cold or
massage or some other exercise,
something, anything, to buy me
some time to figure out what to do.
I was bending the narrative; trying
to make a joint based problem fit
into a muscle weakness paradigm.
This went on for a while, a few
years, stumbling around trying to fix
the knee pain, strengthen the
muscles, and so on, until I
wandered into a fitness equipment
store and discovered something
called a Total Gym.
I had never seen it. Remember, this
was over 25 years ago and Total
Gym was not known at all as it is
now (thanks to Chuck Norris and
Christie Brinkley). I had one of
those "ah-hah" moments. Squats
with a low load and the ability to
adjust the load. Perfect. So, I asked
the sales guy how much it cost.
"Oh, you don't want that. It's a lousy
work out. Just a gimmick," he said.
"Yeah, well, I do want it. How
much do you want for it?" I asked.
And this discussion went on for a
couple of minutes. He finally said,
"I'll sell it to you for $250.00 but
don't come back here complaining
about it. You can't return it."
I bought the Total Gym and it
became a staple in our practice.
By experimenting with the Total
Gym, I discovered that I could test
your leg and determine the amount
of pain free force you could
produce for a single leg squat.
By raising or lowering the machine,
I could increase or decrease the
force going through the leg (and the
force is always some percentage of
your body weight).
I decided to call this a Load
Tolerance Test.
You can think of it as a strength test
though. It's the amount of pain free
force you can produce for a specific
movement and still control the
movement. If during the test, the
movement hurts or you lose control
of the motion, the test stops.
So let's go back to the earlier
example. You weigh 150 pounds
and climbing stairs and squatting
hurts your knee. I test you on the
Total Gym (doing a single leg squat
to about a 70 degree knee angle)
and discover that at 110 pounds,
your knee feels fine. Any more
force than 110 pounds though, you
hurt.
Most people, when they hear
something like this, immediately
think, "So, you're saying I need to
lose 40 pounds?”
No. Not at all. What the test results
mean is that your leg "strength" is
less than your body weight.
Think about this for a minute. Why
do joints hurt? Physical demand
exceeds physical capability. So,
climbing stairs is way too hard for
your leg (specifically your knee).
Every time you go up a stair or
squat down to the floor, you exceed
your leg strength by 40 pounds.
If you start exercising at this new
load though, your muscles still
won't get tired. The reason is that
the test reveals the amount of force
your leg can withstand, not the
amount of force your muscles can
produce. In most cases, the test
stops at the onset of pain, not
muscle fatigue.
Now, it seems as if I'm right back
where I started. I know your leg
strength, which is great, but I still
can't make your muscles fatigue.
And, if my goal is to increase the
strength of your quadriceps, I have
to figure out a way to tire out your
muscles. Right?
Increasing your muscle strength is
important but to do that, you have to
increase your joint strength first.
But, at the time, I hadn't quite
figured out how to strengthen a
joint.
I was close. I was experimenting,
reading, but I was missing some key
components until I read an article
by Robert Salter, MD and realized I
was behind in understanding joint
healing.
Dr. Salter had discovered that
injured joints healed better, more
completely, if those joints were not
immobilized but were allowed to
move. However, he also discovered
that the joints not only had to move
but had to be protected from too
much force. The injured tissues
were fragile. At the time of his
discovery, injured joints were
usually placed in a cast or
immobilization brace.
Salter was encouraging his
colleagues to get people out of the
casts and get their joints moving,
but the medical community couldn't
understand how that would work
nor how to do it, so they refused,
and for the next twenty years, all but
ignored his work.
Salter didn't give up and now his
ideas are considered the gold
standard following practically any
type of knee surgery. Injured joints
are rarely casted or immobilized
anymore and if they are, it is for as
a short of a time as possible.
So, while the idea of moving
injured joints is now much more
common, the other half of the
equation failed to make it across the
chasm: controlling the force into the
joints. Sometimes patients will be
told to use crutches for a while after
surgery and encouraged to progress
easily or slowly with their
exercises or weight bearing. But,
"easily" or "slowly" are vague and
about the last thing you want when
it comes to rebuilding joint strength
is to be vague.
Most knee joint pain is caused by
tissues that cannot withstand the
force they are exposed to.
The patellar mechanics can make
that worse but keep in mind that
there are plenty of people walking
and running around with less than
optimal mechanics who have no
symptoms (Of course, there are
situations, such as arthrofibrosis,
adhesions of the patella to the
tendon, patella fracture,
subluxation, and dislocation -
among others that can create knee
pain).
The complete answer is a new
narrative - one that combines tissue
healing and strengthening with
respect for biomechanics. You need
good control of the hip, flexibility
in the ankle, and knee joint tissues
that can withstand the force.
Chapter 15
THE LOSS OF
EQUILIBRIUM

K nee pain represents a loss of

balance
within the body.
or equilibrium

This balance is often referred to as

“homeostasis”--a physiologic
process in which the body self-
regulates to maintain a certain
condition.
When it comes to your joints, the
rate of cartilage wear and
replacement is relatively even as
long as the environment inside the
joint remains undisturbed.
This balance can remain intact for
many years until the rate of wearing
down of the joint begins to exceed
repair.
As long as your body can withstand
the forces you encounter, all is well
at least in terms of how you feel.
But, when something tips the scale
and either the strength of the body
decreases or the forces you
encounter go up, you’ll develop
symptoms.
The internal environment of the
knee joint is no longer in balance.
A friend of mine--she’s in her 60’s-
-enjoyed a trim, athletic body for
most of her life without doing any
exercise. In fact, she will tell you,
“I hate to exercise.”
Until just the past couple of years,
she’s had no unusual aches or pains
either. Her body was in
equilibrium. She could do what she
wanted, eat what she wanted and
didn’t gain weight.
It’s like she had a bank account that
would never run out of money.
But now she has knee pain when
she climbs a flight of stairs, squats
down to pick something up off the
floor. And her pain increased quite
a lot after going to a concert where
she danced the night away.
She’s confused. “I don’t understand
why my knees hurt because I didn’t
do anything!” she exclaims.
Well, the reason her knees hurt is
precisely from not doing anything.
Her knees gradually weakened over
the years until the state of
equilibrium shifted.
In other words, her joint slowly
changed and once the forces of
everyday life exceeded the strength
of the joint, she began to hurt.
This situation with my friend is a
reminder that cartilage doesn’t have
a nerve supply. Your joints can’t
talk to you directly like a sore
muscle can. There are usually
symptoms though along the way but
they’re subtle things - like aching
that hangs around for a couple of
days and goes away. Or you notice
your knee is stiff after sitting in a
movie but then dissipates when you
walk around.
The goal of a joint strengthening
program is help your body return to
a state of equilibrium. When that
happens, you’ll feel better and
you’ll be able to do more.
Chapter 16
A PRIMER ON PAIN

W e've all experienced pain

at some time in our lives.
But what exactly is pain? Where
does it come from? And why isn't
there a consistent way to treat it? To
alleviate it? Why do some people
improve with one kind of treatment
while someone else with exactly the
same pain doesn't improve at all?
Pain is a sensation just as cold or
itch is a sensation. But pain carries
with it two other components that
cause you to assign value that you
don't necessarily assign to, for
example, a simple itch on your
arm.
Pain is a combination of physical,
mental, and emotional inputs to the
brain.
For example, let's say I stub my toe
on a coffee table. I injured
something in and around the toe
(physical) and I begin to feel pain.
Because I know what happened and
why I hurt (mental) and I believe I
will get better over time (emotion),
I don’t assign much value to the
pain. I’m not angry or upset, well,
maybe other than for a minute or
two. A region of the brain that
handles the mental/emotional aspect
of pain chooses to “turn down the
volume”. In a few days, I feel better
and gradually get back to normal.
But what happens if one day, while
walking your dog, your right knee
starts to hurt? You didn't fall, twist
it, jerk it around in any way. You're
just walking and you notice pain in
the knee. What do you do? Well,
most people shrug it off, assume it
will go away. And sometimes it
does. But when the next day arrives,
and the day after that it keeps
happening, then what?
Now your mind gets to work. You
start assigning more significance to
the feeling. There may be some
physical cause but because you
don't know what it is, you start to
wonder, worry. The more you
wonder and worry, you begin to
fear that something awful might be
going on or that you might not get
better. “What if I need surgery?
What if this is something bad? Why
isn't this going away?" Then the
pain seems to get worse.
"There is a completely separate
system for the emotional aspect of
pain — the part that makes us go,
'Ow! This is terrible.'” - David
Linden, neuroscientist, Johns
Hopkins University.
The cycle continues until you can
calm the mental/emotional part of
the brain. Part of the answer is to
know more about why you hurt,
what to do about it, and roughly
how long it takes to get better.
Pain is an indicator or sign of
something that's not quite right. It's
closer to a warning indicator light
in your car like the "check engine"
light. If your check engine light
comes on, you take it in to the auto
shop and they figure out why the
light came on and then what to do
about it. If you ignore it, well,
usually that doesn't turn out so great.
If you try to fix it yourself, good
luck (there can be ten or more
reasons that a check engine light
comes on and most require
mechanical skill to fix).
Pain is definitely “A” problem. It’s
just not THE problem. Once you
have a clearer picture of what’s
going on with your body and your
knee, what the problems are, you
can make different choices. Those
choices translate into changes
within your body which in turn alter
the way you feel.
Pain Is In Your Head
“The next exercise is completely
voluntary. I would like to
emphasize this. You do not have to
participate if you do not want to,”
said the leader of the workshop.
I was attending a multi-day retreat
on self-discovery a few years ago
and we were approaching the end
of the weekend. The room was
dark, my chest was vibrating as if I
had been plugged into a wall socket
from the thumping of the music that
was playing.
“This exercise is about
understanding pain. For many of
you, this will be scary but if you
can do what I suggest, you will
move beyond the discomfort. You
will see that pain is not suffering.
Pain is a sensation. We add the
suffering,” he explained.
“You have two choices. You can
either stand and hold your arms out
to the side so that they are parallel
to the ground or you can sit on the
floor, legs outstretched in front of
you, and clasp you hands behind
your back. You will then bend
forward as for as you can. In either
case, you will hold the position for
as long as you can. The record is 60
minutes.”
“If at any time, you feel that you
need to stop, then stop. Listen to my
voice, follow my instructions. Let’s
begin.”
I chose sitting on the floor with my
legs stretched out in front of me. I
was nervous but intrigued. Moving
past pain? What is that? And with a
chronic, degenerative spine
condition, I knew that sitting on the
floor and bending forward would
be a problem. I knew I would hurt
and probably fairly soon into the
exercise.
I leaned forward and felt the
tightness in my lower back and into
my legs. My mind started whirring
and sputtering. Oh, this is going to
be bad. Just you wait and see.
You’ll be lucky if you can walk out
of here.
The workshop leader began.
“Breathe slowly. Follow the breath
with your mind. Put your attention
on what you’re feeling in your feet,
then your knees, hips, lower back,
shoulders, neck, head.”
And so I did. But at about five
minutes, my spine felt like it was
beating my brain with a sledge
hammer. Everything hurt. And now
the pain wriggled its way into my
legs. I couldn’t focus on anything
but how awful this was.
“Breathe. Slow, easy, deep breaths.
If you are uncomfortable, place
your attention on that feeling. What
color is it? What color is that
feeling?”
Color? How do I describe pain as a
color? “All feelings have color.
Just take what your mind gives you.
What color is this feeling?”
I slowed my breath but struggled
keeping my attention on it. My
lower back felt like it was going to
tear apart. My legs were tingling,
burning. I wasn’t sure if I could feel
my feet anymore. I was miserable.
I went back to the breath. Color.
What color? Where’s the color?
And then I saw in my mind, a cloud
of grey and red swirled together.
Where did that come from?
“And what shape is this feeling?”
the leader asked. “Look at it
closely. Is it round, square, jagged?
Big, small? Flat or 3D? Look at the
shape closely,” he said.
Shape? I could see a swirling,
rotating mass of color but no
discernible shape. How long can I
do this? Where’s my breath? I have
to get up…no, I don’t. Shape,
where’s the shape?
I had started a timer at the beginning
of the exercise and had glanced at it
once when I was about five minutes
into it. I had no idea how much time
had passed. So, I glanced again.
Eight minutes. You have got to be
kidding me! Only 8 minutes!
I still couldn’t find a shape. I was
about to quit when the workshop
leader repeated his instructions.
And then I saw the glob of grayish-
red morph into something. What is
that? The shape was round like a
tennis ball with tiny projections all
over it – sort of like a weapon from
the Middle Ages. It was spinning.
Am I losing my mind? “Look at the
texture of the shape. What do you
see? Smooth, rough, dimpled,
dented? What does the surface look
like?
A grey-red, round mass with a
rough, spiked surface rotating in
space.
About this point, I realized I still
hurt but I didn’t care as much about
it. I could feel the “pain” but it had
no meaning, no suffering with it. It
was just a thing, just another
sensation like an itch or pressure. I
had moved past pain into just
sensation. I had lost track of the
time so I glanced at the timer. It had
been just over 30 minutes.
I stopped around 35 minutes not
because of pain but I thought going
another 20-30 minutes with both of
my legs feeling numb might not be
such a good idea.
As I returned to the upright sitting
position, I had a few immediate
thoughts. Oh, this will be
good….standing up should be
really fun if I can do it at all…this
is going to really hurt.
But I had no pain at all. None.
Normally, I could sit on the floor
with my legs outstretched for a few
minutes but getting up would be a
struggle – stiff, sore – followed by
a short period of inflexibility as I
tried to straighten up. It would pass
quickly but the longer I sat like this,
the worse it would be.
Not this time. I had no ill-effects at
all. And none the next day either.
How is that possible? What
happened exactly?
Pain is complicated. In some cases,
the cause is clearly physical like
when you fall off a ladder and
break your leg. But in this case, was
the pain I experienced coming from
an “injury”? Was I damaging
something and was that why I hurt?
Pain is processed in your mind.
When you cut your finger, it’s not
the finger that hurts but a region in
the brain that provides the sensation
and processes the experience.
Some pain, as in my case at the
workshop, emanates from fear. And
it feels like it could be something
bad. The initial feeling I had was a
stretching sensation mixed with a
level of discomfort. At that point,
my prior experiences with this
sensation came into play. And I
have had plenty of unpleasant
experiences with “pain”. In my
case, I was anxious about hurting
before I had even attempted the
exercise. My mind was preparing
for pain. I was anticipating it,
setting myself up for it. I was afraid
of hurting and fear always lowers
the pain threshold.
Fear places you exactly where you
don’t want to be. It makes pain
worse, more frightening and
disabling.
By following the workshop leader’s
instructions, I was able to observe
the sensation and separate myself
from the fear. As I did, the suffering
or what most of us would call
“pain” stopped.
I’ve used this technique since the
workshop with varying degrees of
success. In the workshop, I had
several things stacked in my favor:
the instructions, the environment,
the support from other people, the
music, and my curiosity. To use it
successfully takes concentration and
discipline. Sometimes I have those
things and sometimes I don’t.
Buddhists have an analogy about the
mind and meditation. Imagine a
waterfall with water running over
the edge and in front of a rock wall.
The water represents your thoughts
and emotions. The rock is your
body. Where you want your mind to
be is in the space between the water
and the rock. That is where I ended
up the day I went past pain.
I’m not saying that this technique is
how you should treat pain nor
should you ignore pain. The
technique helps you reduce the
emotional suffering that tends to
come with the pain sensation. Even
brief periods of time of being the
“observer” can be very helpful.
If you have an ache or pain and feel
upset, angry, sad, or some other
unpleasant emotion about it,
consider the technique I that I
described above. You might find it
helpful.

The Absence Of Pain Does Not

Equate To Wellness
I was teaching a class of practicing
physical therapists on the subject of
tissue healing and building physical
capacity a few years ago.
One of the participants raised a
question about pain.
“I just think that once the pain is
gone, the patient is fine. What’s left
to work on if they don’t have pain?”
he asked.
“Your opinion then is if pain is
absent, there is no problem?” I
replied.
“Well, yeah. Don’t you think so?”
he asked.
The student was wearing a forearm
cast from his elbow to his hand.
About a month ago, he had fallen
and fractured his wrist.
“I’m wondering…Does your wrist
hurt now?” I asked.
He paused, looked down at his cast
then looked at me.
“Well, no it doesn’t,” he replied.
The class laughed. I laughed. We all
got the point.
Just because you don’t hurt, that
doesn’t mean there’s not a problem
that needs addressing. For my
student, his problems will begin
when he comes out of the cast. His
hand, wrist, forearm will all be
weak from being immobilized. His
joints will be stiff. And he might
have some pain as well.
Many treatments for Knee
Osteoarthritis target pain relief
which is an important part of the
process. But, some of those
treatments might make you feel
better while leaving you with the
same set of problems that created
the pain and dysfunction in the first
place.
FUNDAMENTAL PRINCIPLE:
The absence of pain does not equate
to wellness.
Chapter 17
WHAT I’VE
LEARNED ABOUT
PAIN

H ere are a few things I've

learned about pain:
1. The severity of injury does not
always equal severity of pain. For
example, take a small needle -
sewing needle - and shove it under
your finger nail (no, don't actually
do it, just imagine it). I guarantee
you that the pain you feel from that
small injury will send you through
the roof.
2. The location of pain does not
mean that's the source of pain.
Trigger points within a muscle can
refer pain to other parts of the body
and even feel tender in the referred
area.
3. If someone tells you "The pain
is in your head", that's true. The
feeling of pain is always in your
mind. Pain is processed within the
brain - not at the source of the pain
signals. The phrase “pain is in your
head” does not mean, however, that
you’re making it up, faking pain or
anything other than pain is real.
4. Negative emotions make pain
worse; positive emotions make
pain better. This is because of how
the brain interprets the pain signals.
Negative emotions act like an
amplifier and spread the signal to
other areas of your brain.
5. Pain doesn't always have a
physical cause. Prolonged stress,
for example, can cause pain that
feels physical.
6. The more you focus on pain,
the worse it gets.
7. Suffering is different than pain.
Pain is a sensation. Everything else
- anger, worry, fear, doubt - is
created within the mind and
attached to the pain sensation. It
becomes a memory.
8. Pain has three components:
physical, mental, emotional.
Western medicine typically
addresses 1/3 of pain - physical.
9. Pain has a threshold, a point at
which the stimulus converts from
one kind of sensation to another.
If you take hold of your left thumb
and pull it down toward the
forearm, slowly, there is a point
where you feel tension or pressure
but not pain. A little more pull and
bingo, pain. Reduce the amounts of
pull, no pain.
10. Each person's pain experience
is unique. What you feel, is your
experience. No one should judge
your experience and you should not
judge someone else’s.
11. Our society and culture (and
marketing by pharmaceutical
companies) makes pain out to be
the bad guy. Get rid of it fast.
Remember, pain is a vital sign. Use
it as a way to interpret what your
body is saying.
12. Pain forces you to be patient.
The human body has certain
principles and rules regarding
healing. You can nudge the body
along but you can't force it to
recover as fast as YOU want it to.
13. The first time a person has an
injury or onset of pain that forces
them out of the lifestyle they
love, for an undetermined amount
of time, he or she will experience
the stages of death and dying
described by Elizabeth Kubler-
Ross: shock, anger, denial,
bargaining, depression, acceptance.
And what enables a person to move
through these stages is hope. For an
injury, I think of the stages not as
death and dying but as loss. And as
long as there is hope, there's life
and the potential for recovery. Hope
is the cornerstone of recovery and
progress.
14. Pain will teach you about
yourself if you let it. How you
manage yourself in everyday life is
likely how you will manage pain.
Do you rush around, are you always
in a hurry? Are you aggressive,
demanding of others? Or maybe
passive and hesitant to speak up?
Do you avoid conflict or enjoy
being the "winner"? Are you
someone who wants to be in control
or prefers to see how things go?
15. Your friends never understand
your situation as much as they
think they do. With good
intentions, friends will offer
suggestions (sometimes phrased as
"you should..."). Politely thank them
and move on. Your path is your
path; not theirs. When they see you
on crutches, they might say, "You're
STILL on crutches?" Smile, nod
your head and say, "Yep". And then
wait. The question is a reflection of
their fear...seeing you makes THEM
uncomfortable which is why they
ask the question. Ignore it.
16. Pain can make you illogical. A
common scenario is some type of
exercise causes pain but you do it
anyway because the idea of not
doing it makes you too uneasy.
17. Pain can be exhausting. The
mental and emotional toll that pain
has on a person can be high even if
the pain is mild. When it becomes
chronic, you'll use up more energy
battling the "worry monster" which
over time depletes you.
Chapter 18
BENCHMARKING

H ow do you know how far

you’ve come if you don’t
know where you started?
This is why it’s important to
benchmark your starting points.
In this section, I have a few
suggestions that help form your
starting point. Later in the book,
you’ll learn how to test your core
strength and leg strength. You can
then add those results to those in
this chapter.
Pain
Pain is mostly a subjective
experience. You may feel a certain
amount of pain but maybe you were
raised to not show pain. Doing so,
perhaps in the family, was frowned
upon.
Being honest with yourself about
pain though is critical to moving
forward.
The most widely used measure of
pain is a pain scale. There are
several different ways to record
pain levels. Below are three of the
more common ways.
0 - 10 scale
The 0 - 10 scale is a numeric scale
where 0 represents no pain and 10
is the worst possible pain
imaginable.
0 Pain free.
1 Very minor annoyance-occasional
minor twinges.
2 Minor annoyance-occasional.
3 Annoying enough to be
distracting.
4 Can be ignored if you are really
involved in your work, but still
distracting.
5 Can’t be ignored for more than 30
minutes.
6 Can’t be ignored for any length of
time, but you can still go to work
and participate in social activities.
7 Make it difficult to concentrate,
interferes with sleep, you can still
function with effort.
8 Physical activity severely limited.
You can read and converse with
effort. Nausea and dizziness may
occur.
9 Unable to speak, crying out or
moaning uncontrollable- pain makes
you pass out.
10 Unconscious. Pain makes you
pass out.

The Wong-Baker FACES ® Pain

Rating Scale uses facial images to
represent the levels of pain.

And here’s the third scale . It’s a

numeric scale but has more detailed
definitions at each level.

Whichever scale you choose, be

honest with yourself about the rating
and use the same scale in the future.

Rating Your Pain

Rating pain can be challenging if
your pain varies from day to day, by
position or movement, or by the
type of activity.
To get the most accurate picture of
your starting point, rate your pain
when you’re lying down. It should
be zero. If it’s not, then you need to
see your family physician and have
him or her assess you.
Then rate your pain during or after
certain activities such as:

walking at a leisurely pace

walking briskly
climbing stairs (how many
steps or flights?)
squatting
exercise (be specific about
the type and movement)
sitting (for how long?)
standing (for how long?)

You might find that your knee hurts

when walking at a level of 2 or 3,
for example, but several fights of
stairs results in a 5 or 6 level of
pain.
Record your pain levels prior to
starting any exercises. After four to
six weeks, repeat the process. You
should see some improvements (you
may not be pain free at this point).
But be patient. It takes some time to
change your body especially if
you’ve had, for example, knee pain
for many months or longer.

The KOOS Test

The KOOS Test (Knee Injury and
Osteoarthritis Outcome Score) is a
questionnaire developed in the
1990’s to help people quantify the
impact of knee pain and serve as a
means of benchmarking their status.
The form is simple to fill out and
score. You can repeat the test at
regular intervals - 6 to 8 weeks - to
identify changes in your condition.
To download the form, go to the
FORMS AND VIDEOS chapter.
Chapter 19
GRAVITY IS KING

T here’s something you must

have to stay alive beyond
food, air, and water.
Gravity.
All biologic systems of the body -
lungs, heart, bones, muscles, joints
for example - need some form of
applied external force or stress to
maintain or improve their health.
This stress comes from gravity.
This is especially true for
astronauts. One of the main
problems with prolonged space
flight is the detrimental effects to
the body from the loss of gravity.
When astronauts spend a long time
in space, they battle loss of bone
density, muscle strength,
disturbance in balance, and
problems with the cardiovascular
system among other issues.
I divide gravity into three
environments: Sub-Gravity,
Gravity, and Super-Gravity.
A Sub-Gravity environment
contains a range of forces that are
less than the weight of the body. A
Gravity environment’s forces will
be equal to the weight of the body
while a Super-Gravity environment
will have loads that are greater than
the weight of the body.
Here are a few examples:

Riding a stationary bike is

a Sub-Gravity force on the
knee and foot (depending
on how much resistance
and speed you use)
Walking in chest-deep
water in a pool is a Sub-
Gravity force
Walking is a Gravity level
 of force
Rising from a chair is a
Gravity level of force
Running is a Super-Gravity
force
Squats with a barbell or
dumbbells is a Super-
Gravity force.

The force due to gravity is what

makes our bodies work optimally.
When you hurt or feel stiffness or
aching with everyday activity or
various types of exercise, if you
reduce the effect of gravity, in
almost every case, you’ll feel better
and actually get stronger.
For example, if your knee hurts
while going for a walk (Gravity
level force), you might be able to
walk in a pool without any
discomfort (Sub-Gravity force). In
the pool, you’re still applying a
force to your leg and knee but it’s
much less than walking on land.
In a similar way, if your knee hurts
performing a single leg squat
(Gravity level force), it may not
hurt while performing a squat with
both legs (Gravity level force with
a reduction in total load - one leg
versus two).
Problems arise - pain, stiffness,
aching for example - when you are
functioning or exercising at a level
too far beyond what the body can
do or needs to do. In a way, it’s like
what happens to astronauts when
they return to Earth. For a period of
time, they have to be careful. Their
muscles, bones, and other tissues
can’t handle the repeated loads of
Earth’s gravity. Their entire body
has adapted to Sub-Gravity loads
(some astronauts report difficulty
speaking because even their tongue
- a muscle - has adapted to the
micro-gravity loads of space).
Astronauts often go through several
months of physical rehabilitation to
restore their strength and mobility.
Imagine what might happen to an
astronaut who has been living on
the International Space Station for a
year if, after returning to Earth, they
immediately started lifting weights.
The Super-Gravity load of the
weights on their Sub-Gravity
adapted bodies would result in
injuries and delayed recovery.
The same kind of thing can happen
to people with Knee OA or
Tendinopathy.
If your knee feels okay walking
around and maybe climbing stairs,
you know your “functional zone" is
within body weight forces or
gravity. But, if your knee starts to
hurt when you run, you're now well
outside your functional zone.
Your knee is exposed to Super
Gravity forces but it can withstand
Gravity level forces.
One of the keys to rebuilding your
leg and body strength is
understanding how to adjust
exercise to help you move from a
Sub-Gravity level or tolerance to
Super-Gravity.
Chapter 20
DEMAND,
CAPABILITY, AND
PAIN

W e all have a certain amount

of physical capability:
strength, endurance, and flexibility.
Some of us have more than others,
but we all have some. So think of
your current physical state and the
things you do easily everyday, like
perhaps cleaning your house or
taking your dog or kids for a
leisurely walk. These things place a
certain amount of Demand on your
body. And as long as you can meet
the Demand and recover from it,
you’ll feel ok.
But when the Demand is greater
than your Capability and you don’t
recover, you’ll notice symptoms
(e.g. when the physical loads are
above the BLUE line on the graph
below) and in cases of overuse or
injury, they persist or reoccur.
This means something in your body,
usually more than one thing, is
weak.
The symptoms are not always pain
though. Symptoms are feelings or
sensations that depart from your
normal experience and you interpret
them in context of the activity or
environment.

If you’ve ever completed an

exercise routine and a day or two
later noticed muscle soreness, that’s
an example of a Demand that is
slightly greater than your
Capability. But, in almost every
case, after a few days, all is well.
You recover and get stronger as a
result.
One afternoon, I was in a hurry so I
ran up a few flights of stairs to get
to our clinic. I took the steps two at
a time and moved quickly.
When I reached the top, I was out of
breath.
I didn’t think much of it since I had
just run up the stairs. I expected my
heart to pound and my breathing to
be labored.
But what if twenty minutes later my
heart was still thumping hard and
my breathing was shallow?
Now the symptoms take on a
different meaning. I could be having
a heart attack.
If the symptoms are far enough
away from your normal experience,
you’ll notice it. Usually, that’s pain
but sometimes it could be a sense of
fullness in your knee, stiffness, a
dull ache.
A few years ago, a friend of mine,
Julie (not her real name), mentioned
that her knees ached after about a
30 minute walk. She wondered if I
had any exercises that might help.
“I think my muscles are weak and
that’s why my knees are bothering
me,” she said.
“How long have you noticed that
your knees have been aching?” I
asked.
“Oh, I don’t know, maybe a few
months I guess. Sort of depends on
what I do but it’s not a big deal. It
goes away,” she replied.
“Usually the aching is a sign that
your joint is weak. You likely have
weakness in your muscles but to
help your knees, you’ll want to
strengthen your joint,” I explained.
I described the basics of what
would be involved. She said that
she didn’t think it was that bad and
she hates to exercise.
Her knees still bother her and now
she has trouble going up and down
stairs.
Julie’s aching is her body’s way of
telling her that she has exceeded her
Capability for whatever the
activities might be. In Julie’s case
it’s walking and has progressed to
include climbing stairs.
When you notice sensations or
feelings that seem unusual or new
and they persist or reoccur, there’s
a good chance you have exceeded
your Capability. The first thing to
do is to lower the Demand. I cover
this more in a later chapter but
without bringing the Demand and
Capability into balance, you’ll do
more harm than good.

Functional Zone
Walking at a comfortable pace
creates a reactive force into your
leg / body that is slightly greater
than your body weight.
The reactive force is about 20-30%
(or 1.2 to 1.3) more load than the
force of your leg hitting the ground.
If you weigh 160 pounds, that’s 192
pounds of reactive force per foot
strike.
Your leg and trunk muscles, fascia,
tendons, bones, and ligaments work
together to absorb and distribute the
force. These tissues act as a kind of
suspension system for your joints.
A body that functions well and is
pain free is in a state of
equilibrium. The force produced by
your foot hitting the ground is offset
by the force absorbed within the
soft tissue suspension system.
The Demand and Capability are
balanced. You are in equilibrium.
Force Produced = Force Absorbed
But, when some part of the
suspension system fails to do its
job, the force traveling up the leg is
greater than what the tissues in and
around the knee can withstand.
The result is you hurt.
Day to day life is spent in what I
call the FUNCTIONAL ZONE
(FZ). This zone is created by a
certain amount of Load Intensity and
Load Duration and your ability to
withstand both.
Things like walking, housework,
going to work, doing whatever you
might do during your day would fall
into this zone.
And as long as you can meet the
Demand, you feel just fine.
 The Functional Zone

Above the FZ is the ADAPTATION

ZONE (AZ). You spend time in this
zone when you exercise, train, or do
some other physically demanding
task. Your body can adapt to the
loads and durations in this zone, but
how well it does depends on how
far you have crossed into the AZ
because, at some point, you’ll cross
over into TISSUE FAILURE and
INJURY.
Injury, technically, occurs with any
type of exercise. It’s just that your
body can recover easily from the
“injury” so we tend to not think of it
as an injury. But, for example, when
you go for a run, and the next day
your thigh muscles are sore, you’ve
injured those muscles. Another day
or two later and you feel fine. So,
the issue isn’t whether you get
injured from an activity or exercise,
it’s how easily and quickly you
recover.
As an example, Diamond Point #1
on the graph below represents
falling off your bike directly onto
your knee. A high level of force or
load and a short duration, which
when combined, can bruise your
knee or even break it.

Adaptation Zone
​Point #2 is an activity like
gardening. In terms of physical
loads, it’s usually not too high
(unless you’re hauling dirt and bags
of mulch around) but will last a
longer period of time, maybe even a
few hours. In this case, I’m
referring to things like weeding,
raking, and a little digging - lower
load activities when done over a
long period of time can put you at
risk of injury. You’re on the low
side of the AZ, though, so your body
will likely recover.
Point #3 represents something like
snow skiing. The physical loads
may exceed your ability to adapt
depending on how aggressively you
ski, how long you ski and how fit
you are. But, by being too far
outside the AZ you’ll likely end up
with an injury that lingers for some
time.

The Changing Zones

The FZ and AZ are not fixed. They
can expand or shrink depending on
certain variables and conditions.
Over-training (doing too much, too
soon, too fast, too often), injury, and
inactivity can cause the AZ and FZ
to shrink.

The Changing Zones

Many of us can remember days

when we were - at least we thought
we were - in great physical
condition. I had lunch one day with
my banker. A guy I’ve known for
almost thirty years. He was
explaining his “workout” routine to
me which was inconsistently
playing racquetball.
His elbow hurts and his knees ache
and sometimes his back hurts. And
he’s about 30 or 40 pounds over his
ideal weight for his age.
I just listened until he said, “I know
I need to get in better shape and I
know what to do. I just gotta’ get off
my butt and go do it!”
I said, “Roy, you haven’t the faintest
idea of what it takes to get in shape
now. When were you in great
physical shape? When you were
18? 20? And you’re what now? 63?
Do you think the kinds of things you
did forty years ago will work for
you today?”
He looked down at the ground for a
moment and then looked up and
said,”Yeah, I guess you’re right. I
like to think I can get in shape
because I once was, but getting
there isn’t so easy.”
This is why people, well-
intentioned, get hurt. Their FZ and
AZ have shrunk but they don’t
realize it until, like my banker, they
decide to get in shape, do some
physical task they haven’t done in a
long time or do more than what
they’re used to.
Look at the graph again, now with
the same activities as before, but
with a much narrower AZ and FZ.
Notice how far outside the zone
Point #1 and #3 sit. Now when you
fall off your bike onto your knee,
you’ll probably break something.
And when you decide to go snow
skiing and haven’t skied in years
nor exercised, you’ll fall and tear a
ligament or break your arm instead
of just feeling a little sore for a day
or so.
The FZ and AZ areas will shrink if
you keep doing things - activities,
exercise, hobbies - that place you in
the Tissue Failure / Injury zone.
And as a result, it gets easier to re-
injure yourself.
Rick, 33 years of age, an avid snow
skier and a guy who loves the
outdoors, was referred to our
practice after having been through
several months of rehabilitation,
twice, and a surgical procedure for
his right knee.
He had developed right knee pain
one day while skiing but despite his
doctor’s advice of rest and anti-
inflammatories, the pain persisted.
He then went to a physical therapist
who told him that his knee cap was
tilted and wasn’t moving properly
and that’s why he hurt.
Rick dutifully carried out the
exercise routine designed to move
his knee cap back into place with
quad sets, taping, electrical
stimulation, manual mobilization of
the knee cap, and general leg
strengthening.
But after a couple of months, he
wasn’t much better.
He was then referred to an
orthopedist who told him that, yes,
the problem was his poorly
positioned knee cap but to fix it
would require surgery.
Rick had the surgery, went back to
rehab for a few months yet still had
knee pain with exercise and he felt
that there was no way he could ski.
Rick did some research online and
found a renowned orthopedist in
Dallas, Tx. He called the office and
made an appointment.
After the interview and examination
by the orthopedist, Rick heard some
shocking news.
“Well, my friend. The guy you need
to see is in Austin, Texas! How
about that?” said the surgeon.
So, Rick makes his way back to
Austin and sees me.
After my history and exam, I
explained that Rick didn’t need
anymore surgery. I went over the
concept of the FZ and AZ which he
understood at once.
“So, basically, the stuff I’m doing is
too hard, too much and my knee
can’t heal up and get any stronger,”
he said.
“Well said. In a nutshell, yep that’s
the deal. We have to change the area
under the curve and I know how to
teach you to do that,” I explained.
The good news is that you can
expand the FZ and AZ zone and I’ll
show you how.
Chapter 21
COMMON
TREATMENTS FOR
KNEE PAIN

Cold Versus Heat

I get asked this question a lot.

“Should I use heat or cold?”
You may have heard that you should
always use ice for 24-48 hours after
an injury and then use heat. Or
maybe you’ve heard the reverse.
There’s a lot of conflicting
information about something as
simple as heat or cold.
The research on whether to use heat
or cold is not deep nor does it
agree. Some research shows that
using cold after surgery and after
acute soft tissue injury fails to
change the outcome, while other
research suggests that cold is
effective at reducing pain following
an acute injury, within the last 72
hours.
If your injury is acute, ice is often
the rule of thumb to help control
pain and swelling. But it depends
on the body part that’s injured.
For example, in the shoulder, the
rotator cuff muscles, often the site
of shoulder pain, rest deep in the
shoulder. Deeper than the
application of cold or ice can
penetrate. But in the knee or ankle,
where the injured tissues are often
close to the surface, ice can be
effective in reducing pain and
swelling temporarily.
I don’t know of any research that
proves this but my observation from
working with clients that aching
knees, or a more chronic injury,
generally respond better to warmth.
This can be a heating pad, a pack
that you heat up in the microwave, a
hot tub, or bath.
Whether you use heat or cold, the
application is usually 15-20
minutes. Most people feel better
from the application; some have
longer lasting relief than others, but
few find permanent relief.
Use cold for an acute injury to help
reduce pain and some swelling. Or
use it after the acute phase if cold
just feels better to you than warmth.

Mice Is Better Than Rice

The old standby RICE - Rest, Ice,
Compression, Elevation - has been
replaced by MICE - Movement, Ice,
Compression, Elevation.
Compression and elevation have
been shown to help control
swelling with or without the
application of cold. Cold helps
reduce pain, but it seems that cold,
by itself, doesn’t reduce swelling as
much as cold and compression.
Soft tissues tend to heal more
quickly and completely if you can
move the injured area intermittently
during the recovery phase. But the
load applied to the injured part
used during the movement must be
low.
For example, the gold standard
following almost any knee surgery
is the use of a Continuous Passive
Motion device - CPM. This device
moves your knee for you so slowly
you can barely perceive it and has
almost no load or force.
Researchers discovered that
patients had fewer post-operative
problems and generally healed
faster if they used a CPM. (There is
an exception to MICE and that is
within the first 2-3 days following a
moderate to severe injury, rest is
best. Then you can start moving the
injured area gently.)
Capsaicin
Capsaicin is a natural analgesic
cream that you apply to the skin.
Use a small amount, rub it in
thoroughly, and wash your hands.
Do not rub your eye or other
sensitive areas of your body while
you have any amount of capsaicin
on your hands.
The cream can cause a hot or mild
burning sensation (in about half the
people). Some people seem to like
it while others don't. Apply the
cream to the affected knee four
times a day.
According to one study, 80% of the
capsaicin-treated patients
experienced a reduction in pain
after two weeks of treatment. 1
You can find capsaicin at most
drugstores and grocery stores.

Turmeric
Turmeric is a spice that is also used
to treat symptoms of joint pain. It is
usually taken in pill form up 1000
mg/day. However, it is also a
natural blood thinner so don't mix it
with any prescription blood
thinners or take it two weeks or less
before a surgery.
In a study in 2009, turmeric (active
ingredient is curcumin) was
compared to Ibuprofen in 107
people with knee joint pain. 2 The
result was the turmeric was about
as effective as the Ibuprofen in
relieving pain.

Comfrey Root Ointment

Comfrey (Symphytum officinale) is
a plant of the Borage (“forget-me-
not”) family of plants. Since
medieval times, people have used
the leaf and root extracts of this
plant for alleviating a large number
of ailments.
A 2007 study showed that applying
an ointment with comfrey root
extract reduced knee pain by 55%
over a three week period. 3 And just
to be sure that it wasn't the massage
that did the trick, people who
received an ointment without the
comfrey root also improved about
10%. So the comfrey root appears
to relieve knee pain better than just
massaging an ordinary ointment on
your knee.
If your knee pain isn’t substantially
better in three weeks, see your
family doctor to determine if you
need other medications or
treatments.

What About Drugs?

Non-Steroidal Anti-Inflammatory
Drugs
Maybe you've heard or read
somewhere that taking a Non-
Steroidal Anti-Inflammatory Drug
(NSAID) like Ibuprofen or Advil,
before you run, exercise or just to
get through the day, helps shoo the
pain away. If your knees or hips or
back normally hurt, a little
Ibuprofen can be magic.
How bad can that be for you?
After all, you can buy it in any
grocery store or drug store.
As it turns out, pretty bad actually.
Researchers examined the blood of
runners who took Ibuprofen before
and during a long endurance race
and compared the findings to
runners who did not take the drug. 4
They discovered some disturbing
things:

Biologic markers of
inflammation and
increased immune system
response were higher in
the drug group than in
runners who had not taken
the drug.
Signs of mild kidney
impairment in the drug
group.
Low-level endotoxemia, a
condition in which
bacteria leak from the
colon into the bloodstream,
was found in the runners
who took Ibuprofen.
Runners had no more or
less pain than the group
 who did not take the drug.

In addition, Ibuprofen and other

non-steroidal anti-inflammatory
drugs (NSAIDs), like Aleve or
Motrin, can interfere with the
body’s natural healing response.
Injuries to tendons, bones, cartilage,
and ligaments can take longer to
heal and heal less completely with
chronic use of NSAIDs. 5
Certain types of NSAIDs can have a
negative effect on cartilage volume
or thickness (called non-specific
NSAIDs such as Aspirin, Advil,
Motrin, Aleve) while other types of
NSAIDs, Cox-2 Inhibitor (Celebrex
is the only Cox-2 Inhibitor on the
market in the US), do not appear to
have these effects.
However, there is a time and place
for NSAIDs. For acute injuries,
pain relief, and short term use,
NSAIDs can be helpful and
relatively safe (some people still
have gastrointestinal side effects).
However, when you're using the
drug to allow you to do something
like go for a run, exercise or
perform daily tasks, that’s when you
run into trouble.
Pain is real. Pain is whatever you
feel and however you feel it. Don't
let anyone tell you that what you
feel is not real. Pain can sometimes
be from emotional distress
(including joint pain) without much
of any physical injury (although
back and neck pain tend to be more
common sites for emotionally
driven pain). That doesn't make it
any less real. It does call for a
different kind of approach to solve
it, but it's still real.
When you hurt, what you want first
is pain relief. Then, once you have
a sense that you can control the
pain, you'll have more room in your
mind for the idea that what you
really need to do is increase your
physical capacity; your ability to
produce and absorb force.

Nutraceuticals
What’s a “nutraceutical”?
A nutraceutical is a food or food
product that provides health and
medical benefits, including the
prevention and treatment of some
diseases.
Because these substances are not
considered drugs, they are not
regulated by the Food and Drug
Administration so some less
scrupulous manufacturers make
wild claims about the effectiveness.
But there are some nutraceuticals
that are effective in people with
knee pain associated with changes
in the joint surface.
Many people with achy, stiff, sore
joints who have been diagnosed
with OA are unaware of certain
nutritional supplements that help the
joint rebuilding & strengthening
process. Some may be using
supplements, but are unclear about
the dosage or frequency. Below are
my suggestions for proper use of
nutritional supplements.
The supplements are:

Glucosamine (GLUE-CO-
SAH-MEAN)
Chondroitin Sulfate (CON-
DROY-TIN-SULF-ATE)
SAMe (SAMMY)
Omega Three Fatty Acids
ACES (Vitamin A, C, E,
and Selenium)
Avocado Soybean
Unsaponifiables (ASU)
Astaxanthin (asta-ZAN-
thin)
 Collagen Protein
Supplement
Rooster Comb Extract

Glucosamine / Chondroitin
Sulfate
Glucosamine is an amino sugar that
produces special proteins
(glycosaminoglycans or GAG) your
cartilage needs to bind water.
Healthy, sturdy cartilage traps
water molecules which allows it to
deform and bounce back protecting
your bone and other structures.
Dosage (based on body weight):
 Less than 120 pounds -
1000 mg / day
120 to 200 pounds - 1500
mg/day
More than 200 pounds -
2000 mg/day

Frequency

Two times per day (divide

daily dosage in half)

Chondroitin Sulfate, a component of

GAG, is a water magnet and retards
the degradation of cartilage. Both
Glucosamine and Chondroitin
Sulfate have been extensively
studied and both have been shown
to reduce the symptoms of joint
injury / disease as well as enhance
the basic infrastructure of cartilage.
Dosage (based on body weight):

Less than 120 pounds -

800 mg/day
120 to 200 pounds - 1200
mg/day
More than 200 pounds -
1600 mg/day

Frequency:
 Two times per day (divide
daily dosage in half)

The brands I suggest are Osteo-Bi-

Flex and Triple Flex. I’ve used
these successfully and they’ve been
studied. They have in them what
they claim to have.

Does Glucosamine - Chondroitin

Sulfate Really Help?
The New York Times published a
report in 2006 suggesting that
Glucosamine / Chondroitin Sulfate
(GCS) was of no use to people with
knee pain. In fact a rheumatologist
at Boston University, Dr. David
Felson, said, "It's a null trial. It
doesn't work any better than
placebo."
So, what’s the truth? Is it worth
taking or not?
What the New York Times article
failed to report is that GCS was
effective in relieving pain in people
with moderate to severe knee pain.
In fact, almost 80% of people with
moderate to severe pain reported
significant relief. Now, in everyday
life, how many people with mild
knee pain are going to take a
supplement to relieve their pain?
Not many.
And the other thing about GCS that
didn’t make the mainstream media
is its disease modifying effects. A
treatment is considered disease
modifying when it aims to correct
the source of the problem and alter
the natural disease progression.
GCS was shown to be just that. In a
2009 study that lasted two years,
that was randomized, double-blind,
placebo controlled (the gold
standard in research design),
researchers examined people’s
joints via X-Ray. What they wanted
to know was if the joint space
would narrow more or less in the
group who took GCS compared to a
group who took a placebo.
The GCS group had much less joint
space narrowing - meaning that they
lost less cartilage - than the placebo
group. The conclusion the authors
had was:

“The long-term combined

structure-modifying and
symptom-modifying effects
of GCS suggest that it could
be a disease-modifying
agent in patients with knee
 OA.”

So, bottom line, yes, GCS is

helpful.

SAMe
SAMe or s-adenosylmethionine, is
a naturally occurring substance in
your body resulting from the
metabolism of the amino acid
methionine, and has been used
extensively as a treatment for
depression. In an Italian study, the
researchers discovered that the
subjects who also had knee pain
due to osteoarthritis reported much
less pain after taking SAMe.
Double blind short term studies
since then have shown SAMe to be
as effective as Non-Steroidal Anti-
Inflammatory Drugs (ibuprofen).
Dosage: 200-400 mg
Frequency: Three times per day on
an empty stomach.
Precautions: flatulence, vomiting,
diarrhea, headache, and, in
depressed patients, anxiety. SAMe
should not be taken concomitant
with anti-depressive agents to
avoid serotonin syndrome-like
symptoms such as tremors,
tachycardia, tachypnea, and
hyperreflexia.

Omega Three Fatty Acids

Omega Three Fatty Acids are the
kind of fat called an unsaturated fat.
Most frequently found in cold water
fish, Omega Three is also found in
flaxseed oil and in capsule form.
Insufficient Omega Three will
cause your cells to use saturated
fats resulting in more fragile and
easily damaged cell walls.
Dosage : 1000 - 2000 mg/day (fish
oil tablets)
Precautions: "Omega-3 fatty acids
should be used cautiously by people
who bruise easily, have a bleeding
disorder, or take blood-thinning
medications because excessive
amounts of omega-3 fatty acids may
lead to bleeding. In fact, people
who eat more than three grams of
omega-3 fatty acids per day
(equivalent to 3 servings of fish per
day) may be at an increased risk for
hemorrhagic stroke, a potentially
fatal condition in which an artery in
the brain leaks or ruptures. Fish oil
can cause flatulence and diarrhea.
Time-release preparations may
reduce these side effects, however.”

Avocado Bean Unsaponibiables

(ASU)
Avocado-Soybean Unsaponifiable
or ASU is derived entirely from
vegetable sources; from the oil of
avocados and soybeans.
ASU has been shown to improve
joint health by stimulating the
production of new cartilage while
reducing the breakdown of existing
cartilage.
These changes improve both the
framework, shock absorbing ability,
and friction-free properties of
cartilage.
ASU also decreases pain,
inflammation and the need for pain
relievers and anti-inflammatory
drugs, in the majority of users. It
also appears to work for those
people who have more severe loss
of cartilage.
Avocado Soy Unsaponifiables
Dosage: 300mg/day
Astaxanthin
Astaxanthin (pronounced "asta-
ZAN-thin") is a naturally-occurring
carotenoid found in algae, shrimp,
lobster, crab, and salmon.
Carotenoids are pigment colors that
occur in nature and support good
health.
As a powerful anti-inflammatory
and pain reliever, Astaxanthin
works in much the same way drugs
like Celebrex work - by blocking
COX 2 enzymes but does so without
the side effects that come with anti-
inflammatory drugs (GI irritation,
heartburn).
Dosage : 4-16 mg / day taken with
food

ACES (Vitamina A, C, E, S)
While a complete and balanced diet
that includes plenty of fresh fruits
and vegetables can supply you with
ACES, many people either do not
have such a diet or are inconsistent
with their diet. ACES are excellent
anti-oxidants and improve cell
function.

Vitamin A: 5000 IU per

 day
Vitamin C: 500 - 2000 mg
per day
Vitamin E: 100-400 IU
per day
Selenium: 55-200 mcg
per day

I like Twinlab DualTabs. They have

all of these vitamins in the dosages
you need.
The above supplements require 2-3
months of consistent use before you
will notice any significant
improvement.
Rebuilding joints requires adequate
water, the necessary building
blocks (glucosamine, chondroitin
sulfate), controlling inflammation
with a natural anti-inflammatory
(SAMe) and sturdy cell walls
(Omega Three Fatty Acids, ACES),
plus specific joint exercises to aid
in the transport of nutrients and
signaling cellular activity.

Collagen Protein Supplement

Collagen is the most abundant
protein in the body making up
nearly 35% of total protein and is
found in skin, bone, and cartilage.
For joints, it forms a scaffolding
like like structure to which new
cells cling to form a solid structure.
In fact, the way collagen behaves in
your knee is a lot like how liquid
crystals behave on a smart phone
screen.
In response to pressure, the
collagen changes its arrangement to
provide the best support or
organization. Upon removal of the
pressure, the fibrils return to their
prior state. 6
In injured or weak cartilage, the
ability to organize into a protective
state where the collagen acts like a
biologic mesh holding the cartilage
components together is lessened.
Using the smartphone metaphor, the
touch screen would begin behaving
in erratic ways.
Our diets provide the collagen we
need provided the diet is rich in
whole foods and protein. The
typical Standard American Diet
though is often light on protein and
heavy on processed foods.
A Collagen Protein supplement can
help. It’s been shown to reduce
joint pain and help protect the
joints. 78
How do you add collagen to your
diet?
You can add bone broth soup or
consider a powdered supplement to
mix into your foods or beverages (I
have no financial interest in any
product or tool I suggest).

Rooster Comb Extract

Rooster Comb Extract (RCE) is
rich in something called Hyaluronic
Acid (HA). HA is what gives the
fluid in your knee its thickness or
viscosity.
A viscous synovial fluid improves
the ease of motion in your knee,
helps transport nutrients and also
serves as a shock absorber. 9
In arthritic joints, the synovial fluid
becomes thin or watery which then
exposes the cartilage to larger
compression forces.
Physicians sometimes inject HA
into a painful knee, one type of
injection is SynVisc, to help
improve the fluid quality.
There have been a few studies that
have shown RCE taken as a
supplement can reduce pain and
slow the degradation of articular
cartilage. 1011 Typical dosage is
between 80 and 100mg per day.
Chapter 22
THE MYTH OF
STRETCHING

S tretching is a “scared cow” of

knee pain or any other body
pain for that matter.
It’s a myth - a widely held but false
belief - that stretching will prevent
injury or fix an ache or pain.
There’s a running trail in downtown
Austin where hundreds of people
run everyday. If you watch what
people do prior to their run, nearly
all of them will stretch.
The hamstrings, quadriceps and calf
muscles are the top three.
Why?
Injury prevention and to improve
running performance.
But does stretching work?
The research suggests that it
doesn’t.
How did this myth around stretching
get started?
The assumption is that a more
flexible muscle would be less
likely to be injured. That idea
seems plausible enough but also
assumes that injuries occur at the
point where the muscle is most
stretched or stressed.
And, where in the range of motion
do most injuries occur?
Not at the extremes or limits of
range. A 100 meter sprinter has
tremendous flexibility in the legs /
hips yet the “pulled hamstring” that
these sprinters get happens well
within the normal limits of the
muscle. 1
More stretching won’t reduce the
incidence of injury.
Here’s some evidence:

The Center for Disease

Control looked at 361
studies on stretching
before exercise, with a
wide variety of stretching
exercises, and concluded
that stretching doesn’t
reduce injury rates. 2
Two studies also arrived at
the same conclusion - one
by the SMBD-Jewish
General Hospital and
another by McMaster
University:
“stretching before exercise does
 not reduce the risk of
injury.” 3 4

The problem is that the idea of

stretching seems to make sense. A
more flexible muscle might handle
the force of activity better than a
less flexible muscle. But, the
injuries in nearly every case happen
during the lengthening of the muscle
or what’s called an eccentric
contraction.
The force created during the
eccentric phase is much higher than
during the shortening or concentric
phase.
Too much force => injury.
What does help prevent injury? A
gradual over-all warm up. 5 Raise
the body temperature by, in the case
of running, walking briskly
followed by a few intervals of slow
jogs and walks.
I’m not saying that working on
flexibility or mobility is a waste of
time. It can be part of your routine
to improve your overall movement
but if you’re using stretching to treat
knee pain, it’s of little value.
Chapter 23
COMMON
EXERCISES USED
FOR KNEE PAIN

I received a question from a

reader of my blog a while ago:

“I’m currently doing

research into Patellofemoral
Syndrome rehab, as I've
been suffering with knee
pain in my right leg after
running, on and off for 3 or
4 years. I have seen
a therapist four times over
the last couple of weeks,
who diagnosed the problem
as a mal-tracking patella,
caused by a combination of
over pronation of my foot
and a weak VMO. I've been
given a selection of
exercises and 'treatments'.
These include:

Stretching of hamstrings,
quads and calf muscles (all
are very tight, hamstrings
are particularly short).
Theraband balance
exercises and quad
strengthening exercises
(straight leg raises, partial
squats etc.) - all outside
the pain zone.
Molded orthotics for
running and every-day
shoes.
Strapping/taping
instructions for when I
need/want to exercise with
reduced discomfort.
Although I acknowledge
your point on isolation of
the VMO, are you making
any alternative suggestions
for therapy, or would your
opinion be that the above
treatments are suitable and
 sufficient.

Many thanks for your help.

John (not his real name)”

The list of treatments is common.

And I would not consider any of
them to be inappropriate.
But, the list is incomplete.
The main problem with
Patellofemoral Syndrome (or
Patellofemoral Pain Syndrome) is
that the physical demand of the
activity is greater than your
physical capability. When the
physical demand is too high,
symptoms appear.
When your foot hits the ground, the
force of your body weight travels
back up the leg and through the
knee. The lining on the ends of your
bones, the articular cartilage,
disperses some of that force but
when the cartilage is too soft (as in
the case of Patellofemoral
Syndrome), more of the force
travels into the bone and other
structures (tendon, ligament, joint
capsule). As the force accumulates
and exceeds the tissue capability,
your knee may hurt (cartilage
doesn't hurt because it doesn't have
any nerve fiber in it).
Here's my impression of the pros
and cons of the exercises John
mentions.

Stretching of hamstrings, quads

and calf muscles
Pros: A more elastic muscle would
be, in theory, better able to absorb
force over a longer period of time
(although the theory is
fundamentally flawed as I discussed
in the chapter on stretching).
Cons: If the muscle is tight from
irritation and swelling of the joint
(which is almost always the case),
stretching is rarely effective. You
may be more flexible right after the
stretching but within hours, you're
just as tight as before the stretch.

Theraband balance exercises and

quad strengthening exercises
(straight leg raises, partial squats
outside the painful zone, etc.)
Pros: Stronger muscles help protect
the joint and help prevent knee pain.
Cons: To make the muscles
stronger, you have to use a
resistance that creates a high level
of fatigue. The force required to
fatigue the muscle is typically
greater than what the joint can
withstand. You either end up with a
sore, swollen, achy joint or muscles
that have gained little strength once
you get up on your feet.

Molded orthotics for running and

every-day shoes.
Pros: Orthotics alter the movement
of the leg (tibia and femur) via the
foot thereby reducing the pressure
under the patella (kneecap) and
improving general alignment of the
leg.
Con: Small changes in foot
alignment can lead to large changes
in joint pressures sometimes for the
better and sometimes not.
Secondary complaints of lower
back or hip pain are common.

Strapping/taping instructions for

exercise with reduced discomfort.
Pros: Can reduce pain by altering
sensory input to the brain.
Cons: You have to wear tape and
unless your exercise is designed to
improve the joint health, you may
exercise too hard and not know
it....until later.
The missing ingredient in the list is
a strengthening regimen for the soft,
weak joint surface. Almost every
exercise program that you find for
PFS targets muscle (quadriceps
strengthening, stretching of the
hamstrings, etc.) and having
stronger muscles is helpful but
weak muscles are not the primary
or only problem.
The muscular weakness is most
often in response to the changes in
the joint (soft, weak cartilage and /
or swelling). Some clinicians argue
that cartilage does not respond to
exercise; that it is biologically
inert.
However, there is ample scientific
evidence showing that cartilage
does respond like other biologic
tissues of the body (muscle, tendon,
ligament, bone) as long as the
motion-force combination is within
a certain range. 1 You may not be
able to regenerate articular
cartilage with exercise but you can
certainly improve the health of the
injured or diseased cartilage. And,
healthier cartilage translates into
increased physical capability.
Chapter 24
BEATING KNEE
PAIN IS AN INSIDE
JOB

S am is 52 years of age, about 30

pounds overweight
otherwise a healthy guy. He has a
but

busy life. Married, three children

and a demanding work schedule
leaves little extra time in his day.
Sometimes he’ll get up early to go
for a jog or on the weekends he
might walk 9 or 18 holes of golf or
take their dog, Scooter, for a walk.
About three months ago he noticed
that his left knee hurt one morning
after a 3 mile jog. The pain didn’t
last so he didn’t think much of it but
two weeks later, his knee ached and
felt stiff, so he decided to see his
family doctor.
His family doctor examined him,
took some x-rays and said, “Well,
most likely this is arthritis. There’s
nothing obviously wrong and, well,
you’re not getting any younger. Just
about everybody gets this and
there’s not much you can do about
it. I’ll give you a prescription and
you need to take it easy on the
exercising for a while.”
As Sam walked back to his car,
questions began to emerge. How
did I get arthritis? I’m not THAT
old…and does this mean I just get
worse? And how do I deal with
this? Will I have to take
medications forever?
Sam stopped jogging and playing
golf. He took the non-steroidal
medication the doctor had
prescribed. After about three
weeks, he noticed his knee didn’t
hurt. But when he resumed his
jogging and golf, his knee began to
ache and often lingered for a few
days. When he noticed that walking
caused pain, he called his family
doctor who then referred him to an
orthopedic surgeon.
The surgeon told Sam that his
problem wasn’t surgical and there
wasn’t anything he could do for him
that Sam wasn’t already doing. He
could try seeing a physical therapist
and issued a referral to a local
physical therapy clinic.
His physical therapy consisted of
exercises to strengthen his leg and
quadriceps (thigh) muscle,
stretching for his hamstring and calf
muscles and other procedures
(electrical stimulation and cold
packs) to help reduce his pain.
After about six visits, the therapist
gave him exercises to do on his
own at home.
But Sam had trouble with the
strengthening exercises.
He noticed that his knee ached more
after sessions when the exercise
intensity and resistance had been
increased. He felt he was making
some progress but was also
frustrated that he couldn’t strengthen
his leg.
Sam’s situation is not unusual.
Because OA weakens the inside of
the joint, the forces required to
strengthen the leg are often greater
than what the knee joint can
withstand. The result is an increase
in symptoms.
And no one had discussed other
options with Sam, other non-
surgical ways to help strengthen his
joint.
Addressing the problem of OA is a
process that starts inside the joint
and works out to the muscles and
not the other way around which is
how many practitioners treat OA.
Strengthening muscles to “support”
the joint, in theory, is not a bad
idea. In practice, it’s an uphill
battle and rarely effective over the
long term.
The solution has three parts. If you
leave out any component, you will
have much greater difficulty getting
back to an active life.
The solution is in the intersection
of Strength, Movement, and
Choices.
Strength is the strength of soft
tissues - tendon, ligament, cartilage,
fascia and muscle - which is
something you can improve with the
proper forms of exercise and
nutrition.
Choices refers to how you make
decisions and the attitude you have
that influences your decision
making. It’s not just having positive
attitude. Yes, if you think and
believe you can improve, your
chances of doing so are much higher
than if you have a negative outlook.
And what you think often
determines what do.
But sometimes people will choose
to do something that is not in their
best interest like running when your
knee hurts.
Or maybe you have a problem being
patient and diligent.
Your choices ultimately determine
your success.
How you make decisions and what
you choose to do and not do is
something you cultivate. It’s a
process much like strengthening
your leg is a process.
Movement, refers to the quality and
quantity of joint motion. When your
motion is smooth, controlled, well
coordinated, we say you have
optimal movement.
When you address all three, you
maximize your chances of recovery.
When you don’t, you might get
better, you might get partially better,
you might not get better or you
might get worse.
Chapter 25
HOW TO IMPROVE
JOINT HEALTH
WITHOUT
EXERCISE

I get emails from people all over

the world who are battling some
type of joint pain.
And many of these folks find
conventional exercise difficult
because the load or force used in
the exercise is more than what their
joint(s) can withstand.
They try the exercises, find they’re
too easy, increase the difficulty to
tire out the muscles and the joint
starts to hurt or ache.
How do you get out of this cycle?
Here’s an example.
I received this email recently from
a reader (I’ve changed the name,
city and any other personal
information for privacy reasons):

“I’m winding up some work

with a local PT for knee
problems from
osteoarthritis. I bought your
knee runners book last
summer and was having
good luck with it until I tore
my meniscus – just turned
my knee too quickly walking
around. I also have your
book about losing weight.
I’m hoping to get back into
my Total Gym program and
add a whole body routine to
help me lose weight. I need
to lose at least 65 pounds.
Currently my left knee is the
problem as that is the one I
hurt last fall. I take
Glucosamine, Chondroitin
and MSM along with fish
oil and a multivitamin. I’m
 also changing my diet to
eliminate excessive sugar
(mostly from soda). My
doctor has told me my OA is
moderate (medial only) just
starting bone on bone
contact.
Thanks, Jim.”

The first thing Jim needs to do has

nothing to do with exercise.
If Jim could lose just 10 pounds of
excess fat, his knee would instantly
tolerate up to 30 pounds more load.
For every pound you lose, your
joint improves its tolerance to load
by three pounds. 1
Jim’s problem – wanting to lose
weight but can’t exercise due to
joint pain – is common. In fact, the
majority of my physical therapy
clients were either frustrated
because they had the same problem
as Jim or they had gained weight
since being injured.
So, what do you do? How do you
lose weight without exercise?

It’s The Calories, Stupid!

According to some experts, calories
in and calories out. That’s all that
matters. It’s a numbers game. Get
the numbers right, you lose weight.
Get them wrong, you gain weight.
But it doesn’t work like that exactly.
Here’s how it supposedly works:

Find your “ideal weight”.

In Jim’s case, let’s say it’s
165 pounds.
Multiply your ideal weight
by 10 to get your maximum
calorie intake per day
target. For Jim, that’s 165
 x 10 = 1650 calories.
Track EVERYTHING you
eat or drink, record the
calories and keep your
total calorie intake below
the maximum target.
Track all your activity and
record the calories spent
on the activities.
Get ready to be miserable
for an extended period of
time.

How much weight you lose and

how fast depends on how much
difference there is between your
usual intake of food and your new
target maximum… so the theory
goes.
As an example, let’s assume Jim
has been consistently eating around
2500 calories per day.
If Jim reduces has calorie intake to
1650 calories, then he has an 850
calorie per day deficit. After seven
days of this, he will have total
deficit of 850 x 7 = 5950 calories.
Let’s round that up to 6000 for
slightly easier math.
One pound of fat holds about 3500
calories of energy. By creating a
6000 calorie deficit, Conventional
Wisdom suggests Jim’s body will
“burn” fat to make up the
difference. Jim should lose about
1.7 pounds per week with this
approach.
Now add in exercise, and let’s
estimate a conservative amount of
200 calories of some type of
activity per day.
Jim’s total weekly caloric deficit is
~ 6000 (from not eating as much)
plus 1400 from exercise for a total
of 7400 calories.
Instead of 1.7 pounds per week, Jim
should lose just over 2 pounds per
week.
Why not just suggest this to Jim?
Just keep it simple. Count calories
in, subtract calories out and bingo,
weight loss.
Because this is why.
Calorie counting is a challenging
if not miserable lifestyle for most
people. Imagine, for the rest of your
life, counting everything you eat or
drink. I’m all for data tracking but
having to measure and track all
foods forever and all activities is
an overwhelming thought. Even
Weight Watchers has come to the
conclusion that counting calories is
a mistake (and for what it’s worth,
like most things I talk about or
suggest on my web site, I’ve done
the whole calorie counting thing
too).

“We needed a program that

recognized that calories are
most definitely not created
equal.
We knew that counting,
budgeting and planning still
made fundamental sense, but
we wanted a better and
 more accurate currency. We
wanted a POINTS formula
that was much more
“opinionated” about food
choices beyond just
calories.” – David
Kirchhoff, President and
CEO of Weight Watchers
International

Calorie counting assumes that the

type of food you eat is less
important than the quantity of food.
This can lead to food “hoarding” –
purposely not eating for a period of
time to permit a binging on sweets
or other more desirable or
“comfort” foods.
Not a great lifestyle choice.
I’m not saying that calories are
irrelevant. And I’m not saying you
should never count calories.
Sometimes, knowing the calories
can provide guidance on the
quantity of food but my advice is, if
you’re going to count calories,
clean up your diet first (more on
that below).
If you eat too much of anything, you
can gain weight. But in order to
develop a lifestyle, a way of living
that is sustainable, counting calories
fails almost every time.
Counting calories is imprecise.
For the formula to work, you have
to weigh and / or measure
everything you eat or drink and
record your activity in terms of
caloric output. Activity trackers -
heart rate monitors, smart watches -
can over state caloric expenditure
by over 50%. You think you used
500 calories at the gym when in fact
it’s likely closer to 200 to 250.
Calorie In - Calorie Out formula
is missing some key variables.
There’s more to the formula than
Calories In - Calories Out.
Instead of Calories Out, it’s Total
Daily Energy Expenditure which
looks like this:

Your body strives for equilibrium

or homeostasis. It finds ways to
become more efficient to put itself
back in balance.
One of the ways it does this is
through your Resting Metabolic
Rate (RMR).
Your RMR is the rate at which you
use energy to run the various
functions of the body. Repair
injuries, replenish energy stores,
run biologic processes, etc.
And since the body has been wired
to preserve itself, when your
caloric intake drops suddenly, the
body’s response is to lower your
RMR. It’s seeking a state of
balance.
Think about it. You don’t have to be
fit to stay alive. Your body can
adjust the output to match the input
and sustain that balance for many
years.
When you go on a crash diet, you
slash the energy input. You’ll lose
weight but your body begins
tinkering with the output side.
N.E.A.T
NEAT stands for Non-Exercise
Activity Thermogenesis. People
who are fidgety, bounce their leg
while they sit through a meeting for
example, tend to have high levels of
NEAT. And that small amount of
activity over the course of days,
weeks, months gradually shifts your
RMR up. 2
Basically, move more often in
natural, non-exercise ways.
Perhaps the easiest way to
implement NEAT into your day is to
set a timer for 60 minutes and place
it across the room. When it goes off,
get up and go turn it off. While
you’re up, take a 5-8 minute walk.
When you return, set the timer again
for an hour.
What happens is that these small
bursts of activity add up over the
course of a day and boosts your
metabolism.

Is Rush Limbaugh Right?

Although, maybe you agree with
Rush Limbaugh – all that matters is
the calorie.
Limbaugh reported on a study
conducted by a Mark Haub, a
professor of nutrition at Kansas
State University.
Professor Haub was overweight
and decided to use himself to prove
a point: all that matters in weight
loss is calories.
So, he placed himself on a diet of
Twinkies with some Ho-Hos,
Doritos, sugar loaded cereals, and
Oreos. He ate these “foods” at three
hour interval.
After ten weeks of this “diet”,
Professor Haub had lost 27 pounds,
lowered his “bad” cholesterol, and
raised his “good” cholesterol.
Mr. Limbaugh says this about the
study and his interpretation of it:

“I love being right. Folks,

it’s a thrill. I have to tell
 you, you don’t know what
it’s like to be right as often
as I am, particularly when
you’re simply following
instincts, when being right
really doesn’t have that
much to do with formal
education, just being street-
wise smart, just having
common sense, having the
guts to say what you know
to be true…”

Well, you’re not right this time

Rush.
What the sample-size-of-one study
didn’t talk about is the effect of
food on your body over time.
The human body is amazingly
resilient. We can introduce a variety
of “toxins” – cigarettes, sugar,
hydrogenated oils, among other
things – and live a long time with
no obvious negative effects.
You don’t get lung cancer in two
months. You don’t get Type II
Diabetes in two months. You don’t
get high cholesterol and high blood
pressure in two months. And you
don’t become obese in two months
(maybe overweight but not obese).
It takes years to develop these
diseases which is part of the
problem. There’s not much in the
immediate future to cause you to
reassess your choices and many
people struggle with delayed
gratification which is what living a
healthy lifestyle includes.

The Secret? It’s Just One Thing

There’s one thing. One thing, if you
get it right, will help you balance
your body fat without much or any
exercise.
More important than the quantity of
food, is the type of food.
That’s the one thing.
For example, the Pima tribe of
Arizona had virtually no incidence
of obesity, diabetes or other
“lifestyle” diseases until their diet
changed from indigenous food
sources to the food supplied by the
US government – white flour, sugar,
processed cereals / foods – and the
more “modern” lifestyle of
sedentarians along with fast, more
convenient foods.
Here’s a group of people who had
an apparently well balanced blend
of food and activity that fit their
genetic heritage and as a result
were quite healthy for a long time.
Then, they changed both variables.
They became less active and ate a
more “modern” diet. And over
several years, they developed the
lifestyle associated diseases of our
culture.
And the same thing is happening to
Asian nations.

The Steps to Losing Weight

When You Can’t Exercise
Step 1 - A Food Journal. You need
to keep track of everything, I mean
everything, you eat or drink for
seven days without changing from
what you would normally eat or
drink. At the end of the seven days,
you’ll have a reasonably good
snapshot of your diet.
Step 2 - Examine the food journal.
Look for patterns. Do you skip
breakfast? Do you eat similar things
for lunch and what sort of food is
it? What about snacks or sodas?
How about alcohol? What do you
have for dinner? How often do you
dine out? What you want is
consistency. yes, it can be boring to
reduce your meal choice but you
have to keep your eye on the goal.
Once you make your eating choices
more mindful, then you can
introduce more variety. But, in the
beginning, boring wins.
Step 3 - Think baby steps. Change
lasts when the changes are small
and become incorporated into your
lifestyle. You don’t have to change
everything in your diet all at once.
Pick one meal and change it. Just
start with one thing and build on
that.
Step 4 - Baby step: Eliminate any
added sugar. Before you completely
re-work your diet, start with tossing
the sweets, sodas, cookies, and
ANY food that has sugar added to
it. Read the label. You might be
surprised at how many foods have
added sugar. Fruits are okay – you
have to eat a LOT of fruit a LOT of
the time for it to be truly bad for
you. I doubt you can eat that much
fruit. For example, if you drink
three 20 ounce Cokes a day, you
would have to eat 9 really large
apples to get the same amount of
sugar (and I’m not even talking
about the kind of sugar – that’s
another story).
Step 5 - Baby step: Don’t eat
anything out of a package or a box.
Choose from the following types of
foods to assemble your meal plan:

meat, fowl, fish, eggs,

vegetables, fruits, nuts,
seeds, healthy oils
limit grains to quinoa and
whole grains for now (you
may be able to expand that
option later – it depends
on how your body handles
the carbohydrate)
Cheese is okay as long as
it’s real cheese and not, for
example, Velveeta
Step 6 - Keep Portions the size of
your fist. If you keep your food
portions to roughly the size of a
closed hand – fist – you’ll be close
in terms of quantity of food. It beats
weighing, measuring, and counting
all the time.
Step 7 - Eliminate alcohol. Alcohol
will change your body’s
metabolism or the rate at which it
uses energy. 3 This makes you much
less likely to lose weight in general
even if you add exercise. Avoiding
alcohol consumption will make a
huge difference in your body fat
levels. And it helps your liver too.
Step 8 - Be real. A lot of people
feel that they have to be all or
nothing when it comes to a change
especially diet. Big mistake. Adopt
a more realistic perspective. If you
can change at least 50% of what
you’re currently eating to something
that is more “whole”, you’ll help
yourself a lot. If you can hit 80%
(and that’s my personal plan),
you’ll be in much better health,
have more optimal levels of fat, and
feel a lot better.
If you do the above steps, you’ll
naturally lose excess fat until your
body reaches an equilibrium. And
very likely, at that point, you’ll be
within healthy ranges of body fat.
You will increase your joint load
tolerance significantly.
And you haven’t even added
exercise.

Why Exercise Is Not The Sole

Answer To Losing Weight
Some of my clients have told me
that they exercise so they can eat
whatever they want.
And, this works, sort of, until you
can’t exercise at the intensity or
duration you need to.
Then the wheels come off the
wagon. The wagon goes off the
cliff. Life feels like one long series
of disasters.
You gain weight. You’re frustrated
because you gained weight so you
eat (or drink) to reduce the stress
created by the weight gain.
But eating and drinking leads to
more weight which leads to more
stress which leads to more eating
and drinking.
Then you get bitchy. Irritable.
Am I close?
This is why I strongly suggest you
NOT count calories or use exercise
to “balance” the calorie scale.
Purposeful exercise is best used to
“harden” your body; to make you
more resilient, more capable and
not to create a caloric furnace.
The first step is to overhaul your
diet and as you lose weight you get
a fringe benefit: for every pound of
fat lost you gain three pounds of
increased force capacity in your
joints.
The Role of Diet in Joint Pain
I've covered how nutraceuticals can
influence both the symptoms and
disease process of OA and how
body weight influences joint pain.
But what about your diet? Can what
you eat or drink affect OA
symptoms? Make the problem
worse? Or better?
Some of the pain from arthritis is
from the inflammation of the joint
tissues.
And what you eat or drink can
influence the magnitude of
inflammation.
Researchers followed 4330 people
over four years looking at the
relationship between those people
who adhered to the Mediterranean
Diet and the risk of pain and
symptoms of OA. 4
They concluded that people with
higher adherence to the diet had a
much lower risk of pain and
symptoms of OA.
The Mediterranean Diet consists of
:

Plant-based foods, such as

 fruits and vegetables,
whole grains, legumes and
nuts
Replacing butter with
olive oil and canola oil
Using herbs and spices
instead of salt to flavor
foods
Limiting red meat to no
more than a few times a
month
Eating fish and poultry at
least twice a week
Drinking red wine in
moderation (optional)

Andrew Weil, MD published an

Anti-Inflammatory diet which is
similar to the Mediterranean Diet.
You can learn more about his diet
by visiting his website (https://
www.drweil.com/diet-nutrition/
anti-inflammatory-diet-pyramid)
Gluten
For some people, the presence of
gluten in their diet seems to act as a
joint pain trigger (gluten is a group
of proteins found in grains such as
wheat, barley, and rye).
Gluten sensitivity is a much milder
than something like Celiac Disease
- an auto-immune disease caused by
gluten. Gluten sensitivity is a
controversial topic within the
medical world. While there are
tests for Celiac Disease, there aren't
tests for gluten sensitivity.
The easiest way to determine if
your joint symptoms might be
worsened by gluten is to remove it
from your diet.
Gluten is often found in:

breads
pastas
crackers
chips
cookies
cereals
beer
malt/malt flavoring
soups
commercial bullion and
broths
cold cuts
French fries (often dusted
with flour before freezing)
processed cheese (e.g.,
Velveeta)
mayonnaise
ketchup
malt vinegar
soy sauce and teriyaki
sauces
salad dressings
imitation crab meat, bacon,
etc
egg substitute
tabbouleh
sausage
non-dairy creamer
fried vegetables/tempura
gravy
marinades
canned baked beans
commercially prepared
chocolate milk
breaded foods
fruit fillings and puddings
hot dogs
ice cream
root beer
energy bars
trail mix
syrups
seitan
wheatgrass
instant hot drinks
flavored coffees and teas
blue cheeses
vodka
wine coolers
meatballs, meatloaf
communion wafers
veggie burgers
roasted nuts
beer
oats
 oat bran

Quite a list. You can probably see

the challenge of removing gluten
from your diet. Gluten is in so many
commonly consumed foods that it
becomes almost impossible to
eliminate it if you, for example,
have a family and need to maintain
a consistent menu.
You could start by removing the
easier items on the list - breads,
pastas, chips, cereals, alcohol - and
make a note of your symptoms.
Generally, if you follow a diet with
no processed foods, no alcohol, or
sugar and focus on whole foods and
grains (the items in the Weil diet or
the Mediterranean Diet), you'll
increase your chances of having
less joint pain.
Chapter 26
WHEN A GOOD
KNEE GOES BAD

O ne of the first signs of a knee

joint problem is a sense of
stiffness in the knee.
Stiffness is one of the few ways
your knee joint can communicate its
state of health. With no blood or
nerve supply, the protective lining
over the ends of your bones,
articular cartilage, has few options
to let you know it’s in trouble. If it
could speak, the joint might say,
"Hey, you know all that running
you've been doing? Well, you're
killing me down here!" Instead, it
sends a slow, steady signal waiting
for you to acknowledge it.
Unfortunately, most of us do not
know "jointese”. How the joint
“speaks” to you is much like
understanding a foreign language. If
you travel to France and don’t
understand the French language,
you’ll spend most of the trip
bewildered.
There are two types of stiffness -
short term and long term.
Your knee joint has a membrane of
specialized connective tissue called
the synovium. The synovium is a
thin layer of cells that lines your
joint and controls the biochemical
environment of the joint.

Synovial lining of the knee

What happens inside your joint
reminds me of the movie starring
Jim Carrey, “The Truman Show”.
In the movie, Jim Carrey plays a
man whose life is actually a TV
show although he doesn’t know it.
His world is a huge, sophisticated
TV studio set that controls
everything about his day: the
weather, people, places, and events.
Your synovium is like the studio set
of the Truman Show. Inside the
joint, everything that happens is
controlled by the synovium. Healthy
synovium secretes a thick, nutrient-
rich fluid that bathes the cartilage
and helps maintain a firm, cushion-
like capability.
The long term stiffness of a joint is
primarily due to the shearing of
cartilage cells creating tiny
cartilage fragments in the joint.
These tiny fragments are absorbed
by the synovium which in turn
becomes inflamed. When the
synovium is inflamed or irritated,
the fluid will be thinner and the
cartilage becomes softer. The
condition of a joint with soft,
thinning cartilage is often referred
to as Degenerative Joint Disease
(DJD) or Osteoarthritis.
The more inflamed or irritated the
synovium becomes, the more it
swells and since it has an
abundance of nerves and blood
vessels, the dull sense of aching and
stiffness soon follow.
The short-term stiffness, however,
is different. On the surface of
articular cartilage, secreted by the
synovium, is a surface-active
phospholipid (SAPL). The SAPL's
job is to provide the lubrication you
need in the joint and to prevent the
layers of cartilage from melding
themselves together or gelling. In
the case of DJD, the synovium does
not produce as much SAPL and
therefore, you feel stiff; the layers
begin to gel until you get up and
move.

Swelling in The Joint Means

Weakness in the Muscles
If your knee is frequently stiff and
achy, you most likely have some
degree of swelling in the joint.
In most cases, the swelling isn’t
detectable to the eye. When you
visually inspect the joint, it may
look identical to the other knee.
But the thigh muscles on the painful
or symptomatic leg will not be as
strong nor be able to contract as
forcefully as the other leg.
Why is this?
The presence of a wee bit of
swelling in the joint will inhibit the
quadriceps muscles from fully
contracting. 1 This is called
arthrogenic muscle inhibition.
It’s not that the muscles don’t
contract at all. They just don’t have
full strength capability. The amount
of swelling needed to cut the
strength of the quadriceps by 30 to
50% is only approximately 30ml or
1oz. For reference, a shot glass
contains 1.5 ounces of fluid.
To develop the strength you need in
your knee, the first step is to
eliminate any swelling in the joint
and establish a healthy joint
environment.

How to Reduce Swelling

There are a few simple things you
can do to reduce the signs of
swelling in your knee.
They are rest, elevation,
compression, and controlled
movement.
Rest means interrupting your
activity and getting off your feet for
a few minutes several times a day
as opposed to one long period of
inactivity. If you combine REST
with ELEVATION, raising your foot
/ leg, with some support such as
pillows, above the level of your
heart, you can make a big difference
in the amount of swelling in your
joint.
 image source: wikihow

If you add some gentle

compression, either in the form of a
compression sleeve or Ace Wrap,
while in the resting position, you
make things even better for
yourself.
If you use an Ace Wrap, start the
wrap below the knee and wrap
upwards gradually reducing the
pressure of the wrap.
For a compression sleeve, click
here (I do not have any financial
arrangement with companies whose
products appear in this book).
Easy motion, for example stationary
bike cycling with little to no
resistance can help reduce
swelling. Gently peddle for about 5
minutes at a time at least twice per
day.
When you can contract your thigh
muscles and create a strong, solid
muscle contraction, you’ll know
you have the swelling under
control.
Chapter 27
JOINTS ARE NOT
MUSCLES

R obert is an energetic, trim,

attorney in his 40’s. He goes
to Bikram Yoga several times a
week for his “fitness” routine
(Bikram Yoga is performed in a
warm. almost hot, environment).
Fitness is critical to him; it’s part of
his lifestyle. He likes the way
Bikram Yoga makes him feel and he
thinks it helps him keep his weight
under control.
When I asked him if he ever did any
other kind of exercise he said, “Oh,
yeah, I used to work with a trainer
at a gym but I just found that I hurt
more and more after the sessions. I
mean, it kept me lean and
everything, but my body hurt too
much.” In Robert’s case, he found
another way to exercise that was
kinder and gentler on his joints but
not kind and gentle enough. He said
that he still hurt; just not as much or
as often.
Weak joints need to be nudged to
get stronger; not pushed.
To work through a joint weakness,
you first abandon everything you
know to do for muscles including
how hard you work, how fast, and
how long.
Joints like things to be easy.
Muscles like things to be tough.
Joints change slowly. Muscles
change fast.
Joints need a lot of motion. Muscles
need a lot less.
The kind of exercise you do to
strengthen muscles is way too hard
for a weak joint. In fact, weak joints
are often the reason people either
don’t exercise or eventually quit.
They hurt too much; too often.
Joints need to be nudged into health;
not pushed.
Joints are not muscles.
Chapter 28
CHOICES ARE
EVERYTHING

P art of the solution in The 90

Day Knee Arthritis Remedy,
includes how you make decisions,
the framework you use for decision
making.
And you might be wondering why.
Decision making stems from your
mindset. A mindset is like a
guidance system, a collection of
beliefs, that help us make decisions
or influences our reactions. And for
most of us, this guidance system is
on autopilot.
We’re not even aware that we’re
using it.
Here’s an example. One of our
clients, Margaret, was frustrated by
her lack of progress.
She said, “I’ve been doing
everything right but I’m not any
better. And it’s been a month.”
“Ok, but what you do mean that
you’re not any better?” I asked.
“I still hurt!” she exclaimed.
“Do you mean with everyday
activity or while sitting or
something else?” I asked.
“No! When I run! I still hurt
running!” she replied with
exasperation.
“I see. I understand. Now, when we
first met, what did we talk about it
in terms of time frames and when
you should start running again? Do
you remember?” I asked.
Silence. It felt like an hour but was
more like 10 seconds.
“No, I guess I don’t remember that.
I thought I could keep running as
long as I was doing the exercises
and the other stuff,” she replied.
Margaret’s guidance system or
mindset was set on running despite
my instructions to the contrary. And
she wasn’t even aware of it.
Why is that? Why would she not
hear me? Was she deliberately
sabotaging herself? Doubtful. More
likely, she had what I call a
“guidance glitch”.
The guidance system still functions
but is takes you in a direction you
don’t want to go. Kind of like when
a missile guidance system has a
glitch and the missile lands in the
wrong place.
Making changes in your life is hard.
You have to apply a different kind
of thinking than the kind you
typically use.
In Margaret’s case, she wasn’t
thinking as much a she was on
autopilot. She reacted and was
directed by what is referred to as
First Order Thinking.
First Order Thinking is easy. You
don’t slow down to evaluate the
ramifications of the decision. You
just do it.
But if we are to be successful, to
achieve maximum performance, we
have to think in a different way.
The kind of thinking is called
Second Order Thinking.
Second Order Thinking asks
questions such as what are the
possible outcomes if I do this?
What’s the chance I ‘m wrong?
What other options do I have have
that might be better?
Back to Margaret, if she had
slowed down and asked herself a
few more questions, do you
suppose she would still choose to
run or exercise on a painful knee?
Maybe but the likelihood is much
less.
Chapter 29
GUIDANCE
GLITCHES

T
book.
his chapter is one of the most
important chapters in the

Getting past the aches and pains

from a painful knee requires more
than just a technique, an exercise, or
a different way of eating.
As much as anything, the game is
won or lost by your ability to get
past or fix “guidance glitches”.
A guidance glitch is anything that
sends you off in the wrong
direction, keeps you in the same
place or even sends you in reverse.
The key to fixing your guidance
system or mindset is to become
more aware of the common things
that serve as mental / emotional
glitches.
Here they are:

Lack of Acceptance
Self-Doubt
Inattention
Impatience
Loss of Discipline
 Worry

Lack Of Acceptance
Phil Jackson, former coach of the
Los Angeles Lakers, said in his
book Sacred Hoops, "In Zen it is
said that the gap between accepting
things the way they are and wishing
for them to be otherwise is the tenth
of an inch between heaven and
hell."
Your frustrations, unhappiness, and
worry are not just from what you
think, but also from how tightly you
hold onto those thoughts. You are
unwilling to let go and accept your
situation. To change, you must
accept or “receive with consent”. It
is only from this action, from a
conscious choice to yield, that you
will have a clear perspective on the
path that is best for you and those
around you. To heal, you must
accept your injury, your actual
abilities. In Zen, this is called a
“Beginner’s Mind”. You must be
open, have an attitude of
acceptance, and willingness to
learn.
I have worked with many people
who have had the “Beginner’s
Mind” and many who have not.
While the technical aspects of
beating knee pain are important,
your mindset is critical. In fact,
without the “Beginner’s Mind”, you
will fail.
Basically, the problem is this: you
want to be someplace other than
where you are and your refusal to
accept the place you’re in only
serves to increase your suffering.
I’m not suggesting this is easy. And
it’s not all done at once either. You
have to work at it.
There’s a great story that I think
highlights this ability to accept
one’s current situation and it took
place on the way to the moon.
Ken planned for years to make the
flight. He studied, practiced, and
trained with tireless intensity. As
the medical staff explained his
condition, Ken struggled to accept
the news. His fate on Apollo 13’s
flight to the moon was sealed
because of the measles. Although he
was certain their diagnosis was
wrong, there was nothing he could
do now but stand aside and watch.
In April 1970, Apollo 13
experienced a series of problems en
route to the moon. As a result, they
had to abort the mission and return
to earth. The crew was told to shut
down the command module and
power down all the computers to
preserve the little battery energy
remaining. On Earth, NASA
scrambled to develop a startup
sequence that would use only 20
amps of power.
They called Ken Mattingly for help.
Ken sat in the flight simulator for
hours working on the sequence. The
frustration levels were high as time
was running out. With each trial
Ken exceeded 20 amps.
The Flight Operations Director told
him to omit something, to get the
amperage down to 20. Ken
exclaimed, “I can’t! They need
every one of these steps to get back
here!” Flight Ops responds, “Ken,
you’re telling us what you need.
We’re telling you what we have to
work with – 20 amps.” And in that
moment Ken accepts “what is” and
goes back to work.
Later, Ken developed a sequence
that used only 20 amps of power.
Everyday, people struggle accepting
“what is”. Some of us spend hours
wishing for what was while others
fear what might be. The hours
slowly expand into days and the
days into weeks. Accepting “what
is” frees your mind to work on what
could be. The mind constantly seeks
solutions and evidence to support
our thoughts. If we are anchored to
the past or fearing the future,
suddenly everywhere we look we
discover something to reinforce our
position.

What we think is what we

feel, what we feel is what
we do, and what we do is
what we get.
What would have happened if Ken
Mattingly refused to accept the
reality of the 20 amp limit? Apollo
13 wouldn’t have been one of
America’s greatest recoveries. It
would have been a tragic disaster.
You have to accept where you are
to get to where you want to be.
Just like Ken Mattingly did and
oddly enough, when you do this,
you’ll discover new things,
solutions, and make more progress.

Self-Doubt
 “As a single footstep will
not make a path on the earth,
so a single thought will not
make a pathway in the mind.
To make a deep physical
path, we walk again and
again. To make a deep
mental path, we must think
over and over the kind of
thoughts we wish to
dominate our lives.” -
Henry David Thoreau

You will, I can almost guarantee it,

find Doubt sitting on your shoulder
whispering to you, “This won’t
work. You’ll never get better. Don’t
you think you’re just wasting your
time?” It’s a normal reaction, but
one that if left unchecked, will ruin
your return to an active life.
Doubt is an emotion that can over
take your logical, rational mind. So
one antidote to doubt is an action
list and then work the list. Action
(with new thoughts) is the broom
that whisks Doubt away.
Not only might you doubt the
program, you may also doubt
yourself; whether you’re up to the
task, whether you can really do it.
I’ve been there. I think many of us
have. Could be a new job,
relationship, routine, a marriage,
divorce. Whatever is new can bring
Doubt with it.
So, what can you do?
Here are five things that I have
used. Yes, I am not immune to self-
doubt, and have suggested these
solutions to clients:

Recognize that the

reason you feel the way
you do is because you’re
going after something or
trying something that
means a lot to you. Your
dreams are often the most
fertile soil for doubt.
Acknowledge it.
Write it down. Get your
worries and thoughts out of
your head. Stop playing
“thought ping-pong” all
day and get it out through
the fingers. Then, after
each doubt, write down
why you CAN reach your
dream. Maybe it’s a friend
who will support you or
maybe it’s because you’ve
been through some other
struggle that you can
reference.
Remind yourself why this
dream is so important to
you. What does being
active again mean to you?
How does it move you,
touch you, transform you,
build you up?
Create something
positive to go back to
when you feel doubt
rising. This can be an
affirmation or a photo or
music. Anything that
creates a powerfully
positive stirring inside
you. When I was in the
 midst of a back injury
following a skiing
accident, a friend of mine
sent me a video. I watched
that video many, many
times. Maybe it will help
you. Click here to see it.
You’re not alone. You’re
not the only person that
feels the task is too big or
you might fail:

“I have self-doubt. I have

insecurity. I have fear of
failure. I have nights when I
show up at the arena and I'm
like, 'My back hurts, my feet
hurt, my knees hurt. I don't
have it. I just want to chill.'
We all have self-doubt. You
don't deny it, but you also
don't capitulate to it. You
embrace it.”
- Kobe Bryant

“There has been a lot of

self-doubt and unwelcome
events in my life.”
- Al Pacino

“I don't believe anyone ever

suspects how completely
unsure I am of my work and
myself and what tortures of
self-doubting the doubt of
others has always given
me.”
- Tennessee Williams

“You shouldn’t focus on

why you can’t do something,
which is what most people
do. You should focus on
why perhaps you can, and
be one of the exceptions.”
- Steve Case, co-founder
AOL
Inattention
I use a phrase with my clients:
“Place your attention on your
intention.” Too often, people who
hurt will use some gimmick or
gadget to shoo away the pain so
they can just keep doing whatever
they want even though they still
hurt.
What do you suppose your intention
is when you do something like this?
Where is your attention being
placed? My guitar teacher, Jim
Collard, describes the process of
learning the instrument to climbing
stairs. Sometimes the step is high;
the riser is tall and you work and
work and work to get up to the next
step. If you try to work on things
that are three or four steps up higher
than where you are, you’ll just end
up frustrated and actually play
worse than if you slow down, play
at your level, master that, and then
move up. If you want to heal, get
stronger, and run, place your
attention on the step you’re on.
There are many drills and exercises
in this book to improve your overall
leg function and strength. Some of
them look simple. But where you
place your attention during the drill,
how you execute the drills, for
many of them, is the key to making it
work for you.
John Wooden, one of the greatest
college basketball coaches in
history leading UCLA to four
perfect 30-0 seasons, 88
consecutive victories, and 10
NCAA championships, said, "I
continually stress to my players that
all I expect from them at practice
and in the games is their maximum
effort."
Maximum effort includes giving
your attention in the moment to
whatever it is you’re doing and
doing it the very best way you can.

Impatience

"How poor are they who

have not patience!
What wound did ever heal
but by degrees?"
- William Shakespeare

I don't know about you, but I would

like to think I am a patient person. A
friend tells me I have a high
tolerance for difficulty, but I am not
sure that quality is a good thing. If
you are too tolerant or patient you
may miss opportunities, but if you
are impatient you may miss them as
well.
What does it mean to be patient?
When is patience good and when is
being patient actually disguised as
settling or giving up? Is there a
difference between being patient
and being a patient? Is it possible to
be a patient patient?
The Shorter Oxford English
Dictionary on Historical Principles
defines a patient as "a sufferer";
"one who is under medical
treatment"; or "a person . . . to
whom . . . something is done". The
origin of the word patient is from
the Greek root "patior" meaning "to
suffer". Patience also means
"calmness or without discontent; not
hasty; not overeager; composed”.
The first use of patient as a medical
term dates back hundreds of years.
Considering the barbaric nature of
medicine at the time (surgeons were
also barbers don't forget - puts a
new twist on "getting your ears
lowered"), one who was patient
was a person who endured suffering
and did so quietly.
Even today in certain medical
circles, patients who ask questions,
know their options, or question a
medical opinion can be labeled as a
"bad" or "difficult" patient.
But patients are rarely patient. Our
society infuses us at an early age
with the thirst for rapid gratification
and as technology advances, our
tolerance for delay declines. We
want things quickly, will go
elsewhere if we have to wait, and
are generally always in a hurry. No
wonder we cringe when we hear,
"Well, it will be several months
before you can exercise (or run,
hike, cycle - insert your favorite
activity) again."
I think patience is easier to develop
when you understand the nature of
your problem. To understand the
problem means that you know the
facts about it and its significance.
For example, assume you have pain
in the front of your knee. It hurts
when you walk, climb stairs, or run
and you would just as soon not be
bothered by the constant and
persistent discomfort.
First, you must gather information
about why your knee hurts. Is it an
injury to your tendon, your joint
surface, your bone or bursa, a
referred pain from muscles in your
thigh or from your hip joint? Or is it
something else?
Until you have narrowed the
possibilities, you will have little
patience.
Without the knowledge, there can be
no understanding. Thus, armed with
no information, you may try all sorts
of things to alleviate the symptoms.
Things like heat, cold, magnets,
knee straps, massage,
electrotherapy and the list goes on.
Since fuzzy knowledge yields fuzzy
solutions, the result is a growing
level of frustration and impatience.
Lack of knowledge and
understanding can also lead to
quitting. Many people give up trying
to beat an injury or come back from
a surgery because they don’t know
precisely what to do, how to do it,
and what to expect. They settle.
This is not being patient. This is
quitting. Granted, it may be from
ignorance, but it's still quitting.
I know how hard it is to be a patient
patient. We all would like our
wounds to heal faster than they do.
However, you can only push the
body as fast as the body will
permit. The best you can do is to do
your best. Gather the facts. Ask
questions. Spend your time around
people who will help you find
answers. Exhaust all options and
give your injury what it needs to
heal. Be persistent and diligent and
remember what Will said, "What
wound did ever heal but by
degrees?"
Knowledge leads to understanding
and understanding is the key to
patience.
Seek knowledge first.

Loss Of Discipline
Most people think of being
disciplined as doing something they
don’t want to do. However, being
disciplined is not forcing yourself
to do something when you don't
want to do it. Discipline is derived
from discere which mean "to learn".
Being disciplined means carrying
out what you have learned.
Discipline is taking action with
knowledge.
When you’re undisciplined about
your program or training, it’s
usually because you have missed a
crucial step in the learning process
or you refuse to accept that a
particular activity will be of
benefit.
For example, I often suggest a basic
exercise, one that is also suggested
by thousands of trainers, clinicians
and doctors, to help reduce knee
pain and improve function of the
knee. In fact, this exercise is so
easy to do, you can do it almost
anywhere.
Yet, many people, when I ask them
how many times they did the
exercise that day, will sheepishly
admit that they hadn’t done it at all.
They are undisciplined.
Sometimes, that’s because I’ve
failed to get the point across.
Sometimes it’s because the client
doesn’t want to believe that
something so simple could be so
helpful. Or, sometimes, oddly, the
client doesn’t really want to get
better (and that’s another book unto
itself). Whatever the reason, remind
yourself that a lack of discipline is
primarily a lack of knowledge and
understanding.
Get clear on the what, how, and
why of your plan and your
discipline will improve.

Worry

“Supposing a tree fell

down, Pooh, when we were
underneath it?” asked Piglet.
“Supposing it didn’t,” said
Pooh after careful thought.
Piglet was comforted by this
(from Winnie the Pooh).
When you hurt, your inner Piglet
shows up. You see more bad things.
Things that could be bad, things that
someday could go wrong.
Worrying is Doubt’s brother. They
walk together next to you trying to
nudge you one way or the other onto
a path of self-defeat. Worrying is
borrowing trouble from the future. It
serves little purpose unless it
prompts you to do something.
Of course, worrying makes sense if
you live in the woods and have
sticks for weapons. Yeah, I would
worry about lions, tigers, and bears,
too. However, you’re worrying
about things like, “Will I ever get
better? Will this go away? Can I run
again?”
Am I right?
When you hurt, Piglet will convince
you that there's nothing you can do;
you might as well accept your poor,
miserable lot in life and just do less
and less and less; all is lost.
Sometimes Piglet is in you and
sometimes he's the people you
associate with or talk to. Stay away
from Piglets. Don't listen to Piglets.
They are not helpful. Find some
Pooh in you and get around some
Pooh people. Pooh helps you see
possibilities and possibilities fuel
your efforts.
When you’re worrying, you need
more Pooh.
Chapter 30
A PRIMER ON
STRENGTH

A s I mentioned before, leg

strength is protective against
knee pain. 1
But what does “strength” mean?
What comes to mind when you hear
the word?
By definition, strength is the amount
of force a muscle or group of
muscles can produce for one
repetition or a one repetition max
(1RM). For example, performing a
squat using extra weight to make the
movement so difficult that you can
do just one squat.
This example is a squat with 665
pounds (plus his body weight)
repeated for five times. In other
words, his 1RM is more than 665
pounds.
Researchers use a special device to
measure knee extensor strength
(straightening the knee), for
example, during an isometric
contraction.
The device can be placed against
the lower leg and the examiner
resists the subjects effort to
straighten the limb and records the
force reading on the device.

Source:
http://www.australasianmedical.com.au

However for most of us, this isn’t

practical to do nor is it useful
information.
In practical terms, when we use the
word “strength”, what we mean is
“stamina” - the ability to produce a
certain amount of force over a
period of time. However, so as to
not confuse things, I’ll stick with the
word “strength” but remember I’m
not referring to a 1RM kind of
strength.
For example, the ability to squat a
certain number of times with a
certain amount of force is one way
to measure leg strength .
To develop strength, you have to
use your muscles to the onset of
fatigue. This is followed by rest
which allows the muscles to
recover and grow stronger.
How do you know when your
muscles have reached the point of
fatigue? And how much fatigue is
enough?
Muscular fatigue is the decline in
the muscles ability to produce
force. You may feel burning, aching,
tightness in the muscle(s), struggle
to complete the movement or
maintain the movement form.
I use a numeric scale to rate the
fatigue where 0 equals no fatigue
and 10 equals extreme fatigue.
Extreme fatigue is when you can’t
perform one more repetition.
In most cases, you don’t need to
reach extreme fatigue to benefit
from strength training. An easy way
to determine if you have achieved
the proper amount of fatigue is to
pay attention to what your face does
during the exercise.
When you reach approximately the
7/10 level of fatigue, you will
exhibit what is called the “face of
effort”. 2
You’ll grimace involuntarily. And
you’ll start to struggle performing
the exercise. When this happens,
you can stop the exercise and rest.

Face of Effort

There’s one more component to

achieving the right amount of fatigue
- repetitions.
A repetition is one complete
movement of an exercise which may
involve a body part or several body
parts.
A set is a certain number of
repetitions.
For example, if you stand up from a
chair and sit back down, that
complete cycle of the up and down
motion is one repetition.
For the purposes of this book,
muscle strengthening is defined as
achieving a 7/10 level of fatigue
within 10 to 20 repetitions (there
are exceptions which I cover later
in the book). For example, if you
perform 10 repetitions of an
exercise with a certain amount of
resistance and have a fatigue level
of 5, you will not have much benefit
from the exercise.
In this case, you need either more
resistance or more repetitions.
If you perform 3 repetitions and
have a fatigue level greater than
7/10, you are using too much
resistance and may risk an injury.
For strengthening, aim for a 7/10
level of fatigue with a resistance
that you can overcome 10-20 times.
This combination will provide you
enough fatigue with less risk of
injury.
In most cases, between muscle
strengthening sets of exercise you
should rest for 60 seconds. This
allows the working muscles to
replenish their energy stores to
perform the next set of repetitions.
Chapter 31
A NEW KIND OF
CROSS TRAINING

M aybe you’re familiar with

the term “cross training”.
By definition, the term means, “the
action or practice of engaging in
two or more sports or types of
exercise in order to improve fitness
or performance in one's main
sport.” 1
I’m using the term in a different
way.
Instead of training in one sport to
help performance in another sport,
we’re going to train one leg to
boost performance of your injured
leg.
What if you could exercise one leg
and improve the strength of the
other leg without having to exercise
it?
Well, you can. The principle that
underlies this form of “cross
training” is called contralateral
strength training and has been
known to exercise scientists for
over 100 years. 2
In a nutshell, by using exercises
designed to strengthen, for example,
the right leg, the left leg will
increase in strength as well. The
gain in strength in the non-exercised
leg will be about half of the gain in
the exercised leg.
In a study done in 2011, subjects
performed eight weeks of strength
training — using only one leg . In
the graph, notice that that they
increased strength in both legs. 3
You might be wondering how this
could possibly happen.
The purpose of this study was to
answer that question. Could you
exercise one side of the body and
document changes in strength in the
opposite side?
The researchers used magnetic
pulses to the brain to investigate the
role of the nervous system. They
found a significant reduction in
“corticospinal inhibition” in both
legs which means that the exercise
improves the transmission of the
signal from the brain to the muscle.
This transmission applies to both
sides of the body.
Keep in mind that the increase in
strength is limited to muscle and not
the joint itself.
But this comes in handy.
As you’ll learn later, the first phase
of rebuilding the strength of your
leg is focused on the joint. While
you’re doing this for your affected
knee, you can be strength training
the other side so when you’re ready
to pursue muscle strength training
for the affected knee, you will have
already boosted your muscle
strength some in the affected knee.
Chapter 32
CORE STRENGTH

Y ou might be wondering why

you need to exercise the core
if your problem is a painful knee.
A little background info and then
I’ll connect things.
First, “the core” is a loosely used
term. The term means different
things to different people. Some
think of the core as just the
abdominal muscles while others
include trunk muscles and still
others include abdominal, trunk,
and hip muscles.
For our purposes, “the core” is the
region of the body between the mid-
chest and upper thigh.

The CORE of the body

The Core Muscles

The muscles of the core act as the
internal brace increasing the
stability of the body. 1 From injury,
surgery, or disuse (from a largely
sedentary lifestyle), these muscles
weaken and in some cases fail to
function at all, leaving you with
muscular imbalances and at risk for
injury.
The core is sort of a “Grand Central
Station” when it comes to
transmission of loads and direction
of forces. When your foot hits the
ground, the force travels up the leg
to the knee, then into the hip and
lower back. If, for example, your
hip abductors or hamstrings are
weak, this leads to an uneven
distribution of force and may result
in an injury.
In one study, researchers examined
two groups of runners - one with
injuries and one group without. 2
They wanted to know the strength of
certain core muscles in the hips and
if there was a difference between
the two groups. And there was. The
injured group had much weaker hip
abductor and external rotator
muscles than the uninjured group.
This led the researchers to conclude
that the imbalance may be a factor
for injuries in recreational runners.
Other benefits to you from
improving your core strength
include:

Movement in everyday
activity such as bending to
pick something up off the
floor, put on shoes, turn in
your car or even standing
in one spot for a while
Reducing back pain
Lifting, pushing, pulling
activities
Sports related activities

An additional benefit of core

strengthening is that the exercises
will also help strengthen the
connective tissue (fascia) that runs
through the area of the core and into
the lower extremity. As you
exercise the hip muscles, for
example, you also build the tension
capacity or strength of the fascia in
the upper and lower leg (the
suspension system that I cover later
in the book).
As I mentioned before, the fascial
network plays an important role in
supporting the knee from above and
below the joint. Blending the core
exercises with leg strengthening
exercise provides your knee with
enhanced support and balances the
forces through the knee.

How Strong is Your Core?

There are a number of tests
practitioners use to assess core
strength. I chose three of the simpler
ones to do at home.
Test #1: The Plank
 The Plank

​The Plank uses four points of

support - two forearms and two feet
- to essentially suspend the rest of
your body. This forces your trunk
muscles to hold you off the ground.
It’s both spine and knee friendly.
To perform the test:

Lie on the floor face down.

 Prop up onto your
forearms.
Now lift the rest of your
body up onto your toes.
Hold this position, your
body in a straight line, for
as long as you can or until
90 seconds pass
whichever occurs first.
Record your results.

If you hold the position for less than

90 seconds, your core needs
strengthening. Most of my clients
can’t reach the 90 second goal the
first time so don’t be discouraged if
that happens to you.
Test # 2: The Side Plank
To perform the Side Plank test:

Side Plank

1. Lie on the floor on your side (it

doesn’t matter which side - you’ll
test both).
2. Place one foot on top of the other.
3. Prop up on your elbow and
forearm.
4. Lift your hips until your body -
head, trunk, hips, knees - are in a
straight line.
5. Hold this position for as long as
you can or until 45 seconds
whichever occurs first.
6. Record your results.
7. Repeat on the opposite side.

Test #3: Single Leg Balance

 Single Leg Balance

To perform the balance test:

Stand up straight.
Hold your arms at your
sides.
 Lift one leg off the floor
and hold it off the floor.
Do not touch the other leg.
Look straight ahead and
stand in this position as
long as possible or 90
seconds whichever occurs
first.
The test ends if you touch
the other leg, touch the
floor or you move your
arms.
Repeat on the other leg.
Record your results.

VIDEO: click here

Chapter 33
TEST LEG
STRENGTH
(WEIGHT
BEARING
CAPACITY)

T here's a good chance that

you're reading this book
because weight bearing activity -
anything from walking to climbing
stairs to running - creates knee pain.
The following tests help identify
your weight bearing capacity and
help determine which exercises you
need.
Sit to Stand Test

Get a standard dining room

chair (or any firm, sturdy
chair).
Stand in front of the chair.
Cross your arms on your
chest.
Sit down and as your rear
end touches the chair, stand
back up. Keep equal
weight on your legs. Do
this five times and the sit
down and rest.
 Sit to Stand test

Did you hurt at any point during the

movement or after?
You have to be honest about this or
you’ll just waste a huge amount of
time. Pay attention to what you feel.
If you find yourself saying,”Well
it’s not that bad” or “Not really”,
you hurt.
Performing the Sit to Stand test
helps you determine how much
bodyweight each knee tolerates.
Either less than 50% (if you had
pain during or after the Sit to Stand
Test) or greater than or equal to
50% (if you passed the Sit to Stand
Test without having any pain during
or afterwards).
But it's possible to “pass” the test
by unintentionally favoring one knee
over the other, e.g 60% on the right
and 40% on the left, by pushing
with more force through the leg that
is stronger or pain-free.
If you pass the test without being
able to tolerate a full 50%
bodyweight, then certain exercises
that you will learn later in the book
might be too difficult for you.
To fine tune the Sit To Stand Test,
repeat the test for one minute
counting the number of repetitions
you can perform pain-free and with
good control.
While you may still be favoring the
knee, the increase in volume will
uncover your true capability. This
will save you frustration and time
because you'll be performing the
exercises in a way that more
closely matches your actual
capability.
Normative values for this test
(which vary by age and gender) are
between 30 and 40 repetitions in
one minute.
If your knee hurt during this
movement or after, then you know
that your weight bearing capacity is
less than 50% of your body weight.
Record your results.
VIDEO: click here
A Special Device to Test Leg /
Joint Strength
Years ago, I discovered a product
called a Total Gym which is one
type of a Variable Incline Plane
(another is a Total Trainer).
I use a VIP when a client can't
perform the Sit to Stand test due to
pain or weakness or has difficulty
in adjusting the forces needed for
certain types of exercise in order to
do them in a pain free manner.
If you have a special event to attend
and need a suit, you might be able
to go to Macy’s or some other large
department store and find one that
fits. You have to try on a few
perhaps but it might work out just
fine.
But sometimes it doesn’t fit and you
have to have the suit altered or
tailored. In some cases, even
custom made.
The VIP helps “tailor” the load to
the individual to find just the right
amount of force, to find the best
“fit”. This book offers more of an
“off the rack” option for people.
For a more customized approach,
we offer coaching and consulting
services (see the end of the book in
the chapter on About the Author for
details).

Variable Incline Plane

When I first saw the Total Gym in a

fitness store, I asked the sales clerk
how much it cost.
“Oh, you don’t want to buy that. It’s
not a very good strength building
thing. It’s the last one we have and
we’re not getting any more,” he
said.
“Ok but how much is it?” I asked.
“So you still want to buy it? It’s
about $200 but I can let it go for
less if you take it out of here and I
don’t have to deliver it,” he replied.
“Deal,” I said.
The benefit of the device, as I saw
it, was that I could fine tune the
load for a client and easily use low
loads for exercises like squats.
By adjusting the angle of the device
up or down, you can increase or
decrease the force into the legs as
you perform a squatting motion.
The ability to make small
adjustments in load makes it
possible to identify an amount that
does not create symptoms and / or
permits a well controlled movement
pattern.
For example, let’s assume you
weigh 160 pounds and rising from a
chair hurts your right knee. This
means that 80 pounds of force is too
much for your right knee (80 pounds
of your 160 pounds on each leg).
Depending on the make and model
of the VIP, the highest or most
upright position will be about 60%
of your body weight. At 160
pounds, the load would be 160 x.60
or 96 pounds for both legs.
If you were to perform a squat with
this load, your right knee would
likely not hurt. In fact, with a little
testing, you could find a load level
that permitted a single leg squat.
The VIP has become a central
component of much of our work
with clients because it provides
more control over the loads and
subsequently the volume of
exercise.
A weak knee joint needs both
controlled load and motion to
improve. The VIP provides both.
One of my clients came to see me
from Colorado where she worked
as a forest firefighter. She had
chronic knee joint pain and despite
her best efforts and those of her
therapists, she could not don the
gear and climb the uneven terrain
without considerable knee pain.
After our consultation, I suggested
she purchase a VIP and follow a
program at home.
She purchased a VIP and worked
diligently on the program.
She started out using the VIP at a
much lower angle in order to find
the sweet spot or what we refer to
as Load Tolerance. Her goal was
30 minutes of squats per day broken
into several short session of 5-10
minutes.
Over a few months, she had
progressed herself to 30 minutes of
squats, continuously, at the highest
level on the device (which in her
case was 70% of her body weight).
She was pain free and had no
problems climbing and hauling gear
up the mountain.
Think for a minute about how strong
you must be to squat for thirty
minutes using 70% of your body
weight.
For my client, this meant a load of
135 pounds (not her body weight
plus 135 pounds) for 30 minutes.
Breaking that down more, at a
typical movement pace of 15 squats
per minute, she performed 450
squats at 135 pounds per squat.
A total load of 60,750 pounds.
That is a lot of joint and leg
strength.
The main objections from readers
about the VIP is the cost of the
device and the testing and
calculations required to use it
properly.
The cost of a VIP can range from
$200-300 to $2500 depending on
the make and model.
For a list of options and more
information, click here to go to my
website.
I don’t include a detailed section in
this edition of the book on using a
VIP. Feedback from some readers
has been that the process of testing
and determining proper progression
using a VIP is not simple and
straight forward. I understand why
someone might feel that way and
after a lot of thought and discussion,
I decided to leave it out of this
book.
The tests and exercises we suggest
in this book, however, will work
for many people. Some may need
more precise control of load and
motion - like having a custom made
suit - which is when a VIP becomes
more important to have (we offer
coaching services to assist you in
the use of a VIP). For personal
guidance in how to use a VIP to
strengthen the knee, please contact
my colleague Laurie Kertz Kelly for
a free 20 minute Strategy Session.
Chapter 34
HOW TO GET THE
MOST OUT OF
EXERCISE

T here are two components for

using exercise to get stronger.
The first is muscle fatigue. Without
sufficient fatigue, you will notice
little to no improvement.
The second is rest and recovery.
More exercise, more often is not
better. The objective is to fatigue
the working muscles and allow the
muscles sufficient time to recover.
This process is referred to as
Supercompensation.

Supercompensation curve

In the image above, A represents an

exercise session and B your day off
or recovery. The day off allows
your body to adapt; rebuild itself
and get prepared for another
session. During the rest and
recovery phase, because the body
always wants to be prepared and
spend as little energy as possible,
you build up a greater capacity and
reserve than when you started.
If you add another training session
within the Supercompensation area,
your fitness and capability go up. If
you start another session too soon,
in the B area, your capability will
decrease. But, if you rest too long,
that positive adaptation fades and
you end up back where you started.
As you age, the recuperation period
becomes longer for more intense
sessions. You may not like the idea
of needing more rest but it is what it
is. There’s not much you can do
about that but respect it.
Some people misunderstand what I
mean by rest. It’s not lying around
or being still. Rest can be active as
long as you’re not exerting yourself
too much.
How long should you rest? In most
cases, if you fatigue your muscles
on, for example, Monday, you
should rest at least until Wednesday
and sometimes longer.
If you develop significant muscle
soreness from an exercise routine,
you should wait until the soreness is
gone - which might be a week or
more - and then change the intensity
of the exercise. You don’t need to
be sore to make significant gains.
A common mistake is to push
yourself too fast and not allow
enough rest between sessions.
Everyone wants to get better faster
but your body gets better on its
timeline. And the rules of
physiology, the rules around rest
and recovery, are clear. Adding
more exercise before you have
recovered will make you weaker
over time.

The Power of Sleep

Another important factor in
recovery is sleep. And, well, most
of us do not get enough sleep. So
when you add exercise to your day,
in whatever form that might take,
you need enough sleep to help your
body repair itself.
How much sleep is enough?
 www.sleepfoundation.org

A friend of mine likes to say that he

needs just four hours of sleep a
night. His wife often says, “That’s
what he likes to think. But he falls
asleep sitting in a chair during the
day if he closes his eyes for a
couple of minutes.”
Yes, some people can manage on a
low number of hours but most of us
can’t.
Clients often wonder why I’m
talking about sleep as part of a
strategy to improve knee function.
Think of it like this. When your
body needs to repair some part of
itself, it uses more energy to do it.
And that process of repair largely
happens over the course of a night’s
sleep.
If you’re in sleep debt, or you owe
yourself a certain amount of sleep
per night, the repair process is
much less efficient. If you’re behind
10 or fewer hours in a week, you
can “catch up” by sleeping 3-4
more hours over the weekend and
1-2 hours the next week. But if your
sleep debt has grown over many
years, it could take several weeks
of extra sleep.
The health risks increase as your
sleep debt rises. sleep debt mounts:
weight gain, diabetes, heart disease,
stroke, and memory loss.
Adequate rest, which includes
sleep, is a critical factor in
overcoming any injury.
Rest IS Therapy
This is the most underrated, under
used, ignored and misunderstood of
almost any knee rehab option
around.
And yet, of all of the treatment
options, it has perhaps the greatest
benefits.
Rest.
When you hear the word, you may
think I mean the lie down in bed
kind of rest.
But that’s rarely helpful.
The key to rest, and a more accurate
term is relative rest, is to reduce
your activity and loads until you’re
in the Functional Zone (FZ) and
then move your knee within that
zone.
The challenge is understanding how
narrow your FZ might be and what
kind of movement to use, how often,
how much.
The longer you’ve had knee pain,
the greater the chance of having a
narrow or small FZ. With an injury,
both the FZ and the AZ shrink (on
the graph, the move down and to the
left). This can in turn make certain
activities difficult to do without
aggravating your knee.
Some activities may not seem like
an activity at all. We tend to
associate movement with an activity
but for knee arthritis, sitting with
your knee bent can push you into the
Injury Zone. This is because when
the knee is bent greater than twenty
degrees, the pressure under the
kneecap and in the joint rises
considerably. The pressure on
sensitive tissues goes up and before
long you hurt.
And you may be scratching your
head wondering what happened. I
didn’t do anything! Well, you did.
You placed your knee under too
much static load.
I offer ideas on how to get around
this later in the book. But for now,
view using rest as a therapeutic tool
instead of a restriction or a source
of frustration.
How much rest is enough?
This is a question we get from
clients routinely. My answer is “as
much as it takes”. That might be a
week, a month, or several months.
In this time frame, most people are
not inactive but they are being
mindful of what they do.
One of my clients, in her 30’s and a
competitive cyclist, had injured her
left knee from cycling accident. She
had been through a couple of
therapies - massage, physical
therapy, acupuncture and still had a
number of problems.
Her knee would sometimes ache at
rest (sitting or lying down), she
noticed pain when going up and
down stairs, she couldn’t cycle at
the intensity she wanted to, she
couldn’t walk her dog more than
about 10 minutes before her knee
hurt.
Her day was to go to the gym early,
swim, cycle, and do some weight
lifting but she told me she didn’t do
any weightlifting with her legs.
Then she went to work, sat most of
the day, and after work, would do
some “light cycling”.
I began to unpack the activities. I
was intrigued by the weight lifting
so I asked her to show me the
exercises.
All of them were done in a weight
being position. Overhead press,
curls, bent over row among others.
But the one that surprised me the
most was a position where she was
up against a wall in a sitting
position while lifting a pair of
dumb bells.
Based on her problems that I listed
earlier, can you see that this
exercise in particular is way too
much load for her knee?
I asked her if her knee hurt when
she did this and she said, “Well,
yeah a little but mostly it’s later and
so I don’t think it’s related.”
For her, we had to come up with an
exercise routine that would reduce
the loads on her leg as well as a
rehab approach that would
encourage her joint to strengthen.
You might be thinking, “I’ve done
that and it didn’t work!”
That might be true but in my
experience, most people think of
“rest” as giving up an activity, for
example running, but fail to
understand how everyday activities
can overload their knee.
I mentioned sitting but there are
other activities that also carry
increased load:

Standing
 Lifting, Pushing. Pulling
Carrying
Driving - especially stop
and go traffic
Cycling - dependent on
angle and resistance
Squatting

A common reaction from runners

and other athletes is “I have to do
something! I just can’t do nothing!”
The idea of not doing something is
as mentally and emotionally painful
as their knee is physically painful.
Digging into why that’s the case is
beyond the scope of this book but if
you feel this way, if you battle
internally against the idea of
relative rest, you’re not alone. But,
if you want to recover and rebuild
your capabilities, ignoring your
need for rest and the limits of your
body is a prescription for failure.

The Most Common Outcome of

Misused Rest
One of my clients, a woman in her
forties, I’ll call her Sheila, had right
knee pain for many years. She loved
to run, exercise, and lift weights.
She was an active, vivacious
person, and did her best
to ignore the pain.
However, as with many people, the
pain eventually got to her. She
finally ended up seeing me and one
of the first things she said to me
was, “Don’t you tell me to quit
running! That’s what every single
doctor says and I already tried it
and it didn’t work! So don’t even
go there!”
“And why didn’t it work?” I asked.
“Well, how should I know! I did
what I was told to do! I’m a good
patient! Geezzz...do I have to do
this again?”
“OK. So first of all, calm down.
I’m on your side. Tell me what you
were told to do. Help me
understand what the process was
that you went through.”
“Yeah, OK...yeah...I’m sorry. I’m
sorry. I just get so frustrated with
all of this. So, anyway, the doctor
said to stop running and doing
anything that hurt my knee for two
months and then to come back and
see him. He did an X-ray and said it
was okay. He said I was just
overdoing things and my body
needed to rest and then I would be
okay,” she explained.
“And that’s what you did? Stopped
for two months and then went back
to see him?” I asked.
“Yep. I did. I avoided stairs when I
could. I tried not to pick stuff up
from the floor. I tried really hard to
not do things that would make my
knee hurt. And he was right! After
two months or so, my knee didn’t
hurt! I was so excited!”
“And when you went back to see
the doctor, what happened?” I
asked.
“Well, he looked at my knee and
kind of poked it and bent it around,
and said I was ok. I could go back
to running now.”
“So, when did you start running
again?”
“The next day! It was early
morning. I love to run in the
morning. And I felt just fine. I ran
about three miles...no I think it was
four that day. It was great!” she
explained.
“So what happened?”
“I don’t know. I ran like always and
went back to the gym, too, you
know for the weight lifting because
I’m concerned about osteoporosis,
and I guess it was about two weeks
or so later that my knee hurt a little
bit,” she said.
“And....?” I asked.
“I just kept running. And it
gradually got worse. See? Stopping
the running didn’t help. And I’ll bet
that’s what you’ll want me to do,
too,” she answered.
“No, I think it did help you. It just
didn’t fix the issue. You went from
two months of inactivity to suddenly
running again. Your body wasn’t
ready. You may have recovered, but
you hadn’t retrained your body to
run.”
This story is a common one. By
giving up running and being careful
with her other activities, Shelia
moved herself out of the Injury Zone
into the Functional Zone.
But the size of the Functional Zone
and Adaptation Zone did not
change.
What changes the area under the
curve for those two zones is proper
physical exercise and recovery.
Since Sheila hadn’t done any
exercise or any rehabilitation, her
knee joint and associated tissues
were not any stronger. The result
was that she started running again
on a weak leg.
Rest is a tactic or a tool and not an
overall strategy. You’ll need to use
it and in many cases, properly
executed, rest can alleviate a lot of
symptoms. But it doesn’t mean
you’re good to go.
Chapter 35
SUSPENSION
SYSTEM
STRENGTHENING

B uilding your suspension

system strength and resilience
is a key factor in overcoming and
preventing knee pain.
But the way you go about it,
especially when your knee hurts, is
not like muscle strengthening
(although strengthening muscle
certainly helps).
Strengthening the soft tissues of the
body, the connective tissue, (tendon,
ligament, fascia, cartilage, bone)
requires lower force or load and a
higher number of repetitions than
muscle strengthening.
The main reason for this difference
is due to the lower metabolism of
soft tissue compared to muscle.
The metabolism, or the rate at
which energy is used, of the body’s
tissues is directly related to the
blood supply to the tissue.
Muscle fiber has ample blood
while cartilage has little to no
direct blood supply. And
correspondingly, muscle has much
higher metabolism and healing rate
than cartilage.
The graphic below represents the
healing hierarchy with muscle at the
top - because it responds more
quickly to injury or exercise and
cartilage at the bottom because it is
the slowest to respond.
 Rate of Healing / Metabolic
Activity

How much is enough? There isn’t

any research that I’m aware of that
suggests a specific load and
repetition number to use for
ligament, tendon, or fascia so we
have to apply a bit of physiology
and common sense.
Generally, I suggest the range of 50
to 100 repetitions for tendon,
ligament, and the myofascial slings
while bone and cartilage need 100+
repetitions and generally the higher
the better for bone and cartilage.
How I arrived at those numbers
was from knowing that muscle
strengthening is well documented
with repetitions under 25 while
bone and cartilage is also
documented in the high volume
range of well over 100 repetitions.
Therefore, tendons, ligaments, and
fascia are in between muscle and
cartilage/bone.
Another way to look at is that if
your knee hurts, you will have a
tough time loading your leg
sufficiently to achieve muscle
strengthening. This is often what
happens with people undergoing
rehab. The loads are either too high
and cause knee pain or too low and
fail to achieve either muscle or
connective tissue strengthening.
There’s a mismatch between the
stimulus (muscle strengthening) and
the need (joint and soft tissues). The
result of the mismatch is a slowing
or even reversal of functional
improvement.
The connective tissues require
physical stress but unlike muscle
you don’t have a feedback
mechanism when you have fatigued
them. To overcome this, I use
muscle fatigue indicators for the
tendons, ligaments and fascia since
muscle is attached or influenced by
these tissues. What I look for are
signs of mild muscle fatigue within
the desired repetition and load
range.
For example, to strengthen the
suspension system of the lower
extremity and trunk, you could use
this exercise: Leg Swings
You might see this exercise used as
part of a warm up routine but by
increasing the number of repetitions
and slowing the movement, it
becomes a strengthening exercise
for the suspension system.
 Leg Swing exercise

​Leg Swings are a little easier to do

if you lightly hold on to a surface
about waist high. Swing your leg
across your body and back like a
pendulum allowing your body to
rotate back and forth through the
hip. You swing the leg easily not
aggressively. Taking 4 seconds to
move one way and 4 seconds to
move the other.
The weight bearing leg and trunk is
doing most of the work. The goal
repetition count is at least 50 reps
with a low or mild fatigue in the left
leg (as done as in the picture). If the
rep count is below 50, you can
make this easier by performing it at
a table or counter where you can
bend forward and support more of
your weight on your hands.
For the purposes of this book, the
Core and Joint Strengthening
exercises will also serve to
strengthen the soft tissue elements
of the Suspension System.
Many exercises that are in the
“core” category can be used for
Suspension System strengthening
but the exercises almost always
have to be adjusted to allow for a
greater number of repetitions.
Here’s another example of a core
exercise that also strengthens the
Suspension System: a push up.
Push Ups are used, mostly, for
upper body strengthening. For most
people, the repetition maximum is
rarely over 20 although there are
people who can crank out 100
pushups.
In order to get the repetition count
in the proper range with the proper
fatigue (mild muscle fatigue), you
have to make the pushup much
easier to do.
So, instead of doing pushups on the
floor, use the wall.
 Wall Push Up

Stand facing the wall about 12 to 18

inches away with your feet shoulder
width apart. Place your hands on
the wall at about shoulder level and
perform a push up. Focus on
maintaining proper push up
position.
Because the load level is low,
you’ll be able to perform many
more repetitions than a standard
push up while engaging nearly all of
the core muscles.
Chapter 36
STRENGTHENING
QUADRICEPS

S trengthening the quadriceps

and leg muscles is one of those
things that seems obvious, but just
to make my point, I’ll share some
science with you.
Quadriceps strength is protective
against knee pain. In fact, weakness
of the quadriceps (thigh muscle) is
a major risk factor for the onset of
osteoarthritis which is one of the
reasons so many standard
treatments suggest strengthening the
quadriceps.
Most exercise programs start with
isolating the quadriceps muscle by
using something called “quad sets”
and straight leg raises because
weight bearing exercises - squats,
etc - are often too painful.
A quad set is an isometric exercise
of the thigh muscle. You tighten the
thigh muscle as tight as you can and
hold it for a prescribed period of
time and relax. Then repeat the
exercise a specific number of times.
The thinking behind using quad sets
contains two parts.
 The exercise will
strengthen the muscles and
be much less painful since
you’re not up on your
injured leg. And stronger
muscles should “protect”
the joint.
One of the reasons people
hurt is that the knee cap is
not in the right place. It’s
tilted off to the outside of
the knee.

Since the quadriceps muscle -

vastus medialis oblique (VMO)
appears to be angled such that when
it contracts it would pull the knee
cap over, strengthening that muscle
will help solve knee pain.
Or so the thinking goes.

Vastus Médiales Oblique

There are benefits to quad sets and

straight leg raises which I will
share with you later in this book.
But, the idea that the patella being
out of place is a cause of knee pain
and that you can isolate the VMO
and strengthening is incorrect.
The VMO is one of four muscles
comprising the quadriceps muscle
group. These muscles are supplied
with a nerve, the femoral nerve,
which regulates their function.
When the nerve sends information
to the muscles, it sends the same
information to all four. In order to
isolate the VMO from the other
muscles, it would need its own
nerve supply. Even though this is
the anatomical truth, many
practitioners insist the VMO can be
isolated and strengthened. This
myth has led to several scientific
investigations and thus far, not one
investigation supports the idea that
isolated strengthening of the VMO
is possible.
Now, just for fun, let’s assume you
could make the VMO contract by
itself and you could selectively
strengthen it. Would it matter? It
would only matter if the fibers of
the VMO actually aligned in such a
way to pull the patella away from
the side of subluxation.
And an anatomical study proves that
assumption wrong, too. 1
Peeler studied the muscle fibers of
the VM (VMO) and discovered
“there was no significant
correlation between any of VM
(VMO) insertion length, VM
(VMO) fiber angle, limb alignment,
and Patellofemoral Joint
Deterioration (PFJD) location and
severity. The results of this study
did not support the hypothesis of a
relationship between structural
parameters of the VM (VMO)
muscle, limb alignment, and the
location and severity of PFJD in
this subject group.”
Weakness of the VMO is also not
the main culprit but weakness of
quadriceps as a whole is one of the
factors that can lead to knee pain.
There’s another reason that quad
sets and straight leg raises are
minimally effective. Remember the
chapter on strength? What’s
required for your muscles to get
stronger? Fatigue. When you first
start doing quad sets, you may
experience fatigue. Some people
fatigue within 10-20 repetitions.
But before long, they can do 50, 75,
100 repetitions with mild fatigue. If
the fatigue is mild, there will be
little muscular strength
improvement.
We use quad sets but add a couple
of tweaks to them.
One is making sure the knee angle is
correct and the use of the
quadriceps is not overpowered by
the gluteal or calf muscles.
The other tweak is to do something
we call a “sizzler”.
Sit down on the floor or
bed.
Place a small towel roll
under your knee.
Pull your toes up toward
your head. Keep your knee
straight (your ankle will
bend.
Now slowly tighten the
thigh muscles as tight as
you can and hold for 10
seconds.
Include tightening the
hamstrings and buttock
muscles, too. This is the
“sizzler” effect.
Technically it’s called
 “hyper-irradiation”. When
you tighten more muscles
at once, the target muscles
tighten even more.

Video: click here

Quad sets do something else for you
that is perhaps even better than
strengthening the muscle. Quad sets
improve the synovial fluid in your
knee. Better synovial fluid means
better motion and more protection
for your joint. 2
Perform at least 100 of these per
day for the first three weeks. You
can break this up into sets of ten at a
time. You can perform them sitting
at a desk (with your knee straight)
or even if you’re standing in line
someplace. You won’t have a towel
under your knee of course but you
can still tighten all of the muscles.
Quad sets are not a bad thing or
wrong to do but keep in mind that
you will need to advance your
exercises beyond quadriceps
strengthening in order to build total
leg strength.
Chapter 37
JOINT
STRENGTHENING
LAWS

T here are certain laws or rules

I’ve discovered when it
comes to strengthening joints.
By following these laws, you’ll
maximize your chances of building
healthier, stronger knees.

Law 1 - Move It or Lose It

There are two main ingredients for
healthier knee joints: motion and
controlled load. 1

A weak or injured joint needs

movement and a lot of it. But, the
movement must not exceed the
joint’s capacity. In other words, the
motion should not aggravate your
knee.
Sometimes this means moving your
knee slowly for brief periods of
time--2 or 3 minutes--and then
resting and going again.
Motion for joints is like making a
deposit in a bank account. It builds
the joint’s tolerance for load. Aim
for at least 30 minutes of pain-free
motion per day.
Light repeated motion of the knee
improves the quality of the synovial
fluid. And remember that synovial
fluid feeds your cartilage.
This is where the story of the
Tailgater comes in.
“Why does this feel so good on my
knees?"
“Why does this work?"
“What's happening in my knees
when I do this?"
These are commonly asked
questions by people who first
experience the wonder of
Tailgaters. This is a simple,
seemingly too simple really,
exercise performed on a special
device called an NK Table.
An NK Table is an ancient tool in
physical therapy dating back to the
1950s. It was invented as a
strengthening device; one of the first
knee extension machines.
The machine has two adjustable
bars or resistance arms on each
side. The intent of these arms was
to restrict the range of motion of the
exercise and to change the
magnitude of force
within the arc of
motion.
But I found that if you
placed your legs on top
NK Table
of the resistance arms
and used a very light
weight, the machine
could help you swing your legs -
kind of like sitting on the tailgate of
a pick up truck and swinging your
legs in the air.
Hence, the name Tailgater. Notice
that the leg is on top of the
resistance arm and that the leg is
moving quickly (reason for the
blurred image - click here for the
video). Tailgaters feel great if you
have almost any kind of knee pain.
In fact, we have some clients who
just want to sit and swing their legs,
and if they had their way, that's all
they would do. So it's natural to
wonder why something so simple
can be so helpful.
 NK Table - Tailgater exercise

First of all, the idea that easy

motion on arthritic joints is helpful
is not new. In the 70's, Robert
Salter, MD, invented the Continuous
Passive Motion (CPM) device
which helped patients move their
knees after surgery.
He found in his research that
injured joints healed faster and
more completely if they were
moved gently and moved a lot. Of
course, at the time, all of his
colleagues thought he was crazy.
They were placing people in long
leg casts thinking that injured joints
had to be protected.
Well, it turns out that both camps
were right.
Diseased or injured joints need
motion, but the load that
accompanies that motion must be
light - at least in the beginning.
Salter's machine drastically
reduced the load on the joint while
it also moved the joint. The CPM
has become the gold standard after
procedures like Knee Replacement
and ACL Reconstruction.

Continuous Passive Motion

Machine

​You probably won’t have an NK

Table or a CPM machine but there
are a few other ways to create light,
repetitive motion in your knee or
what we call Joint Strengthening
exercise.

Joint Strengthening Exercise

Options
A mini-skateboard. Sit down in a
chair. Place your foot on the
skateboard. Slide your foot back
and forth slowly, smoothly.
A furniture mover. These work
best on carpeted surfaces. Do the
same thing as with the skateboard.
A rocking chair. Yep. Rocking
chairs create small, light motions in
the hip, knee, and spine. They really
work.
Swing your legs in water while
sitting on the edge of a pool. For
this to work, you have to swing
your legs very slowly. Otherwise,
you'll fatigue the muscles too fast.
Buy a special elastic tube, a Grey
Cook Band, and do a “leg slider”.
You attach the elastic tube in the top
of a door frame and close the door
on the strap. Then lie down on a
couple of pillows or a foam wedge.
Place the other strap on your foot.
Place your foot on a furniture
mover. Now, just slide your foot
back and forth.
Cycling - clients often ask if they
can use a stationary bike as a way
to improve their joint health and the
answer is, it depends. It depends on
how much easily available motion
you have in your knee, how easily
your knee symptoms are provoked,
and how easily you can control the
resistance on the bike. If you have
at least 120 degrees of knee bend,
your knee is not easily irritated and
you can control the cycling
resistance, using a stationary bike is
an option.
A mini-bike. This is an inexpensive
device that works well for easy
pedaling. It’s not intended for a
“cardio” workout. You have to
experiment with how far you place
the device from a chair to find a
comfortable range of motion and
position.

Example of a Mini-Bike
A Hovr. If you sit for a large part of
your day, getting enough joint
motion is difficult to do. The Hovr
is designed to solve that problem.
It’s similar to the Mini-Bike but has
more of a swinging action to it
(similar to the Tailgater).

The HOVR

With any of the above, aim for 15

minutes per session and three
sessions per day. I’ve had clients
who start with 2-3 minutes, rest a
few minutes and repeat periodically
through the day which can also
work. The key is to move slowly
and feel almost no fatigue in the leg
muscles. The purpose is not to
strengthen your muscles; it's to
improve the quality of the fluid in
your knee.

Law 2 - It’s Not a Sprint

I don't know about you, but I would
like to think I am a patient person.
A friend tells me I have a high
tolerance for difficulty, but I am not
sure that quality is a good thing. If
you are too tolerant or patient you
may miss opportunities, but if you
are impatient you may miss them as
well.
What does it mean to be patient?
When is patience good and when is
being patient actually disguised as
settling or giving up? Is there a
difference between being patient
and being a patient? Is it possible to
be a patient patient?
The Shorter Oxford English
Dictionary on Historical Principles
defines a patient as "a sufferer";
"one who is under medical
treatment"; or "a person . . . to
whom . . . something is done". The
origin of the word patient is from
the Greek root "patior" meaning "to
suffer". Patience also means
"calmness or without discontent; not
hasty; not overeager; composed”.
The first use of patient as a medical
term dates back hundreds of years.
Considering the barbaric nature of
medicine at the time (surgeons were
also barbers don't forget - puts a
new twist on "getting your ears
lowered"), one who was patient
was a person who endured suffering
and did so quietly.
Even today in certain medical
circles, patients who ask questions,
know their options, or question a
medical opinion can be labeled as a
"bad" or "difficult" patient.
But patients, however, are rarely
patient. Our society infuses us at an
early age with the thirst for rapid
gratification and as technology
advances, our tolerance for delay
declines. We want things quickly,
will go elsewhere if we have to
wait, and are generally always in a
hurry. No wonder we cringe when
we hear, "Well, it will be several
months before you can exercise (or
run, hike, cycle - insert your
favorite activity) again."
I think patience is easier to develop
when you understand the nature of
your problem. To understand the
problem means that you know the
facts about it and its significance.
For example, assume you have pain
in the front of your knee. It hurts
when you walk, climb stairs, or run
and you would just as soon not be
bothered by the constant and
persistent discomfort.
First, you must gather information
about why your knee hurts. Is it an
injury to your tendon, your joint
surface, your bone or bursa, a
referred pain from muscles in your
thigh or from your hip joint? Or is it
something else?
Until you have narrowed the
possibilities, you will have little
patience.
Without knowledge, there can be no
understanding.
Thus, armed with no information,
you may try all sorts of things to
alleviate the symptoms. Things like
heat, cold, magnets, knee straps,
massage, electrotherapy and the list
goes on.
Since fuzzy knowledge yields fuzzy
solutions, the result is a growing
level of frustration and impatience.
Lack of knowledge and
understanding can also lead to
quitting.
Many people give up trying to beat
an injury or come back from a
surgery because they don’t know
precisely what to do, how to do it,
and what to expect. They settle.
This is not being patient. This is
quitting. Granted, it may be from
ignorance, but it's still quitting.
I know how hard it is to be a patient
patient. We all would like our
wounds to heal faster than they do.
However, you can only push the
body as fast as the body will
permit. The best you can do is to do
your best. Gather the facts. Ask
questions. Spend your time around
people who will help you find
answers. Exhaust all options and
give your injury what it needs to
heal. Be persistent and diligent and
remember what Will Shakespeare
said, "What wound did ever heal
but by degrees?"
Knowledge leads to understanding
and understanding is the key to
patience.
Seek knowledge first.

Law 3 - Pay Attention

I use a phrase with my clients:
“Place your attention on your
intention.” Too often, people who
hurt will use some gimmick or
gadget to shoo away the pain so
they can just keep doing whatever
they want even though they still
hurt.
What do you suppose your intention
is when you do something like this?
Where is your attention being
placed? My guitar teacher, Jim
Collard, describes the process of
learning the instrument to climbing
stairs. Sometimes the step is high;
the riser is tall and you work and
work and work to get up to the next
step. If you try to work on things
that are three or four steps up higher
than where you are, you’ll just end
up frustrated and actually play
worse than if you slow down, play
at your level, master that, and then
move up. If you want to heal, get
stronger, and run, place your
attention on the step you’re on.
John Wooden, one of the greatest
college basketball coaches in
history leading UCLA to four
perfect 30-0 seasons, 88
consecutive victories, and 10
NCAA championships, said, "I
continually stress to my players that
all I expect from them at practice
and in the games is their maximum
effort."
Maximum effort includes giving
your attention in the moment to
whatever it is you’re doing and
doing it the very best way you can.
Paying attention also means
“listening” to your body.
Even if the exercise seems absurdly
easy, much too easy to have created
any symptoms, and you feel
stiffness, aching, pain, your body is
telling you something.
It’s telling you to slow down. “Hey,
I’m struggling here! I need some
help!”
Ego often gets in the way. We don’t
want to believe we are as weak as
we are. So, we ignore the message
and press on.
This rarely works out in our favor.

Law 4 - Progress in Never Linear

I've never met a client who has
said, "I hope there a lot of twists
and turns, unexpected things, and
major setbacks in our work
together."
Everyone wants a straight road.
Full speed ahead to
Recoveredville.
I know I do.
The road to Recoveredville is
anything but straight.
Straight roads are boring though. If
you don't believe me, come on
down to Texas. Plenty of long,
straight, dry, dull roads. Drive a
few of them and you'll see what I
mean.
But to be excited about setbacks is
just not normal. No one is going to
look at the unexpected ups and
downs of a rehab program as,
"Wow, this is fun!"
If you go into a rehab process
thinking that progress will be fast
and you'll never have a setback,
you'll be disappointed, frustrated,
and likely angry.
Try to think of the rebuilding your
knee, hip, shoulder, or whatever
area of your body that's injured, as
a project instead of a "treatment".
And like any significant project, it
takes time and usually longer than
you think it will.
I learned something from a wise
man a few years ago, Tim McClure-
-the mastermind behind the "Don't
Mess with Texas" anti-litter
campaign. He told me that a secret
to building almost anything is to
make a little bit of progress each
day.
Just show up and do one small thing
to push the needle forward.
It's one of the most difficult things
to do.
Why? Because when you're
working on one small thing, like
getting your quadriceps to contract,
it can feel so far away from the end
point, running again or hiking or
playing a sport, that you start
wondering if things will ever get
better or if you'll even finish.
You worry you'll be stuck right
where you are...forever.
Below is a drawing that a client of
mine made after one of our
discussions on the nature of
progress (her name is Heidi
Armstrong and she has a wonderful
coaching service,
injuredathletestoolbox.com, that
grew out of her journey through 8
knee surgeries).
We were talking about how easy it
is to forget where you were, where
you started because setbacks are
inevitable.
And as soon as you stumble, your
mind kicks in with all sorts of
negative comments.

Because everyone’s journey is

different, one thing I suggest is to
use metrics or benchmarks.
Even if the metrics are small things.
When I met Jo (not her real name),
she was recovering from a below
the knee amputation of her left leg. I
was her first visit to rehab.
Sitting slumped in a wheel chair
about three feet from me with her
husband standing next to her, Jo
wouldn't look at me. She stared at
the ground.
I said, "Jo, how can I help you?"
I waited. It was a while before Jo
said anything.
She let out a long sigh and then
said, "You know, I just want to get
my own clothes. I want to walk to
the closet and pick out the clothes
I'm going to wear so I don't have to
ask my husband to do it for me."
I said, "We can do that Jo. Let's talk
about where we should start."
Together we started a list of things
Jo needed to be able to do. It was a
list of markers. Small metrics. She
had to be able to stand in one place
without help and recover from
small bumps and nudges. She had to
stand on just her left leg for 10
seconds. She had to move on and
off her left leg with control.
It turned into a long list.
And off we went.
Jo worked her tail off. She not only
got her clothes out of the closet but
she played golf and danced.
In the end, it really all comes down
to what you believe. Do you
believe you can overcome the
bumps, curves, and obstacles of
rehab road even if the timeline is
long and arduous? Or will you pine
for the straight road that asks
nothing of you and gives you even
less in return?
I believe people can overcome
enormous barriers if they will
believe in themselves. Maybe I'm
wrong but then again, what if I'm
not?
I'll leave you with this video…
What do you believe?

Law 5 - Dream Big, Start Small

“You are never too old to

set another goal or to dream
a new dream.” ~C.S. Lewis

Wanting something that is out of our

reach can be motivating yet when
the goal is too far away, the struggle
to achieve it can lead to frustration
and unhappiness.
The challenge of setting realistic
expectations came up often when I
was teaching in physical therapy
school. My students struggled with
how to help their patients establish
goals that they could achieve within
the time frame allotted.
Some patients wanted to, for
example, run or play a sport which
seems fair enough until you learn
that they've had unrelenting knee
pain for ten years, are 30 pounds
overweight, and rarely exercise.
Other people seem to aim low. One
client, a woman who had gone
through a difficult shoulder surgery,
was convinced that if she could just
comb her hair, she would be
satisfied. By aiming low, you limit
frustration and disappointment but
also limit your potential.
Part of the equation for happiness
includes how to set expectations for
yourself that are motivating and
rewarding without being too grand
and out of reach or too low and too
easy to achieve.
What Makes Expectations
Realistic Or Unrealistic?
Three things come into play when
you ponder the answer to this
question.
The Magnitude of the Task.
Setting your goals high isn't an issue
in and of itself, but many of us tend
to think we can accomplish more in
a given period of time than we
really can. For example, a group of
women who entered a weight loss
program (all of whom were
classified as obese), expected to
lose much more weight in the study
despite the input and opinions of
several experts. At the end of the 48
weeks, the women averaged about a
35 lb. weight loss which was in
line with the experts projections.
The women were disappointed.
I've experienced this too but have
learned how to make the necessary
adjustments to increase my level of
happiness.
I started playing trumpet in 2011
after a thirty-five year break.
Trumpet is a physically demanding
instrument and requires diligence
and patience to develop your
playing ability.
Although I knew that my progress
would be slow, after about three
months I was frustrated and
miserable about how poorly I
played and could not see one
positive thing about the choice to
re-start my love affair with this
instrument.
The magnitude of the task was
large. I had in my mind that in a
matter of months I could be on stage
at Carnegie Hall or playing front
and center in a hip jazz band. This
expectation or goal was unrealistic,
and if I hoped to ever play
anywhere, I would have to find a
way to make peace with the slow
progress.
The solution--and this is true even
in the case of the women in the
weight loss study--was to find an
expert or someone with much more
experience and understanding about
the rate of progress.
I found a teacher and he explained
to me, patiently, what I could expect
to achieve over the ensuing months
and years.
While hard to hear, I knew he was
right.
The key to managing the magnitude
of change is to accept the present
without letting go of hope.
The women in the study could still
want to lose more weight than what
the experts suggested was
reasonable, just as I can hold onto
the idea that I might make faster
progress than my teacher believes.
But, to hold onto your happiness,
you have to accept that the lofty
goal in your mind may never happen
but let hope keep the dream alive.
Time Frame and Ease of Change.
The ease of change and the time to
achieve the goal is often
overlooked when setting
expectations.
In my case, practicing is, at times, a
grueling experience. It's physically
tiring and mentally challenging.
Developing the various trumpet
technical skills, acquiring the
knowledge of music theory, sight
reading, improvising, and
developing your own "tone" takes
daily practice and the
improvements come in small
increments.
To make this process easier, take
the big goal and "chunk" it--create
smaller goals that require less time
to achieve. As you hit these smaller
milestones, be sure to "celebrate"
your success.
Small rewards issued frequently
tend to be more motivating than
large rewards issued infrequently.
Assumed Change Effect.
Sometimes we assume that losing
20 pounds or increasing our bank
balance will bring us a new, higher
level of happiness. And the
unspoken motive is what we
believe other people will think
about us.
For example, some research has
shown that while compensation is
important to people, at some point it
becomes neutral. The issue is what
other people think about my
compensation. Sort of "keeping up
with the Joneses."
To counter this, be honest with
yourself about why you're setting
your goals and what achieving those
goals will do for you. If you
discover that your motive is, for
example, to look like someone else,
to have the "body of your dreams"
because you'll be happier or feel
better about yourself, be aware that
happiness is state of being and not a
destination. If you can enjoy the
process to your goal, almost
without regard to achieving it,
you'll likely experience more
happiness.

Is It Possible To Be Realistic
About Being Unrealistic?
Setting lofty goals is not a bad
thing. But to optimize your
happiness, be honest with yourself
about the magnitude of change, the
time to achieve it, and the degree to
which you have attached your sense
of self to whether you achieve the
goal or not.
By being honest about these things,
you can still hold in your mind what
seem like opposing thoughts: being
realistic about your goals while not
giving up on what may appear to be
an unrealistic dream.
Chapter 38
CORE EXERCISES

B elow are the core exercises I

use in The 90 Day Knee
Arthritis Remedy training routine.
They also serve to strengthen the
suspension system.

Core Exercise #1: Single Leg

Stance

Stand up straight.
Arms held next to the sides
of your body.
Lift one leg off the ground
as in the image.
Keep your hips level and
avoid turning them either
way.
Hold the position as long
as you can. The target is 90
seconds.
Perform 3 repetitions.
Repeat with the other leg.
Core Exercise #2: Hip Burners
The Hip Burner Series consists of
three movements all performed in
the same starting position.
Position 1
 Hip Burner exercise

Lie down on your side

(either one because you’ll
do both) on the floor or a
firm surface.
Bend the bottom leg at the
hip and knee until each are
about a 90 degree angle.
Align the top leg in a
straight position. The knee
should be straight so that
the entire leg draws a
straight line from the hip,
knee, and ankle.
Lift the leg up about 6
inches and slightly back.
Lower the leg down
parallel to the floor.
Lift the leg back up and
repeat until you feel a high
level of fatigue in the hip
muscles (a 7 or higher on a
fatigue scale of 0 -10 ,
where 0 is no fatigue and
10 is extreme fatigue).
The movement should be
 smooth, well-controlled.
Stop if anything hurts or if
you’re unable to produce a
smooth, controlled motion
and maintain the form.
Count the number of
repetitions you performed
and make a note.
Rest 60 seconds and
proceed to Position 2.

Position 2
In the same starting
position as Position 1,
bring the leg forward to
about a 45 degree angle of
the hip while keeping the
knee straight.
Repeat the same up and
down movement as in
Position 1. Stop if anything
hurts or if you’re unable to
 produce a smooth
controlled motion and
maintain the form.
Record the number of
repetitions.
Rest one minute and
proceed to Position 3.

Position 3
 In same starting position as
Position 1, move your leg
backward about 30
degrees while keeping the
knee straight.
Repeat the same up and
down movement as in
Position 1 and 2.
Stop if anything hurts or if
you’re unable to produce a
smooth controlled motion
and maintain the form.
Record the number of
repetitions.

Video: click here

Core Exercise #3: Bird Dog

Bird Dog exercise

Start on all fours position

(hands and knees). Use
plenty of padding under
your knees.
 Slowly extend one leg and
the opposite arm. Keep
your back straight as you
do this.
Hold for three-seconds
then bring the hand and
knee to each other meeting
at about the chest. This is
one repetition.
Do as many repetitions as
you can and record. The
target is 20 repetitions.

Video: click here

Core Exercise #4: Plank

Plank exercise

The Plank exercise is

performed just like the
Plank test.
Lie on the floor face down.
Prop up onto your
forearms.
 Now lift the rest of your
body up onto your toes.
Hold this position, your
body in a straight line, for
as long as you can. The
target is 90 seconds.
Record your results.

Video: click here

Chapter 39
LEG EXERCISES

Y ou’ll find descriptions of all

the leg strengthening
exercises in this chapter.
Back Slider on NON-PAINFUL
leg with rotation force (vector)

Back Slider with Rotation

Force
Perform this exercise ONLY on
your non-painful or stronger leg.
You will be taking advantage of the
“cross training” effect of the central
nervous system. The improvements
you develop on the non-painful leg
will cross over to the painful side
without performing the exercise
own that side.
For the Back Slider, you will need:

A furniture mover or
comparable.
A Gray Cook Band (GCB)
or comparable.
How to use a Gray Cook
 Band - click here.
A sturdy door that closes
toward you or other sturdy
anchor point for the band.

To perform the Back Slider:

Anchor the middle of the

GCB in the hinge side of
the door with your painful
side closest to the door
attachment.
Step away from the door
until there is slight tension
in the band.
Turn so you are parallel to
the door (see image).
Hold the strap handles
(foam part) in your hands
in front of your chest.
Step away from the
attached end until there is
slight tension in the band.
Stand on the non-painful
leg. Place your opposite
foot on the furniture mover,
and slide it backwards as
you push your hands
straight forward
performing a reverse
lunge. Keep your body
moving in the up and down
direction - don't allow the
 band to pull you off
balance.
Return to the starting
position. This is one
repetition.

Video: click here

Assisted Back Slider

 Assisted Back Slider

For the Assisted Back Slider, you

will need:

A furniture mover or
comparable.
A Gray Cook Band (GCB)
 or comparable.
A sturdy door that closes
toward you or other sturdy
anchor point for the band.

To perform the Assisted Back

Slider:

Insert the straps of both

ends of the GCB in the top
of the
Place the large foam
handle around your trunk
(see image). This will
stretch the band providing
you with some assistance
as you stand.
Step away from the
attached end until there is
slight tension in the band.
Slide the foot - the non-
painful leg - on the
furniture mover backward
performing a reverse
lunge. The distance is
about one step length. Your
knee bends less than 90
degrees - about 75
degrees. Keep your body
moving in the up and down
direction. Control the
movement of your knee -
keep it pointing straight
 ahead.
Return to the starting
position. This is one
repetition.

Video: click here

Physioball Wall Slides - Staggered

Stance
For the Physioball Wall Slides -
Staggered Stance, you will need:

Small or medium sized

 physioball (also called
exercise ball, stability ball
or swiss ball).
Smooth wall surface.

Wall Slides - Staggered Stance

To perform the Physioball Wall

Slide - Staggered Stance:
Place the physioball
against a flat wall surface
Turn around and place
your back against the
physioball (see image).
Your feet should be
shoulder width apart.
Move your feet forward
about 12 inches and
roughly shoulder width
apart.
With your painful or
weaker leg, take a small
step forwards (a few
inches).
Perform a squat motion to
about 75 degrees of knee
 bend keeping your back
against the ball.
Return to the starting
position.
This is one repetition.

Video: click here

Assisted Side Slider

 Assisted Side Slider

​For the Assisted Side Slider, you

will need:

A furniture mover or
comparable.
A Gray Cook Band (GCB)
or comparable.
A sturdy door that closes
toward you or other sturdy
 anchor point for the band.

To perform the Assisted Side

Slider:

Anchor the GCB at the top

of a door - closer to the
hinge side of the door.
Place the large foam
handle around your trunk
(see image).
Step away from the
attached end until there is
slight tension in the band.
Slide the foot - the weak or
painful leg - on the
furniture mover sideways
performing a side lunge.
Your knee bends less than
90 degrees - about 75
degrees. Keep your body
moving in the up and down
direction. Control the
movement of your knee -
keep it pointing straight
ahead.
Return to the starting
position. This is one
repetition.
After finishing the sets on
one leg, repeat on the
exercise on the other leg.
Video: click here

Skater Squat (non-painful leg)

Skater Squat

For the Skater Squat, you will need:

 A furniture mover or
comparable.

A Skater Squat requires two

motions: a Back Slider plus a
sweeping motion of the sliding leg
along with a corresponding
sweeping motion of the upper body.
The sweeping action forces the
weight bearing hip abductors and
rotators to hold your limb in place
and it also creates a balance
disturbance.
As your leg fatigues, especially in
the hip, you’ll notice that it wants to
drift out - away from the midline of
the body. Focus on keeping the leg
driving toward the midline. It might
feel as if it’s going too far, but if
you look in a mirror, you’ll see that
your leg is actually in a neutral
position.
Video: click here

Single Limb Stance - Superman

 Superman - Single Leg Stance

For the Superman exercise, you

will need:

Gray Cook Band (GCB)

Sturdy door that closes
toward you or other sturdy
anchor point for the GCB.

To perform the Superman:

Start in a standing position
(stand tall).
Bend the weight bearing
knee slightly.
Lean forward by bending
at your hip while extending
the opposite leg (see
image).
Bend only as far as you
can control the motion at
which point stop and
balance the leg.
Hold the position for 5
seconds.
This is one repetition.
Complete the indicated
 number of sets and then
repeat on the opposite leg.

If the Superman exercise is

uncomfortable on your weaker leg,
try the following:
OPTION 1:

Attach the middle of the

GCB in the top of a door.
Hold the straps, one in
each hand and turn away
from the door.
Step out from the door
until there is slight tension
in the band.
 Perform the exercise as
described above using the
GCB to assist you.

OPTION 2:

Perform the exercise while

holding onto the top of a
chair (hand opposite the
weight bearing leg), table
or other comparable
surface.

Video: click here

Squat with Hip Resistance

Squats with Hip Resistance

Use an elastic band of light

resistance around the knees
as pictured above.
Place your feet about
 shoulder width apart. Turn
your feet out a small
amount.
Squat down slowly to
about 75 degrees of knee
bend (as pictured) and
hold the position for 3
seconds.
Return to standing over
three seconds. This is one
repetition.

Pay attention to your form. As you

fatigue, one or both of your knees
may tend to move inward. Keep the
knees pointing straight ahead.
Video: click here

OPTION - Assisted Squats (or Sit

to Stand)
If this movement is uncomfortable,
you can opt for the Assisted Sit-to-
Stand.
The tools needed are:

1 GCB (Gray Cook Band)

or comparable
A standard door that closes
toward you or other secure
 anchor point.

Assisted Squats

To perform the Assisted Squat:

Insert the straps of both

ends of the GCB in the top
of the door to the right
(toward the hinges).
Place the large foam
handle around your trunk
(see image). This will
stretch the band providing
you with some assistance
as you stand.
Keeping your knees
pointing straight ahead,
perform a squat. As you
squat down, straighten
your arms (see the video).
Squat as far as you’re
comfortable or until your
knees are close to a 90
degree angle and then
 stand up. This is one
repetition.

Video: click here

Athletic Drills
Single Leg Squat Driver
A Single Leg Squat Driver is a
combination drill of a Single Leg
Squat followed by a driving up and
forward of the non-weight bearing
leg (in the picture, it may look like
a reverse lunge, but you just barely
touch down with the rear leg).
For example, if you perform the
lunge on the left leg, the right arm
comes forward. As you return to the
upright position, you drive the right
leg up and lift the left arm - similar
to a running movement.
 Single Leg Squat Driver

Video: click here

Side to Side Hops
This exercise prepares you for
impact loads. It’s simple to do but
can be very fatiguing. Here’s how
to do it.

Attach the GC Band to the

door frame or other sturdy
frame.
Loop the other end around
your waist.
Start in a standing position
with your feet slightly
wider than shoulder width.
Stand on the left leg and
hop sideways to the right.
Control the landing, pause,
and hop to the left. With
each repetition, keep your
knees high. The band will
resist you in one direction
and increase loading in the
other.

Side to Side Hops

Video: click here

Sprint - Hop
To do this exercise, you’ll need a
bench or other object about 9-12
inches high (you could even use a
stack of bath towels).

Stand on one side of the

bench or object.
Crouch in a running
position and “sprint” in
place.
At the end of the sprint
period, hop over the other
side and begin sprinting
again.
Make sure you land on the
forefoot of your foot and
not on the heel or on the
entire foot. Landing on the
forefoot uses your calf
muscle as a spring and
helps absorb some of the
force.
 Sprint Hops

Video: click here

Jumping Jack Splits

This is a combination drill of
moving in one plane of motion (the
Jumping Jack part) and then
switching to a another plane of
motion (the split). By doing this,
you load your knee in multiple
directions and increase the impact
load.

Jumping Jack Splits

To do the Jumping Jack Splits:

 Perform Jumping Jacks for
the repetition or time
target.
As you reach the target,
you hop up and land in a
split lunge position.
Hop up and reverse the leg
position landing in a lunge
position.
Return to the Jumping
Jacks.
This is one repetition.

Video: click here

Chapter 40
HOW TO KNOW IF
YOU NEED A
COACH

Y es, I know I’m biased.

But sometimes working with a
coach can move you closer to your
goals faster than doing the work on
your own.
Here are some signs that you might
benefit from some professional
help. (If you don’t see yourself in
these signs, you can still work with
a coach if you feel like it might be
helpful to you.)
You’ve had some success,
but not as much as you
would like.
You’re unsure of how to
progress (how fast, what to
change & when).
You prefer the
accountability of working
with someone.
You don’t feel confident
where to start / or in
prioritizing the initial
exercises.
You’re not sure about
activities to limit and for
how long.
I recommend Laurie Kertz Kelly
because I have worked with her for
a number of years and she
understands the concepts
completely.
Laurie is a coach who utilizes the
concepts in this book to provide
clients with customized, step-by-
step action plans. This eliminates
time-wasting trial and error-- often
saving people several months of
frustration and setbacks. One of
Laurie’s past clients who lives in
Finland states, “Coaching like this
takes a lot of guesswork out of the
equation.”
If you’re like most readers who
consider working with Laurie, you
may feel skeptical about whether an
online video approach will be
effective. Gary, a client from Ohio
admits, “I was concerned that
[Laurie] would be able to see me
well enough to know if my legs,
feet, and body were in the right
position but it really worked out
well.”
More than anything, readers are
ready for something that will yield
success. Kelly, a client from
California recalls, “I had worked
with four physical therapists
previously, and I felt like I just
really wasn’t making progress.
They kept having me start with easy
exercises, but as soon as we moved
on to the harder ones, my knee
would hurt more. So I was really
fed up and looking for something
that would work.”
Chapter 41
THE ROUTINE

T here are two routines - Track

1 and Track 2.
Use Track 1 when your Sit to Stand
test results are less than 50% body
weight and use Track 2 when your
results are 50% or greater.
Each track references exercises
from the chapters on exercise
descriptions. If you need a refresher
on how to perform an exercise, just
go to the chapter that explains the
exercise.
Answers to the Six Most
Frequently Asked Questions
Where do I start?
The routine is divided into Track I
and Track II.
Use Track I if your weight bearing
capacity test results (Sit to Stand
test) were less than 50%. Use Track
II if the results were greater than
50%. If you start with Track I, upon
successful completion, begin Track
II.
Both tracks start with movements
and exercises to nourish your knee
joint. These exercises are not
designed to produce muscle fatigue
(except for Quad Sets). After you
complete this part, proceed to the
next section.
How do I know how much to do
(how often should I do the
exercises)?
In each section, you’ll have specific
instructions to help you determine
the ideal number of repetitions or
duration and sets as well as any
required rest between sets and
number of days per week.
How do I know if I’m improving?
Before you start the exercises, take
note of your current status - pain
levels, stiffness, and activity level.
You will use this later to record
future results and it will help you
“see” the changes that have
occurred.
After six weeks, repeat the process.
Improvement rates vary from
person to person, but up to a 25%
improvement in six weeks is the
most common rate of change.
What if my knee hurts?
Symptoms that stem from activity or
load generally improve when you
stop the activity or reduce the load
or intensity of the activity.
If you experience any increase in
symptoms, return to the joint
nourishing / strengthening exercises
until the symptoms subside. Then
resume the exercises but reduce the
exercise intensity (resistance or
load, repetitions, sets, frequency).
Once you have completed at least
three days of the exercises without
an increase in symptoms, you can
return to the prior level of intensity.
Any time you have symptoms that
do not improve with reduction of
exercise intensity or with rest, you
should contact your physician for
his or her evaluation.
When do I stop doing the
exercises?
As long as you continue to benefit
from the exercises, you can continue
with them. Re-assess your status
every six weeks. Once you have
achieved the initial goals, you can
transition to a generalized fitness
program.
When can I start "exercising"
again?
Once you have completed Track II,
you should be able to resume
general strengthening and
conditioning exercises (but keep in
mind your tolerance to activity and
load - pace yourself).

How to Use “The Routine”

To help you rebuild the strength of
your leg(s), increase the width of
your FZ (Functional Zone) and AZ
(Adaptation Zone), I have included
something I refer to as “The
Routine”. The Routine (there are
two - Track I and Track II) contain
different exercises to improve joint
strength, suspension system
strength, core strength and leg
strength.
The Routine is divided into sections
with a list of the included exercises
along with recommended number of
repetitions, sets, rest periods and
days per week.
If you need a refresher on how to
perform the various exercises, go to
the chapter that covers the exercise
focus (e.g. If your need a refresher
on Core exercises, go to the chapter
on Core Strength).
Track I and Track II - Joint
Strengthening Exercises
Quad Sets

Perform at least 10
repetitions = 1 set
Perform at least 5 sets per
day every day
Goal is 10 sets per day or
100 repetitions
Choose one or more of the
Joint Strengthening
exercises to do for 15
minutes or more, three
times per day (see the
 chapter - Joint
Strengthening Basics).
Some people find that 15
minutes is too long. If
that’s the case, then reduce
the time to 5 minutes or
whatever interval works
for you. The objective is to
move your knee gently,
intermittently over the
course of a day.

Track I and Track II - Core and

Suspension System Exercises
Choose any two of the following
Core and Suspension System
Exercises (create new combinations
each time you exercise). Perform
these 2-3 days per week.

Single Leg Stance - hold

the position for as long as
you can and then repeat on
the opposite leg. This is
one set. Perform a total of
three sets. Goal is 90
seconds on each leg.
Hip Burners - perform the
exercise to a 7/10 level of
fatigue. Repeat on the
opposite leg. This is one
set. Perform three sets.
Goal is 15 repetitions in
each position with a
fatigue level of 5/10 or
less.
Bird Dog - place padding
under your knees. Perform
the exercise as described
until you reach a fatigue
level of 7/10 or greater.
Perform three sets. Goal is
20 repetitions with a
fatigue level of 5/10 or
less,
Plank - perform the
exercise as described.
Goal is 90 seconds with a
fatigue level of 5/10 or
 less.

Track I - Leg Muscle

Strengthening Exercises
Choose any two of the following
Leg Muscle Strengthening Exercises
(create new combinations each time
you exercise). Perform these 2 days
per week with at least 2 days of rest
between these exercises.
The first set of an exercise is
considered your "max" (fatigue
level of 7/10). Make a note of the
repetitions or, if the exercise uses
time, the duration. The second
second should be 80% of the first
set. The third set should be 60% of
the first set.
Example: In the Assisted Sit to
Stand, you completed 15 repetitions
in the first set with a fatigue level of
7/10. The second set will be 12
repetitions (80% of 15) and the
third set will be 9 repetitions (60%
of 15).

Assisted Sit to Stand -

perform the exercise as
described for three sets
with one minute of rest
between sets. Goal is 25
repetitions with a fatigue
level of 5/10 or less.
Back Slider on NON-
PAINFUL leg with
rotation force (vector) -
perform the exercise as
described for three sets
with one minute of rest in
between. Goal is 25
repetitions with a fatigue
level of 5/10 or less.
Assisted Back Slider -
perform the exercise as
described for three sets
with one minute of rest in
between. Goal is 25
repetitions with a fatigue
level of 5/10 or less.
Assisted Side Slider -
perform the exercise as
described for three sets
with one minute of rest in
between. Goal is 25
repetitions with a fatigue
level of 5/10 or less.
Skater Squat on NON-
PAINFUL - perform the
exercise as described for
three sets with one minute
of rest in between. Goal is
25 repetitions with a
fatigue level of 5/10 or
less.
Sit to Stand - Staggered
 Stance - perform the
exercise as described for
three sets with one minute
of rest in between. Goal is
25 repetitions with a
fatigue level of 5/10 or
less.

Track II - Leg Muscle

Strengthening Exercises
Choose any two of the following
Leg Muscle Strengthening Exercises
(create new combinations each time
you exercise). Perform these 2 days
per week with at least 2 days of rest
between these exercises.
The first set of an exercise is
considered your "max" (fatigue
level of 7/10). Make a note of the
repetitions or, if the exercise uses
time, the duration. The second
second should be 80% of the first
set. The third set should be 60% of
the first set.
Example: In the Squat with Hip
Resistance, you completed 15
repetitions in the first set with a
fatigue level of 7/10. The second
set will be 12 repetitions (80% of
15) and the third set will be 9
repetitions (60% of 15).
Squat with Hip
Resistance - perform the
exercise as described for a
total of three sets with one
minute of rest between
sets. Goal is 25 repetitions
with a fatigue level of 5/10
or less.
Back Slider on NON-
PAINFUL leg with
rotation force (vector) -
perform the exercise as
described for a total of
three sets with one minute
of rest between sets. Goal
is 25 repetitions with a
fatigue level of 5/10 or
less.
Single Limb Stance
Superman - perform the
exercise as described for a
total of three sets with one
minute of rest between
sets. Goal is 15 repetitions
on each leg with a fatigue
level of 5/10 or less.
Physioball Wall Slides
Staggered Stance -
perform the exercise as
described for a total of
three sets with one minute
of rest between sets. Goal
is 25 repetitions with a
fatigue level of 5/10 or
 less.
Skater Squat on NON-
PAINFUL leg - perform
the exercise as described
for a total of three sets
with one minute of rest
between sets. Goal is 25
repetitions with a fatigue
level of 5/10 or less.

Progression

Squat with Hip

Resistance - perform the
exercise with additional
weight. Start with 10
pounds and adjust as
needed to achieve the
desired fatigue for a total
of three sets with one
minute of rest between
sets. Goal is 25 repetitions
with a fatigue level of 5/10
or less
Back Slider on EACH leg
with rotation force
(vector) - perform the
exercise as described for a
total of three sets with one
minute of rest between
sets. Goal is 25 repetitions
with a fatigue level of 5/10
or less.
Physioball Wall Slides
Equal Stance - perform
the exercise with feet
equally aligned and add 10
pounds of extra resistance.
Adjust the extra weight as
needed to achieve the
desired fatigue for a total
of three sets with one
minute of rest between
sets. Goal is 25 repetitions
with a fatigue level of 5/10
or less
Skater Squat on EACH
leg - perform the exercise
as described for a total of
three sets with one minute
of rest between sets. Goal
is 25 repetitions with a
fatigue level of 5/10 or
less.
Chapter 42
THE ROUTINE
ADDENDUM:
ATHLETIC
PREPARATION

R unning is falling and catching

yourself over and over at a
high speed.
The best way to do this in order to
protect your joints is to maximize
use of the suspension system.
How do you do that?
When you move - walk or run - you
have a choice of how you perform
the movement. You can move with a
sense of ease and grace, with a
spring in your step, or you can
move with a heaviness allowing
your foot to hit the ground with
more of a thud.
Learning how to run with lightness
is a key factor in lowering your risk
of injury or overuse.
Movements are learned first and
then filed away in your nervous
system to run on more of an
autopilot basis. Imagine how much
mental energy and time it would
take if you had to consciously
execute every movement you made
over the course of day.
The great thing, and sometimes the
worst thing, about the human body
is how quickly it learns.
Most people don’t think about how
they run (which is normal), what’s
happening to the body, how the foot
hits and leaves the ground which is
entirely normal.
To change your style of running
requires awareness of what you’re
doing and then removing something.
To move with ease, lightness, and
grace is not something you add to
movement. Those components are
already there in your system. The
process is learning how to remove
elements that are interfering with
the lightness of movement.
In one of my continuing educations
classes for physical therapists, I
gave the students an assignment that
highlighted how the body could
learn a movement in seconds.
I brought one student to the front of
the room and asked him to walk at a
normal pace up and down the room.
It was a large hotel conference
room so there was plenty of space
to walk.
While he was walking, I asked the
class to watch and study his
movement closely.
Then I asked another student to
come up and walk behind the first
student. Her task was to walk as
closely to his style as she could
without any practice.
In seconds, she was able to identify
certain characteristics of his
movement and mimic it with near
perfection. The other students
started to laugh. Seeing two people
walking with nearly the same
movement pattern was peculiar and
fascinating.
One of the students in the class
suggested that maybe it was a fluke;
that only the young woman who was
mimicking the movement she saw
was capable.
Good point. So, I asked another
student to show us.
And another.
And another.
Every student in the class could do
it. And at one point we had six
students walking in a line with
nearly the same movement pattern.
How could they do this so quickly?
By being acutely aware of their
movement and removing certain
parts to allow the emergence of a
new movement.
ASSIGNMENT: Try the experiment
I described above with two or three
family members or friends. Pay
close attention to how you’re
moving and what you must do to
mimic another and how quickly you
can do it. This is the same basic
process you will use to learn how
to run lightly.
There are five components of
running that naturally create a
springier and lighter style of
running:

Keep your stride length

short. Avoid over striding
and reaching too far out in
front of you.
Land on the midfoot or
forefoot.
Stay upright - avoid
leaning forward at your
hips.
Can you hear your feet
hit the ground? If so, your
foot strike is too heavy.
Implement a new running
form gradually. Practice
your new form for a few
 minutes at a time. Give
your brain the chance to
learn the movement
pattern.

When you start running again, focus

on the creating a springy quality for
each stride. And only run as long as
you can maintain the lightness in
your steps.
Sometimes, that means running for
10 seconds and walking for a brief
time and repeating those intervals.
Yes, there are a lot of people who
run with heavy feet and seem to feel
fine but they are not you.
Remember that you’re introducing
high levels of force to your knees
and utilizing the natural suspension
system in your body can only help
you.
Run lightly.
Here’s a video demonstrating how
to run lightly.
And here’s Dr. Daniel Lieberman, a
professor of biology at Harvard
University. Dr. Lieberman studies
running, in particular the
components that create a light
running style. Here he is discussing
those elements (click here to watch
the video):
To qualify for the Running
Preparation routine, you should
have met all of the goals of the
Track II exercise progression.

Single Leg Squat Driver -

perform the exercise as
described for a total of
three sets with one minute
of rest between sets. Goal
is 20 repetitions with a
fatigue level of 5/10 or
less.
Side to Side Hops -
perform the exercise as
described for a total of
three sets with one minute
of rest between sets. Goal
is 20 repetitions with a
fatigue level of 5/10 or
less.
Sprint - Hop - perform the
exercise as described for a
total of three sets with one
minute of rest between
sets. Goal is 20 repetitions
with a fatigue level of 5/10
or less.
Jumping Jack Splits -
perform the exercise as
described for a total of
three sets with one minute
of rest between sets. Goal
is 20 repetitions with a
fatigue level of 5/10 or
less.
Chapter 43
RETURN TO
RUNNING

W hy not just start running

again?
After an injury, your body will often
not have all of the physical reserves
needed to withstand 20-30 minutes
of uninterrupted running. By using a
graduated program, brief
interruptions permit your body to
perform more total work even if the
interruptions or rest periods are of
a relatively short duration. In most
cases, you can avoid symptom
production, stimulate tissues to
grow stronger and regain your
running ability.
To start the Return to Running
phase, you must complete the Track
II routine and comfortably perform
the exercises on each leg. For
example, the Skater Squat starts as
an exercise for the non-painful leg.
As your painful leg becomes
stronger, you will be able to
perform the exercise with each leg.
During the first four weeks, run two
days per week. Take at least one
day off between sessions. You can
perform strength training exercises
on other days as long as you have
no symptoms.
On weeks 5-8, run 3 days per week
and on weeks 10-12, you can
increase to four days per week.
Although you may feel that you can
run more often, please adhere to
this regimen. Your body needs the
recovery time between sessions.
Follow the program below using
the following general guidelines:

Mild discomfort may occur

(on a scale of 0-10, where
0 = no pain and 10 =
severe pain) of a 3/10 or
 less.
If you have discomfort
during any running portion,
stop and continue with
walking only.
If you hurt the following
day, do not run again until
the pain has subsided.

The program has defined running /

walking times however, run only as
long as you can maintain a good
running form and a lightness to your
steps. If this means that after
running ten steps you notice that you
can’t maintain a “springy” quality to
your running, walk for the specified
duration. When the next round of
running starts, aim for more
“springy” steps.

The Program
 Return to running program

Days/week:
Weeks 1-4: 2
Weeks 5-8: 3
Weeks 10-12: 3-4

Rules: Do not advance to the next

week if you experience any
increase in symptoms.
Chapter 44
TOOLS AND
EQUIPMENT

T o perform the exercises in The

90 Day Knee Arthritis
Remedy, you will need the
following (we have no financial
interest with any of the companies
that sell the items):

Furniture mover (slider) -

click here as an option to
purchase
Sturdy chair
Standard interior /exterior
door with door handles
Access to a stationary bike
or comparable (see Joint
Strengthening Basics
chapter for other options)
Gray Cook Band or
equivalent - we suggest the
pink (light) band to start
with
How to use the Gray Cook
Band - click here
Chapter 45
FORMS AND
VIDEOS

B elow are the forms used to

document status and progress:

For the KOOS test, click here.

For the form to record test results,
click here.
For the form to record exercise
data, click here.
Videos
Video list (click on the name to
view the video - you will need an
Internet connection):

Sit to Stand Test

Side Plank
Single Leg Balance
How to Evaluate a
Variable Incline Plane
How to Perform A Quad
Set Properly
Tailgater video
Leg Slider with GCB
The Hovr in use at a desk
Single Leg Stance
Hip Burners
Bird Dog
Plank
Assisted Squats (or Sit to
Stand)
Back Slider with Rotation
Force
Assisted Back Slider
Assisted Side Slider
Skater Squat
Sit to Stand Staggered
Stance
Squat with Hip Resistance
Single Limb Stance -
Superman
Physioball Wall Slides -
staggered stance
Springy Running Style
Dr. Daniel Lieberman on
running style
Single Leg Squat Driver
Side to Side Hops
Sprint - Hop
Jumping Jack Splits
Chapter 46
ABOUT THE
AUTHOR

D oug Kelsey (“DK”) is a

physical therapist, author and
teacher whose specialty is helping
people build resilience - fitness
across multiple domains - to
enhance their performance, health,
and life.
He has helped thousands of people
bounce back from a variety of
injuries and surgeries over his 30+
year career.
He was the Founder of Sports
Center Physical Therapy in Austin,
Texas and currently owns The
Kelsey Group - a specialized health
and fitness business also in Austin.
He has conducted over 20,000
consultations and 100,000 training
sessions with people ranging from
professional and Olympic athletes,
weekend warriors, and moms and
dads who want to feel better, be in
better shape and enjoy their lives.
Doug is an accomplished author,
inventor, and teacher. Formerly
Associate Professor at the
University of Oklahoma Health
Science Center, he holds two
patents, has written several articles
for scientific publications,
conducted over 250 seminars and
has published several books.
To get exclusive info for readers
of The 90 Day Knee Arthritis
Remedy, click here to sign up on
the email list.

Coaching Services
You may be a good candidate for
coaching services if:

You want to apply the

principles and approach
 outlined in this book,

AND

You have questions

pertaining to your
particular situation about
how to implement these
recommendations.
You want to eliminate the
guesswork of getting
better.
You want assurance that
your improvement occurs
as efficiently as possible.
You are looking for a
 customized, step-by-step
plan.
You’ve consulted other
professionals and tried
multiple ways of
improving your knee(s),
and you don’t want to
waste any more time.

If one or more of the above

statements are true for you, contact
my colleague Laurie Kertz Kelly for
a free 20 minute Strategy Session.
To learn more about Laurie, visit
her website by clicking here or
visiting www.kertzcoaching.com.
SPREAD THE
WORD

First of all, thank you for

purchasing The 90 Day Knee
Arthritis Remedy. I know you
could have picked any number of
books to read, but you picked this
book and for that I am most grateful.
If you enjoyed this book and found
some benefit from reading it, I’d
like to hear from you and hope that
you could take some time to post a
review on Amazon. Your feedback
and support will help me improve
my writing on future projects and
make this book even better.
Your review will also help others
who may be searching for help with
hip OA.
You can follow this link by clicking
or tapping here now.
I want you, the reader, to know that
your review is very important and
so, if you’d like to leave a review,
all you have to do is click here and
away you go. I wish you all the best
in your future success!
 NOTES

8. Most Common Painful

Conditions of the Knee

1 Manninen, P., Riihimaki, H.,

Heliovaara, M., & Makela, P. (1996).
Overweight, gender and knee
osteoarthritis. Int J Obes Relat Metab
Disord, 20(6), 595-597.
2 Khan KM, Cook JL, Kannus P, et al.
Time to abandon the “tendinitis” myth:
Painful, overuse tendon conditions
have a non-inflammatory pathology
[editorial] BMJ. [Accessed 16
September 2011].Published March 16,
2002. [Ref list]
3 Fukashiro, S., Komi, P. V., Jarvinen,
M., & Miyashita, M. (1995). In vivo
Achilles tendon loading during jumping
in humans. Eur J Appl Physiol Occup
Physiol, 71(5), 453-458.

9. A Primer on the Knee Joint

1 Bell, C. J., E. Ingham, et al. (2006).

"Influence of hyaluronic acid on the
time-dependent friction response of
articular cartilage under different
conditions." Proc Inst Mech Eng H
220(1): 23-31.
 10. A Primer on Articular
Cartilage

1 Sophia Fox, A. J., Bedi, A., &

Rodeo, S. A. (2009). The Basic
Science of Articular Cartilage:
Structure, Composition, and Function.
Sports Health, 1(6), 461–468. http://
doi.org/10.1177/1941738109350438

11. A Primer on Tendon

1 Benedict, J. V., Walker, L. B., &

Harris, E. H. (1968). Stress-strain
characteristics and tensile strength of
unembalmed human tendon. J
Biomech, 1(1), 53-63.
2 Komi PV, Salonen M, Jarvinen M,
Kokko O. In vivo registration of
Achilles tendon forces in man. I.
Methodological development. Int J
Sports Med. 1987;8 Suppl 1:3-8.
3 Komi PV. Relevance of in vivo force
measurements to human biomechanics.
J Biomech. 1990;23 Suppl 1:23-34.
4 James SL, Bates BT, Osternig LR.
Injuries to runners. Am J Sports Med.
1978; 6:40-50.
5 Benjamin M, Ralphs J. Functional
and developmental anatomy of tendons
and ligaments. In: Gordon SL, Blair SJ,
Fine LJ, editors. Repetitive motion
disorders of the upper extremity. 1995
6 Williams JG. Achilles tendon lesions
in sport. Sports Med. 1986;3:114-35.
 12. The Suspension System

1 Boling, M. C., Padua, D. A., &

Alexander Creighton, R. (2009).
Concentric and eccentric torque of the
hip musculature in individuals with and
without patellofemoral pain. J Athl
Train, 44(1), 7-13.

13. Biomechanics and Knee Pain

1 O'Donnell P, Johnstone C, Watson

M, McNally E, Ostlere S. Evaluation
of patellar tracking in symptomatic and
asymptomatic individuals by magnetic
resonance imaging. Skeletal Radiol.
2005 Mar;34(3):130-5.
2 Näslund J, Näslund UB, Odenbring
S, Lundeberg T. Comparison of
symptoms and clinical findings in
subgroups of individuals with
patellofemoral pain. Physiotherapy
Theory and Practice. 2006
Jun;22(3):105–18. PubMed
#16848349.

21. Common Treatments for Knee

Pain

1 Deal CL, Schnitzer TJ, Lipstein E,

Seibold JR, Stevens RM, Levy MD,
Albert D, Renold F. “Treatment of
arthritis with topical capsaicin: a
double-blind trial.” Clin Ther. 1991
May-Jun;13(3):383-95. PubMed
PMID: 1954640.
2 Kuptniratsaikul V, Thanakhumtorn S,
Chinswangwatanakul P,
Wattanamongkonsil L, Thamlikitkul V.
“Efficacy and safety of Curcuma
domestica extracts in patients with knee
osteoarthritis.” J Altern Complement
Med. 2009 Aug;15(8):891-7. doi:
10.1089/acm.2008.0186. PubMed
PMID: 19678780.
3 Grube, B., J. Grunwald, et al.
(2007). "Efficacy of a comfrey root
(Symphyti offic. radix) extract ointment
in the treatment of patients with painful
osteoarthritis of the knee: results of a
doubleblind, randomized, bicenter,
placebo-controlled trial."
Phytomedicine 14(1): 2-10.
4 Nieman, D. C., D. A. Henson, et al.
(2006). "Ibuprofen use, endotoxemia,
inflammation, and plasma cytokines
during ultramarathon competition."
Brain Behav Immun 20(6): 578-84.
5 Almekinders, L. An in vitro
investigation into the effects of
repetitive motion and nonsteroidal anti-
inflammatory medication on human
tendon fibroblasts. American Journal of
Sports Medicine. 1995; 23:119-123
6 Sheetal R. Inamdar et al. The Secret
Life of Collagen: Temporal Changes in
Nanoscale Fibrillar Pre-Strain and
Molecular Organization during
Physiological Loading of Cartilage,
ACS Nano (2017)
7 Bello AE, Oesser S. Collagen
hydrolysate for the treatment of
osteoarthritis and other joint disorders:
a review of the literature. Curr Med
Res Opin. 2006 Nov;22(11):2221-32.
8 Bruyère O, Zegels B, Leonori L,
Rabenda V, Janssen A, Bourges C,
Reginster JY. Effect of collagen
hydrolysate in articular pain: a 6-month
randomized, double-blind, placebo
controlled study. Complement Ther
Med. 2012 Jun;20(3):124-30.
9 Tamer, T. M. (2013). Hyaluronan
and synovial joint: function, distribution
and healing. Interdiscip Toxicol, 6(3),
111-125. doi:10.2478/intox-2013-0019
10 Kalman, D. S., Heimer, M.,
Valdeon, A., Schwartz, H., & Sheldon,
E. (2008). Effect of a natural extract of
chicken combs with a high content of
hyaluronic acid (Hyal-Joint) on pain
relief and quality of life in subjects with
knee osteoarthritis: a pilot randomized
double-blind placebo-controlled trial.
Nutr J, 7, 3.
11 Yoshimura, M., Aoba, Y., Watari,
T., Momomura, R., Watanabe, K.,
Tomonaga, A., . . . Nagaoka, I. (2012).
Evaluation of the effect of a chicken
comb extract-containing supplement on
cartilage and bone metabolism in
athletes. Exp Ther Med, 4(4), 577-580.
doi:10.3892/etm.2012.646

22. The Myth of Stretching

1 Shrier I. Stretching before exercise:

an evidence based approach. British
Journal of Sports Medicine.
2000;34(5):324-325.
doi:10.1136/bjsm.34.5.324.
2 Thacker SB, Gilchrist J, Stroup DF,
Kimsey CD Jr. The impact of
stretching on sports injury risk: a
systematic review of the literature.
Med Sci Sports Exerc. 2004
Mar;36(3):371-8. Review. PubMed
PMID: 15076777.
3 Shrier I. Stretching before exercise
does not reduce the risk of local muscle
injury: a critical review of the clinical
and basic science literature. Clin J
Sport Med. 1999 Oct;9(4):221-7.
Review. PubMed PMID: 10593217.
4 Hart L. Effect of stretching on sport
injury risk: a review. Clin J Sport Med.
2005 Mar;15(2):113. PubMed PMID:
15782063
5 Herman K, Barton C, Malliaras P,
Morrissey D. The effectiveness of
neuromuscular warm-up strategies, that
require no additional equipment, for
preventing lower limb injuries during
sports participation: a systematic
review. BMC Med. 2012 Jul 19;10:75.
doi: 10.1186/1741-7015-10-75.
Review. PubMed PMID: 22812375;
PubMed Central PMCID:
PMC3408383.

23. Common Exercises Used for

Knee Pain
1 Roos, E. M. and L. Dahlberg
(2005). "Positive effects of moderate
exercise on glycosaminoglycan content
in knee cartilage: a four-month,
randomized, controlled trial in patients
at risk of osteoarthritis." Arthritis
Rheum 52(11): 3507-14.

25. How to Improve Joint Health

Without Exercise

1 Messier SP, Gutekunst DJ, Davis C,

DeVita P. Weight loss reduces knee-
joint loads in overweight and obese
older adults with knee osteoarthritis.
Arthritis Rheum. 2005 Jul;52(7):2026-
32.
2 Levine, J. A., Vander Weg, M. W.,
Hill, J. O., & Klesges, R. C. (2006).
Non-Exercise Activity Thermogenesis.
The Crouching Tiger Hidden Dragon
of Societal Weight Gain, 26(4), 729-
736.
3 Baraona, E., & Lieber, C. S. (1979).
Effects of ethanol on lipid metabolism.
J Lipid Res, 20(3), 289-315.
4 Veronese, N., Koyanagi, A., Stubbs,
B., Cooper, C., Guglielmi, G., Rizzoli,
R., . . . Maggi, S. (2018).
Mediterranean diet and knee
osteoarthritis outcomes: A longitudinal
cohort study. Clin Nutr.
doi:10.1016/j.clnu.2018.11.032

26. When a Good Knee Goes Bad

1 Spencer, J. D., Hayes, K. C., &
Alexander, I. J. (1984). Knee joint
effusion and quadriceps reflex
inhibition in man. Arch Phys Med
Rehabil, 65(4), 171-177.

30. A Primer on Strength

1 Becker, R., A. Berth, et al. (2004).

"Neuromuscular quadriceps
dysfunction prior to osteoarthritis of
the knee." J Orthop Res 22(4): 768-73.
2 de Morree H.M., Marcora S.M.
(2010) “The face of effort: Frowning
muscle activity reflects effort during a
physical task.” Biological Psychology
85, 377-382
31. A New Kind of Cross Training

1 Webster’s Dictionary
2 Carroll TJ, Herbert RD, Munn J,
Lee M, Gandevia SC. “Contralateral
effects of unilateral strength training:
evidence and possible mechanisms.” J
Appl Physiol 1985). 2006
Nov;101(5):1514-22. Review. PubMed
PMID: 17043329.
3 Latella C, Kidgell DJ, Pearce AJ.
“Reduction in corticospinal inhibition in
the trained and untrained limb
following unilateral leg strength
training.” Eur J Appl Physiol. 2012
Aug;112(8):3097-107. doi:
10.1007/s00421-011-2289-1. Epub
2011 Dec 27. PubMed PMID:
22200796.

32. Core Strength

1 Dello Iacono, A., Padulo, J., &

Ayalon, M.(2016). Core stability
training on lower limb balance strength.
J Sports Sci, 34(7), 671-678.
doi:10.1080/02640414.2015.1068437
2 Niemuth, P. E., R. J. Johnson, et al.
(2005). "Hip muscle weakness and
overuse injuries in recreational
runners." Clin J Sport Med 15(1): 14-
21.

36. Strengthening Quadriceps

1 Peeler, J. and J. E. Anderson (2007).
"Structural parameters of the vastus
medialis muscle and its relationship to
patellofemoral joint deterioration." Clin
Anat 20(3): 307-14.
2 Miyaguchi, M., Kobayashi, A.,
Kadoya, Y., Ohashi, H., Yamano, Y.,
& Takaoka, K. (2003). Biochemical
change in joint fluid after isometric
quadriceps exercise for patients with
osteoarthritis of the knee.
Osteoarthritis Cartilage, 11(4), 252-
259.

37. Joint Strengthening Laws

1 Zhang, S. L., Liu, H. Q., Xu, X. Z.,

Zhi, J., Geng, J. J., & Chen, J. (2013).
Effects of exercise therapy on knee
joint function and synovial fluid
cytokine levels in patients with knee
osteoarthritis. Mol Med Rep, 7(1),
183-186. doi:10.3892/mmr.2012.1168