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Prior to working with me, my client Brad* had tried several approaches to eliminate his knee pain. He had seen multiple orthopedic surgeons, physical therapists, a chiropractor, and a rolfer. He had imaging studies (including X-rays taken two years apart), stretched his hamstrings daily, strengthened his hips, and used a foam roll consistently. He completed a series of Pulsed Electromagnetic Field treatments and multiple whole body cryotherapy sessions. He was taking ibuprofen and Meloxicam before and after each sand volleyball match. And he had been receiving gel injections every 6 months.
What Are Gel Injections?
Gel injections involve inserting hyaluronan or hyaluronic acid into the knee joint through a needle. The purpose of this substance is to cushion and lubricate the knee joint-- specifically the cartilage covering the ends of the bones inside the knee.
While it doesn’t work for everyone, some people get temporary or partial knee pain relief for a few months or sometimes up to a year. Brad reported that his knees felt 20 - 50% better for 2 - 4 months following each injection.
The purpose of gel injections is to increase the viscosity, or the thickness, of the fluid within the knee joint. Healthy joint fluid is thick (like the consistency of egg whites), and it protects the surfaces of the bones inside the knee-- the end of the thigh bone (femur), the back of the knee cap (patella), and the top of the shin bone (tibia). These bony surfaces are all covered by a layer of cartilage, and healthy joint fluid acts like a lubricant and a shock absorber for this cartilage.
But when cartilage gets weaker-- which happens with chondromalacia or osteoarthritis-- microscopic pieces of cartilage inside the knee shear off during activities and exercise. These microscopic bits of cartilage float around inside the knee joint-- eventually contacting and irritating the lining of the knee. (This lining is known as the synovial membrane.) An irritation to the lining of the knee causes thinner, more watery fluid to be produced.
How to Improve the Effectiveness of Gel Injections
The recommendations immediately after gel injections usually include avoiding “hard weight-bearing activity” for a certain period of time and gradually resuming “normal activities.” These recommendations are pretty vague, so it is difficult for most people to follow them.
What constitutes a hard weight-bearing activity will vary based on a person’s fitness level and the severity of the arthritis or chondromalacia.
Moreover, normal activities for one person may be hiking and household chores, but for another person, normal activities may include running and weight lifting. All of these normal activities stress the knee in different amounts, so someone who gets gel injections should not return to all of these activities at the same time. It may take a few weeks to return to light housework and more than three months to start running again.
The more challenging the normal activity is, the more time and preparatory exercises that will be required before returning to that particular activity without resulting in knee pain.
Based on my experience working with hundreds of clients with persistent knee pain, I believe what determines whether gel injections help or not is related to performing the right type and amount of activity and exercises after the injections.
I use a two-fold process to help clients figure out what activities and exercises are best for them.
Part one determines specifically how much activity the knee joint can tolerate without causing the pain and thinner fluid to come back. Once clients know what this level is, they temporarily avoid the activities that overload or hurt their knees.
Temporarily avoiding certain activities following gel injections is important, but so is performing the right types and amounts of exercise.
Part two involves prescribing the correct dosage-- the type and amount-- of exercise for the knee. This eliminates the guesswork of how to resume normal activities. (To learn about the four traits that most of my successful clients possess, watch this video.)
An alternative to Gel Injections
But many of my clients never get gel injections. Some of them are not good candidates. Others are not a fan of needles. In all of these cases, there is another option.
By contracting the muscles on the front of the thigh, the thickness of the fluid inside the knee increases [source]. The safe and simple way to do this is by performing an exercise known as a Quad Set. It needs to feel good or neutral, and it needs to be done frequently throughout the day. (For details about how to optimally perform Quad Sets-- and why they work -- watch The Ultimate Guide to Quad Sets.)
Brad’s Solution to Knee Pain
In addition to the gel injections that he was getting every six months, Brad began to complete Quad Sets several times each day. While he was sitting at his desk at work and in the evenings when he was at home, he performed gentle knee motion.
After some initial resistance, Brad stopped running, jumping, and playing volleyball for several months-- activities that were overloading and hurting his knees.
Brad also bought a variable incline plane, making it possible for him to perform the squatting exercises that I prescribed. My exercise prescription for Brad changed as his Squat Load Tolerance improved. (To see how I measure Squat Load Tolerance, watch this video.)
After several months of working together, and as the spring season approached, Brad informed me that he needed to play volleyball again. I knew his knee joints (the cartilage inside his knees) weren’t as strong and resilient as they needed to be to endure the forces of volleyball without any symptoms, and I shared this insight with him.
He took ibuprofen and Meloxicam before and after playing three volleyball games. Not surprisingly, he had pain afterwards. But unlike before, his pain resolved by the next morning. Brad was pleased with the improvement, stating "I'm convinced my cartilage is healthier now."
We continued to work together, and he took another break from volleyball. When he returned to playing that summer, the ibuprofen he took was for his back (related to a previous lumbar disc herniation) and not for his knees.
A year later, Brad emailed me, “Just want to let you know the tournament went well! Had a great time. 4 and 2 overall. Lost in playoffs… I played the best I've played in a long time... I was able to get lower than usual on passing and setting… I'm very happy!”
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