Everything you need to know about TRAINING CLIENTS WITH BAD KNEES

With a little planning, servicing and maintenance you can help clients with 'bad' knees get back on the road to fitness, says Anna-Louise Bouvier.

It's frustrating having bad knees, especially arthritic knees. Knee osteoarthritis is now one of the leading causes of pain and disability in the adult population worldwide, and the prevalence is increasing largely due to the growing proportion of overweight and elderly people. As fitness professionals who have the opportunity to be at the forefront of tackling the obesity epidemic, it is also very important to understand that many of your clients are at high risk of injury and aggravation. If they hurt themselves every time they try to exercise, they will become increasingly frustrated and despondent.

By understanding some of the key issues in relation to arthritic knees you can customise programs, which will allow you to help your clients find ways to keep fit and strong without aggravating their knees. Research shows that muscle strength around the pelvis and in the legs provides support and control to the knee joint and can subsequently lead to less pain. This muscle control also provides a solid foundation on which to start building a level of fitness, which will give your clients more resilience and stamina for all the physical things they want to do in their lives.

Classic cars and classic bodies

Imagine the deconditioned bodies of your older and more overweight clients are like lovely old classic cars that they would like to recondition. Those cars probably have quite a few creaks and clunks – but they also have potential. The last thing you would do is take that car out on the road and put the pedal to the metal. Yet, even with their creaky crunchy knees, that is the way many people approach exercise. They wake up one day and think, 'I need to lose weight so I am going to get fit. They spend the next week walking very fast, huffing and puffing up hills and stairs. Just when they think they might be getting somewhere, their knees start playing up. Every time they exercise the pain gets worse and within a few weeks they have to stop, feeling dejected and depressed. It doesn't have to be this way. With a little planning, servicing, maintenance and patience you can gradually help those pre-loved bodies get back on the road!

The 5 Ws of exercising and arthritic knees

THE PROBLEM: Being overweight creates a vicious cycle. When a person is overweight it is harder to move around and the extra body load means more stress is placed on the knees, which potentially leads to more pain when they attempt exercise. Research has found that from the age of 30, every 5kg a person is over their recommended BMI (body mass index) equates to a 36 per cent increased risk of osteoarthritis. Unfortunately, the more a person's knees are playing up, the harder it is to find forms of exercise that allow them to increase their metabolism.

WHAT YOU CAN DO: If when you first screen your client you find they have bad knees, recommend they see their local physiotherapist and possibly consider a regular grease and oil in the form of some gentle massage or acupuncture. Call the physio or even go in with your client. It's a great way to build connections with local health professionals. They will know you genuinely care about exercising your clients safely and can also give you some specific strategic knee exercises you can help supervise with your client. It also means that the next time they have a client with bad knees, you will be front of mind as a great, safe, exercise professional to refer their client to.
Walking is a great starting point for exercise, but many people with bad knees will struggle to complete even a short walk. You may need to think about ways to take gravity out of the equation – using an exercise bike, for example. You will need to try various seat heights to establish which is best for taking the load off each individual client's knees. Most will prefer slightly higher and back from the handlebar. If even a stationary bike is too aggravating, try some upper body work with the client in sitting, and then some abdominal work in lying. Then recommend a hydrotherapy class or a very gentle aqua class to give them some aerobic conditioning. Research has also shown tai chi exercises to be a good starting point, as they allow you to work on your knee control as you gently bend and straighten without too much speed or load.

Osteoarthritic knees need strengthening, but traditional squats and lunges can be very aggravating. A good starting point is very gentle isometric work such as a simple high wall squat. This provides support and allows the client to build strength without pain. Instruct them to position their back against the wall and then slide up and down, keeping the back against the wall in a squat position until they find the 'sweet spot', i.e. the point where they have no knee pain. Start with a simple 10-second hold at this point and then come up and repeat the isometric three times. If that doesn't stir them up, you can gradually lengthen the hold over a few weeks and then build up to performing squats without the support of the wall.

Wheel alignment
THE PROBLEM: The kneecap is designed to slide in that beautiful groove in the knee joint created by the angle between the femur and the tibia. Things like hip tightness, weakness in the buttock muscles, falling arches in the feet and tight calf muscles can all contribute to changing the alignment of these bones and in turn affect the tracking of the kneecap in its groove. Just as poor wheel alignment in a car can create a rub on your tyres, poor bone alignment in the lower limb can create a rub on the bones, cartilage and ligaments of the knee.

WHAT YOU CAN DO: Have a good look at your client's leg alignment when you first assess them. Women with very wide hips are particularly prone to knee arthritis. New research is showing that the deep buttock muscles of the hip play a critical role in taking the load off the knee and are often weak in people with osteoarthritis. Patients are often amazed how much relief they can achieve by learning to activate these muscles efficiently. If you think they may have some specific muscle imbalance, get them to the physio who will give them some targeted exercises for these small weak muscles, some simple relieving stretches and potentially some advice on taping the knee to ease pain and improve kneecap tracking. They may also suggest they go to a podiatrist to have their feet assessed and aligned, which can also help to take the load off the knees.

THE PROBLEM: Worrying is an understandable part of having pain. People worry about having pain, about making it worse and about what will happen in the future. Research has shown that the less people with osteoarthritic knees knew about their condition, the more fearful they felt and the more pain they reported.

WHAT YOU CAN DO: Education is vital. The more a person can learn about their condition and how to manage it, the more confident they are likely to feel about their future. Things like understanding that a certain level of discomfort may be OK in certain exercise situations, and that some pain is 'good pain' – for example, a post-exercise ache versus 'bad pain' which is sharp and intense – are important. The Arthritis Australia website (www.arthritisaustralia.com.au) is an ideal starting point for up-to-date and accurate information. You may also suggest they join a support group and spend time talking to people with similar issues. You may even consider getting a group of clients with similar problems to exercise together.

Wonky posture
THE PROBLEM: Posture is one of the simplest things you can change to immediately take the load off your joints. While aerobic and strengthening exercises are important, postural exercise habits are also vital. Clients who stand slumped with all their weight on the one leg, and hang on one hip are very common. While it may seem comfortable in the short term, in the long term it loads up the hip and knee joints and switches off the deep buttock muscles which can really aggravate the hip and knee joints in that leg. Similarly, always leaning on things like benches, chairs and walls when standing also switches off the core and weakens the vital postural muscles that can help create support and stability for the lower limb.

WHAT YOU CAN DO: Teach them to start changing their everyday habits. As a 24/7 trainer, you can teach them to change their brain to change their pain. Teach them that when their knee aches they should check whether they are standing evenly on both feet and not leaning on anything. Make them aware of how to balance their weight evenly between the front and back of both feet to distribute the load. The simple reminder cue I use is 'Two legs!' A great tip for straightening people up is to get them to imagine they have a light shining out of their chest around their breastbone. Gently lift that light so it is shining directly forward (not up to the ceiling). This will also immediately activate their core muscles and make them feel stronger, straighter and more stable. Keep repeating 'Two legs' and 'Shine your light' to drill the habit into their brain.


1. Osteras N et al; Commentary on Telephone-Based patient self management program might be effective in reducing osteoarthritis-related pain . Journal of Physiotherapy 2011 Vol 57 125
2. March LM and Bagga H, 2004, Epidemiology of Osteoarthritis in Australia, Medical Journal of Australia, vol 180 (5 suppl) pp.S6-S10 www.mja.com.au/public/issues/180_05_010304/marl10381_fm.html
4. Ezzo, J, Hadhazy, V, Birch, S, Lao, L., Kaplan, G, Hochberg, M and Berman, B; 2001, Acupuncture for osteoarthritis of the knee: A systematic review. Arthritis & Rheumatism, 44: 819–825. doi: 10.1002/1529-0131(200104)44:4<819::AID-ANR138>3.0.CO;2-P
5. Grimaldi, A; Assessing Lateral Stability of the Hip and Pelvis Manual Therapy 16 (2011) 26-32 doi:10.1016/j.math.2010.08.005
6. Somers et al; Journal of Pain and Symptom Management Vol 37 5, 863-872 May 2009
7. Bouvier, A; The Feel Good Body Harper Collins 2010 available www.dymocks.com.au or www.annalouisebouvier.com.au Everyday Basics for a Better Back www.physiocise.com.au
8. McAlindon T et al; Changes in Barometric Pressure and Ambient Temperature Influence Osteoarthritic Pain. American Journal of Medicine, 120:429-434, 2007

For more information on simple steps to change your posture and take the load off your joints, read The Feel Good Body or the new DVD Everyday Basics for a Better Back

THE PROBLEM: Last but not least, any person with severe arthritic knees will be able to tell you when a change in the weather is on the way! The research is still not definitive but it appears that both lower temperatures and rising barometric pressure seem to be associated with an increase in reports of pain.

WHAT YOU CAN DO: If a client knows that cold weather affects their knees, suggest that they think about simple things like keeping the knees warm, especially prior to exercise. Some elasticised support braces (like Thermoskins) have thermal qualities which can be very soothing. Similarly, heat and wheat packs can also provide some good short term relief in cold weather. The most important thing is to keep moving when it's cold. Cold stiff joints are more likely to be painful, so gently moving them to keep heat and circulation flowing is vitally important. If your client's head is telling them to stay inside and sit still, it's your job to keep them gently moving and improving their strength. Even just advising them to do simple knee extensions when they are sitting at home can be enough to keep the joint moving and the synovial fluid circulating.

Anna-Louise Bouvier, BAppSc (Phys)
Anna-Louise is a physiotherapist, former Australian Fitness Presenter of the Year and the executive director of Physiocise, an innovative program of exercise and education classes for bad backs and wobbly bodies. She regularly appears on ABC radio and The Today Show and was an expert in the ABC documentary Making Australia Happy. Anna-Louise is author of The Feel Good Body (Harper Collins) and recently released her DVD Everyday Basics for a Better Back.