I cringe every time I hear someone say: “I can’t ___ because of my knees.” Knees are vulnerable by design, knees are precious, but too often people give up being vigorous without a proper fight because of knee issues. And inactivity often dooms one to more function loss down the road, especially with your idle knees.

I’ve struggled to maintain a respectful balance with my knees for 40 years. Happily, I can now say that my knees are the best they’ve ever been in my adult life and I am using them hard. I’m very intentional about positioning them in knee-unfriendly situations but there are few activities that I don’t do at all because of my knees. 

In my mind, “finessing” is the winning strategy. When it comes to knees, giving up and not doing tends to backfire as does “pressing on regardless” and ignoring their complaints.

So, if no one has been able to fix your knees for you, it is time to figure out how you can make them the best that they can be. We call that switching to “Project Mode.” That means making solving the problem a top priority. Usually the ‘fix’ first requires gaining a deeper understanding of the problem and then being disciplined and committed to doing whatever it takes to improve it. So far, switching into Project Mode always delivers results for us. 

Shed the Weight
Lightening the load is a gift to your entire body and your joints are no exception. You have probably felt the head-to-toe strain from carrying a heavy bag of groceries or a heavy piece of luggage and extra fat is no different. Maintaining normal weight will reduce the wear and tear on your knees with every step and reward your diligence with fewer bio-mechanical issues for years to come.

Ditch the High Heels
High heels put undue strain on the medial (inner) side of your knees and increase the odds of developing osteoarthritis in the joints. High heels are fun and flashy but are losers for your knees. Like with many choices, not running with the herd in high heels will literally keep you running years longer. 

And among the purists, even the usual heel elevation seen on running shoes or trainers is enough to degrade the biomechanics of your feet and what goes on in your feet affects your knees. It’s a trade-off between how you look in the present and how your knees will perform and feel in the future.  

If you’ve spent a lot of time in high heels (or cowboy boots), your calf muscles may have become overly short. Begin a calf stretching program right away to lengthen both calf muscles in each leg to prevent injury to them, or your feet, as you spend more time closer to the earth on your own heels. Be sure to do both bent knee and straight leg calf stretches because a bent knee stretches one muscle (the soleus) and a straight knee is required to stretch the other (the gastrocnemius). 

Icing is the safest way to reduce joint inflammation and you may want to start your icing program immediately if your knees are swollen or uncomfortable. 

I’ve used screw-top ice bags filled with ice cubes, retail-grade gel packs, and professional grade gel packs. We have found the professional grade gel packs to be far superior to the alternatives. They are quick and easy to apply, cover a large area with a serious chill, and aren’t messy.

We keep 2-3 hefty gel packs in the freezer at all times and use 4” wide elastic exercise bands to lash them on the knee and adjacent muscles. Wrapping them firmly ensures full contact (unlike with the often-mentioned bag of frozen peas) and makes it easy to stand and putter while icing, which improves compliance. 

We love our polyurethane ColPaC Cold Therapy reusable gel packs from Chattanooga. Available from Amazon.
Ice for 10-20 minutes and no more often than every 2 hours. And of course, discontinue icing if the area starts feeling numb. Icing triggers vasoconstriction (narrowing of the blood vessels) and if you ice too long, the body will flip a switch to vasodilate to protect the tissues from freezing. Best to remove the ice before blood flow increases to the area.  Do let your muscles warm-up before doing anything demanding with your knees after icing.

The worst side effect I’ve experienced from icing is a bit of frost nip from gel packs being too cold. That resulted in superficial skin damage like a mild burn. If a gel pack seems dangerously cold, I now cover my skin with a thin piece of cloth before applying the cold pack.

Icing is also an effective way to help ailing muscles, whether it’s a spasm, soreness from overuse, or ongoing stiffness. The more superficial the involved muscles are, the more effective the icing will be. 

NSAIDs (non-steroidal anti-inflammatory drugs) are highly recommended to combat joint inflammation, which usually accompanies knee pain. I however, no longer use them at all. I took aspirin for decades to reduce knee swelling and I am concerned that that practice permanently damaged my kidneys. 

A few years ago I took the recommended high doses of ibuprofen for a knee injury, which seems to have triggered irreversible tinnitus (ringing in the ears). Now I go against the standard recommendation of using NSAIDs for inflammation and never take them.

Braces & Surgery 
I don’t use knee braces because most designs put pressure on the kneecap, which compounds my problems. I’m sure that they are helpful for some conditions but definitely not mine.

I have no direct experience with knee surgery so cannot comment. But from observing others who have had surgical repairs, my best advise is to be fastidious about performing your physical therapy and following the post-op icing instructions. Among the handful of people I’ve been close to who have had knee surgery or replacements, the best long term outcomes have been awarded to those who highly complied with their rehab program.

Bulk-Up Your Quads
The Theory
The first real game-changer piece of advice that I received regarding my swollen knees came from an orthopedist about 30 years ago. Like is so often the case, the solution to my challenging problem was simple in theory: bulk up my quads (quadriceps, the 4 massive muscles of the front thigh). 

Keeping the quads big and strong is a good starting point for many knee problems—perhaps even if you don’t really know what is amiss. Beefy muscles help stabilize the knee joint if the inelastic ligaments can’t do the job any more. 

And in my case, bulky quad muscles lifted the knee caps slightly, giving more clearance inside the joints. That additional clearance helped with the irritation created by the roughness under my knee caps and with the rubbing on the outside edges of the joints from my “lateral compression of the patella” or tilted knee caps.

I recently heard a corroborating story about beefy quads, ones that were in an older ski patrol guy who sought medical care for knee pain. Looking at his x-rays, the doctor told him that basically he no longer had any functioning knee joints though they now could give him a pair surgically. His over-developed muscles had been doing the job of the knee joints for years and he didn’t even know it. 

First Attempt: Ankle Weights
My orthopedist recommended leg raises with ankle weights for resistance training to bulk up my quads, which I found pitifully inadequate. In hindsight, a better strategy would have been working with a trainer to develop a gradual, but intense, quad strengthening program.

For me, it took running 20 miles/week to sufficiently bulk my quads to get pain relief. I iced my knees multiple times a day (and took aspirin) to counter the swelling caused by the running while I gradually increased my distance. Once I hit the 20 miles/week mark, I no longer had to ice them as often because I finally had the clearance in the joints that I needed.

Not only did I need to bulk up my quads--but I had to keep them that way—permanently. Pain is a good motivator and if 3 days pass without me doing quad-bulking activities, my knees are at risk of hurting again. That was the bad news but the good news is that the threat of knee pain has kept me highly motivated to maintain a vigorous conditioning program for 30 years.

I eventually switched from running to cycling to keep my quads buff. The pounding of running is hard on knees, which is eliminated with cycling, but cycling can also be stressful to knees for those of us with serious bio-mechanical misalignments. 

I can only cycle if I use lubricated Speedplay Frog cleats with 26 degrees of “float,” or rotation. That rotation of the cleats allows my heels to pivot side to side in response to where my knees have gone rather than force my knees to track a straight line when pedaling. Being forced into a fixed position when pedaling is very irritating to my knee joints.

Maintaining high cadence—high RPMs—was also critical for making cycling a knee-friendly sport for me. The faster you pedal, the less force that goes through the knee joint with each revolution, and the less accumulated strain on the joint.  Some bike computers will register your RPMs to help you learn just how fast you must pedal. It took several years of experimenting to get the gear and technic right so I could ride hard enough to keep my quads big without knee pain. 

Saddle (seat) height is often mentioned as an important detail for reducing knee pain when pedaling. I never found micro-managing saddle height to make any difference for me—close is good enough for my knees.

Hiking Hills
Hiking uphill is another great way to strengthen your quads though most people don’t have the time or access to venues to rely on hiking for their entire quad bulking program. We currently mix cycling, running, and hiking, which makes staying fit more interesting and varies the stresses on my knees while keeping my quad muscles well developed.

Climbing stairs also works well to develop and maintain quad strength. Increased security measures have however limited access to the long staircases in most buildings. I use them when I can, especially when traveling. And I do keep a hand over the railing because it’s easy to lose my focus after a few laps in a stairwell.

I’ve heard “Don’t ever do squats!” more than once from health care professionals and I disagree. I always take “Don’t ever do ____” with a grain of salt. “Why not? For how long? And what about modifications?" are my immediate reactions. “Don’t ever” has its place in life but I believe it is often a convenient oversimplification when it comes to  knees that is, at best, valid in the short term but potentially disastrous in the long term.

Yes, squatting puts strain on the knees but a healthy knee should be able to take it. The trick is to get your knees well enough to do squats again, not eliminate them from your movement patterns forever. 

You are doing partial squats every time you get up and down from a chair or toilet. You need to be able to squat to live robustly in the world. And not squatting decreases the range of motion you use in your ankles, setting you up for even more problems.

I’ve been forced to temporarily eliminate squatting with several knee injuries but I always come back to them. Squats are one of the indicators I use to measure the completeness of my latest recovery. 

After 1 recent knee injury, I discovered that it was the first squat, or a single squat, that was most difficult. I suspected that some helpful patterning that signaled which muscles needed to release and which needed to apply power had gotten confused during the long recovery. So, rather than resume doing my usual 25 squats at a time, I shifted to doing a single squat several times during the day to restore the needed signaling. It didn’t take long to regain the proper patterning so I could squat with ease.

I’ve also found squatting to be a great counterpose to long distance cycling. The knee bends thousands of times in a narrow range of motion when pedaling and full squats remind the muscles that they have other jobs to do, other places that they can go.

Of course, you need to squat properly, with your knees tracking over your toes and not dropping inwards as is the tendency. Squatting in front of a full length mirror or engaging an observer is very helpful in checking your technic. 

Take it very, very easy if you’ve lost some of your ability to squat. Start by only doing a couple squats a few times a week in your comfortable range and then slowly increase the depth and repetitions from there. And consider holding on to a heavy piece of furniture while squatting to transfer a little bit of the load from your knees into your upper body.

Other Strength Work
Hamstrings Too
Regardless of how you pursue quad bulking, be sure to balance that new strength with strength in the opposing muscles, the hamstrings (back thigh muscles). Ask for help at a gym to assess the balance between your quad and hamstring strength if you aren’t familiar with the needed equipment. 

You’ll be determining the maximum weight you can lift with your quads on a leg press machine and your maximum lifting ability on a hamstring curl machine to calculate the needed ratio. You want to know the maximum weight you can press or lift in a single rep, not multiple reps. 

The number I’ve most recently heard is that your hamstrings should be able to lift 60-80% of what your quads can lift. You increase the risk of knee injury if the hamstrings are weak relative to the quads, which is often true in women independent of their level of fitness. We are currently doing what is known as a Nordic hamstring curl to keep our hamstrings strong—an exercise that requires a helper but not a machine. Here’s a link to a “how to & why” article:

Core Strength & Gluteal Amnesia
In the mid-2000’s, medical researchers started reporting that increasing core strength was generally more effective than focusing on the knee to solve knee problems. It was counter-intuitive but I was coached 25 years ago to always look to the joint above and below a problem area, which with a knee, would mean looking to the hips and ankles. The hip muscles are considered part of the core.

Even more recent research from running clients at a sports clinic revealed that  almost all of their knee problems could be improved or fixed by core strengthening, specifically in the hips. Strengthening the hip abductors (in the buttocks) was considered by some as THE best thing you could do for knees, with strengthening the hip external rotators next in line. Strengthening these 2 muscle groups would often reduce or eliminate low back pain as well. And one study suggested that decreased hip abductor strength was the single most profound strength difference between 20 and 80 year old women.

We discovered a few years ago that Bill had a significant case of “gluteal amnesia,” a term applied to glute (buttock) muscles that are slacking. We identified 4 exercises to strengthen his glutes and, amazingly, on a steep hike at the end of the first week of his new program, he took off like a rocket. He clearly had weakness but in addition, his glutes had forgotten when they should be working. Other muscles, like the hamstrings and piriformis, were doing the job of his glutes.

There are many articles and videos available online to guide you on core strengthening and more specifically, addressing gluteal amnesia.  Below is one link:

For me, this advanced medial quad stretch is #1 for my knees.
Strength work needs to be balanced with flexibility work to keep the muscles resilient. I believe that an overall stretching routine is helpful for the knees as well as a bit of targeted stretching. 

Stretching the quads, especially the medial (inner thigh) quads, the hamstrings, and calves is important for knee health. But the buttock muscles and other core muscles affect the biomechanics of the knees as well, so shouldn’t be neglected.

If you don’t have a history of self-guided stretching, you might find it easiest to join a yoga class or a stretching class to get started. There are multiple ways to stretch most any muscle group and the trick is to find a combination of stretches that suit you so you will perform the them on a regular basis.

Such simple tools, but so powerful for "re-rigging" my knees.
Professional Massage & Self Massage
I consider both receiving professional sports massage and performing self-massage as essential for my maximal knee health.

I think of knee joints as being like puppets: the movements and expressions of both are controlled by figurative or literal wires. My current knee pain is often the indirect or direct result of the adjacent muscles being tight or unbalanced relative to their opposing muscles. For me,  massage can re-rig my wires.

I seek sports massages rather than general relaxation massages to support my knees. Sharing my latest observation of “It hurts here” gets the masseuse to my current hot spots quickly. As he/she identifies the irritated tissue, I start asking questions like “Which muscle is it, what activities irritate it, what can I do to help it recover?” There is no substitute for an experienced professional in keeping my tissues healthy and reducing imbalances. But massages are expensive and I benefit from daily work, so that’s where the DIY comes in.

My knowledge of yoga and anatomy both help me craft my stretching and self massage programs but you can do a lot to help yourself with less knowledge. Ask your masseuse to write down the names of the key muscles that are giving you trouble and for suitable stretches and how to massage them yourself. Armed with the muscle names, search for articles and YouTube videos addressing stretching, massaging, or injury recovery for even more tips. There is a wealth of quality information available online.

Absolutely "sensational" if you need it: softball massage of the lower adductors.
A few years ago I discovered that closed-cell foam rollers were wonderful for a general massage of the thighs. And with daily, painful use, I was able to eradicate the chronic tightness in my ITBs, or iliotibial bands, that run along the outside of the thighs. I like to roll the length of my quads with as many passes as it takes to soften them, especially after a hard workout, to reduce tugging on my knees.

The newer Trigger Point rollers are firmer than the original closed-cell foam rollers and allow digging deeper to release troublesome knots. Either style of roller can be used locate a 'trigger point’ or painfully knotted bit of tissue. Apply as much steady pressure as you can bear to the spot by resting on the roller for 20 seconds, then move on. It will be painful and if you are lucky, you’ll feel the knot collapse or release under the pressure. Over days, or perhaps weeks, you’ll be lengthening the “wires” pulling on your knees and may discover a new ease in your knee movements.

I recently began using a softball to press deeper yet into the most troublesome muscles, gradually coaxing them to release. I especially like using a softball against my lower adductors, which are just above the knee on the inside of the thigh. The softball also works well on a small knot I get in the ITB of the outer thigh and the glute muscles in the buttocks. If the softball is too intense, resume using a foam roller until the tissues soften enough to go deeper.

"Roll, roll, roll" those quads & they will eventually soften.
Forefoot Striking

Switching from being a heel striker to a forefoot striker has been absolute magic for my knees. In the past, a 4000’ descent resulted in very swollen knees and painfully sore quads, but now such a downhill hike will hardly leave any residue in my body. I also attribute my current boney, non-swollen knees, to forefoot striking. All the other changes I made over the years helped my knees and allowed me to stay active to get to this point, but the results of the gait change have been monumental.

Forefoot striking is actually very difficult to do on flat terrain, where it becomes more of a flat-footed walk. It is on the uphills and downhills that the gait really is activated.

By forefoot striking, the force from your foot striking the ground is largely absorbed in the 30-some joints in each foot, beginning in the ball of the foot. With heel striking, the force is transmitted directly through the big heel bone into the knee and hip. One also shortens up their stride with forefooting, which keeps your center of gravity over you feet more than when heel striking, a shift which also subjects the knees to fewer torquing forces.

Switching to being a forefooter should be a drift, rather than an abrupt change. Some overworked muscles need to shrink a bit, others need to get bigger and stronger. Calf muscles need to lengthen because forefoot striking is best done in minimalist shoes with no lift at the back of the shoe. And to be most effective, the feet need to become more flexible and stronger. 

Using gravity & a softball to massage more deeply into the upper adductors.
To forefoot strike well, you need thin, flexible shoes with a wide toe box. Thin, flexible shoes allow the feet to come alive and to function more like bare feet. The wide toe box allows your toes to spread so that they can better do their stabilizing job. 

Weaning yourself out of boots and into trail shoes will also spare your knees. Rigidly bracing the ankle, which is designed to move in multiple planes, forces the knee to react to tipping and twisting when walking or running. The knee joint is only supposed to let the leg bones go forward and back in 1 plane. The leg bones need to swing like a pendulum at the knees, not swivel, like they can do at the hip and ankle. Best to keep the ankles free from boot support so that they can get strong and do their job of protecting the knee by processing extraneous motion at the source. 

Below are several pieces I’ve written since 2009 about barefooting, minimalist shoes and forefoot striking.  for 2011:  Fitness Focus: Forefooting Prep “Recent Side Trips” 
--Minimalist Footwear I
--Hiking Barefoot (how it began in 2009)

A Portland, OR podiatrist that advocates natural foot care, Ray McClanahan, has a website with great information about feet: He has many wonderful articles and videos that include the glories of minimalist shoes. I recommend his 12 minute introductory video in which he describes his professional transformation from using surgery and orthotics to correct foot and knee problems to using minimalist footwear and his toe spacers instead:

Zero heel lift is a winner for both your feet & your knees.
To Run Again
When we dabbled with barefoot hiking in late 2009 and then became minimalist shoe hikers, I began fantasizing about running again. We ran our single marathon back in ’89 and gave up the sport a few years later because we were both plagued with injuries. We switched to cycling because it was knee and hamstring friendly compared to running. But the forefoot striking gait of barefoot and minimalist shoe activities was proving to be far less harsh on our bodies than heel striking. Maybe, just maybe, I could run again with this different gait.

Nothing compares with the portability and the convenience of running to get an efficient CV workout and to strengthen my quads and I longed for that expediency. Cycling and hiking were much more dependent on location and the weather and generally required more time for the same results. Even with forefooting, I didn’t expect my knees to tolerate the demands of running as a primary sport but hoped it could become a cross-training activity.

We again cautiously eased into a running program last winter (2013/14) while in Palm Springs with the initial efforts being 1-2 minutes of jogging at a time during hikes. The goal was to build to running an accumulated 30 minutes. That would prepare us for running the same amount of time during the uphill-only mountain run we’d participate in in July of 2014. We achieved that goal, though just. My goal for the next year was to nudge my time up to 45 minutes, perhaps an hour, by the summer of 2015.

Our first (& only?) mountain run: Check out the wide toe boxes on our shoes.
The prior abundance of caution with our fledging running program paid off: by September 2014 I was up to 45” and in less than 2 months more I was running over an hour. And little more than a month later, in early December, I cracked 90”. That was long enough: the emphasis would now only be on maintaining that performance level without injury. Since I was running on trails, I didn’t know what my speed was, and didn’t care. My goal was solely to have running as one of my conditioning options for CV and knee health and that was it.

Trail Running
One of the cornerstones of our new running program in 2014 was to only run on trails, not roads or sidewalks. Not only would most of the trail surfaces be softer than the streets, they would be delightfully uneven.

When reading about the causes of sudden-onset walking or running injuries, treading on uneven surfaces is often listed as a culprit. We both however had decided that the opposite was true for us: walking or running on smooth, flat surfaces was more injurious than uneven ones with grade changes.

“Repetitive use injury” is a common label for a wear and tear injury vs a sudden, traumatic event, whether it’s your thumb, shoulder, or knees. And for our bodies, running on a track or a street was a set up for a repetitive use injury in our lower bodies because the same forces were applied to the tissues with every foot strike. But when we ran on a trail, especially one that ascends and descends, every step was different, decreasing the repetitive nature of the use. We also noticed that we were far less fatigued when we ran on trails vs streets, presumably because the level of effort and angles of applied forces were constantly changing.

Intervals: Intensity With Less Stress
I began playing with intervals in June 2014 as a part of our last-minute preparation for the July mountain run that we’d mostly speed hike. I picked the easiest routine that I had read about: warm-up walk for 20 minutes; run hard up a steep hill for 1 minute; walk down for 2 minutes; and repeat the 3 minute routine 10-15 times. 

Intervals are a slick trick for us because we feel little or no discomfort from the effort the next day. It seems that limiting the running motion to 1 minute bursts and having them be uphill eliminates the repetitive use injury aspect of the running. Running uphill results in landing with less force than on flat terrain because there aren’t as many G’s  generated by the shortened leg swing. Our forefooting gait lessens the damage even more, as does doing our intervals on trails instead of asphalt.

I measured my heart rate when we did intervals in Death Valley in the fall. I hit a high of 168 beats/minute and had an average of 132 beats over 40 minutes even though we only ran uphill a total of 12 minutes of those 40 minutes. Intervals give us a big CV payback with little risk of injury as well as keep our legs tuned for the unique stresses of running.

If running isn’t in your life, consider popping up your quad strength and fitness level with intervals by using a walking gait at your maximal level of effort for a minute at a time up a steep hill.

Less Is More
It’s heresy, but we are currently experimenting with only running twice a week. I’ve long known that when doing resistance training that the standard every-other-day regime doesn’t provide enough recovery time for me. If I’m building muscle doing push-ups or weight lifting, I need at least 2 days rest between work-outs. I reasoned that if that was true with resistance training, why wouldn’t it be true for my legs with running as well?

Recently changing to an 8 day workout program instead of the employment-driven 7 day schedule allowed us to have 3 high-output activities each week+ while in Palm Springs: 1 long run, 1 set of intervals, and 1 all-day hike, with more recovery time. The extra day per week gave us more flexibility with our rest or relative rest days on which we sometimes did easy bike rides or social hikes.

It’s early into our twice/week+ running schedule but we noticed that our speed and distance are  effortlessly increasing, so at this point, we consider it preliminary validation that running twice a week is sufficient to prevent injuries from running too little. 

Perhaps it’s aging or perhaps it’s the better weather, but I am much more committed to a warm-up walk now than when I ran in my 30’s and 40’s. There was more time pressure then, so I did about a 5 minute walk to my starting point and began my run. And more often than not, it was either cold or raining, which made walking for 20 minutes before running decidedly unattractive. Ideally, I would have dressed for the weather for walking, then gone back home to adjust my attire for being warmer when running, but that never happened.

But as traveling retirees, we have more time and make a point to be in better weather, so we can budget a 20 minute warm-up walk before running. And sometimes we do make that warm-up into a loop from and to our camper to drop-off a jacket or drink more water. It feels right to be giving my body the warm-up time and I’m suspicious it’s contributing to my success with fending off running injuries.

Self-Care on the Course
As cyclotourists, we learned the value of stopping when our knee joints or other tissues were being stressed. We gradually developed the discipline to stop as soon as complaints were being registered and stretch or massage to release the irritation. Five minutes would resolve almost any complaint and sometimes as little as a 1 minute quad stretch or a deep squat would set things right. Nipping a problem in the bud is far more important than sticking to a schedule.

The same is true when running: stopping to tend to a brewing problem is always a good investment. And if the distress isn’t readily resolved at its inception, then walking back home might prevent a serious injury.

Write Your Own Rules
Our lesson to ourselves about increasing our athleticism as we get closer to being Medicare card holders has been to innovate when designing our training programs. We are breaking many rules with our running regime because doing so is, so far,  working for us. It began with switching from heel striking to being forefoot strikers in minimalist shoes in late 2009 and most recently evolved into limiting our runs to twice a week, mixing long runs with intervals, and only running on trails. If my knees are happy, I’m happy and we’re all happy these days.

Hopefully you have some new ideas as to how you can coax your knees into being more active again. Look to online resources for the information that is missing for you, such as how to perform stretches for specific muscles. My intent was to provide concepts and key words to speed your research instead of bogging you down with more details.

Establishing a stellar relationship with your knees may take years, so best to get started now. Mine has certainly been a ‘2 steps forward, 1 step back’ process over decades, but now I feel like a winner when it comes to my knees. I continue to invest many hours a week, directly and indirectly, in my knee health but it’s the only way that they will allow me to play hard and feel good at the end of the day so that is what I do.