Clients with Degenerative Hip and/or Knee Conditions

As our population ages there is an increasing need for qualified health and fitness professionals to work with individuals with degenerative joint conditions. Of these degenerative conditions, the hips and knees are among the most common regions that impair function and lead to orthopedic surgery. To effectively work with these individuals and to become a viable part of the client’s health care team, the fitness professional must understand the degenerative process and how to tailor an exercise program to help these individuals achieve their health and fitness goals. The fitness professional will be introduced to the Integrative Movement System™ and how these principles create the foundation for successfully working with individuals with degenerative joint conditions. Finally, the fitness professional will be guided through modifications and adaptions of exercise progressions so they understand how to apply the principles in working with individuals with degenerative hip and knees regardless of the individual’s current level of ability or functional goals.

Learning Objectives:

1. The fitness professional will be able to identify the challenges and opportunities of working with the client with degenerative hips and/or knees.
2. The fitness professional will be introduced to how habits directly contribute to degenerative hip and/or knee conditions.
3. The fitness professional will discover how the principles of the Integrative Movement System™ are instrumental in helping the client with degenerative hip and/or knees work towards achieving their functional goals.
4. The fitness professional will be able to apply the principles of the Integrative Movement System™ into a corrective exercise program for their clientele.
5. The fitness professional will understand how to modify and progress virtually any exercise pattern from the most basic to more advanced versions so that they are able to confidently work with individuals with degenerative hips and/or knees.

Arthritis is the leading cause of pain and physical disability. While nearly 27 million Americans have some form of it (Centers for Disease Control), osteoarthritis of the hip and knee is ranked the 11^th greatest contributor to global disability (Cross et al. 2014). Individuals with hip and knee osteoarthritis (degenerative joint disease) show an increase of all mortality as compared with the general population (Neusch et al. 2011). Death in individuals with osteoarthritis is 1.6 to 2 times higher as compared with the general population (Centers for Disease Control). 

Individuals with osteoarthritis are more likely to experience joint pain and therefor reduce their activity which in turn leads to increased health risks. This suggests that osteoarthritis is more than just a simple problem of joint pain; the physical discomfort and accompanying loss of function leads to decreased activity and increases the likelihood of systemic diseases such as cardiovascular disease for a large portion of the global population.

While advancing age is often blamed for the development of osteoarthritis, the author has personally witnessed hip surgery to repair labral tears and remove bone spurs (a common sign of degenerative joint disease) in active individuals as young as 15 years of age. It is common to see total hip replacements in individuals that are between 50 and 60 years of age with no prior history of hip trauma or genetic predisposition.

Although traumatic injury and genetics play a role in some cases, osteoarthritis is often referred to as a ‘wear and tear’ disease because it most commonly occurs over time (American Academy of Orthopedic Surgeons). In fact, most cases of osteoarthritis are related to one thing: an individual’s habits. It is how these individuals are sitting, standing, walking, exercising, carrying about their activities of daily living that is the greatest determinant as to whether or not they will develop osteoarthritis (Osar 2014).  This article will discuss how habits lead to degeneration and demonstrate a principle-based strategy for working with individuals with hip and/or knee osteoarthritis. 

Habits as a Cause of Osteoarthritis

As mentioned in the introduction, habits are the most common cause of the degenerative process. Non-optimal alignment and altered myofascial control is responsible for perpetuation of osteoarthritic changes. When a joint is not aligned, the cartilaginous surfaces are not properly positioned to support the demands of continuous wear and tear during daily life and/or exercise. Over time this leads to degenerative changes of the cartilage surfaces and the development of bone spurs.

Alterations in myofascial tissues generally accompany joint changes. There is often shortness of certain tissues and lengthening in other regions. For example, shortness of the lateral hamstring, lateral head of the gastrocnemius, and iliotibial band result in external rotation tibia. External rotation of the tibia will lead to altered alignment during walking, running, and squatting (see images below).

Images 1-2. Note the external rotation of the tibia in the left leg as compared to the right leg, a common alignment issue that directly contributes to knee degeneration (image 1). Note how this woman loads her knee as she runs; she maintains this same non-optimal alignment of the lower extremity (image 2). This non-optimal alignment as she walks, runs, and climbs stairs is what leads to degenerative changes in the knee over time.

Another common example of how habits lead to non-optimal alignment is common with the hips. Throughout most activities of daily life the femoral head should be centrated (aligned and controlled) within the acetabulum of the pelvis and the posterior hip complex should remain relaxed (images 3-4).

           Images 3-4: centrated hip                                   Images 5-6: non-centrated hip

It is common for individuals to over-activate or ‘grip’ their posterior hip complex to stabilize their pelvis and hip (image 5). Many individuals will also grip their posterior hip complex to help support the pelvic floor (this is a common reaction in individuals with urinary incontinence) as well as to make the posterior hip region appear smaller. The challenge is that when individuals grip their hips they drive the femoral head forward within the acetabulum (Lee and Lee 2013, Osar 2012). When the individual maintains this position during their movement patterns such as walking, running, squatting, etc. this begins to create wear and tear of the soft tissue structures around the hip including the labrum (recall the surgery on two active 15 year old athletes).  Eventually this habit of gripping leads to bone spurs and loss of joint space and directly contributes to degenerative joint disease of the hip.

It is these chronic habits, the compromised ways these individuals are holding their body to either compensate for a previous injury, as a result of a repetitive job or sport, or in attempt to change their aesthetics that lead to most cases of degenerative hip and knee issues. The goal of the fitness professional is to help these individuals recognize and change these patterns so they reduce the stress upon their joints and develop more optimal patterns.

The Principle-based Solution to Osteoarthritis

When working with individuals experiencing osteoarthritis of the hips and knees the goal is to help them develop optimal alignment and control of their joints (Bryant and Green 2003, Osar 2014). Additionally, the fitness professional must design their client’s program around exercises that minimize further damage while promoting joint alignment and control.

The Integrative Movement System™ was created to help fitness professionals that work with the general population develop a stabilization and movement strategy to restore more ideal alignment and control. The Integrative Movement System™ is based around three simple principles: alignment, breathing, and control (Osar 2012, 2014). When the joints are aligned to support proper loading, there is three-dimensional breathing to provide proper stabilization of the core, and the myofascial system is able to optimally control joint position and movement, the individual can move without compensation. If any one of these principles is compromised, the individual will compensate and establish non-optimal habits for stabilization and movement.

The fitness professional must help the individual develop alignment and control of the lower extremity and then be able to design their client’s exercise program around the most appropriate exercises given their current condition. While there are many lower extremity patterns that can be utilized, most patterns are generally considered to be knee or hip dominant depending upon which joints are primarily involved in the movement.

Knee dominant exercises include patterns where there is movement around the hip, knee, and ankle joints. Generally included in this category are squats, lunges, and step ups and all variations of these patterns.  Hip dominant patterns are those patterns where there is minimal to no movement of the knee or ankle and the motion comes primarily from the hip. Hip hinges, deadlifts, and bridges are examples that fit into this category.

Ideally, an individual’s program would include both knee and hip dominant patterns. When dealing with clients that have hip or back problems patterns where the load is shared over several joints – knee dominant patterns – are generally preferred. For individuals with knee problems, hip dominant patterns tend to generally work better since there tends to be limited movement of the knee joint during the exercise.

In addition to getting clients stronger, improving range of motion, and developing improved balance, a primary responsibility of the fitness professional’s job is to minimize risk. They should be helping their clients minimize risk of further injury or incurring greater wear and tear upon their joints. Understand that in order to help clients preserve their joints, the fitness professional will choose the patterns that place the least amount of stress upon their joints.

The remainder of this article and accompanying videos will discuss the corrective and progressive exercise patterns that are helpful when working with clients with degenerated hips and/or knees.

Corrective Exercise Patterns

Happy Baby

The happy baby progression is one of the go-to positions for teaching proper alignment, breathing, and control of the trunk, spine, and lower extremity. The individual begins lying on their back with their legs supported on a stability ball (pictured below) or chair. While the stability ball is great for use in the gym, a chair or bench is more ideal as it positions the hips in their natural alignment. The goal is to align the TPC and the hip, knee, and ankle-foot complex while in this position.

The individual will breathe three-dimensionally to release any chronic gripping around the hips and trunk. Since the diaphragm fascially blends with the diaphragm, transversus abdominus, psoas and quadratus and co-activates with the pelvic floor, three-dimensional breathing functions to activate the deep myofascial system. The deep myofascial system is pivotal to maintaining joint control of the core and to counteract the need for excessive and/or inappropriate levels of myofascial gripping around the hips (Osar 2012, 2014). Decreased gripping around the hips will help ensure more optimal alignment of the pelvis and lower extremity.

Once the individual is able to align and breathe with supported legs, they can lift their legs off the ball or chair. The lifting and lowering of the legs should not alter the individual’s alignment or cause them to over-grip for control. Perform three breathes with elevated legs before returning to the starting position for 3-4 sets.

Images 7-8: supported and unsupported Happy Baby

Lying Leg Curls

The lying leg curl pattern is an excellent way to train lower extremity alignment in individuals with painful and/or stiff knees or hips. Because this pattern is performed in the supine position, it is very effective for recruiting the hamstrings while minimizing stress upon the knees and hips. When the tibia is aligned with the femur, lying ball curls are very helpful in aligning the entire lower extremity in individuals with external tibial rotation.

With the legs positioned on the ball or over a coffee table, chair, etc., the individual will gently push their heels into the ball and pull their knees in towards their chest. They will pull their knees in towards their chest as far as they can without discomfort. Maintaining the downward pressure of the heels into the ball, they will roll the ball away from their chest. Leg movement should not change the position of the pelvis or spine during the pattern and the individual must relax the hip musculature during the pattern to aid in release of chronic myofascial tension around the hip.

Images 9-10: lying leg curls

The happy baby and lying leg curl helps establish the alignment, breathing and control necessary for upright mechanics. The progressive exercise patterns that follow demonstrate one knee and hip dominant pattern that can be utilized. The important point regarding knee versus hip dominant patterns is this: use the pattern(s) that best enables the client to be successful. Sometimes clients with knee problems can do well squats and individuals with hip problems can perform an appropriate hip hinge pattern. Make the exercise appropriate for your client meaning if they are able to maintain optimal alignment and control and it doesn't create additional stress upon the compromised joint, it is a good pattern for the individual.

Progressive Exercise Patterns

Supported Squat

Once the individual has developed optimal alignment and breathing through the previous patterns, the supported squat is one of the best patterns to teach individuals how to maintain the same alignment in the upright position. It also teaches an individual how to coordinate the ideal position of the pelvis while sitting back into their hips which enables the individual to release chronic hip gripping while training optimal lower extremity alignment.

The hands are placed about chest level and hold lightly to a rack or door handles for support – the individual should not be holding their body up with their arms. During the pattern, the individual maintains TPC alignment while sitting back into their hips. For chronic hip grippers, a great cue is to get them to ‘release’ through their posterior hips and/or make their sits bones (ischial tuberosities) ‘go wide’ during the eccentric phase. The goal is to activate and not be overly aggressive by over-contracting the gluteals during the concentric phase. As they stand up, they should do so without gripping the posterior hip which tends to drive the femoral head anteriorly and creates compensation through the knee. Perform 1-2 sets of 15-25 repetitions.

Goblet Squat

Once the squat pattern is established as described above, the client may be progressed to a loaded version. Whereas traditional barbell squats can alter trunk and spine position, goblet squats allow maintenance of the core during the pattern which is key for minimizing spinal stress as well as for releasing chronic hip gripping. Again, the goal is to maintain pelvic alignment, hip centration, and lower extremity alignment remains similar to the supported squat pattern. Perform 3-4 sets of 10-15 repetitions.

Hip Hinge

The hip hinge is an excellent pattern for teaching dissociation of the pelvis from the femoral head. The goal is to maintain alignment of the trunk, spine, and pelvis as the pelvis is rotated up and over the femoral heads. This pattern is instrumental in teaching an individual how to determine and become aware of the true length of the hamstrings and the range in which the pelvis should be positioned for patterns such as deadlifts and bent over rows. Once the pelvis stops anteriorly tilting, the movement is over and they return to the upright position. Any further forward movement once the pelvis stops anterior tilting is being caused by spine flexion.

The individual sets up their feet about hip width apart with their foot, knee, and hip aligned. They will place their hands over their pelvis with their fingers wrapped around the ASIS (anterior superior iliac spine) and their thumbs around the PSIS (posterior superior iliac spine). They will release (relax) any posterior hip gripping and feel as if they are lifting the pelvis up and over their femoral heads. Essentially they are anterior tilting however it should be an active movement versus simply letting the entire pelvis shift posteriorly. The movement stops when they can no longer feel movement (anterior tilting) of the pelvis. Perform 2-3 sets of 10 repetitions.

Hip Hinge Deadlift

Once the client has developed the awareness and control of the hip hinge they can be progressed to a loaded version. Usually only light weights are required since there is such an eccentric load on the posterior chain throughout the pattern.

The client has already established their range of motion in the hip hinge pattern. Holding weights (barbell, dumbbell, kettle bell, or medicine ball), the individual will perform their hip hinge pattern being sure to maintain their TPC as well as lower extremity alignment. They should activate the posterior chain without over-squeezing or gripping to return to the upright position. Perform 2-3 sets of 10 repetitions.

See the video clip for demonstration of the supported squat, goblet squat, hip hinge, and hip hinge deadlift patterns:

Also note that even if the client has knee problems, they likely have to maneuver curbs or stairs so part of the functional goal is to help them develop a strategy to minimize stress during those activities. For example, if they have a painful and/or degenerated hip or knee, they may have to take stairs one at a time and go up sideways with their unaffected limb being the lead leg so less stress is placed upon the compromised limb. Helping the client with joint pain and/or degeneration find strategies for activities of daily living can reduce soft tissue stress, can often times prolong joint integrity, and empower the individual to continue to move.

Conclusion

In this article we discussed how degenerative joint disease is a global problem that takes a toll on individuals health and well-being. While often attributed to genetics and old age, degenerative joint disease is largely related to an individual’s habits. The fitness professional is in the best position to help these individuals develop a strategy for improving function and maintaining an active lifestyle. Clients with specific joint problems require their programs be tailored to fit their needs which requires the fitness professional to choose the appropriate exercise and develop a program that is unique for the individual. When the client’s goals are married with a program that safely and effectively helps them address their needs, the fitness professional will be instrumental in helping many individuals with degenerative joint conditions who previously had no other options besides medication or surgery.

References:

American Academy of Orthopedic Surgeons. http://orthoinfo.aaos.org/topic. Downloaded August 1, 2014.

Bryant, CX. and Green, DJ. (2003). ACE Personal Trainer Manual. Third Edition. San Diego, CA: American Council on Exercise.

Centers for Disease Control and Prevention. http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Downloaded August 1, 2014.

Cross, M., Smith, E., Hoy, D., Nolte, S., Ackerman, I., Fransen, M., Bridgett, L., Williams, S., Guillemin, F., Hill, CL., Laslett, LL., Jones, G., Cicuttini, F., Osborne, R., Vos, T., Buchbinder, R., Woolf, A., March, L. (2014). The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Annals of the Rheumatic Diseases. 2014 July;73(7):1323-30.

Lee, LJ. and Lee, D. (2013). Treating the Whole Person with The Integrated Systems Model. Vancouver, CA: Discovery Physio course handouts.

Nuesche, E., Dieppe, P., Reichenbach, S., Williams S., Iff, S., Juni, P. All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study. BMJ. 2011 March;342:d1165.

Osar, E. (2012). Corrective Exercise Solutions to Common Movement Dysfunction of the Hip and Shoulder. Chinchester, UK: Lotus Publishing.

Osar, E. (2014). Integrative Movement Specialist™ Certification. Course handouts. Chicago, IL.