If you’ve been told that you have bone-on-bone knee pain and are wondering what you can do, join us to find out whether exercise is the help you need or if you should go under the knife.
Today we’ll cover a bunch of common questions and then give you five exercises for bone-on-bone knee arthritis to help strengthen the muscles around the knee so you can stay active or prepare for surgery.
As always, you can watch our YouTube video on Bone-on-Bone Knee Pain and follow along with the exercises.
What is Bone-On-Bone?
Bone-on-bone knee pain occurs when you lose the articular cartilage that coats the end of your bones.
Normally, we have cartilage that coats each of these joint surfaces, which allows the joint to move in a frictionless, smooth fashion.
Bone-on-bone means that you’ve actually lost the articular cartilage on both sides of the joint.
The way to make sense of it is by looking at how many of the compartments of the knee it affects. For example, it could affect just the patellofemoral compartment. Or it could affect the medial (inside) compartment of the knee or even the lateral compartment of the knee.
Initially degenerative arthritis tends to affect just one small area of the joint surface, but over time it can evolve to affect both sides of the same compartment and multiple compartments.
The more compartments that are involved, the more severe your arthritis.
What’s Chondromalacia Patella?
A lot of people message us saying that they’ve been diagnosed with chondromalacia patella, so what’s that all about?
It’s a condition that affects the articular cartilage of the kneecap. If you don’t do anything to change how you’re loading your kneecap (in medical terms, the patella), you eventually can have bone-on-bone arthritis under the kneecap.
Does a Bone-on-Bone Diagnosis Mean You Need Surgery?
It depends on how many compartments are affected and most importantly, how this affects your lifestyle.
Dr. B says:
They definitely do have ongoing symptoms, but they’ve learned to kind of manage those symptoms.”
If you cannot control the symptoms to enjoy the quality of your life, then a total joint replacement is a very effective solution.
What are the Treatment Options for Bone-on-Bone Knee Problems?
Treatment puts you in a bit of a pickle because even the best medical science today can’t put cartilage back on the joint.
So what are the next steps?
Ice and anti-inflammatory medications.
Let’s say you go to the doctor. They may offer you injections, like PRP stem cell injections, Synvisc, or cortisone.
Stem cell injections still won’t regrow your cartilage. Also, be careful about having multiple injections into the joint, particularly if you’re considering joint replacement.
Dr. B says:
But let’s say you’ve got an important event coming up – a wedding or you’re going on a trip – and you’ve done something where you’ve blown out your knees and can’t walk. You’ve been doing your knee osteoarthritis exercises and are still in pain.
Then a cortisone injection makes sense to decrease inflammation to get you through a few weeks and get you back on track with your exercises.
But having an injection of cortisone every four to six months to manage your symptoms, in my opinion, is not a good way of going. Eventually, you may end up with a joint replacement and if you have all of these injections, you’re not fixing the root cause.
You’re decreasing inflammation and pain, but you’re not putting cartilage back on the bone.
Studies have been done looking at patients with joint replacements after multiple injections and they’ve got an increased number of complications, particularly infection.
We’re paranoid about infection as orthopedic surgeons.”
Should People with Bone-on-Bone Use a Knee Brace?
Knee braces can be effectively used for people who want to be really active.
What happens if you have bone-on-bone arthritis is that there’s normally a ligament that stabilizes the knee.
When you lose the cartilage, that ligament will lose its normal tension. It’s hard to compensate for that with just muscle strength alone.
If you’re going to play a sport that requires changes in directions, stops, and starts, getting an unloader knee brace to help protect the ligament and the joint can be very, very effective.
Should I Avoid Exercising With Bone-on-Bone?
Everybody should do isometric exercises if possible.
That means you have the joint in one position and then contract the muscles. It’s excellent for OA pain relief and will help you control the joint’s movement so that you aren’t significantly overloading it.
You have to be a little bit careful about exercising when you have bone-on-bone arthritis if you can’t maintain proper alignment of the joint or the proper movement pattern. If you’re getting sharp pain or your knee is blowing up and swelling, that’s a message that this isn’t the right exercise for you.
Exercising to maintain your mobility to keep the muscles turned on as best you can is ideal. You won’t make your knee perfect because we can’t put the cartilage right back on the end of the bone.
Focusing on the joints above and below is super beneficial because you can take the pressure off the bone-on-bone area.
Exercising using common sense isn’t going to make you perfect. Still, it’ll prevent you from deteriorating, and if you need surgery, it’s going to help you recover from the joint replacement so much more effectively.
Exercises for Bone-on-Bone Arthritis
We’re going to go through five exercises to strengthen the knee, but really strengthen the feet, ankles, and hips. Then we’ll integrate them into a pattern to take some of the load off the knees.
We want stronger knee muscles to support the knee directly. We also want to decrease the forces that have to go through the knee that need the knee muscles need to absorb. We do that by working the foot and the hips.
Exercise 1: ASMR: Anterior Thigh/Quads
To start off, we’re going to release some muscle tension.
One of the best techniques for this is active self-myofascial release (ASMR) for the quads and anterior thigh.
All you need is a foam roller.
- Lay on your front with the foam roller just above your kneecap
- Roll yourself slowly down, so the roller moves up your thigh as you bring your heel toward your butt
Do 1 – 2 minutes per side.
ASMR lengthens and stretches the quads. It also breaks up any adhesions and trigger points (aka knots). Those could be restricting the quadriceps from their full range of motion and cause excess tension on the knees and kneecap.
The key is matching the rhythm.
As you roll, bring your heel to your butt. It shuts off the quads and gets you deepening into that muscle.
If you hit any hot spots and you’ve never used a foam roller before, you’ll know when you hit one because it’s painful. Most people tense up. That’s normal.
When you hit hot spots, try to pause there for a second, breathe, and on the exhale, try to relax and melt the muscle over the roller. Then continue on your merry way.
When you first start, spend a little more time and go a little slower. You’ll have to pause more so time for two minutes per side, but after doing it daily for two weeks, you can drop it down to every other day or three days a week for another couple of weeks. Then, after that, drop down to one or two times a week, and that’ll help you maintain good tissue pliability and good quality of the quads to decrease the pressure and forces that go through the knees.
Exercise 2: Quad Ramping
The next exercise I’d like to teach you is something that we call Quad Ramping.
Quad ramping is learning how to gradually increase the amount of tension that goes through the quads. It’s an isometric technique that Dr. B loves.
It focuses on and activates the quads, but you also get the hamstrings activated too. This can help to keep the knee feeling better.
For Quad Ramping, you need your leg on a roller, pillow, or something to prop it up so that your knee is slightly bent.
- From a propped, slightly bent position, slowly flex your quad
- Start very slow, maybe 10% ramp up to 80-90%
Perform 2 sets of 3 reps on each side. Do all three reps on one side, then go to the other.
If you need to work your way up to 2 sets, that’s okay too. Keep at it and build up that quad endurance while you’re developing the control of the muscle.
The activation might be difficult at first. You may have poor control, especially of the VMO (that muscle just above the knee on the inside). It happens to a lot of people, so don’t fret. Just practice it, and you will get better.
So what you want to do is, over 30 seconds, ramp it from zero up to 100% – or as high as you can go without causing any undue pain.
Hold it for 10 seconds, and make sure to breathe! Keep that VMO active if you can. If you don’t seem to be getting any activation there, poke it a few times with your finger, and that should wake up the muscle.
Ramp it down over 20 seconds, gradually releasing the muscle. Don’t just relax it all at once. Think about slowly ramping down 5% at a time.
Keep your knee nice and stable throughout.
Exercise 3: The Short & Skinny Foot
We want to make the foot skinnier, and we want to make the foot shorter. What we’re focusing on is pressure through the metatarsals (the bone underneath each toe.) You want to keep pressure through the foot into the ground through that entire area.
Another technique that we teach is to actively spread out your toes. If you can’t do it actively, just kind of pull them out. That’ll help you get the short foot.
- Put one foot slightly forward, spread your toes
- Bring your body weight forward to create metatarsal pressure
- Keeping the pressure, try to make the foot skinny and short, pulling the metatarsals together and toward your heel
- Hold for 4 seconds
- Gradually release
Perform 3-6 reps per foot.
If you’re doing it on a mat, you might be able to keep the mat slightly pulling in towards your heel. That’s good!
Again, pull through the metatarsals, keeping pressure even on the big toe and the little toe metatarsal, and try not to over-curl your toes. Make sure you have a little bit of body weight on that because it’ll help to integrate the pattern so we can bring it into movements of everyday life.
Exercise 4: Slumpy Psoas Activator
The next technique is called the Slumpy Psoas Activator.
We designed this unique exercise to get the psoas muscle (which you can feel in the front crease of your hip, running between your hip and into your leg) fired up and active.
It’s one of the hip flexor muscles. Its job is to lift the foot off the ground. So it flexes the hip, and it’s often sleepy and weak in people because of all the sitting that we do.
So we’re going to fire this up. The reason why we’re using it for bone-on-bone knee pain is that when this muscle doesn’t fire up, another muscle has to compensate for the hip flexion job.
The rectus femoris tends to jump in to help pick up the slack left by a sleepy psoas. It’s a quad muscle that runs down your thigh and inserts right into your kneecap. If it’s doing more work than it should, it’s going to put more stress on the patella and on the knee in general. It could also lead to tracking issues (where the patella slides around where and when it shouldn’t) which in turn further irritates an already cartilage-less knee.
So the Slumpy Psoas Activator will help you get the psoas working and shut off the rec fem.
- Sit in a chair with terrible posture
- Lift one foot off the ground
- Flex the hip (you should be able to feel the psoas working with your finger if you poke it)
- Place your hands on your knee
- Press with your hands
- Once your psoas activates, straighten into good posture
- Stick your butt out once your back is straight
- Hold for 5 seconds
- Keep the psoas activated while you lower the foot to the ground
Repeat on the other side.
If you don’t feel the psoas activating, try bringing your foot more toward your midline (external hip rotation) to get it working. If your feel muscles activating on the side of your hip, those are other hip flexors, and keep trying to center your foot until you can get the psoas activated.
As you perform the exercise, imagine sucking your thigh bone up into your hip. It’ll help create that healthy hip pocket that will stabilize your joints up and down the kinetic chain.
Exercise 5: Hip & Foot Focused Squat
The last exercise is the Hip & Foot Focused Squat.
We just woke up the intrinsic foot muscles in the short and skinny foot exercise. The intrinsic foot muscles build up your arch. We activated your psoas, and now in the Hip & Foot Focused squat, we’re going to use those things in a normal squat movement pattern.
Before we get into it, consciously activate the glutes. Just stand for a moment and fire up the glutes, hold for 10 seconds, and make sure your knees aren’t turning out. You should notice (especially if you don’t let your knees turn out) that you start to feel some activation in the front of your hip – the psoas, the adductors. We’re going to fire those up in this exercise, and we want them to be activated beforehand to ensure they’re doing their job through the range of motion in the squat.
Ramp down your glute activation gradually. Gradual activation and gradual release help develop better control of our muscles and body in general.
- Start with the Short and Skinny Foot, maybe 50 – 80% activation
- From there, keep good posture just like any squat, keep the glutes on, and keep the foot activated
- Lower your bum, keeping your chest up with a neutral spine (you’ll hinge at the hips and the knees)
- Keeping the foot activation, squat as low as you can
- Slowly rise back up
- Relax all your muscles
Perform 2 sets anywhere from 6 to 10 reps.
Add some load if you can do 2 sets of 10 reps with good range of motion. Hold a weight right in front. Maybe a little dumbbell you can load up with weights. Because the more we can build the strength in the feet and hips to control the squat, the better it is, and the less stress that’ll go through your knees.
Starting with the Short & Skinny Foot helps co-contract the psoas that we already turned on in the Slumpy Psoas Activator.
Go nice and slow because we want to build strength and this activation pattern throughout the full range of motion. No momentum! We want to make sure those muscles stay on the whole time.
Arms in front will help your balance. If you can get all the way down, keeping those muscles on, great! If not, don’t worry. Going nice and slow help you to feel the range where muscles just let go. Maybe your hips let go, maybe your feet. But wherever that range is, stop just short of it. That’s your maximum range of motion right now, so use that as a benchmark for where to come back up.
If you have pain with the squat, only go as far as you can comfortably, start to pay attention if you have more pain when either your glutes or your foot muscles have shut off.
Over time, your range of motion will increase where you can keep those muscles in line. That’s how when we have glutes, hips, and feet on, there’s going to be less needed from the muscles around the knee, like the quads or hamstrings. Less compensating muscles or fewer activities needed from those muscles around the knee will decrease the amount of stress that goes through the knees. In turn, less stress on the knees helps keep them a little bit more pain-free as you go.
What’s the Next Step?
Those are five exercises for bone-on-bone arthritis to give you an idea of Coach E and Dr. B’s approach to dealing with bone-on-bone knee pain. As you advance through the exercises above, take a look at some advanced knee osteoarthritis exercises.
If you like those, you might like a more structured, comprehensive approach to knee pain. Click here to learn more about Knee Pain Solution.
Knee Pain Solution is a program that will walk you through all of the concepts that we’ve talked about here, but more in-depth and starting with your current knee pain level so that your knees stay as healthy as possible for as long as possible.
This article was reviewed and updated on January 5, 2023 by our Chief Medical Officer, Dr. Erin Boynton, MD, FRCS to include new research and information on latest surgical developments. Read more about Dr. B here.