help with physical therapy expectations
March 26, 2015 6:36 AM   Subscribe

Currently having Physical Therapy for hip anteversion/knock knees and general postural issues; what kind of pain is it 'normal' and beneficial in the long run to feel? Only muscular or is it okay for PT to provoke the outside of knee pain that I want to fix as well?

I come at you today with a physical/subsequently emotional issue.

For the last three or so years I've been having pain in the outside of my right knee only when I walk longer distances. In the beginning I brushed it off, but in the past few months my whole body started 'failing' on me {I pulled a muscle in my arm which took six weeks or so to heal; my elbows and wrists and joints in general felt much weaker and prone to aches that were never there before etc.} so I finally decided to attempt to fix it all with physical therapy. A bit of background here: I'm a student and have always led an extremely sedentary lifestyle, have not had any exercise that lasted for more than three or so weeks in the past 12 years and have bad posture. This being said, I am also extremely thin {not gaining weight eventhough I eat more than people larger than me} and my uncle, who's an orthopedic doctor, diagnosed me since birth with femoral/hip anteversion, which results in genu valgum {aka knock knees} and walking with feet pointed outward.

I've had a couple physical therapy sessions already and now I have pain in the outside of my right knee- where I usually get it if I walk too long- even when I just sit down {wasn't there before and I didn't walk long distances in the meantime, so I know PT provoked it}- and frankly I'm very afraid of this. From my understanding of what the therapist said AND what I read online, we should be working on strengthening the gluteus, back, thigh muscles {some say abductors, some quads}, so I totally expected muscular pain in those areas- but now this 'old' pain coming back concerns me.

Right now we're focusing on stretching exercises {some require a hands and knees position, bird dog is the worse one for my knees, if you ask me}, as well as balance exercises, where I stand on one leg and kick with the other or rotate the upper body and such, as well as stretching with the core on the ground and the legs up at 90 degrees {pardon my not so technical language, I do not know the precise names}, not much strengthening yet to my knowledge.

So I guess my questions for you all are:
-is there anyone here who has the same issues I do and wants to share her/his experience with physical therapy, their routines, the outcome, what helped and what did not? It would be a great help for me.
-is it normal during therapy for these sort of misalignment issues to feel the pain you're supposed to be fixing? Pretty much, should I be concerned about feeling the knee pain I'm supposedly trying to avoid? Or should only muscle soreness be felt?
-being really thin, both my knee and lower back {pelvis bone, maybe?} bones have no padding whatsoever, so when I get on my knees to do exercises or do stretching with the back on the ground they hurt quite a bit because of direct contact with the floor. Is this...'beneficial' {sort of like mild muscle soreness means what you're doing is working} and necessary or not? Is there any way I could avoid it?

Of course I intend to discuss this with my therapist next time, but if anyone could help giving me some prospective about what's normal or not and what to expect and such from a patient's povs {or second opinions from other professionals too of course} I would be really grateful to you all, as this whole issues worries me quite a bit. Thank you.
posted by opalshards to Health & Fitness (9 answers total) 1 user marked this as a favorite
Does putting a pillow under your knees help? When I've done PT exercises and found them uncomfortable, the PT and I have worked together to find a way for me to do them comfortably. That's involved things like adding padding (pillows) or adjusting hand position (flat push-up style vs fists, etc). You could try doing the laying-down exercises on a bed/yoga mat/carpet to add more padding there, too.
posted by triscuit at 7:13 AM on March 26, 2015

I haven't ever done PT for knee issues, but I have worked one on one with yoga teachers specifically in reference to knee issues. I don't know if that'll be useful/transferable or not.

In case it is:
- for boney knees and spine, rather than a pillow, I'd choose something a bit more stable. For me, folding a yoga mat into a double or triple layer or using a heavy yoga blanket folded a few times is perfect.
- when my knees hurt on the inside or outside, my teachers point out to me that it's usually a hip flexibility issue. Doing exercises to open my hips (especially internal and external rotation) help me avoid side-of-knee pain the most. I know a lot of yoga poses to work on this, but I don't think that listing them would be helpful to someone working with a PT. (Feel free to MeMail me if you think it would be helpful after all.) One of the scariest-to-me poses for knee health is Hero's pose, where you essentially kneel down with your butt on your heels, but then move your heels sideways so your butt is on the ground. I hate it. I'm scared of it. I am assured by my specializing-in-anatomy, trained-by-MD-specialists yoga teachers that it's the best thing I can do for my knees. (Don't try to do it based on that description-- I don't want to be responsible for your knees getting hurt! Ask your own medical professional about it.) The guidance they have given me is that yes, I will feel sensation in my knees, but anything stabbing, shooting, or searing is a no-go.
- building more even strength in your lower body sounds like just the right thing for helping your knee health. Heres an article on knee pain and strengthening knees (in yoga not PT, sorry) that might help give some context to the work that you are doing with your PT.

I will say that as someone with joints that tend slightly to overextension/injury, I have found yoga to be really helpful in strengthening and stretching surrounding muscles to make my joints much healthier and stronger.
posted by instamatic at 7:52 AM on March 26, 2015

Ask your therapist about IT band pain. Look it up; there are videos on Youtube showing you how to roll out your IT band using a foam roller. IT band pain can definitely manifest as knee pain that is very intense and uncomfortable.

(What instamatic is describing about hip flexibility is related to IT band pain.)

In my experience with PT, exercises might feel uncomfortable, and you might challenge your fitness level with them--but they should not cause straight-up pain. You are not there to be tortured. So speak up.
posted by FergieBelle at 9:44 AM on March 26, 2015

Response by poster: Thank you everyone for your replies.


putting a pillow below my knees helped with the left one {the 'good' one}- at first I did the exercise without and I think that is what caused me some short lived pain right after it, but I did use a pillow under the right one from the start {the bad one} and the outside still hurt a bit. I think this pain was due to the nature of the exercises rather than the lack of support per se. I tried the stretching with a pillow underneath my back today and it definitely helped, but the therapist said it arches my back. I think I will definitely look into the yoga mat, maybe folded. I do hope we can find a way to exercise/change routines around my pain triggers.


Everything is useful, no worries! What kind of knee issues, may I ask? / did you have issues taking yoga up when you started in terms of exercises making you ache and then it improved? My hip rotates weirdly enough on its own...I will bring it up to the therapist anyway. I looked the Hero's pose up and it does look somewhat scary in a 'I'm going to break in 3,2,1...' sort of way. The issue is precisely how to determine what 'sensation' is to me- somebody with a higher pain tolerance may describe what I feel as pain as sensation, for instance, so it's confusing to draw the line. How about your knees being tender to the touch for instance? I read the article and found it really interesting, thank you.


Researching the location of my pain the IT band had already come up- point is that I don't know if I have that or it's just the weird angle my knees are at that make me sore. I will ask about that, thanks for giving me the idea to. I will talk to him tomorrow and see what comes out of it.
posted by opalshards at 5:20 PM on March 26, 2015

I do not have your condition, but after picking up a sport as an overweight adult (after not doing much physical activity before the age of 24) I tore a ligament in my knee and went to physical therapy. I was a little knock-kneed, and my PT had me work on the muscle groups you are working on. PT and building strength in general can be painful. I hate the phrase "no pain no gain" but it has proven true for me. HOWEVER you should definitely mention the pain to your PT while it's happening so they can determine whether it's natural or a problem.

Example: My wrists used to twinge and hurt when I would attempt push-ups, certain yoga poses, and free weight curl type things. I did a LOT of slightly painful pushups and downward-dog before this stopped. I had to build up the forearm and upper body muscle strength to take the strain away from whatever part of my wrist was hurting. Now I have no problems. It sounds like you will have to do the same for the muscles supporting your knees.

My personal takeaway from PT as an adult is: it's AMAZING what your body can do. Don't believe for a second that you won't be able to do anything your PT asks of you (even if you can't do it perfectly right away). I found it helpful to visualize how my form should look for each exercise, and deliberately clench the muscles I am supposed to be using during the first few repetitions of each.

Best of luck!
posted by stompadour at 9:54 AM on March 27, 2015

I would get a consult from a second PT on the program.

Your program sounds a bit odd. Stand on one leg and kick with the other is a strength exercise. I am surprised you got this without the classic lying down glute exercises - clamshells, bridge, side lying hip abduction. the latter being the remedial exercises.

Your PT should be working with you to make the exercises more comfortable - crushing bony bits is not part of the pain. PT does hurt and it can make things worse before making it better. That said, there are bad PTs out there inflicting pain for nothing and it's hard for consumers to differentiate between good and bad. Only way is to get a couple of assessments and try a different program.
posted by crazycanuck at 10:41 PM on March 27, 2015

I don't have the type of knee issues I would go to PT for, specifically. What I have is very slightly hypermobile joints that tend towards injury a little faster than most people. I will second stompadour's experience, in that what has been most amazing for me with respect to yoga is that it's helped me build muscle strength gradually, which protects my joints. It also helps my strength develop in a balanced way, so for instance my quads, hamstrings, glutes, and hip flexors "match" each other (rather than say, strong quads and tight hamstrings and IT band from running). That sounds similar to what you are working on in PT.

For what it's worth, I was having an anatomy discussion with my yoga teacher yesterday specifically about avoiding injuries while building strength, and she emphasized that maintaining proper form while limiting range of motion was the most critical issue. (In her example, a chaturanga, or yoga push-up where instead of dropping your knees and changing body mechanics you want to start by moving down only an inch until you build strength to go down 2, 3, 8 inches.) It's possible that might be relevant to your PT work? She did her anatomy training with the orthopedic surgeon/yoga teacher Ray Long, who has a fascinating web site that breaks down how specific exercises work to strengthen and "heal" various parts of the body. So you can go there, search "knees" or "hips" and get anatomical diagrams and specific yoga poses and activation cues to build strength and avoid injuries. (Again, I'm not suggesting that instead of PT, but it's fun to read and get more information that you can then ask your PT about.)
posted by instamatic at 5:32 AM on March 28, 2015

Response by poster: Thank you for replying.

I talked to my orthopedic doctor/uncle yesterday {whilst the therapist was there too}; his opinion was that it's normal to have some degree of pain in joints that were not used too much/ached, considering they're now under more stress. He said that in order to make it better, we could have decreased the time focused on exercises like bird-dog and standing on one leg only, and added we should focus on the hip external rotators as well

Afterwards, my therapist avoided having me do bird-dogs at all and introduced bridge {in the end pushing one leg up too} and side lying hip abduction exercises; other ones I've been doing are kneeling hip-flexor stretches, childs pose, supermans {with and without stretching the arms too}, streching the spine and that stretching with the back on the floor and the legs up at a 90° angle I talked about. We focused more on the left leg, since he said I have weaker muscles there, despite it being the leg that's not hurting {he said that my right one has stronger muscles but, being my dominant leg, undergoes a lot more tension that is of course misaligned}. During the exercises I didn't feel tension/pain in my knees at all {we also used pillows for the bony parts up until I buy a yoga mat}, I had some cramping in my left thigh {again, leg that we worked on more}, but it was fine. Today though I have some discomfort in my right knee again when I walk- though it doesn't feel like the pain I feel if I walk too long- it's more like tension, in a way, and the knee is not as tender to the touch as it was last time.

Am I heading in the right direction according to you all? I thought that maybe, since the pain didn't start immediately but rather around 20ish hours later, it could be just the normal 'soreness' one feels after exercising and that I feel it more in my knee since it's weaker.

@stompadour: it's reassuring to know you're all better now and it was actually useful. Did your wrist hurt just while you were doing the exercises or even afterwards?

We added some of the exercises you mentioned yesterday, bridges and side lying hip abductions specifically, and dropped the one leg kicking. Does that make my program more less weird? I will keep in mind the suggestion about getting a second opinion regardless, thanks.

Everybody loves yoga for knees! I'll consider taking it up after PT/if it doesn't work. I do try to do my exercises as he explains them to me and he also corrects me if I'm doing anything wrong, but I will put extra care in trying to do them as correctly as possible. I started reading the website you suggested- seems really good, but it does take a while to absorb all the information. Thank you!
posted by opalshards at 10:01 AM on March 28, 2015

I had pain in my wrists during the exercises, but very little afterwards. I did have muscle soreness, which I've gotten better at distinguishing from actual pain. It sounds like you're going in the right direction, and kudos to your PT for working with you and trying different exercises. As you progress with your PT, random things might twinge and feel different-- not always bad, just different. When you're injured (or just doing PT), it's easy to get hypersensitive to pain and discomfort; I had to remind myself that all of those muscles and tendons are connected, so a sore hip muscle might make my knee pop and that's OK.

Cheers to strength and health!
posted by stompadour at 9:46 AM on April 1, 2015

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