PT Classroom - Kettlebells for Knee Pain ׀ by Ben Fung, PT, DPT

According to a survey by the Center for Disease Control and Prevention, 30% of adults reported some type of joint pain during the last 30 days. Knee pain ranked as the primary joint of complaint for this particular survey (1).

In the world of rehabilitation, scientific literature has been pointing to the muscles of the hip as a major player in knee pain (2). Strengthening the Hip Abductors (Gluteus Medius) and the Hip External Rotators have been specifically highlighted as a source of pain relief for the knee (3, 4). This stands to good reason when analyzing the functional mechanics of the knee; the orientation of the knee is controlled by the position of the femoral head. The position of the femoral head is controlled by the muscles of the hip. In other words, the hip dictates the orientation of the knee in space, and thus, acts as the guide-wire for the muscles of the knee. A good directional pull from the muscles of the knee encourages good movement at the knee joint itself. Good movement decreases stress forces which then can decrease wear and tear, and, ultimately offers pain relief.

To address knee pain by strengthening the hip, kettlebells can be used as a functional therapeutic exercise. Here are a couple kettlebell exercises which can target the muscles of the hip:

High Knees

The Hip Abductors are responsible for maintaining pelvic motion and femoral alignment during function. The High Knees are a great exercise for the Hip Abductors because it combines strengthening with balance. In this exercise, the lifting leg is the extremity which applies force. The stance limb is the side which is being strengthened. This exercise is performed by raising a kettlebell up by the foot until the knee of the lifting limb is at the height of hip – a “high knee”. By lifting up the kettlebell using dorsiflexion and hip flexion, a sudden downward force is created on the side opposite to the stance limb. This force then requires the hip muscles of the stance limb to engage and prevent a sudden drop in pelvic height on the lifting side. There are a couple compensatory movements to watch for including excessive leaning, lateral shifting, and forward flexion of the spine. The forward flexion of the spine is caused because when lifting the kettlebell with the “high knee” technique, the lifting extremity utilizes the hip flexors which are connected to the lumbar spine. If one does not control posture and engage the muscles of the stance limb, then the body will want to flex forward. If there is trouble with leaning or weight shifting, then a lighter weight should be used.

Side Swings

Resisting the motion of hip abduction and external rotation requires that a force is applied which encourages femoral internal rotation and adduction. One of the best exercises to apply this force and thus strengthen the muscles of the hip for knee pain is the Side Swing. By swinging the kettlebell on the side of the body, more weight is pulled over the lower extremity (and hip) you wish to strengthen. This same pull will also attempt to bring the knee and femur into a position of adduction and internal rotation. By side swinging in correct mechanics, we then resist the unwanted motion of hip internal rotation/adduction and therefore will strengthen the hip abductors and external rotators.

The Single Leg Deadlift: Golfer’s Lift Variation

This version of the Golfer’s Lift is a variation of the Single Leg Deadlift. The purpose of this exercise is to focus strengthening at the hip while limiting motion at the knee. Once again, we find ourselves in an exercise where the stance limb is the limb which is being strengthened. By moving into the combination of a deadlift and mini-lunge, the hip abductor must be activated to prevent changes in the horizontal position of the pelvis. By holding the kettlebell on the opposite side of the stance limb, additional muscle recruitment is forced upon the hip abductors. This exercise also requires that the individual is in good control of knee position; avoiding adduction and internal rotation is of key importance. Additionally, maintaining the single leg stance is an added challenge for control and balance. Do your best to limit the contact of the trailing limb. Finally, spinal posture must be preserved for safety during this exercise.

In the address of knee pain, training and strengthening the body in functional movement is always a desireable plus. Many of my patients and clients who used kettlebells for therapeutic exercise consistently remarked that the areas of complaint always felt better after kettlebell exercise. Despite the repetitive squatting motions of most swing based exercises in kettlebells, the population I encounter who most consistently express that their symptoms improve after a session with kettlebells are those who have knee problems. When the call for treating knee pain with exercise is made, I hope that kettlebells will be one of the therapies that will answer the call.

Last revised: July 19,  2012
by Ben Fung, PT, DPT

References
1) Center for Disease Conrol and Prevention. http://www.cdc.gov/Features/dsJointPain/
2) Dolak et al. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70. Epub 2011 Jun 7.
3) Bolgla et al. Comparison of hip and knee strength and neuromuscular activity in subjects with and without patellofemoral pain syndrome. Int J Sports Phys Ther. 2011 Dec;6(4):285-96.
4) Khalil Khayambashi et al. The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial. J Orthop Sports Phys Ther 2012;42(1):22-29, Epub 25 October 2011. doi:10.2519/jospt.2012.3704