Stairs With Sore Knees: From Struggle to Success!

Stairs can be a major stressor for those of us with sore knees. Oftentimes, older adults begin to avoid stairs as much as they can, and even choose homes that are on one level for this very reason. When stairs are the only option, there may be extra difficulty, both because of issues with the knee joints, as well as the deconditioning of muscles that may have occurred as a result of not going up and down stairs as frequently (use it or lose it). The act of choosing to continue to use stairs as we age is a great way to maintain strength in the lower body, but this will only be beneficial if we can climb stairs with ease and efficiency. Rather than making stairs the enemy, how can we begin to see stairs as a healthy challenge that will help us maintain our strength and mobility?

Biomechanics of stairs:

It may be helpful to understand a little bit of the biomechanics of stairs, or the physics of the movement. Going up stairs is a concentric action, in which the muscles shorten as they contract, creating a force that overcomes resistance. Most of the concentric action occurs about the hip and knee joint, and key muscles for going up stairs are the quadriceps (front of thighs) that act to extend the knee, and the hamstrings (back of thighs) and gluteus maximus (large buttock muscle) that shorten to extend the hip.

We also require use of our hip flexors (front of abdomen to front of hip) to lift our foot to the next step. In addition, if we learn to ascend stairs using more of our body, muscles on the sides of our bodies can also help, including our gluteus medius (side hip muscle) and quadratus lumborum (side of waist/low back). We can rely on the integrity of our skeletal structure to help direct the forces required to go upstairs, as we can send our body weight over our supporting leg, thereby requiring less overall muscular effort to go up stairs.

Going down stairs is actually more difficult for many people, especially those of us with knee issues. The skeletal system of our bodies is extremely important for supporting and directing forces. Going upstairs, we are able to rely on our skeletal structure more reliably, whereas going downstairs requires the supporting knee to be very bent, which makes the muscles in the front of the thigh have to work much harder. Going down is an eccentric action, which means muscles have to lengthen while contracting, as they control against the force of gravity. In other words, eccentric contractions are kind of like controlled falling. These types of contractions are actually more difficult for our muscles, which is why eccentric training is an excellent way to improve tissue strength and resilience. However, if our muscles lack the strength to control our movement during gravity, we might notice going down stairs, sitting down into a chair or toilet, or lowering ourselves to the floor may turn into more of a “plop” than a smooth motion. This indicates that our muscles lack eccentric strength, and our joint tissues may be taking a great deal of strain as we do these activities. 

Another reason why going down stairs might be more difficult for some is that it tends to isolate the knee joint more than going up stairs. As described above, going up stairs can make great use of the muscles of the hips and core. In going down stairs, notice that the knee might travel far over the toes, and very little movement actually happens in our hip. As the knee travels over the toes and the quadriceps contract eccentrically, pressure builds up in our knee which can be an irritating factor, especially if we lack eccentric control or if there are other factors at play that are impacting our movement efficiency.

Strategies for a “bad day”:

Although practicing stairs is a great way to get better at stairs, sometimes we have to modify how we do it based on pain and discomfort. Think about an early morning. In the winter. Perhaps you “overdid it” yesterday, and your knee is speaking to you. Or perhaps, you had a knee replacement surgery not so long ago and your knee simply is not in shape to do stairs normally. If this is the case, here are some strategies for bringing more ease into your life:

1) Up with the strong, down with the sore:

This popular adage is well known for anyone who has had a knee replacement. Many will say “up with the good, down with the bad”, but why the negative self-talk if we could just say sore? This advice simply means to go up and down stairs one at a time, rather than your leg traveling past your other leg to the next step. Also, when going up, lead with the leg that is stronger, not experiencing as much discomfort, etc. And when going down, lead with the sore leg. This will make sure the strong leg is doing both the concentric and eccentric action to give the sore leg a break.

2) Try backwards, or sideways:

This tip is mainly for going down stairs. If one were to go down stairs backwards, mechanically, it would look a bit more like going up stairs in which we can use our hips a bit more rather than isolating the knee. For safety reasons, it is extremely necessary to practice this first before gallivanting down the stairs backwards. Try standing on the bottom step, holding on to the railing. Then slowly lower one foot down to the ground, followed by the other foot. Then come back up, practicing several times to get the hang of it. Similarly, when going down sideways, the knee does not have to travel so far over the toes. We are able to bend at the hip more to lower down to the next step. Going down sideways will also make it possible to hold on to a railing with both hands. On a bad day, consider going down backwards or sideways leading with the sore leg, just as described in the previous strategy.

Strategies for optimizing movement and preventing issues:

On a typical day perhaps if our knees are not a bother, and we would like to embrace the healthy challenge of doing stairs in an efficient and strain-free way, consider the following recommendations:

1) Root your heel to rise, bend side to side:

Rooting to rise means to take advantage of the force that the ground gives you, known as the ground reaction force. As we might remember from Sir Isaac Newton, every force has an equal and opposite reaction. When we put weight into the ground, the ground exerts an equal and opposite force back up into our skeleton, allowing our bodies to move. By focusing attention on our ability to harness ground forces, we might be able to navigate stairs and other movements with a greater sense of clarity. By placing our heel completely on the step when going up, we can actually push down through our heel as our body leans forward over our foot. By pushing down through our heel, we will rise up to the next step, thereby rooting down to rise up. The muscle that pushes our heel down is the same muscle that extends our thigh back, which is our gluteus maximus, the strongest muscle in our body. If our heel is dangling off the step, we cannot make as efficient use of ground force, and more force may be required from our knees.

When going up stairs, we can train ourselves to move partially in the lateral plane, rather than only the sagittal plane to take further stress off the knees. Put simply, we can let our body side bend help us ascend to the next step. This is a difficult concept to describe that must be felt in the body to understand. One way to think about it is relating the action to pushing down on a trash can pedal to lift the trash can lid. If the right foot presses down on the step, the left side of the pelvis will lift up, bringing the left leg to the next step. In this case, the right foot would be pressing on the imaginary trash can pedal and the left side of the pelvis would be the lid.
This action is accomplished mainly by the gluteus medius as well as the quadratus lumborum, which are muscles on the side of the pelvis and abdomen.  

One way to practice this feeling before doing it on the stairs is to try a slow march standing in place. Place hands on the sides of your waist. Begin to lift your left thigh up, thinking about pressing down into the ground through the right foot. Notice that the left side of your waist would get shorter, and the right side of your waist would get longer. Continue in a slow march, paying attention to the changing length of your side body. Imagine that the leg that is holding your weight is pressing down into the trash can pedal, and the side that is coming up is the lid.

2) Practice Step Ups and Downs:

As we learned, eccentric strength is necessary to go down stairs with ease, and concentric strength is necessary to go up stairs. A great way to improve this strength is to practice step ups and downs. On the bottom step or perhaps using a stool as well as something to hold on to as needed, place heel up onto the step and practice driving down through the heel to step up. Keep the same heel on the step, and lower down backwards with control until your other foot touches the ground. Repeat several times, noticing the activation of your thigh, glutes, and side body muscles.

For a more challenging exercise, practice going down a step facing forward. We have learned, this is the most difficult and likely to elicit discomfort of the knee. For this reason, it is important to start practicing by holding on to something, as well as starting with a partial range if you are having difficulty controlling this motion. Start standing on the bottom step, keep one foot where it is, and begin to lower the other foot towards the ground, but only a couple of inches. Then return to the starting position. The key is to lower down very slowly, to ensure you are maintaining eccentric control. Try a few more times, perhaps each time letting the foot travel a little closer to the ground as your other knee bends. Notice the tracking of your standing knee on the leg that is holding your weight as you lower down. Does your knee bend straight forward over your toes? Does it drop in towards the big toe side, or out to the pinky toe side? Does making a change to where your knee tracks impact the comfort and ease of this motion? Spending a little time each day practicing these movements will condition your body and your mind to be primed and ready for the next time you encounter stairs.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

The Carpenter or the Gardener: Which One Are You with Your Body?

One’s participation in physical therapy can certainly reflect either more of a gardener or a carpenter mindset. Many clients come to us who have clearly been to physical therapy in which they were influenced by the carpenter mindset, which may have negatively impacted their experience.

According to Alison Gopnik, parents fall into one of the two categories: gardeners or carpenters. Put simply, a carpenter is one who thinks their child can be molded, whereas a gardener provides a protected space for their child to explore. The psychology and philosophy professor described these two styles of parenting in regards to raising children in her book, The Gardener and the Carpenter. This book is worth a read, but if you are more of a listener, her podcast on the Ezra Klein show is great to listen to on a walk or car ride.

In addition to illustrating the two styles of parenting, Gopnik describes how and why it may get more difficult for us adults to learn as we age. The process of aging itself is not the primary reason it becomes more difficult to learn, but more so our tendencies towards being a “carpenter” rather than a “gardener”, which is propagated by our culture’s celebration of efficiency and hard work over play and exploration.1

In regards to parenting, a carpenter is one who thinks their child can be molded into a particular kind of person. Want them to be a successful doctor or lawyer? Have them spend more hours studying. Why spend time playing on the playground if time could be spent practicing crucial life skills that they will need as an adult? The tendency of a carpenter is to put more effort into everything if you want better results. The irony of the situation is that play is pretty much the most important thing a child can do to ensure they will be successful as an adult. The time spent playing and exploring is absolutely crucial for a child’s rapidly developing brain, as play allows us to learn how to respond to unexpected situations, create, imagine, work well with others, and problem solve. Motor skills are developed by exploring movement in a variety of stimulating situations and environments, which simply cannot be taught in a classroom. For gardener parents, this goes without saying. Those with the gardening style are not concerned with controlling their children and who they will become, but rather providing safe spaces and experiences to allow their children to explore. This style facilitates a dynamic and nurturing environment in which a child is intrinsically motivated to learn, explore, create, and connect.

How does this apply to us adults? Many of us lose our child-like minds as we go through life, seek fewer new experiences, and develop habitual ways of being. We are less likely to question the status quo, spend less time engaging in “play”, and may find it more difficult to learn new ways of being and thinking. Although this is partly because of the pruning that the brain does as we emerge into adulthood (inhibitory control develops which impacts decision making and decreases impulsive behavior)2, it is likely more related to cultural influences. This shift that occurs can be tied back to childhood, as the traditional educational systems tend to fit the “carpenter” model. As we go through childhood into adolescence, we are encouraged to forget about play. We are taught that we must fit into a specific mold measured by standardized tests, and more effort will make us more successful adults.

When it comes to a physical injury or mobility issue, the carpenter mindset can impede our healing. We may become limited in our ability to explore our bodies in a healthy, nurturing way, for our carpenter tendencies might lead us to believe that we have to be strict, rigid, and “correct” with the way we engage with ourselves. 

Let’s consider the example of the supine pelvic clock, a foundational movement of the human body that anyone who has been a client at the Wellness Station is likely familiar with. It is done in a lying down position with knees bent, with the idea of an imaginary clock underneath the pelvis (12 would point towards the head, 6 towards the feet). This type of movement is also commonly prescribed in traditional physical therapy, although typically referred to as a pelvic tilt. The manner in which it is taught might be more reflective of the carpenter mindset, which can detract from the experience.

Consider the following hypothetical conversation between a “carpenter” physical therapist and a client:

Carpenter

Client: How do I do this movement?

Therapist: Tilt your pelvis to flatten your low back against the ground. 

Client: What is this doing for me? 

Therapist: You are finding the correct position for your back- this will protect your spine and strengthen your core. 

Client: What is the correct way to breathe?

Therapist: Breathe out as you flatten your low back, breathe in as you go the other way. 

Client: How many should I do? 

Therapist: Perform three sets of 10 repetitions of this exercise.

Now, same questions but the gardener therapist: 

Gardener

Client: How do I do this movement?

Therapist: Begin to rock your pelvis towards 12 o clock by pressing through your feet and allowing the space between your low back and the ground to decrease. Now, move your pelvis in the opposite direction, towards 6 o clock, allowing the space under your low back to increase.

Notice which parts of you begin to make more contact with the ground, and which parts might lift away.

What sensations are associated with going towards 12? How about going towards 6? Which body parts do you feel are moving? What can you do to bring more ease and comfort into this movement pattern? What variations of this movement pattern can you explore? 

Client: What is this doing for me? 

Therapist: This is a foundational movement of the human body that is providing an opportunity for learning to occur. We can use it to calm the nervous system, improve awareness and ease of movement, and gently stimulate areas of your body that may be contributing to your pain patterns. 

Client: What is the correct way to breathe?

Therapist: Rather than believing there is a correct and an incorrect way to breathe, recognize that life is dynamic and our bodies will naturally breathe for us in ways that will depend on the situation. Begin to become aware of how your breath is responding to the movement. Is there a feeling of synchrony between breath and movement?

 Client: How many should I do? 

Therapist: Take your time exploring this movement, and rest often. There are no specific number of sets and reps that I will prescribe. It is up to you to listen and respond to what your body is asking for. Once you do not feel like being attentive to this movement anymore, it is time to explore something else.

It may be clear that the actual movement is not as important as the context and the manner in which it is performed. Embracing a child-like mind and a “gardener” attitude in relation to the body is the recipe for healing and graceful aging. Our bodies have the tools they need to heal, but we must provide the right environment in order for them to heal. Healing requires an environment that is nurturing, compassionate, and dynamic, the same kind of environment we hope to provide for our children. Throughout your experience in therapy and beyond, consider moving away from the rigidity of a carpenter mindset, and begin to consider how you can become a gardener for the sake of your healing journey. 

References: 

1.https://www.npr.org/sections/goatsandsoda/2018/05/28/614386847/what-kind-of-parent-are-you-carpenter-or-gardener 

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6721973/ 

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Turning Chores into Cheerfulness: PT in the Kitchen

How often do we all find ourselves in the kitchen, scrubbing away at the never-ending pile of dishes, chopping, cooking, wiping surfaces, sweeping, and otherwise trying to get back to the baseline cleanliness that we hope to maintain? For many of us, these activities are a chore, and we look forward to being able to put our feet up and bid the kitchen farewell. For those of us with mobility issues and/or pain, standing for a long time in the kitchen while performing these highly physical tasks of bending, reaching, and turning can become extremely tiresome and even insurmountable on a bad day.

Here are a few tips and tricks for turning these dreaded chores into a much more enjoyable experience:

Try silly moves!

Turn your kitchen activities into a dance. Turn on your favorite music that gets you moving and grooving. Sing along and dance to the music as you wipe down counters. Glide your hips around as you scrub the dishes. Take a break every so often from the task and just move to the beat. This will make the activity far less repetitive, it will allow you to move your body in a variety of ways, and you will begin to associate an otherwise unenjoyable activity with joy. 

Make it a practice in mindfulness

If you have a regular meditation practice, you may be familiar that the intention of mindfulness is to be fully present (and non-judgmental) at any given time. For many of us, we may intend to meditate regularly but perhaps feel like we don’t have the time, and easily let the habit slip away throughout the business of life. So why not make something we already have to do a practice in mindfulness? Practice bringing your full, complete attention into the task at hand, breaking free of judgment and reactivity. Feel the wetness and heat of the water, the weight of the dishes in your hand. Notice where your mind goes when the task may present with frustration, such as dried food caked onto the dishes, accidentally dropping a fork into the metal sink, etc. Can we flex our “mindful muscle” as we perform this activity that we don’t love to become more present in what we are doing? You may find that this makes the chore more engaging, interesting, and enjoyable.

Consider biomechanics

Many Wellness Station clients describe activities in the kitchen as extremely limited due to pain or mobility challenges. Trying silly moves and mindfulness can help in these situations. In addition, we want to consider some biomechanical principles to make sure we are moving with the least strain on our joints as we do these physical tasks. Here are some tips: 

• Whenever bending to lift something (such as a dish from the bottom rack), send your pelvis back as you bend down, and tuck your pelvis under as you stand up. Read our blog post on Bending & Lifting. When in doubt, consider moving your pelvis opposite of where you are reaching. 

• When reaching overhead (e.g. putting a glass on the top shelf), consider how you can use your body more efficiently. If reaching up with the right hand, glide your pelvis to the right, and allow your left heel to lift up. You should feel the right side of your body lengthening, and the left side shortening. 

• Use your body weight to help with repetitive tasks. For example, when wiping down a surface, sweeping, or vacuuming, try shifting your weight from side to side. In other words, don’t wipe with your arms, but wipe with your hips. 

If these cues are not fully clear, your Wellness Station therapist can help clarify by providing individualized movement lessons to help you and your brain figure out how to perform any of these tasks with greater efficiency and ease.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Wellness Station for Athletes: Hit or Miss?

We have been asked before whether our approach here at the Wellness Station is suitable for athletes. Regardless of age and sport, the care provided at Wellness Station can be extremely beneficial, as we are able to offer care that typically isn’t found in traditional physical therapy practices. Most athletes, particularly in high school or college, are well exposed to strength training and conditioning. Traditional rehabilitation for sports injuries tends to follow this formula of repetitive and progressive loading of the injured area.

What these athletes are not exposed to is neuromuscular re-education and self-care strategies that will help them heal from their injury and minimize the chance that future issues will occur.

When it comes to athletes, our approach truly shines when it comes to recurring injuries. Traditional PT may be great for an athlete with an acute one-off situation, e.g. a football player is tackled and sprains their ACL, etc. However, more often there is an underlying pattern at play, particularly for athletes with a history of repeated injuries. This may look something like tendonitis that pops up in multiple places, a history of concussions, back pain following athletic events, and so on. What we address here is not one body part in isolation, but how the body works together as a whole using biomechanical principles. Traditional rehab generally does not address the underlying movement patterns that may be setting these athletes up for injuries in the first place. We can help athletes to become aware of dysfunctional patterns and habits that may be detrimental to their performance, and provide movement lessons to stimulate kinesthetic learning and positive changes in these areas.

Athletes are very used to being told to push, push, push. Train harder, faster, and stronger. If dysfunctional movement patterns are at play, pushing harder will only add fuel to the fire. Additionally, the mindset of only pushing harder creates a relationship in which the athlete only works on their body, and has difficulty working with their body. The sport itself becomes work, and joy can start to be removed from the equation, potentially leading to burnout.

For sustainable performance, the athlete must unite mind and body into a state of flow, recognizing their own limits and honoring them.

The ability to slow down and listen to one’s body is often completely missing for most athletes, as they are so accustomed to being rewarded only for external achievement. The approach here at the Wellness Station can help athletes to reconnect to their bodies and find joy in movement. This facilitates a deeper connection with one’s body, thereby improving intrinsic motivation for the sport. This will help athletes improve their performance over the long term, avoid repetitive strain injuries, and find more enjoyment in their sport and daily lives. 

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Effort vs Discipline: Creating a Sustainable Home Exercise Program

A sustainable movement practice is not about doing easy things- it’s about making difficult things easy, and even elegant.

Think back to a time where you may have had difficulty with the sustainability of your home exercise program. Perhaps you attended physical therapy for a while, but would not find time to practice your exercises at home. Or you did for a while, but after stopping therapy, the exercise routine started to fade away. Maybe you found you lacked the discipline or the motivation to perform the exercises regularly.

On the other hand, perhaps you had an exercise routine that was simply too much. You put in excessive effort into it, and you found that it was energy-draining, and perhaps actually felt worse after doing the exercise rather than better, and eventually you began to avoid it. These kinds of routines are not sustainable- they do not last over time. 

What are some keys to creating a sustainable routine to maximize the therapeutic effects? Finding the balance between effort and discipline is very important. We want to have discipline- the ability to train ourselves in a consistent, habitual way. However, we don’t want our movement routine to be overly effortful. If we put in too much effort into the movements, we won’t look forward to doing our routine, because it will drain our energy and not be very enjoyable.

You may recall that Feldenkrais-inspired movement lessons emphasize whole body coordination and thus the same action is now accomplished with LESS EFFORT -that is why, especially to children, highly skilled athletes make very difficult activities look easy!

Rather than striving for a strict discipline in which we force ourselves to go through effortful motions, how can we develop a sense of playful discipline, in which we regularly engage in enjoyable movements?

One mantra to consider is a little bit, very often, with ease. It can be difficult to develop a consistent routine in which we are engaging in movement very often. Some helpful strategies could be creating a safe space to dedicate to movement at the same time every day, perhaps first thing in the morning. This may start out as a very short time, five or 10 minutes, and may gradually expand as it becomes more habitual. Gentle movements should also be sprinkled throughout the day, especially during prolonged sitting. One might consider a reminder system such as a phone timer for a brief movement break each hour, or putting up sticky notes near the computer screen. After the initial growing pains of establishing these lifestyle habits of moving very often with ease, positive habits will be formed that will make it much easier to sustain these changes over time. 

An excellent way to build discipline and improve motivation is to focus less on the outcome, and more on the experience. For example, consider healthy eating habits. One strategy is to educate people on how terrible sugar is for you, and all the health benefits of green vegetables. This strategy actually might not be that helpful because it focuses too much on what we should and should not do. However, most of us have a tendency to crave things that perhaps we would be better off without. Only engaging in things we “should” be doing can be draining on our will power. A better strategy would be to fully engage in the experience of a positive health behavior. Take time to slow down and enjoy that delicious veggie bowl. Consider all the nutrients that soaked in from the soil and sunlight, the stunning visual of all the colors, the smooth or crunchy textures, the explosion of tastes in your mouth, and the embodied sense of nourishment after giving your body the building blocks it needs.

Now, apply this to movement! Try not to force yourself to do something just because you think you should be doing it. How can you fully experience the movement? What sensations can you feel? How might it be nourishing your tissues? What can you learn about your body and your tendencies while engaging in movement? What can you have gratitude for in regards to how your body functions? How might this impact the quality of your experience and your relationship with healthy movement practices- and your whole self?

Rather than striving for a strict discipline in which we force ourselves to go through effortful motions, how can we develop a sense of playful discipline, in which we regularly engage in enjoyable movements?

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team