Knees

When Suzanne Delaney attended liturgy at the Carmelite Monastery in Towson, Maryland, she was pleased to find something missing: Many of the old, knee-crunching prayer benches were gone. In the newly redesigned chapel at the women''''s monastery, Sister Delaney found that the women were standing and sitting for worship.

"Kneeling is not necessarily the only posture for prayer," concedes Sister Delaney, a member of the Congregation of Sisters Servants of the Immaculate Heart of Mary.

That''''s a bonus for the nun''''s knees. With all the things that can go wrong with these crucial joints, long hours of weight-bearing worship are the last thing knees need.

In fact, anyone''''s knees are susceptible to a host of problems, including kneecap pain, bursitis, tendinitis, arthritis and ligament and cartilage tears. Any of these problems can cause discomfort and interfere with your ability to get around. But if you start taking care of your knees early, you''''ll never have to say your prayers for them.

A Pivotal Joint

The knee carries the honor of being the largest and most complex joint in your body. In addition to supporting your weight, it allows your leg to bend, straighten and twist and turn a little bit. Because of this wide range of motion, the knee has been dubbed a modified hinge joint.

The joint is basically the juncture where the femur, or thighbone, and tibia, or shinbone, meet. Another small piece of bone, the patella, sits in a groove at the lower end of your leg. As you bend, your patella slides back and forth in this groove. In fact, if you put your hand on the front of your knee, you can feel the patella move. It''''s that roundish piece of bone generally called the kneecap.

Women''''s knees are made of the same components as men''''s knees, but they are constructed slightly differently. Because women generally have wider hips than men, the upper legs slant inward at an angle to meet the knee joints instead of extending straight down. That angle is what doctors call the Q angle, and the larger Q angle in women can translate into knee problems. "The more the knees bow inward, the more vulnerable they are to injury," says John Feagin, M.D., associate professor of orthopedics at Duke University Medical Center in Durham, North Carolina.

A Cap of Pain

Do you sometimes feel a sharp pain right under your kneecap? Could be your kneecap is literally offtrack a little bit--like a train car that''''s about to derail.

Doctors say that pain under the kneecap is a common symptom of women in their thirties and forties. Often this is caused by increased Q angle. Normally, the kneecap tracks back and forth in a groove as the quadriceps muscle on the front of the thigh contracts (straightening the knee) and relaxes (bending the knee). Since the top of the kneecap is connected to the quadriceps by a tendon, an increased Q angle makes the quadriceps pull sideways on the patella, throwing it out of its groove. This irritates the underside of the kneecap, causing pain in that area.

Not all cases of kneecap pain are caused by the wider Q angle, says Daniel O''''Neill, M.D., medical director of the St. Johns Sports Medicine Center in Nassau, Texas. It can also be caused by underdevelopment in the vastus medialis, the strip of muscle that runs along your inner thigh. The vastus medialis is constantly playing tug-of-war with muscles on the outer part of your thigh. When the inside muscle is too weak, it begins to lose this tug-of-war, and the muscle on the outer thigh yanks the patella offtrack. That can cause pain under the kneecap along its inner edge.

This problem is often seen in women who are just starting exercise programs, according to Gerald Eisenberg, M.D., director of the arthritis treatment program at Lutheran General Hospital in Park Ridge, Illinois. "Either aerobics or jogging or even vigorous walking--or other types of activities--may lead to kneecap irritation."

Easing the Knees

You don''''t have to buckle under to kneecap pain. To ease misery--or prevent it in the first place--here''''s what experts recommend.

Go gradual. "Start out on an exercise program in a graduated fashion," says Dr. Eisenberg.

Equipped for Knee Needs
Using a treadmill, riding a stationary bike and doing step-ups on an exercise step are some of the knee-strengthening exercises recommended by experts. Here are tips for using that equipment. Step up to it. Repeatedly stepping up and then back down again can help strengthen the muscles that support your knees, according to Jeff Coilek, P.T., athletic trainer in the sports medicine division at the Cleveland Clinic in Ohio. Put one foot on the exercise step as shown in the illustration. Step up, then slowly lower back down again. Repeat 15 to 30 times on each leg. Start off with a one-inch exercise step and gradually work up to a two-inch step.
	Correct position. When using a stepper, be sure to keep your back leg near the step, with your torso straight.		Incorrect position. Avoid stepping too far back--or leaning forward too much--when you''''re using a stepper. This puts strain on your knees.
Try the treadmill. If you find that walking outside irritates your knees, try walking on a treadmill instead, says Gerald Eisenberg, M.D., director of the arthritis treatment program at Lutheran General Hospital in Park Ridge, Illinois. Some people find that it''''s easier on their knees, he says. Cycle your knees. Using an exercise bike for your aerobic workout will also strengthen knee-supporting muscles. Just make sure the seat is adjusted to the correct height as shown.
	Correct position on exercise bike. The extended leg is still slightly bent.		Incorrect position. The left knee is "locked"--and could be strained and injured.

Dr. O''''Neill adds another guideline: Increase the intensity or duration of your exercise by no more than 10 percent each week. So if you are jogging 30 minutes one week, don''''t suddenly try to run an hour the next week. Instead, increase your time to about 33 minutes the second week, 36 or 37 minutes the third week, and so on. These increases sound small, but that''''s the point. By adding just a little bit, your knees have a chance to adjust comfortably.

Chain your feet. Exercises where your feet stay in constant contact with the ground or floor are called closed-chain exercises. They''''re great for building up the muscles around your knees, according to Jeff Coilek, P.T., athletic trainer in the sports medicine division at the Cleveland Clinic in Ohio. Some exercise equipment is built expressly for closed-chain exercises, including stair-climbers, slide boards, stationary bikes and exercise steps. To strengthen your quadriceps, try to use this equipment whenever possible, he says.

Do the mini-bend. One closed-chain exercise that you can do without equipment is a mini-bend, which stimulates the quadriceps muscle and helps strengthen the inner thigh muscle, says Coilek.

Stand with your feet hip-width apart. Tighten your buttocks. Keeping your feet flat on the floor, bend your knees just a little bit--to about a 30-degree angle--holding on to a table or chair for balance. Do three sets of 30 mini-bends, pausing for a few seconds between each set.

Take a stork stance. To strengthen one leg at a time, you can do the mini-bend on each leg. Standing on one leg while holding on to a table or chair for balance, do three sets of 30 repetitions. Then switch to the other leg and repeat the routine.

Strength train for better knees. If you are going to participate in a weight-bearing exercise program, it''''s a good idea to do a strengthening program for the quadriceps muscles too, says Dr. Eisenberg. "The stronger those muscles are, the truer the patella tends to move in the groove in the underlying femur."

Plica Pain

Though it sounds like a mineral layer under the earth''''s crust, synovial plica is actually a ridge of tissue that runs just underneath or along the inside border of the kneecap. It can sometimes become irritated or inflamed, according to Dr. Eisenberg. "It''''s a fairly common thing in joggers and skiers and other people who are fairly active."

When your knee is slightly bent, you can actually feel the plica. Run your finger along the inside border of your kneecap, and you''''ll touch a small cord of tissue. Dr. Eisenberg describes it as just about as big as a piece of spaghetti. It usually doesn''''t hurt, but if it''''s inflamed, it can be sore to the touch.

The solution? Just give it some rest, Dr. Eisenberg suggests. Take a break from the sport that''''s causing the irritation. When you start again, build up gradually to avoid another round of inflammation. If it continues in spite of the temporary rest, you might want to see your doctor for recommendations, which might include medication or physical therapies such as ultrasound.

Relieving -Itis

Kneecap pain can also be caused by inflammation of the bursa located at the knee joint. Normally, a bursa is a very efficient cushion--a fluid-filled sac that helps reduce the friction between bones and the ligaments that move across them. But if that sac becomes inflamed, you have bursitis--and it can hurt like the dickens.

Suspect bursitis if your kneecap is not only sore but also red, warm, swollen and very tender to the touch. A very common form of knee bursitis in women ages 30 to 45 is prepatellar bursitis, which causes pain on top of the kneecap, says Dr. Eisenberg. "This has in the past been known as scrub woman''''s knee or carpet layer''''s knee."

Scrubbing floors on your hands and knees may not be your style, but knee bursitis can still sneak up on you. If you''''re going to be gardening or doing housework on your knees, be sure to put some kind of pad under your knees, suggests Dr. Eisenberg. You can get knee pads that fasten around your legs or a foam pad to put on the floor. They''''re available at many hardware stores or garden centers. Or just kneel on a pillow when you''''re doing housework.

Another problem is tendinitis in the knee area. You''''ll feel its sting when either the quadriceps tendon or the patellar tendon gets irritated or inflamed, says Dr. Eisenberg.

The best prevention is just taking it easy, especially with strenuous or unfamiliar activities. You''''re leaving yourself open to tendinitis if you''''re using too much weight when you do weight-bearing exercises or if you''''re exercising too vigorously to begin with, says Dr. Eisenberg. Or maybe you''''ve taken up a brand new activity without phasing into it slowly, and you''''re just not used to it.

When Joints Protest Too Much

Arthritis caused by wear and tear can also affect the knee joint, although it''''s usually more of a problem in women over 45, says Dr. Eisenberg. Damage to structures in the knee can cause the joint to shift out of alignment, which in turn leads to degeneration of the bone. Irritation and pain are the result.

You can reduce the risk--or even prevent it--by taking a few sound steps.

Travel lightly. Even if you don''''t have arthritis now, you may be at risk for it later on if you''''re carrying extra weight, says Dr. Eisenberg. To help preserve knee health, keep your body weight under control--with low-fat eating and plenty of exercise.

Be shoe smart. Wearing well-fitting shoes in good condition can help keep your knees healthy. If your foot is out of alignment or improperly supported, that can translate right up to your knee and cause problems there, says Pekka Mooar, M.D., assistant professor of orthopedic surgery and chief of sports medicine at the Medical College of Pennsylvania and Hahnemann University School of Medicine in Philadelphia. Be sure to pick a shoe that is wide enough for your foot and made for the activity you''''re doing--a walking shoe for walking, a tennis shoe for tennis, and a running shoe for running.

Buy your shoes from somebody who understands your needs, Dr. Mooar says. If you have a friend who''''s into walking, ask her if she has found a shoe store with a knowledgeable staff.

Cross-train year-round. The women who think the only way to get exercise is to power-walk or run all the time are headed for trouble, says Dr. Feagin. Cross-training--doing a variety of different types of exercises--can help prevent the wear and tear that comes from doing the same old exercise over and over. To add some variety to your exercise routine and give your joints a little relief, try step aerobics, aqua-aerobics (done in a pool) and plyometrics--exercises that involve jumping, hopping and bounding.

All Torn Up

There''''s a critical structure of tough tissue in your knee called the anterior cruciate ligament (ACL), and when this gets torn, it''''s a serious injury. This ligament plays a major role in stabilizing the knee. ACL tears are more common in high school and college athletes who play sports that require pivoting.

Women playing these kinds of sports are more likely than men to have ACL troubles. In a study conducted at Duke University, for instance, researchers found that women basketball players injured their ACLs six times more frequently than men, says Dr. Feagin. The researchers suspect that the increased injury rate to the ACL may be related to the greater Q angle and the lack of strength of women''''s quadriceps muscles.

For women in their thirties and forties, ACL tears are most often caused by skiing injuries. If you plan to go downhill skiing, prepare for the activity by doing quadriceps strengthening exercises for a couple of months before you go, says Dr. O''''Neill. The stronger your quads are, the better they''''ll support your knee, and you won''''t fatigue as quickly, he says.

See also Joints, Muscular System, Skeletal System