The Fitness Pilates Blog

Fitness Pilates and Knee Osteoarthritis how can we help?

I’ve been teaching this week at Playitas in Fuerteventura and I’m just about to head home and get ready for the busy September period.

We have so much happening over the next few months, with lots of courses coming up, brand-new workshops and training launching, and more live events in the diary.

The Fitness Pilates Summit is just around the corner and is now completely SOLD OUT, which is awesome We’ve also launched our brand-new HOT Sculpt Training, and it’s been brilliant to see so many Pilates teachers signing up for Lift Lean™ Teacher Training so they can confidently introduce more strength and resistance training to their Pilates clients.

September always feels like a fresh start. Clients are returning from their summer holidays, classes are getting busier and it’s a great time to bring new ideas, formats and education into your timetable.

This Week: Knee Osteoarthritis

This week, we’re looking at knee osteoarthritis – what it is, why so many people struggle with it, the common causes and contributing factors, and, importantly, how we can adapt our Fitness Pilates sessions to support clients experiencing knee pain and stiffness.

We’ll also look at which Fitness Pilates exercises and small equipment can be particularly useful, along with movements and exercises that may need to be modified or avoided.

Fitness Pilates & Knee Osteoarthritis

What is it, why do people struggle and how can we help?

Knee osteoarthritis is something most of us will encounter regularly when teaching Fitness Pilates, particularly when working with midlife and older adults.

You may hear clients say:

“I’ve got wear and tear in my knee.”
“I’ve been told not to squat.”
“My knee is bone on bone.”
“I can’t kneel anymore.”
“Stairs are really difficult.”

And very often the response is to become extremely cautious with the knee.

But movement and appropriately progressed strengthening can be incredibly important for people living with knee osteoarthritis.

So, what do we need to know as Fitness Pilates instructors?

What is knee osteoarthritis?

Osteoarthritis, or OA, is a condition affecting the whole joint.

It isn’t simply the cartilage gradually “wearing out”.

Changes can occur in the articular cartilage, underlying bone, synovium and other structures surrounding the knee.

People can experience:

Pain
Stiffness, particularly after being inactive
Reduced range of movement
Swelling
Crepitus – clicking, grinding or crunching
Reduced confidence in the knee
Difficulty with stairs
Difficulty getting up and down from a chair
Difficulty kneeling
Reduced walking tolerance
Weakness around the knee and hip

One really important point for instructors is that the amount of structural change seen on an X-ray doesn’t always correspond with the amount of pain somebody experiences.

Someone can have significant radiographic OA and relatively few symptoms, while another person can experience considerable pain and disability.

What causes knee osteoarthritis?

There isn’t usually one single cause.

Age is a risk factor, but OA shouldn’t simply be dismissed as an inevitable consequence of getting older.

Factors associated with an increased risk include:

Previous knee injury
A history of significant knee injury, including ligament or meniscus injuries, can increase the likelihood of developing OA later.

Genetics
There can be a genetic component to osteoarthritis.

Body weight and metabolic factors
Higher body weight can increase mechanical loading through the knee, while metabolic and inflammatory factors may also play a role.

Joint anatomy and alignment
The way forces are distributed through the joint can influence OA development.

Muscle weakness
Reduced strength, particularly around the quadriceps, can contribute to poorer physical function.

Occupational and repetitive loading
Certain occupations involving substantial repetitive knee loading may increase risk.

It is therefore better to think of knee OA as multifactorial, rather than simply telling clients that they’ve “worn their knees out”.

Why do people with knee OA struggle?

This is where Fitness Pilates can become really interesting.

Pain can lead to someone moving less.

Moving less can lead to reduced strength and physical capacity.

As the quadriceps, glutes and surrounding musculature become weaker, everyday activities can feel increasingly difficult.

The person moves even less because those activities now hurt or feel unsafe.

We can end up with:

Pain → less movement → weakness → reduced capacity → everyday activities become harder → less movement

There can also be fear around exercise.

If someone has been told their knee is “bone on bone”, they may understandably think:

“Surely exercising will wear it out even more?”

This can create fear avoidance and further reduce activity.

Our role isn’t to diagnose or treat osteoarthritis, but we can help people move appropriately, progressively build strength and develop confidence in what their body CAN do.

Should Clients With Knee OA Squat?

This is a great discussion point.

A diagnosis of knee osteoarthritis doesn’t automatically mean somebody should never squat.

Think about how often we effectively squat during everyday life:

Sitting on the toilet.

Getting out of a chair.

Getting in and out of a car.

Picking something up.

If we remove the movement completely, are we actually helping the person maintain their independence?

Instead, we can modify the squat.

Try:

Sit-to-Stand

Start from a higher chair or box.

Feet comfortable, hinge slightly through the hips and stand.

Initially, hands can provide assistance if required.

Progress towards less assistance and/or a lower seat as appropriate.

Supported Squat

Hold a barre, chair or wall for additional confidence.

Work through a comfortable range rather than insisting on depth.

Mini Squat

A smaller range may be much more tolerable.

Over time, range can potentially increase as strength and confidence improve.

Fitness Pilates Exercises To Consider

The appropriate exercises will depend on the individual, but there are lots of possibilities.

Standing

Supported squats
Sit-to-stands
Mini squats
Hip hinges
Standing hip extension
Standing hip abduction
Calf raises
Supported balance work
Controlled weight transfers
Low-level functional movement patterns

Supine

Glute bridges
Bridge variations
Heel slides
Bent-knee fallout
Hip mobility
Core stability exercises
Straight-leg raises where appropriate

Side Lying

Hip abduction
Small-range leg lifts
Clams
Glute strengthening
Controlled hip mobility

Seated

Knee extension
Marching
Ankle mobility
Sit-to-stand preparation
Seated resistance work

Small Equipment Ideas

This is where we can create lots of variety within Fitness Pilates.

Activation Band / Mini Band

Excellent for adding resistance without needing heavy equipment.

Try:

Band above the knees during a sit-to-stand

Encourage control through the hips and knees without forcing the knees aggressively outwards.

Standing band hip abduction

Useful for strengthening around the hip while using a chair or barre for support.

Standing band hip extension

Maintain an upright posture and use a small controlled range.

Lateral band walks

These can be useful for appropriate clients, but keep resistance and distance manageable.

Band clams

A familiar Fitness Pilates exercise for developing hip strength.

Long Resistance Band

Seated knee extension

The band can provide progressive resistance for the quadriceps.

Hamstring work

Use the band to create controlled resistance where appropriate.

Supported standing hip exercises

Great for progressive hip strengthening.

Pilates Ball

A soft ball can work really well.

Try:

Ball squeeze between the thighs

Gentle adductor activation in sitting, supine or bridge positions.

Bridge with ball

Use the ball between the knees as a cue rather than squeezing it as hard as possible.

Seated ball work

Combine upper-body resistance or mobility with lower-body positioning when standing exercise isn’t appropriate.

Light Weights

Don’t forget that knee OA programming doesn’t need to be exclusively about the knee.

Whole-body strength matters.

Use dumbbells for:

Deadlift/hip-hinge patterns
Upper-body strength
Loaded sit-to-stands where appropriate
Farmer’s carries
Functional strength combinations

Progressive resistance training can become an important part of improving overall physical capacity.

What About Kneeling?

Some people with knee OA find kneeling extremely uncomfortable.

There is no reason to insist on kneeling simply because an exercise traditionally happens in four-point kneeling.

Modify it.

Instead of quadruped hip extension, try standing hip extension.

Instead of four-point shoulder work, try it standing against a wall.

Instead of kneeling mobility, find a standing, seated or supine alternative.

If kneeling is comfortable, padding or folding the mat can make it more pleasant.

But if it hurts significantly, choose another position.

Exercises To Be Cautious With

Rather than having a blanket list of “banned” exercises, think:

What is this person’s current tolerance?

You may need to modify:

Deep squats
Deep lunges
High-impact jumping
Fast directional changes
Repetitive high-volume knee flexion
Prolonged kneeling
Exercises that produce significant or escalating pain
High-resistance exercises beyond the person’s current capacity

That doesn’t necessarily mean these movements are forbidden forever.

Some may simply be inappropriate right now.

Think Load, Range, Repetitions & Tempo

This is a really useful Fitness Pilates coaching framework.

If an exercise aggravates someone’s knee, before removing it completely ask:

Can we reduce the LOAD?

Can we reduce the RANGE?

Can we reduce the REPETITIONS?

Can we slow the TEMPO?

Can we provide more SUPPORT?

Can we change the POSITION?

That gives us so many more options than simply saying:

“You have knee OA, so don’t squat.”

What About Pain?

We shouldn’t promise clients that exercise will eliminate their osteoarthritis or tell them to push through significant pain.

Equally, people with OA don’t necessarily need to avoid every movement because they experience some discomfort.

Pain response is individual.

Watch how the person responds during the exercise and afterwards.

If a new exercise causes a substantial increase in symptoms, swelling, instability or symptoms that remain significantly aggravated afterwards, the programme may need modifying.

And, of course, new, unexplained or worsening symptoms should be referred to an appropriate healthcare professional.

The Fitness Pilates Takeaway

When somebody tells us they have knee osteoarthritis, our first thought doesn’t have to be:

“What exercises must they avoid?”

A more useful question is:

“How can I help this person maintain and progressively improve their ability to move?”

Strengthen the quadriceps.

Strengthen the hips and glutes.

Maintain mobility.

Work on balance.

Include functional movements.

Modify range where necessary.