Knee osteoarthritis is one of the most prevalent joint conditions in perimenopausal and postmenopausal women. If you’ve experienced knee pain and thought it might be arthritis, you have likely heard the following said by one (or many) healthcare providers:
- It’s “bone on bone”
- Arthritis is “wear and tear”
This is usually followed up with “Go to physical therapy!”
But what is really happening in a woman’s knee joints in menopause? And what can be done to relieve this common joint pain condition?
What does “bone on bone” or “wear and tear” really mean?
In simple terms, “bone on bone” refers to decreased joint space between the ends of two bones. This is commonly used to describe arthritis where the lower end of the femur (thigh bone) comes into contact with the upper end of the tibia (lower leg) to form the knee joint. In between the femur and tibia, there are a whole host of ligament and cartilage structures that provide stability, promote shock absorption, and cushion the bones from various forces.
As we age, it’s normal for this cartilage to undergo changes, ultimately decreasing its size and thickness, roughening the cartilage, and creating increased friction in joint surfaces. These changes can be likened to discovering grey hairs—a very normal part of the aging process.
What’s really interesting to note here is that 43% of uninjured adults over the age of 40 have changes described as “bone on bone” with absolutely no pain (reference).
So now, you might be asking: Why do I have “bone on bone” AND pain? Let’s dive deeper.
Join Pain vs Pain Sensitivity
Many adults go about their days not knowing or understanding the complexity of their anatomy. They might have a bulging disc, spinal stenosis, knee osteoarthritis or a labral tear, but walk around with no pain. So why is it that sometimes we could be told we have “severe arthritis” and feel absolutely fine. Or other times be told the arthritis is minimal, but we have the worst pain imaginable?
Think of your body as an alarm system that has two modes, on and off.
When the alarm is turned on, it is constantly monitoring the environment for any abnormal changes and will trigger a police response if activated. Sometimes, our bodies stay in the on mode all the time, which is often the result of increased inflammatory signals. As a result, even the smallest stimulus will be perceived as extremely painful and trigger the alarm to go off. Think of a windy day where the tree branches are blowing aggressively towards your window. They might make noise or shake the window panel and trigger the alarm by accident, but is someone breaking into your house? No.
Unfortunately, increasing inflammatory signals is the body’s natural way of responding to injury. The human body has a way of trying to heal itself before requiring outside interventions such as medications. Some bodies respond better to this healing process than others, which is why pain varies person-to-person.
Research on knee osteoarthritis points out that symptoms of pain, tightness, and decreased function are likely more due to chemical (inflammatory), rather than mechanical (changes to cartilage) problems.
Knee Joint Pain in Menopause
Interestingly enough, most studies that investigate osteoarthritis are with male subjects, yet osteoarthritis is more common in women (reference). This higher prevalence is due, in part, to menopause related changes. Let’s explore the physiologic changes that occur in menopause.
Menopause is a period of time when a woman’s body stops producing estrogen and ultimately marks the end of menstruation. Estrogen plays a crucial role in maintaining bone density, influencing cognitive function and mood, modulating our inflammatory response and promoting cartilage health (reference).
With loss of estrogen, one can experience:
- Decreased bone density (osteopenia/osteoporosis)
- Loss of muscle mass
- Tendon irritability (tendinopathy)
- Cartilage changes (osteoarthritis)
- Poor sleep quality
- Decreased energy
- Weight gain
- Brain fog… and more
What we commonly hear when a patient with knee pain comes in for physical therapy:
- My doctor told me I need to lose weight to manage my knee pain
- I can’t squat because it’s bad for my knees
- Won’t lifting weights create more damage to my knee joints?
- My doctor says I should try low impact exercise like biking and swimming
- I used to love running. I wish I could pick it up again, but not with these knees
Sound familiar? All of the above statements are misleading, and unfortunately, limit your potential for recovery.
Here are 3 things you can do to mitigate menopausal joint pain and continue living life to the fullest
1. Strength Training
Strength training, or exercising with weights, can help you effectively manage and mitigate the negative effects experienced with knee osteoarthritis.
Research shows that a sedentary lifestyle is often associated with knee arthritis. One study found that patients at risk of knee osteoarthritis can improve the quality of their cartilage and improve joint symptoms and function with moderate exercise, particularly with weightbearing strength training (reference).
Strength training has been shown to increase:
- Bone density—bonus for perimenopausal and postmenopausal women
- Synovial fluid—the body’s natural mechanism for lubrication between joint surfaces
- Muscle mass—provides support for your joints
- Endorphins—pain relief drugs produced naturally by your own body
Other benefits of strength training:
- Do more in life, later in life, with ease. Hello independence!
- Increase your walking speed
- Decrease your risk of falling
- Improved metabolic health—increased insulin sensitivity and more responsive metabolism
- Improved blood flow and oxygen delivery to your tissues which can decrease pain and improve muscle endurance
- Lower your risk of cognitive decline (reference)
Seriously. If strength training provides all these benefits, why not get started now? Long story short, there is no time to waste!
Here are some exercises (you’re probably already doing) that can be easily progressed within your daily routine and home environment:
- Sit to Stands (a.k.a. SQUATS!)
- Whether from the couch, chair, the toilet, or a weight bench, each one
- Don’t have weights at home? Hold a heavy book, load books into a backpack… or just invest in some weights already. They will serve you for a lifetime of resistance exercise.
- Check out the tutorial by Dr. Caitlin Casella below on finding a comfortable way to squat with knee arthritis.
- Climbing Stairs
- Depending on where you live (city, suburbs, country, etc.) you may or may not encounter stairs on a regular basis.
- Whether you need to go up and down stairs or not, the step-up is a great exercise for strength, single leg balance, coordination, and can be a powerhouse for knee health.
- Find a bottom step or curb and work on ascending/descending to improve your thigh and hip strength.
- Here’s a short video demonstration of how you can use a stair, or in this case a step stool, with a weight in either hand:
2. Aerobic (Cardio) Exercise
As discussed above, symptomatic knee arthritis is an inflammatory condition. Addressing a systemic problem with systemic improvements in fitness can be a real game change for relief.
What does this mean?
It’s not always about treating one body region (in this case the knee joint and surrounding soft tissues) but about improving the health of the whole person to decrease pain and improve function. This is where aerobic, or cardiovascular, exercise comes into play.
Like strength training, aerobic exercise can help relieve menopausal joint pain with endorphins and improved blood flow / oxygen delivery to tissues. By similar but different mechanisms, it also improves metabolic health. And of course the real benefit here, it puts you at lower risk for cardiovascular disease and early death.
Don’t underestimate the general, systemic effects of exercise for joint pain management in menopause. Anything you can do to sustain an elevated heart rate for 15-30 minutes can help.
- Go for a walk, a light jog, or a run
- Running is not bad for your knees!
- Research shows that individuals over 50 years old with osteoarthritis who opted to run by choice experienced improvements in knee pain without adverse structural changes on x-ray (reference).
- If you’re not a runner, go for a long walk or a light jog.
- While you’re at it, you’ll explore your city or neighborhood, discover new places, see your environment in a new light.
- Bonus points if you explore with a buddy and turn your walk or run into social time.
- Use a stationary bike, rowing machine, walk an incline on a treadmill
- Dance around in your kitchen for 15 minutes while you wait for pasta to cook!
Or keep it simple and just…
3. Keep Moving!
Consider movement snacks throughout the day and find activities that YOU enjoy doing. Stand up once an hour, take the stairs instead of the elevator, or take a stroll around the block after your latest Netflix binge.
Ready to do something about your knee pain? Here are three ways I can help:
1. Physical Therapy
If you are local to New York City, come see me for physical therapy. I’ll conduct a thorough clinical examination that covers whole-system health factors as they relate to common musculoskeletal complaints in menopause, a movement screen and physical exam, as well as advice for implementing a strength training program to prevent and treat osteoporosis. Practice Human proudly accepts Medicare and works out-of-network with most insurance plans.
2. Small Group In-Person Strength Classes for Older Adults
For those local to New York City, Durability for Life is Practice Human’s signature small group strength training course. Designed for women ages 65+ who want to feel more confident and capable in daily life and with more demanding physical activity. Appropriate for people with osteopenia, osteoporosis, knee and hip arthritis, and persistent low back pain. Led by physical therapist and strength & conditioning coach Caitlin Casella.
3. Online Strength & Conditioning Course
The Slow Cooker is a comprehensive 15-week online small group strength & aerobic conditioning program designed for women ages 40+. Appropriate if you are perimenopausal or postmenopausal, training with knee or hip arthritis, have osteopenia or osteoporosis, or working with persistent pain. Led by physical therapist and strength & conditioning coach Caitlin Casella.
Author Bio: Dr. Carly Paternite is a physical therapist with a strong interest in neurological rehabilitation and preservation of functional strength throughout the lifespan. We were lucky to have Carly as a PT student at Practice Human in the spring of 2025. Find out more about Carly in her LinkedIn profile.
Next on your reading list: Hip Pain with Menopause: A Strength Focused Guide to Treating Gluteal Tendinopathy
