The Dodgy Knee Cheat Sheet

Teaching students with knee osteoarthritis

A student tells you they have arthritis in their knee. What do you actually do with that information?

Do you avoid deep knee bends? Give them a blanket every time you kneel? Tell them to skip Sun Salutations? Make everything a little gentler?

And how practical is all of that in a busy "gym" yoga class?

Osteoarthritis isn't simply a case of a joint being "worn out" and therefore needing to be protected from movement. Exercise, including strengthening, is actually one of the core treatments recommended for osteoarthritis.

But knowing that and teaching a student with an arthritic knee in the middle of a normal yoga class are two rather different things.

So that's what this Cheat Sheet is about.

First, what is osteoarthritis?

Arthritis isn't one condition; there are many different types. Osteoarthritis (OA) is the most common and frequently affects the knees, hips and small joints of the hands.

It was traditionally described as "wear and tear", but we now know that's too simplistic. OA involves changes to the cartilage, bone and other tissues within the joint and can cause pain, stiffness, swelling and reduced movement.

And just to distinguish the two: osteoporosis affects the strength and density of bones; osteoarthritis affects joints.

Now, what do we actually do with that information when someone turns up to class and says:

"I've got arthritis in my knee."

1. Ask before you modify

"I've got arthritis in my knee" doesn't actually tell you what that person can or can't do.

Ask what tends to bother it. Is it kneeling? Deep knee bends? Putting weight through it? Getting down to the floor and back up again? Repeating a movement several times? Have they already found ways of doing things that work for them? Have they been given any particular advice by their physio or doctor?

You're not diagnosing or treating their knee. You're finding out what you're actually working with.

TEACHER CHEAT: ASK FIRST

Don't modify the diagnosis. Find out what movements actually bother this knee.

2. Change the dose

A pose doesn't necessarily have to disappear because the knee doesn't like the version you're teaching. You can change the range, load, repetitions, duration, speed or support.

Take Warrior II.

The traditional alignment goal might be a front thigh approaching parallel to the floor and the knee at roughly 90 degrees. But that's a choice, not the definition of Warrior II.

Try less knee flexion. The student can still press firmly through the foot and work the legs and hips without taking the knee as deeply into flexion.

Or make it dynamic. Bend the front knee a little on an inhale, straighten it on an exhale and explore the range that feels comfortable today.

And play with the stance. Does heel-to-arch feel better than heel-to-heel? Does shortening the stance change things? What happens if they widen it slightly? Different bodies, and different knees, may prefer different positions.

TEACHER CHEAT: CHANGE THE DOSE

Less bend • different stance • support • dynamic movement • fewer repetitions.

3. The Sun Salutation problem

This is where modifying for an arthritic knee gets much harder in a real class.

You want to teach five Sun Salutation A or Bs. Most of your regular students know what they're doing and want to flow. But one student finds repeatedly getting from standing to the floor and back again difficult.

You don't have to stop teaching Sun Salutations.

What I would do, and this is just a suggestion, is start by modifying the Sun Salutation itself. Rather than repeatedly travelling all the way from standing to the floor and back up, take the class down once and spend a few rounds, flowing or ‘rolling’ between Downward Dog, Plank and Cobra/Upward Dog, before bringing everyone back to standing. (I've heard this called Rolling Dog, Wave Flow or Spinal wave).

Or from Down Dog you could step the right foot forward to replace the right hand and either come into a twist with the left hand on the floor, or come up into a Lunge or Warrior I. This means the people who find getting up and down difficult can stay closer to the floor while everyone else can rise up.

Another useful transition from Down Dog is to walk the hands back towards the feet rather than stepping the foot forward between the hands. From there, soften the knees and use the hands on the legs for support as you gradually roll or work your way back up to standing.

This isn't "law"; it's what I might do. There are lots of options. But seeing as we can probably cue Sun Salutations whilst doing a crossword, and most of our regular students kind of know what they're doing, we have time to offer alternatives that don't feel like a lesser option. It just needs a little planning.

The important bit isn't finding one official "arthritic knee Sun Salutation". It's recognising that the transition itself may be the problem, and finding a way for that person to continue moving with the class rather than standing at the back waiting for everyone else to finish.

TEACHER CHEAT: SUN SALUTATIONS

The transition may be the problem, not the poses. Look for ways to reduce repeated floor-to-standing transitions while keeping the student moving with the class.

4. Kneeling: first work out what hurts

"Put a blanket under your knee" is our standard yoga-teacher response to uncomfortable knees.

Sometimes it's exactly what they need. If pressure on the front of the knee is uncomfortable, more padding can make kneeling much nicer.

But if the problem is deep knee flexion, adding another blanket underneath the kneecap doesn't change the amount the knee is bending.

For example, in Virasana (Hero Pose), sit them higher on blocks or a bolster so the knee doesn't have to flex as deeply. In Child's Pose, a bolster under the body or support between the thighs and calves may reduce the amount of flexion, but sometimes the best modification is simply another resting pose.

And watch the phrase:

"If you need a rest, take Child's Pose."

For somebody whose knees hate deep flexion, Child's Pose may be anything but restful.

Offer Constructive Rest, Savasana or another position that actually feels like rest. Happy Baby may work beautifully for some people too, but because it also involves significant knee flexion, don't assume it's automatically the knee-friendly option.

TEACHER CHEAT: KNEELING

Pressure hurts? Add padding. Flexion hurts? Reduce the bend or change the position.

5. Look at your sequence, not just your poses

You could modify every individual asana beautifully and still make the class miserable for somebody with arthritic knees.

Standing → kneeling lunge → Down Dog → standing → squat → Forward Fold → Tabletop → Down Dog → standing...

That's a lot of getting up and down.

So look at how often you're asking people to get up and down. Where possible, group your standing poses together, then come down and do your floor work rather than constantly travelling between the two.

You don't have to organise every class this way, but if you know somebody struggles with floor transfers, look at your sequence through their eyes before you teach it.

TEACHER CHEAT: SEQUENCING

Look at the cumulative transitions, not just the individual poses.

6. Don't make everything gentle

This is an easy trap. Student says "arthritis". Teacher immediately removes anything remotely demanding. But muscles need resistance to stay strong, and strengthening exercise is an important part of managing osteoarthritis.

Chair Pose, supported squats, Bridge, standing poses and balance work can therefore all be useful.

The aim isn't:

How can I stop this knee being loaded?

It's:

How can I give this person an amount of load they can manage?

TEACHER CHEAT: STRENGTH

Don't automatically remove load. Find a manageable amount.

7. Remember that repetitions are load too

Perhaps your student can comfortably do Warrior II. Great. But you've put Warrior II into three different flows, you've already done five Sun Salutations and you're about to add Chair Pose. One repetition and ten repetitions aren't the same demand.

So think about the cumulative load of the whole class, not just whether an individual pose is suitable.

They might reduce the depth for subsequent rounds, make the pose dynamic rather than hold it, or simply do fewer repetitions. The Yoga International resource listed below suggests reducing repetitions when repeated movements aggravate symptoms.

TEACHER CHEAT: REPETITIONS

One comfortable repetition doesn't mean ten will be comfortable.

8. Move the challenge somewhere else

Modifications sometimes don't work as well as they could in real classes because students don't necessarily want to be in Mountain Pose or Savasana while everyone else is doing something. Even if we've told them that resting is absolutely fine, it can still feel like I can't do what everyone else can do. (Yoga envy ;-)

So rather than simply removing the challenge, sometimes move the challenge somewhere else.

Let's say we're in yet another lunge and I'm thinking poor knees, here we go again. I might say:

"If you want more strength work, hover your back knee towards the floor. Or, if your knees have had enough, straighten the legs a little and take Eagle arms, focusing on spreading across the upper back and lifting the elbows away from the chest."

Both students still have something to work with; they're just choosing where they want the challenge.

And if someone is sitting out a repetition altogether, give them something purposeful to explore while they wait to rejoin: balance, calf raises, foot work, shoulder mobility or breath.

Even Mountain can become interesting. For someone who is steady and confident, closing the eyes or changing the position of the feet on an imaginary tight rope can turn it into a balance challenge. If single-leg balance is comfortable, Tree can be adapted too: keep the toes of the lifted foot on the floor, reduce the time or use the wall for support.

These aren't specifically "knee arthritis exercises". They're examples of how we can give someone something interesting to explore without making them feel they're simply doing less than everybody else.

TEACHER CHEAT: MOVE THE CHALLENGE

Reducing the demand on one part of the body doesn't have to mean reducing the whole practice.

9. Don't turn them into The Person With The Knee

Once you've spoken to them and established some useful options, let them practise.

You don't need:

"Sarah, because of your knee, don't do this one."

I know there can be good intentions behind this. Sarah knows you've remembered her knee and perhaps everyone else thinks what an attentive teacher. But every time we do it, we're also reinforcing an identity: Sarah becomes The Person With The Knee.

There's a little yoga philosophy hiding in here too. Yoga asks us to notice how readily we identify ourselves with labels, roles and stories: I'm stiff. I'm old. I've got a bad back. I've got dodgy knees. We don't necessarily need to reinforce those identities every time we teach.

Instead:

"If deeper knee flexion isn't comfortable today, stay a little higher."

Sarah hears it.

So does the person at the back who didn't tell you about their knee, the person whose knee is inexplicably grumpy today and anyone else who simply prefers that version.

Good modifications don't always need labels.

TEACHER CHEAT: DON'T LABEL

Teach the option, not the diagnosis.

10. Ask what happened afterwards

Something can feel absolutely fine during class and complain later, so what happens afterwards matters too.

But this doesn't have to become another knee-specific interrogation. Ask the whole class occasionally:

"How did your body feel after last week's practice?"

Or, if you've been working with something specific:

"Did anyone notice anything later that day or the following morning?"

You're encouraging everyone to notice how the practice affects their body rather than relying entirely on how something felt in the moment.

And if someone tells you their knee, shoulder or back wasn't happy afterwards, that's useful information for both of you when deciding the dose next time.

TEACHER CHEAT: CHECK LATER

Don't only ask how it feels in the pose. Teach students to notice how their body responds afterwards too.

THE 30-SECOND KNEE CHECK

A student says: "I've got arthritis in my knee."

WHAT ACTUALLY BOTHERS IT?

Kneeling • Deep flexion • Weight-bearing • Repetitions • Floor transfers

WHAT CAN I CHANGE?

Range • Load • Repetitions • Duration • Speed • Support

LOOK AT THE WHOLE CLASS

Am I repeatedly sending them up and down? How much knee load am I accumulating through repetitions?

KEEP THEM INVOLVED

If I reduce the challenge at the knee, can I move the challenge somewhere else?

DON'T SINGLE THEM OUT

Can I teach the option to the room rather than continually giving one person their "bad knee modification"?

CHECK THE AFTERMATH

Encourage students to notice how the practice felt later that day or the following morning, not only how it felt in the pose.

The aim isn't to have a special collection of "arthritic knee poses" ready to pull out whenever somebody mentions osteoarthritis.

It's to get better at changing the practice without unnecessarily removing the person from it.

Happy Teaching

Sandra x

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*A note on sources: This Cheat Sheet draws on current osteoarthritis guidance and research, alongside a Yoga International resource on adapting yoga for arthritis. The yoga-specific suggestions are practical teaching adaptations, not prescribed treatments for osteoarthritis.