Bees do, in fact, have knees, although no kneecap; however, the origin of the phrase “the bee’s knees” is rather unclear. In the late 1700s it referred to something of diminutive size but transitioned to its current meaning, something wonderful, in the 1920s. Some think this was a corruption of the word “business,” others believe it referred to a bee pollen–carrying area, but my favorite origin story is that it might be a reference to popular 1920s Charleston dancer Bee Jackson’s active knees.
Most people refer to their knees as “right” and “left,” but if you now describe them as “my good one" or "my bad one,” no bones about it, you kneed to read on.
We understand the importance of proper undercarriage. Wear and tear of wheels, struts, or shock absorbers turns landings from a greaser on the numbers to something less pleasing. After all, nobody wants to hear Ground telling Captain Kangaroo to turn left on Bravo! The same is true of our knees, hardworking joints which endure enormous stress. Walking generates forces several times one’s body weight through the knee, and climbing stairs can double that. Imagine the strain when pulling an aircraft out of the hangar, running, skiing, or hauling baggage across the ramp. Eventually after too many heavy landings, parts wear out. For some aviators, the ultimate repair involves installing brand-new components, a knee replacement.
The knee is essentially a hinge joint connecting the femur (thigh bone) to the tibia (shin bone), with the patella (kneecap) gliding in front. The patella is a sesamoid bone, meaning it lives within a muscle or tendon, in this case the quadriceps, functioning as a pulley to improve muscle action. Smooth, pain-free joint motion depends on cartilage, a slippery tissue coating the bone ends and rear patella surface. Deterioration of cartilage allows bone to rub on bone, creating a nasty grating sound that we call crepitus, which the patient experiences as pain, stiffness, swelling, and limited mobility.
Bear in mind, pain felt in the knee may be related to a problem higher up, so don’t be surprised if your doctor checks your hips and back first. Additionally, a painful knee can induce an antalgic gait, where one "unloads" the affected joint by throwing more weight on the other side, eventually causing hip pain in that side.
The most common culprit is osteoarthritis, a degenerative process that for decades was described as due to “wear and tear” but is now known to be a complex, whole-joint disease involving mechanical stress, low-grade inflammation, and abnormal tissue repair impacted by age, prior injuries, obesity, and genetics. The cartilage thins out, bone thickening and thinning occurs, sharp spurs develop, and the joint space shrinks. The pain is worse with activity and is helped by rest, so nice an’ kneesy does it.
The word arthritis means inflamed joint and in conditions like rheumatoid arthritis, or joint manifestations in psoriasis, a skin disease, the immune system attacks joint-lining tissue. The result is swelling, pain, and progressive joint destruction that can affect multiple joints and start much earlier in life.
Prior injuries such as a torn ACL (anterior cruciate ligament), damaged meniscus, or a fracture alter joint mechanics, which in turn can lead to accelerated cartilage loss. Deformities at birth, infection, gout, or avascular necrosis, loss of blood supply, are less common causes but all manifest similar symptoms, hence the need for a thorough medical evaluation.
Even a small amount of weight loss can markedly reduce stress to the knees—each pound lost removes four pounds of pressure during walking. Low-impact exercise (cycling, swimming, elliptical training) to increase hamstring and quadriceps strength improves joint stability, and improving core strength and balance helps to moderate a disturbed gait that can worsen symptoms.
Suffering is kneedless; over-the-counter pain relievers (acetaminophen) and anti-inflammatories (ibuprofen or similar) can help, but stronger drugs (NSAIDs or selective COX-2 inhibitors like celecoxib) may be required. Remember that choice of medication matters for pilots, as the FAA disqualifies some; always check first, but non-sedating ones are generally acceptable if the underlying cause has been characterized and is stable. Topical gels and creams either containing aspirin, NSAIDs, capsaicin (derived from chili peppers), or menthol help with pain. There are many supplements containing either glucosamine and chondroitin, turmeric or curcumin, or collagen marketed to help address joint issues, although evidence that any benefit can be attributed to them is mixed. Pills containing omega-3 fatty acids have even less evidence to suggest benefit.
If life is keeping you on your toes but your knees complain, steroid injections reduce inflammation and provide significant short-term relief, typically lasting weeks to months. There is concern that steroids impair tissue integrity and should not be considered prior to surgery. There is less confirmatory evidence that single or repeated injections of hyaluronic acid, a jelly-like substance that can lubricate and act as a shock absorber, are beneficial. Platelet-rich plasma (PRP), a concentrate of the patient’s own blood, can be injected, and research suggests potential benefits for mild-to-moderate arthritis. Stem cell injections are heavily marketed but remain controversial with limited supporting evidence to show consistent benefit. Various protective joint cushions such as hydrogels and cartilage scaffolds are being explored and may represent future alternatives to full joint replacement.
Eventually, many patients complain that pain is persistent and disturbs sleep despite maximal therapy, walking is limited and activities of daily living are reduced. At this point knee arthroplasty is considered, with artificial components replacing damaged anatomy. These consist of a metal component that sits at the end of the femur, a metal baseplate on the tibia, and a plastic spacer to act as cartilage. Although all are most commonly used, in a partial knee replacement, only the affected part is addressed.
Each year, approximately 800,000 knee arthroplasties are performed in the US requiring 60-90 minutes of operating time, usually under a spinal anesthetic plus a nerve block to limit pain. Hospital stay is limited, with many people going home the same or next day, walking with assistance the day of surgery, driving in 3-6 weeks, and returning to normal activities 6-12 weeks aided by physical therapy and self-motivation.
Knee replacement ranks among the most successful operations with around 95% of patients experiencing dramatic pain relief and improved mobility. These implants have a life of up to 25 years, and although the first couple of weeks can be challenging, leading some to wish they had not had the surgery, the vast majority state thereafter that they wish they had agreed to have the operation years earlier.
If your painful knee is better at predicting the weather than 1-800 WX BRIEF, self-ground until things improve. Should you require arthroplasty, self-ground until fully recovered. Before returning to the cockpit, you must have normal strength and mobility, be off any disqualifying medications, and be able to operate rudder pedals comfortably. At your next aviation medical examination, the AME may request documentation including hospital records, operative report, surgeon’s follow-up note, current medication list, and a functional assessment. The key aeromedical principle is simple: if pain or reduced mobility could interfere with safe aircraft control, you should remain grounded. With proper rehabilitation—and a cooperative AME—you may soon be cleared again for smooth landings.
So, if life is fine, but your knees are a grind, don’t have weak knees, taxi over to your local friendly orthopedic surgeon and discuss your options. To find the right doctor, check out the American Academy of Orthopaedic Surgeons, the American Association of Hip and Knee Surgeons, or the American Board of Orthopaedic Surgeons; kneedless to say, they will point you in the right direction.
Fly Well!
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