Knee Pain Basics Part 2

Knee Pain

Programming and Training Thoughts to Reduce Knee Pain

In Part I of our series, we discussed my core philosophy behind knee pain, and how to address it from a theoretical standpoint.  In case you missed it, check it out via the link below:

Knee Pain Basics, Part I

In our second edition, we’re going to talk about specific things you can do within your training program to help alleviate knee pain, or eliminate it all together. While I’m not a big fan of “rules” in training, these are some of the tried and true principles I use in 99% of the programs for knee-pain clients.

Enjoy!

Rule #1 – Vertical shin is your friend

Vertical shin may be the most powerful rule I give you, as almost all knee pain suffers have more issues with deep knee flexion and/or dorsiflexion at the ankle.

When you bend your knee, many think your knee is truly just a “hinge” and it bends forward and back.  This isn’t entirely true.  In fact, when you flex your knee there is a combination of two movements going on:

Rolling – The femur (thigh bone) “spinning” or “rotating” on your tibia (lower leg bone)

Gliding – The femur “gliding” forward on your tibia

The picture below should help illustrate this.

This is something I’ve programmed for years, and in a podcast with Charlie Weingroff we discussed this even further.  When you keep the tibia more vertical, you get a more pure “roll” of the femur, which doesn’t seem to stress the knee as much.  The primary forces you have to deal with are compressive forces.

In contrast, when you allow the tibia to drift forward (increasing dorsiflexion), you get a combination of both rolling AND gliding.  There are always compressive forces involved when you’re standing, but when you get the glide you have shear forces as well.

For this reason alone, most of my knee pain sufferer’s training programs start with vertical shin exercises like pull-throughs, RDL’s, deadlift variations, and possibly even split-squat variations.  Not only do they spare the knee, but they bring up typically weak body parts such as the glutes and hamstrings as well.

Rule #2 – HAMMER hip and ankle mobility

While I’ve mentioned this numerous times in the past, that doesn’t mean everyone is heeding my advice!

Hip and ankle mobility are two of the simplest things you can improve upon to get your knees feeling better faster.  Unfortunately, people assume that they can sit at a desk all day long, and then simply work some foam rolling and mobility magic in their pre-workout routine and all is well.

If you are a big, jacked dude with knee pain, write this down: You probably need to address your hip and ankle mobility on a daily basis!

Products like Assess and Correct give you the tools necessary to customize your warm-up routine and make some major strides with regards to mobility, stability, and movement quality in general.

But pre-workout alone may not be enough.

If you’re really big and/or stiff, or mobility is an issue, try going through a light mobility circuit first thing in the morning.

If you sit all day at work, try purchasing a stand-up desk, or even an Airex pad so you can perform hip flexor stretches while you generate those TPS reports.

And if you’re really big, stiff, and jacked up, you may need to lay off the heavy iron for a few weeks until you get your hip and ankle mobility in order.

I know – sometimes I feel like a pariah having to say these things, but it’s true.  Make a serious effort to improve your hip and ankle mobility, and I think you’ll be shocked at how much better your entire body feels, not just your knees.

Rule #3 – Improve your tissue quality

The focus on tissue quality is something that has really come about in the past 5-10 years. In the past everyone thought it was cool to “get a massage,” and we knew that elite athletes were big believers as well.

That doesn’t mean Regular Joe’s and Jane’s were getting massage on any sort of regular basis, though.

If you’re suffering from knee pain, this is another one of those simple tools that can make a profound difference – and QUICK!  I can’t tell you how many cases of long-term knee pain I’ve seen that have been immediately improved by getting some dedicated soft-tissue work done.

The primary areas people need to hit when suffering from knee pain include the tensor fascia latae (TFL), iliotibial band (ITB), the quadriceps (especially rectus femoris and vastus lateralis), and the calves.

The next question that invariably comes up is, what type of soft-tissue work is best?

People like to debate this point until the cows come home.  Listen:  There are pros and cons to every method.  Some are cheaper and less effective.  Others are more effective and/or powerful, but they aren’t all that affordable.

The idea is to figure out what works for you with regards to time, money and most importantly, results.

Foam rolling is cheap and easy to perform.  If you’ve never foam rolled before and want to learn more about it, I give you a free 47-page manual just for signing up for my newsletter (conveniently located on the right-hand side of the screen).

Massage is definitely a step up from foam rolling.  A good pair of hands can get you moving and feeling better almost immediately.  Unfortunately, good hands cost a lot more money than a one-time purchase like a foam roller. Not to mention, good hands are hard to find!

Active release technique (ART) is even more focused than massage.  Most massage therapists will work in a more “general” sense, and kind of address everything.  In contrast, an ART practitioner will focus on very specific areas – typically scarred, fibrotic or adhered tissues (when two structures basically “stick” to each other).

If you aren’t performing any soft-tissue work in your program, don’t worry about what is best – just start doing something!  Over time, you can try different modalities and see what works best for you and your specific conditions.

Rule #4 – Develop some core stability

Core stability is imperative if your goal is long-term knee health.  But in reality, core stability is imperative if you want just about any joint to stay healthy – it really is that important.

Unfortunately, we’ve still got people arguing over the efficacy of exercises like crunches and sit-ups in a core-training program.  In my opinion, they’re totally missing the boat.

If your only goal is to look hawt at the beach, and you have no regard for your long-term low back health, do all the sit-ups and crunches you want.   If you want more info on this topic, be sure to read my post about Understanding Your Abs.

We can argue until we’re blue in the face as to how efficacious these movements are, but the fact of the matter is we’re focused on the wrong goal.  The goal should be stability – I call it core stability because it’s all encompassing, but it could also be called lumbar stability, pelvic stability, or trunk stability.

The name of the game is stability – NOT movement!

I’ll digress for now, but this topic will be rehashed in the very near future! 🙂

Instead of focusing on the rectus abdominus and trunk flexion, we need to place a premium on developing our external obliques.  The obliques are critical in our “core” equation, as they help control our pelvis, and perhaps most importantly, help bring us back to a more neutral alignment if we’re in a position of anterior pelvic tilt.

Instead of having strong obliques, you’ll often see someone who is very rectus dominant – as a result, they’re not only slouched forward through the shoulders, but they lack pelvic stability as well.

Poor pelvic stability generally leads to an anterior pelvic tilt.  This anterior pelvic tilt leads to ALL exercises being more quad/hip flexor dominant than they should.

And you wonder why your knee hurts???

Instead, we need to get those obliques strong and your pelvis stable.  Getting someone back to pelvic neutral, in a relative sense, makes ALL their lifts more hip dominant.

And for someone suffering from knee pain, this is a wonderful thing.

Rule #5 – Isolate then integrate the hips

I touched on this point previously in Part I, but I wanted to dig a little bit deeper here.

There’s an intimate link between the hips and knees. Weakness or instability in the hips is strongly correlated with knee pain or dysfunction.

Bottom line?  If we want to take a holistic approach to knee health, we need both isolate out the weak muscle groups, and then re-integrate them back into functional movement patterns.

Here’s an example:  Someone is performing a split-squat with their right leg in front, and their hip is adducted (closer to the mid-line relative to their hip) and internally rotated (kneecap points inward).

We could try and cue them out of this all day – and that’s actually the first thing I would try to do.  If someone can successfully perform an exercise without me changing or interfering with their program, I’m all for it.

But if I coach/cue them up and they physically can’t do the exercise correctly, it’s time to address the specific weakness and/or regress the exercise.  In this case, I would focus on addressing the posterior gluteus medius and glute max.

Early in the workout you could start with low-level exercises such as side-lying clams, or even a hip wall slide.  Chances are, these clients have no clue what these muscles are, what they feel like, or how to recruit them.  When I put them in an isolative environment, they don’t have the same preconceived notions of how strong they should be, how the movement should look, etc.

Quite simply, they can focus on using the appropriate muscles.

Once we’ve taught them how to recruit those muscles, it’s time to utilize them in a movement pattern such as the split-squat we discussed above.  Cue them to turn on those same muscle groups – to abduct and externally rotate their hip, to get them in a more neutral alignment.

If you keep hammering away at the integrated exercises, it doesn’t work.

If you only utilize low-level, motor control/facilitation exercises, it doesn’t work.

It only works when you put the two together.

Summary

I hope you now have a better idea of how to develop a training program for someone suffering from knee pain.  If not, you can always pick up a copy of Bulletproof Knees to help you out!

In Part III, we’ll discuss some specific coaching cues and tools you can use to milk these programs for maximum effectiveness.

All the best

Mike

1 Comments

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  1. I've been wondering about your recommendation of the vertical tibia (particularly in Single Leg Solution) as most people coach single leg lunge and split squat variation to allow for some forward drifting of the knee. I was aware of the posterior chain recruitment rationale, but I was not aware of the "rolling" and "gliding" rationale. Thanks for your great work Mike!

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