Coaching Your Way to Healthy Knees!
In this final installment of our knee pain basics series, we’re going to cover specific things you can do in your training sessions to maximize your knee health.
If you’ve been living under a rock the past two weeks and missed the first two installments, be sure to check them out first via the links below.
Now, let’s get into the exact things you need to be watching for when you, or your clients, are training.
Are you really coaching vertical shin?
One of the points I discussed at length in Part I is the idea of training with a vertical shin.
Unfortunately, I know how people move. There are numerous times when I give them an exercise that should be performed with a vertical shin, but they still figure out a way to cheat!
Let’s take a pull-through for example. A pull-through should be performed with a vertical shin, and it should be a very hip dominant exercise. Watch how most people perform pull-throughs, though, and you’ll see a different story.
Instead of keeping the chest up and really focusing on pushing the hips back, they get lazy, squat the weight down, and basically use their quads to perform the movement.
What ends up happening is your entire center of gravity drifts forward, and you end up bringing your quads into the lift.
It doesn’t look like much, but doing this time-and-again reinforces poor patterns and strengthens muscle groups that are already strong to begin with.
Instead, think about exaggerating pushing the hips back, and even pushing the hips UP at the end range of motion. I picked up this tip from Olympic lifting coach Grant “Rufus” Gardis and I can honestly tell you my hamstrings have never been so since employing this technique!
You see the same thing in single-leg exercises as well. When someone performs a split-squat, they should be able to drop straight down and keep the front shin vertical.
If someone is very quad dominant, they will have a tendency to let the front knee “drift” forward. While this isn’t necessarily injurious, for someone with knee pain, this could exacerbate his or her condition.
Don’t just pay lip service to vertical shin. If someone has knee pain and you want to keep them healthy, be diligent about watching their shin angles and making sure that they are properly executing the exercises you have programmed for them.
Quit the Knee Cave!
While vertical tibia is huge for sparing the knee in the weight room, another key concept is controlling knee cave. While you’ll often see knee cave in the gym, you’ll see it even more so in sporting events that require hip stability and control in all three planes of motion.
When strength training the feet, knees, and hips should be in a straight line throughout. If you squat down and your knees have a tendency to fall “in,” you have weak hips (primarily glute max and some posterior glute medius) that need to be addressed. This will generally be magnified when performing single-leg work.
Below is a video of one of our distance runners as he transitioned from slow, controlled movements to dynamic, explosive ones. As you can see, he has a tendency to cave his knee not only when he jumps but when he lands as well.
The goal should be to control knee cave, not only in the gym but on the field as well. An inability to control knee valgus and hip internal rotation could result in a torn ACL, MCL, and/or meniscus.
Single-leg work is fantastic for people with knee pain, and it provides some very specific benefits.
Lengthening the hip flexors
Quadriceps shortness/stiffness is a common finding in people with anterior knee pain. A recent study by Witvrouw  determined that in young athletes who developed patellofemoral pain, the painful knees demonstrated a loss of quadriceps flexibility compared to healthy athletes.
Let’s look at this from a training perspective. Watch as Molly (one of my online training clients) performs her split-squat:
As you can see, she not only has a tendency to drift forward on the working leg side, but she is also always in a position of anterior tilt on the trailing leg!
This illustrates my point regarding pelvic control. If she were able to contract the glutes and external obliques on the trailing leg side, she would have better control of her pelvis. Instead, she recruits the muscle groups in which she is strong for stability: her hip flexors and lower back.
Below is a video of myself. In this case, look at my set-up: My glutes and obliques on the trailing leg side are contracted throughout, bringing my pelvis into neutral and my hip into extension.
As I drop down into the split-squat, it gets really hard to maintain this contraction, as I’m moving into an active stretch. Molly and I are actually quite similar in our backgrounds, as we have both powerlifted and relied upon our quad and lower back strength to get us through.
This isn’t to say my technique is flawless, but it should demonstrate that lengthening the hip flexors via pelvic control and hip position is a benefit of single-leg work.
Posterior chain development
Now that we’ve fixed the back leg, it’s time to fix the front leg.
Once the trailing leg glute/oblique is tight, you need to drop straight down to maintain a vertical tibia. Again, check out Molly’s split-squat:
And again, watch how I attempt to drop straight down – not only does this keep the tibia/shin vertical, but it also helps recruit the glutes/hamstrings to a higher degree.
A final benefit of single-leg training is hip stability. Here’s an example of how someone with poor hip stability may set-up when they perform a split-squat. This is Sarah, another fabulous online client.
As you can see, she has very poor hip stability and as a result she’s forced to set-up with a very wide stance. This widens her base of support, making her more stable.
Here’s Sarah a few months later. We really worked to bring up her weak areas (external obliques, gluteals, etc.) and she’s been dialed in and focused on her technique as well.
Sarah still has some work to do, but that’s a huge change in just a few short months!
Finally, the loads are typically far less in single-leg exercises than they would use in a big, double-leg lift such as a squat or deadlift. In the case of someone with knee pain, a reduction in total loading generally doesn’t hurt.
I can tell you with all honesty that single-leg work is very powerful. If you are interested in learning more about single-leg training or how to incorporate it effectively into your training, be sure to check out the Single-Leg Solution.
Bilateral Lifting – Watch for the Shift!
Another common finding when coaching/training someone with knee pain is a shift when they perform bilateral lifts.
For instance, let’s go back to our patellar tendinosis example from Part II. This gentleman had a significant shift away from his affected side, which was making it very hard to get his hip integrated into the lift.
In essence, his knee was out there on an island with no help from his hip.
I’ve seen it both ways – sometimes your client will shift away from the pain, and sometimes they’ll actually shift to the side of pain, versus away from it.
At the end of the day, the goal is to get them more symmetrical so they are loading both sides more evenly.
One of the most common findings you’ll see is people who set up asymmetrically from the start, and then wonder why their squat is asymmetrical! When coaching your clients and athletes on bilateral lifts, make sure they’re starting from a symmetrical position with regards to stance width, internal/external rotation of the feet/knees/hips, etc.
If you notice a shift when squatting, you could always try an RNT method using a band pulling them towards the side they shift into. This way, they will be forced to “shift” away from the pull, thus evening out their squat.
Unfortunately, as much as I like RNT work for unilateral work, I don’t see the same results during bilateral work.
Instead, I’ll often have the client/athlete squat to a box, limiting their depth to a point just before they shift. As they get stronger and better aligned, depth is progressively increased.
I would be remiss if I didn’t mention the Postural Restoration Institute here as well. Since incorporating some of their pelvic realignment tools (as well as some of our own), the changes we’ve seen with regards to movement symmetry has been astounding. If you’re in the field, definitely check these guys out.
Get them out of Anterior Tilt!
Anterior tilt (and it’s lesser known cousin, swayback) is seen quite often in clients with anterior knee pain. When you’re in anterior tilt, the hip flexors are short and stiff, while the gluteals and obliques are lengthened and weak. The hamstrings are weak as well, but typically overactive in relation to the gluteals.
The solution to getting their knees healthy once and for all is to really hammer the concept of pelvic neutral. Keep in mind this can’t be fixed with just one or two pieces.
The entire training program must not only be programmed to get them out of anterior tilt, but it has to be coached effectively as well!
Split-stance is again a great starting point. Split-stance can teach your clients and athletes what pelvic neutral feels like – how to maintain tension in the gluteals and obliques, while lengthening the hip flexors.
I’ll be doing a video post on the benefits of split-stance training in the next couple of weeks, so definitely stay tuned for that one.
While split-stance is effective, that’s only the starting point for improving alignment and stabilization patterns. When we get down to the nitty-gritty, we need to be cognizant of our stabilization patterns in every exercise.
Doing a bench press? Keep the core and glutes tight throughout.
Military presses? Push-ups? Keep the core and glutes tight throughout.
It’s not just bracing though – we need to have that skinny/tall brace where we’re cuing an external oblique contraction, not just rectus abdominus. If you’re crunched over when you’re bracing, you’re doing it wrong. When in doubt, go back to the PVC pipe.
My favorite series of cues to get someone into the proper alignment goes like this:
- Glutes tight,
- Obliques tight, and
- Chest out.
Here’s a great example of how a push-up can either improve your stabilization pattern, or reinforce a suboptimal pattern.
Below is one our clients at IFAST. As you might imagine, he’s a strong guy from a “lifts” perspective, but his stability patterns when he started left something to be desired. Here’s a video of his push-up:
What’s readily noticeable here is how he chooses to achieve stability. He sits at a desk all day long, and therefore his preferred method of stabilization comes from using his lumbar spinal erectors and his hip flexors. We’ve worked long and hard to get him out of the position, and into a more neutral alignment.
It’s going to take an entire program to get you fixed up, not just one or two pieces. You really need to make core stability and pelvic alignment a cornerstone of your training program if you want to get those knees healthy once and for all.
Finally, it’s not just programming correctly – you actually have to execute each and every exercise with flawless technique if you want to derive maximal results!
So there you have it – my philosophy on knee training, how I write programs to prevent and/or alleviate it, and the coaching issues that matter most.
At the end of the day, though, I can’t answer every question that you might have regarding knee health and knee pain. So if you’ve read the entire series and you still have questions, be sure to post them below.
As well, I would be remiss if I didn’t mention Bulletproof Knees one more time. I feel this is a fantastic product that covers all the ins-and-outs of knee health, and something that belongs on every coach and trainers bookshelf.
If you haven’t already, pick up a copy of Bulletproof Knees today. You won’t be disappointed!
All the best
PS – Kudos to Molly, Sarah, Gabe and the rest of the crew for letting me use their videos in this post. You guys rock!
1. Witvrouw, E., et al., Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. Am J Sports Med, 2000. 28(4): p. 480-9.