And while I’ve already discussed the topic of knee pain numerous times here before, if you’re new to the site I’d highly recommend checking out the articles below as a primer.
I’ve been thinking about this quite a bit over the past 2-3 months. Firstly, I’m always looking for ways to keep my body feeling great while training heavy, and the knees are obviously an area of focus.
But this was really cemented in my brain a few weeks ago when I had an MLS soccer player in for a two-week intensive.
This guy had dealt with knee pain for close to 3 years, and it had severely impacted his ability to play the game he loves. While it’s impossible to define my entire approach to his issues, the below defines (to some extent) what we were working to address with him.
So before I give you the two keys, lets’ discuss some of the biggest reasons people suffer from knee pain.
Causes of Knee Pain
The best way to approach this is to think of the big picture issues that drive many causes of knee pain.
We could talk about diagnoses such as patellar tendinosis, patellofemoral syndrome, IT Band syndrome, etc. But I think, first and foremost, that stuff is better left to physical therapists, orthos, etc.
And furthermore, I don’t want to look at specific “conditions” – I want to think more globally as to what needs to be addressed to alleviate the underlying causes of knee pain.
Two of the biggest issues that I see are:
- Horrible strength training and conditioning programs, and
- Issues with daily postures.
Let’s briefly examine both.
Strength and Conditioning Programs
If you’re an athlete (strength athlete, field-sport athlete, endurance athlete, etc.) you’re probably following some semblance of a strength training routine.
Whether it’s a program that fails to address structural balance around the muscles and joints, poor lifting technique, or some combination of the two, I firmly believe most strength and conditioning programs actually create more pain than they remove.
Don’t change anything.
What is your posture like right now?
Chances are you’re hunched over a computer – your upper back is flexed and shoulders slouched forward, your hips are flexed, and your knees are flexed, too.
While you can optimize this posture to a degree, the reality is staying in this posture for extended periods of time throughout the day wreaks havoc on your body.
A Simple Knee Pain Solution
Here’s an equation I want you to commit to memory going forward.
If you want healthy, pain-free knees, you need to focus on the following:
Hip Extension + Knee Extension = Happy Knees
I said it was simple, but I never said it was easy.
When we look at someone’s posture, we look for straight lines and 90 degree angles. From a side profile, it’s ideal to have a straight line through the ankle, knee, hip, shoulder, and the back of the ear.
If you’re unaware of your posture, I’d highly recommend taking posture pics from the front, side and back to see what yours looks like.
Taking this a step further, one of the tests we highlight in Assess and Correct is our single-leg support view from the side. Again, our goal here is full hip and knee extension.
In a perfect world, we’d have a straight line on that support leg – ankle, knee, hip, shoulder, all in one nice, straight line.
Joints that are stacked vertically on top of each other are happy joints.
So let’s look at both of these components to our equation – hip extension AND knee extension, to get those knees feeling as good as they possibly can.
Developing Hip Extension
When working to get hip extension back, the first question we have to ask is simple:
“Why did we lose hip extension in the first place?”
It’s a great question, and there are numerous answers.
- Lack of training true hip extension in the gym; instead, we often substitute lumbar extension instead.
- Poor core training exercises and methods. Sorry, but all the rectus abdominus work you’re doing to get a 6-pack does virtually nothing to help your posture!
- Programming that doesn’t address structural balance of the muscles and joints.
- Poor pelvic control or alignment.
- Sitting for extended periods of time.
One of the easiest solutions we have to getting more hip extension is to simply get out of hip flexion more often throughout the day.
Use a stand-up desk.
Work on your computer in a mixture of half- and tall-kneeling positions.
Get up and move around every 15-20 minutes.
Go through a mini-mobility circuit every 1-2 hours.
The more you get out of hip flexion, the less likely you are to see adaptive shortening of the hip flexor musculature.
Honestly, this part is easy – set a timer on your computer, phone, or watch, and move around more throughout the day.
If you’re too lazy to do this, try the app I’ve linked to below. I use this on the days when I’m powering through hours and hours of computer work.
With regards to programming in the gym, you need to focus on not only hip extension work, but getting the pelvis back to neutral as well.
If you’re in an anterior tilt all day, your hips are rarely (if ever) going to get into true hip extension.
This is why I’m such a huge fan of half- and tall-kneeling exercises in the gym. They force you to engage the external obliques and gluteals, thus pulling you into a more neutral pelvic position.
Furthermore, neutral pelvis will simultaneously drive improved hip extension.
If you’re unfamiliar with tall and half-kneeling exercises, the video below should help explain how to perform them for optimal results.
Now beyond the static half-/tall-kneeling exercises, this is also why I incorporate so many split-squat variations into my programming as well.
Well executed split-squats train you to properly engage the external obliques and glutes, but they also train you to do so in a dynamic versus a static environment.
It may sound like blasphemy, but it takes a great deal of time before I ever progress someone do a true lunge.
I can reap so many benefits from just having them perform split-squats with ever increasing proficiency, there’s just not a ton of need there, especially early-on in a program.
And if you think lunges and split-squats are easy, watch the video below and try performing them like this. Chances are, they’ll get a little bit more difficult!
Developing Knee Extension
While lots of people talk about developing hip extension, I don’t hear nearly as many people talk about gaining knee extension – but this actually every bit as important if you want healthy knees!
I first got turned onto the concept of knee extension via Dr. Donald Shelbourne. While he’s most well known for his thoughts on accelerated return to play in ACL repair patients, Dr. Shelbourne is also a huge believer in regaining full knee extension.
In my own clients, I’ve seen first hand how many people suffering from knee pain lack knee extension, and how much better they feel as they restore it.
Now again, we have to ask why we lack knee extension in the first place. We can look at the things we mentioned above (training program, behavior modification, etc.), but let’s look at it more from a biomechanical perspective.
There are several reasons people may lack knee extension:
- A Stiff knee capsule,
- A Stiff gastrocnemius,
- Stiff hamstrings,
- Joint restriction, etc.
Now some of these obviously go beyond the scope of this article – I’m not going to tell you how to restore full knee extension using joints mobs, as that’s definitely not my place!
But, what I want you to do is this – think about and address these issues from as many angles as possible.
Work to loosen up the gastroc/soleus complex. Soft-tissue work, static stretching, etc.
Ditto on the hamstrings. This could sound like blasphemy, but some static stretching for the hamstrings in an effort to restore full knee extension could go a long way to alleviating dysfunctions at the knee joint.
Taking this into the weight room, this is actually why I’m a huge fan of step-ups in the programming of knee pain clients.
When you’re on one leg, you’re knee and hip are basically on an island – forced to control and promote movement in all three planes of motion.
The obvious benefit is tri-planar hip and glute strength and control, which we all know plays a huge role in knee health.
But furthermore, if you focus on driving hip extension and knee extension at the top, you have a wonderful knee strengthening exercise as well!
I always laugh when people say the don’t like such and such exercise. The step-up in particular has taken a beating in recent years.
Sure, some exercises aren’t appropriate or great in every case. But if you have someone suffering from knee pain, well executed step-ups can be a great addition to their regimen.
This got a little bit longer than I expected, but hopefully it’s been of benefit to you.
When in doubt, remember the equation:
Hip Extension + Knee Extension = Happy Knees
There’s obviously quite a bit more to it than this, but working to address these two issues can go a long way to improving your knee health, or that of your clients and athletes.
If this article has helped you out whatsoever, please take a moment to help me spread the love.
Give it a ReTweet.
Share it on Facebook.
Or simply e-mail it to a friend or loved one who is suffering from knee pain.
Thanks for your time and good luck with your training!
All the best
BTW – if you want to follow my exact approach to long-term knee health, pick up a copy of Bulletproof Knees. When you add it to your cart, you can even add a copy of my Single-Leg Solution (where I outline all my coaching cues and training tips for single-leg exercises) at a discounted rate to boot!