Knee pain is a gnarly and frustrating issue that leaves you feeling bounded. If you have ruled out any significant trauma to the knee joint through therapist consultancy and medical scans, here’s a post to get your brain fishing for why your knee is acting so munted.
SOFT TISSUE WORK
Muscles, fascia (connective tissue surrounding muscle), tendons (attach muscle to bone) and ligaments (attach bone to bone) start morphing over time in response to the stress you put on them. Tissues can get gnarly due to a lack of mobility and strength (placing unnecessary strain on other tissues), past injury, crappy posture, funky movements (such as squatting with the knees collapsing inward, running with foot pronation, lunging with a hiking hip and trunk lean, etc), eating foods that create inflammation in the body, and repeating the same movements over and over. The tissue above and below the knee joint, with some attaching to the knee itself, can cause the knee to move in a suboptimal way. Unless you have access to a real good physical therapist, there is some work you can get into yourself with the aid of a golf ball, cricket ball, tennis ball or an unloaded barbell. Top areas include;
- GLUTES – Glute stiffness and tightness may be preventing you from being able to move at the hip joint properly, which affects the knee joint. Lie on your back and place a golf ball or tennis ball under the side of your right or left glute. Bend the same side knee and place the foot over the opposite knee. This stretches the glute that you are working on to give it a greater smash. Stay in one area for around ten seconds and move on to another area of tightness around it.
2. TFL (Tensor Fasciae Latae) muscle – this is the muscle that attaches on the side of your hip and inserts into the ITB. If the TFL is tight it can take part in screwing up the ITB, which can pull the kneecap to the side and create pain. Often a big problem and often pretty sore. To hit this one, lie on your side with your knees bent in a foetal position and place a tennis ball, golf ball or cricket ball (depending on your preference of pressure) at the side of the hip on soft tissue.
3. ITB (Iliotibial Band) / Outer Quads – lie on your side and place a tennis ball (or cricket ball if you’re keen) just above the knee. Hold for no longer than 10 seconds, trying to exhale and relax into the pain as much as possible, then move the ball up a little and repeat. You can move all the way up the TFL. You can also just use a foam roller (standard yet I find too soft) or if you are up for something stronger, a PVC pipe works fairly well!
4. HIP FLEXORS, QUADS, ADDUCTORS – these can heavily influence the tracking of the kneecap, since they insert just below the joint and some into the patella tendon. For some tissue smashing with a barbell, sit on the floor with your leg extended out and place an unloaded barbell at the top of the knee (not on the knee or on any bone) and work up to the top of the thigh. You can turn your leg inward to work through more of the outer quads and some of the ITB, turn your leg outward to get more of the inner quads and some adductors, or stay neutral to get the middle quads and hip flexors at the top. The pain can be heavy!! But so good..
You can also get into the quads, hip flexors and adductors (shown in picture below) with a ball.
- HAMSTRINGS – Often a major block to getting enough hip flexion to squat down without having your back rounding out like some sort of primal animal. Tight hammies can also pull at the knee joint where they insert. You can get into these with the barbell with the aid of a partner to guide the bar up the leg, or you can also set the barbell to a low setting in the squat rack and gently sit on the bar, extending and flexing your knee to pin and stretch. Also quite a heavy one. If you don’t have the standard convenience of having your own barbell at home, you can place a golf, tennis or cricket ball under your thigh while sitting on a bench. It doesn’t have the same level of intensity but it’s something.
6. CALVES – The loyal gastroc and soleus.. Most people don’t go to a masseuse to get their calves kneaded, but these are so heavily stressed everyday that you either laugh or cry when you get into these deep. Again, with their insertions, they can influence the mechanics of the knee. My fav for the calves is kneeling on the floor and placing a golf, tennis or cricket (the worst) ball sandwiched between your thigh and shin bone so that your calves get a good smash from the pressure of your own bodyweight. Work the ball from the top of the calf (near the knee joint) to the bottom (on the Achilles tendon) and up again.
7. FOOT – Tight and stuck tissue under the foot can affect the way your ankle moves. They probably also never get any attention, so give them a bit of love.
HIP MOBILITY AND ANKLE MOBILITY
If you have dodgey range in the hip and ankle, you’re likely to do dodgey things at the knee to compensate for the lack of movement above and below. This could be something like caving your knee inward to compensate for an ankle that wants to cave in all the time since it can’t bend properly. Knees collapsing inward when squatting, jumping, running, lungeing and stepping can overstretch the medial structures of the knee (such as the MCL) and cause pain. Add some heavy load to a knee that caves in and you have a recipe for ligament tears. This is why you’ll often hear trainers or coaches obsess over keeping the knees out and over the toes.
Inadequate ankle mobility along with tight calves prevents the knee from moving forward over the toes enough. This causes the foot to compensate by collapsing in, or pronating (allowing for more forward knee migration). When the foot pronates, the tibia internally rotates, which leads to hip internal rotation and hip adduction, and therefore the knee caves in (also called Knee Valgus).
HIP/GLUTE/ HAMSTRING STRENGTH
Inadequate glute/hip strength (which are good at extending, abducting and externally rotating the hip), possibly in conjunction with overactive hip adductors, prevents proper stabilization of the femur. The hips then move into adduction and internal rotation, or you start squatting like you need to badly need to use the toilet.
Inadequate medial hamstrings strength will prevent proper stabilization of the knee which will lead to the knee to cave inward.
Inadequate inner quad (VMO ) strength will fail to allow for proper knee stabilization, which will cause the knee to track inward.
DEEP SQUATTING – Good or Bad for the Knee ? Read this post by clicking here.
TRAINING PLAN FOR KNEE PAIN:
- Fish out overly tight soft tissue and sort it out with a therapist or with your own balls!
- Work on any restrictions you may have in the ankle or hip joints. I teach a series of band self-mobilisations and contract-relax stretches, however have not included these in this post. Maintain your flexibility and don’t neglect your stretching if you know you need it.
- Work on stability drills whilst keeping your knee pointed over your toes.
- Strengthen your ASS!I Click here for ideas and videos – Rock Solid Gluteals.
- Squatting in knee rehabilitation (summary of the DEEP SQUATTING – GOOD OR BAD post): If you’ve had an ACL injury, there is low ACL stress during the squat. Slow squatting, not training to fatigue, and leaning forward from the hips to keep the shins more vertical than in a usual squat will limit shear forces on the joint. If you’ve had a PCL injury, there is moderate stress on the PCL which increases with squat depth, so it is recommended to imit your squat to 60 degrees of flexion, which means not going to parallel (which is 90 degrees) or past parallel. If you’ve had a meniscus tear, avoid deep squatting and squatting with high loads. Two forms of single leg squatting that keep the shin fairly vertical and are therefore less demanding on the knee joint while recruiting the glutes and hamstrings are an assisted pistol squat and a single-leg cable squat;
Assisted Pistol Squat
Single Leg Cable Squat
6. Keep strengthening weak areas as you return to sport and never unfriend glute exercises ever again, they will save your ass.
For more knee strength and conditioning, head to my online strength coaching site.