Pain in the front of the knee is becoming an epidemic among serious lifters weight, athletes and weekend warriors. It was once one of those injuries that we associate primarily with women and blamed on their roster, but no more. I see almost as many men now with diagnoses like patellar maltracking, patellar tendonitis, the IT band syndrome, and just general "anterior knee pain".
There are several factors at play that interact with each other to eventually cause pain and limit performance. Male or female, the causes can be due to poor joint mobility, groups of overactive muscles tight and tense dominant and weak muscles, synergistic domination, and just plain sitting too. In this article I will explore them.
There are a number of common causes of anterior knee pain, but some are more directly related to weight lifting and training for athletics.
1) Increase of the compressive forces in the patellofemoral joint. The compressive forces are most at 0+ degrees of flexion particularly open chain. This is why I recommend to my patients and athletes to stay off the leg extension machine. It is amazing how many people come to rehab and specifically name this machine. Unless the patient is a body builder, they do not need. If they are, then think of limiting the range of motion.
Performing squats with was also shown wider than the normal position and the high position of the bar to increase the compression forces. The idea is that the trunk is in a more upright position that increases quad contribution (while decreasing the load on the buttocks) and creates more compression. Many athletes and serious weightlifters will be reluctant to change their position and support a bar, but enough pain can convince them. For those who use a Smith machine squat (or leaning against a stability ball on the wall), I go back just for that reason. Besides, nobody really moves or lifts like that in real life.
2) Increased stress on the patellar tendon the knee beyond the toes. There are moments in life and in the weight room where the knee will make its way beyond the toes, especially with squats and lunges. If the heels are down and hips properly contribute so no problem. Once the heels are on the floor, you can kiss any glute contribution goodbye. It is quad from there to what means more pressure on the patellar tendon, shear forces, and the nasty compressive forces again as well.
3) Increased knee valgus angle is another popular. Once thought to be limited to women with wide hips, it is surprising how many men now demonstrate this model. It may not appear until they squat heavy, or landing a big leap, but that just tells me they have strong quads and they lack elsewhere. It is quite common to see numbers 2 and 3 together, because once the heels come in knees buckle.
This valgus angulation of the knee is often what's behind issues maltracking patellar. The patella is supposed to slide without friction with knee extension - flexion. When the knees cave inwardly patella laterally follow and come in contact with the femur. The result is a blank in place of the cartilage under the kneecap that will become painful over time. This is a very common problem in the sedentary population when going up and down stairs, lifting, or trying to kneel. For weightlifters, it's squats and lunges.
So why do these things happen? All three of these issues (increased compression forces with greater knee flexion angle, shear forces that the knees go on the toes and knees to go into valgus) will likely produce hundreds or thousands many times a day as we go through our normal daily activities. The key is to limit the amount of force and excessive movement in these directions during training and athletics. To do this these things we must first look at what structures, when not working properly, may cause us trouble.
1) the limitations of soft tissue. The flexor muscles of the hip and TFL are often short and overactive. The problem is they are in opposition to the buttocks, which can then be inhibited (I'll be ranting about the importance glutes and control the knee later).
Anterior / lateral knee pain can also be caused by trigger points in the glute medius and maximus pulling the IT band. The IT group transmits forces glutes to the patellar tendon.
2) dorsiflexion of the ankle restricted. This is often over looked, but it can cause a previous weight change during squatting and follows the activities resulting in the knees over the toes and positions of valgus. To check the mobility of the ankle, start ½ position and ankle in neutral knees. Bring the knee over the foot as much as possible, use a stick to drop a line from the knee to the ground. The knee should be at least 4 inches beyond the foot without the heel to come up or rolling foot in.
3) poor glute function. The glute complex is responsible for hip extension, abduction and external rotation. When the operation of the closed chain, squatting as they resist the femur adduction and internal rotation (knee valgus) and thus reduce the stress at the knee (Ireland et al, 03 and Bolgla et al. 08).
4) Bad trunk control. The lack of control over the stem will increase the forces in the anterior knee during squatting, lunges, and deadlifts. excessive lumbar lordosis (partly the result of weak glutes) limit the ability to sit in the squat, creating a transfer of previous weight and quad dominant movement. Not to mention increasing the possibility of back pain.
So how do we solve the problem of anterior knee pain?
1) Foam Roller flexor group of hip and TFL to inhibit tone and allow a better stretch of the overactive muscles. Be sure to roll glute max and medius to reduce stress on the IT band.
2) Improve ankle dorsiflexion through mobilization and labor mobility. My favorite technique is Brian Mulligan using mobilization with movement to free the ankle. For mobility, the patient takes the test position, I discussed earlier, and places the stick just inside the knee, but it must touch the ground next to the 5th toe. Glide knee forward, keeping it out of the stick. This keeps the ankle supination as it goes into dorsiflexion. Do not allow the heel off the ground.
3) Work hip extension. Poor glute function does not necessarily mean poor glute strength. It can be a matter of the elevator with a dominant strategy quad on a dominant strategy glute. In a squat quad dominant, the athlete begins the movement by bending the knees against the hips. It is more of a right descent vs sat back and down. This movement pattern automatically recruits more quad and let the powerful muscles strong, hip. Not only this constraint increases the knee, it also leads to less optimal squat numbers.
The ability to sit the first depends on the ability to control glute max hip eccentrically. If the patient can simply sit by thinking about it, or heating with a few squats light box, then it is a matter of shaping vs. force. If they can not sit effectively without feeling like they will fall then it is more a matter of force.
Pont variations are an excellent way to teach patients to recruit the glutes and build strength. The patient starts with the two pressure heels into the ground and lift hips until a straight line could be drawn from the shoulder through the hips and knees. The hamstring should do very little to help. If you can feel tighten or patients are cramps while they are replacing the hamstrings for glutes. This is known as the synergistic domination, but that is another article. Just pre-contract, glutes before lifting and be sure to have the press through the heels. Single deck leg progress.
Do not forget deadlifts and / or single leg deadlifts. These are excellent exercises for the overall development of the hip.
4) Enable / strengthening the external hip. The glute complex and some of the smaller external hip rotator muscles play a crucial role in maintaining the alignment of the knee. Knee valgus and patellar maltracking are not necessarily caused by a weak VMO we once thought. It is actually the inability of the hip muscles to prevent adduction and internal rotation of the femur. The knees should be aligned with the medium to outside foot during squats and lunges for proper monitoring of the patella
The question arises again :. Is it a bad muscle activation / pattern? Or is it a weakness? If I have an athlete who can not break in parallel with good form performing a bodyweight squat, then I'll apply pressure outside pressing knees inward. The athlete is responsible for squat and press the knees as hard as possible. Many times, athletes recruit the muscles of the hip enough that they fall into a full squat with perfect technique. If this is the case, they have the strength to do it, but do not activate the appropriate hip muscles.
squat pavilion with valgus
squat Overhead using neuromuscular reactive Technique
Strengthening the abductors and hip external rotators can be done in several ways, but must be done correctly, such as trunk substitutions can support the movement. The first two exercises would be used with someone who could not squat even with activating technique described above. They can evolve into 3 and 4 times the first two exercises are mastered. The athlete who can squat with the activation technique can start with 3 and 4 as part of their warm-up.
- Clamshells are a very basic exercise designed to target the external rotators of the hip in an isolated fashion. Make sure that the patient maintains the stability of the trunk and back resist the knee rises. Add tape or tubing resistance around the knees to progress the exercise.
- Side lying hip abduction is another very simple exercise, but requires careful technique. The top leg must be slightly extended at the hip and in a neutral position slightly turned outside. When you lift the leg, you should be sure of the hip starts the movement and not the trunk.
- sideband walks are with a band or tube around the knees for beginners and advanced ankles for a greater challenge. Athletes take the lead leg and then eccentrically control the back leg as before adducts (effectively work the kidnappers of the two legs together). Watch the remuneration of the trunk here as the QL can laterally flex the trunk to throw the hip abduction. Perform one set of right and left fairly simple rest and the second set in quarter and half squat position.
- Squats with tube around the knees using a reactive neuromuscular training technique designed to activate the muscles hip and prevent the collapse of the valgus knee. Just like the test I described above, using a good amount of resistance and ask the patient to push the knees while squatting. Athletes can use this technique in their warm-up and training.
I can not stress enough the importance of performing single leg squats. When on a leg, hip muscles work even harder to maintain alignment of the lower limbs properly. simple squats leg will not only maximize the protection of the joints of the knee, but are also great for speed and power. Do not worry, I will not go on my one leg training forum here.
5) Do not forget to train for core stability. "Stability" basic exercises, such as exposed and side planks, bird dogs, and fire hydrants, work core muscles by resisting excessive movement through the spine while getting in some work simultaneously the extra hip. Core reinforcing the other hand involves the movement through the spine. Crunches, leg lifts, and hypermarkets are examples of back strengthening exercises. Squats, deadlifts, and lunges require a stable and rigid spine to protect the knees, put up big numbers, and effective focus on sport.
So there you have it. The most common causes of anterior knee pain with lifting and training, and strategies to address weaknesses. Take a close look at what exercises or activities that cause pain and knees are aligned when it arrives. Work these five corrective strategies in patient workouts to keep them healthy knees and keep playing.
- 1. Ireland ML, Willson JD, Ballantyne BT Davis IM. Hip strength in women with and without patellofemoral pain. J Orthop Sports Phys Ther. 03; 33: 671-676
- 2. Bolgla LA, Malone TR, BR Umberger, Uhl TL. Hip Strength and hip and knee kinematics during stair descent and in women with patellofemoral pain syndrome without. J Orthop Sports Phys Ther. 08; 38 :. 12-18
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Joe Heiler PT, CSCS
Joe Heiler MSPT is the owner and manager of content SportsRehabExpert.com, a site dedicated to the advancement of education rehabilitation and performance professionals. The site focuses on orthopedic and sports physical therapy subjects through webinars, audio interviews, articles, manual therapy and exercise videos, and more.
Joe is also the owner of Elite Performance Physiotherapy and Sports in Traverse City, MI specializes in orthopedics and sports medicine, as well as training of athletic performance. It is Graston Technique (GT) and a certified instructor GT SFMA FMS and trained, and is passionate about a number of soft tissue and manual techniques, including Trigger Point Dry Needling and manipulation.
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