Nearly every athlete involved in a jumping based sport has had knee issues at some point in their lives. When athletes have knee issues, it is never one thing across the board why their knees are bothersome, but there are a variety of reasons that knees will flare up with pain. For many athletes, there is typically one “kingpin” factor holding them back from their best performance. It is for this reason that you can never tell an athlete with knee issues, “do this exercise, and you’ll be fine”, but rather a battery of potential issues and fixes should be looked at.
Actual mechanisms of knee injury are typically the result of poor tracking of the patella (kneecap) during knee bend, quad dominated jump mechanics, poor hip control, poor mobility, bad feet, pure inelasticity in movement, or too much elasticity in movement. Let’s get into these reasons, and fear knee pain no more!
10 Commandments of Healthy Knees
1. Have strong and mobile hips
When knees hurt, it is typically not because of a problem with the knee itself, or the quadriceps for that matter. Usually when knees are problematic, it is due to a lack of hip control, which leads to a poor tracking of the knee (the knee doesn’t hinge the way it is supposed to) OR excessive forces sent through the knee itself. A lack of hip control is usually due to a lack of general hip strength, so things like low bar back squats, hip thrusts, single leg squats and a small battery of monster walk and fire hydrant type work will typically square away the strength side of things. From a mobility standpoint, I’ll usually look for a full Olympic front squat with the knees flared out at the bottom as an indicator of decent hip mobility. A mobile groin is important too. To fix hip mobility, crank out stretches geared around helping you get into a deep squat comfortably on a regular basis; simple as that.
2. Have good hip control
In addition to strong, mobile hips, there also must be an element of hip control in movement, particularly single leg movement, since anything dynamic (even jumping off of two legs) is somewhat unilateral in nature. Typically once we injure a knee, the associated glute shuts off to a degree and weakens our control of that leg. This becomes a negative cycle: hurt knee > shut off glute > hurt knee > shut of glute, etc etc. To fight this, a battery of slow tempo, partial-range pistol and skater squats with proper knee tracking is crucial. It is best to do these in front of a mirror to make sure the knee is properly tracking over the toe and not caving inwards to valgus. Slower tempos on these lifts is very useful, as slow eccentric work will “blast the neuromuscular groove” as Pavel would say.
3. Be smooth
Some of the most injury prone athletes I know are those who just have no smoothness to their movement. The gradual absorption and release of force is key in keeping peak joint forces to a minimum. Try doing plyometric work, not for height or max output, but for pure smoothness for a few months and notice the difference in your health and overall movement. Being smooth means being quiet, so keep the noise of plyos to a minimum. Eventually, this concept will also boost performance. Being smooth athletically will help one become more elastic, as smoothness in movement will help provide maximal efficiency of the stretch shortening cycle.
4. Learn to squat with slowly, and with the correct knee hinging motion
This is a big one. During a squat, the knees must properly track over the toes. Athletes will often try this, but rarely do it efficiently. Proper tracking means that the shin moves over an imaginary line from the ankle to an imaginary line between the 2nd and 3rd big toe. Most athletes will track around the first big toe, or further inside. To track correctly, athletes must actively push their knees out. Properly performed goblet squats, using the elbows to shove the knees out at the bottom are a very useful tool here to help athletes get the idea without constantly harping on them. As with the single leg squats, slow eccentric phase bilateral squats are a useful tool in helping strengthen the associated tendons and connective tissue involved with the knee complex.
5. Do plyometrics on a soft surface and watch volumes
Plyometric exercise involves an extremely high rate of force production, so it is important to watch the surface that these are done on. I would always favor grass or field turf if it is available here. Second place is rubber mats. Avoid doing plyos on concrete or wood flooring at all costs. If you have no history of knee issues, you can do plyos in very small volumes on these harder surfaces, but if you are having any knee issues at all, relegate your elastic work to as soft of surface as you can manage. If you don’t do plyos, try and shift some of your jumping work to grass if this is possible.
6. Foam roll your IT band, erring on the side of the quadriceps
Foam rolling the IT band can alleviate some patellar tracking issues, particularly in hip dominant athletes. Hip dominant athletes who produce a big force output through the glute will transmit this force down the IT band, which can make the lateral side of the leg a bit tighter then the medial side. To even this out a bit, do some foam rolling of the IT band and lateral quadriceps to loosen things up there. This typically can help solve issues with hip dominant athletes, and has been one of my own personal favorite methods in my own prehab work.
7. Use a voodoo band
I have never really been aware of exactly how effective voodoo bands can be for knee pain until I actually used one myself. I now believe in these things wholeheartedly. They can’t solve knee tracking issues though, so don’t rely on them to completely solve your pain, but rather use them to make things bearable while you fix your underlying issues. Check out this video by Kelly Starrett for more information on this amazing tool.
8. Be aware of your shin angles
Athletes who tend to live in movement positions with a positive shin angle (knee is always over the toe) will always struggle with knee issues, no matter what else they do. These athletes need to learn to move with their shins just a bit more vertically, so this means learning to do things like RDL’s and kettlebell swings correctly, strengthening of the hips and posterior chain, movement drills to incorporate the posterior chain to running and jumping, as well as well-taught plyometric and depth jump work.
9. Strengthen your feet
If an athlete’s arch is constantly collapsing, it causes a negative chain of events that can be unfortunate for the health of the knee. A collapsed arch leads to pronation, which means the ankle rolling in and the foot turning out to the side, away from the body. When athletes move with their feet rotated outwards, the knee’s tendency will be to roll in towards the midline of the body in jumping, running and squatting. It is difficult to get these athletes to squat well, and elevating their heels is usually a must. Arch collapse can be avoided by working diligently on short foot exercises, as well as doing general barefoot movement on a daily basis. Learning to maintain an arch in the foot during squatting and deadlifting exercises is huge for anyone, and especially flat footed athletes.
10. Work on building the lower quad
Strengthening the lower quadriceps and VMO (although you really can’t isolate the VMO) seems to be the first thing that many coaches look at when athletes have knee pain, but it is very supplementary to many of the other techniques I have listed. Even though the VMO can’t truly be isolated (as many seem to think), some methods that strengthen the lower thigh can help knee issues. The best exercises to strengthen the lower thigh are going to be any deep squat, and then specific leg extension work, such as reverse sled drags or terminal knee extensions. The best terminal knee extension work is going to be somewhat functional to movement, so pairing a TKE with a single leg squat is the optimal way to go to both improve patterns and get some specific strength. If you are going to use TKE’s, the stimulus needs to be significant enough to force adaptation and ultimately hypertrophy in this area. Check out 1:10 of the below video to see a terminal knee extension combined with a squat. This is a better method of using this type of movement.
Conclusion
Knee pain can be debilitating, but it doesn’t have to stop you! Take these rules of treating knee pain to heart, and watch your pain decrease and performance rise to new heights.
If you enjoyed this post, check out the new and improved 10 Commandments of Healthy Knees
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