Treat Your Own Knee Pain
Let’s talk about knee pain. The knee is the simple, yet complex hinge joint that sits between the hip and the ankle. The knee is where the upper leg meets the lower leg and it’s where problems will often manifest when there are mobility or strength deficits at the hip and/or the ankle. Knee pain is more common among the active population because the knee is more vulnerable to abnormal stress when exposed to certain movements and increased loads. Common movements that trigger knee pain include: running, squatting and lunging. Many people often resort to avoiding these movements all together in order to avoid aggravating their knees. What if I told you that you can in fact run, squat and lunge effectively without knee pain? How you ask? You are about to find out!
I already know what some of you are thinking. I can hear the excuses in my head, because, I have heard them all before. Maybe you tore your ACL when you were younger, maybe you’ve had an MRI, which shows a meniscus tear, maybe you’ve been diagnosed with osteoarthritis in your knee. All of these things will absolutely leave your knee vulnerable to pain, injury and aggravation when stressed. But, have you ever thought about why these various tissue injuries happened to you in the first place? Sure you may have had a specific traumatic event that caused the injury but what if an overlooked mobility or strength issue or, more likely, issues predisposed you to suffering that injury in the first place? Even more so, what if that injury lead to movement compensation, muscle firing pattern issues, and joint stiffness that ultimately lead to other injuries or increased rate of wear and tear on your joint? All of these things are likely at play and should not be ignored when addressing your “bum” knee that just can’t seem to tolerate any level of activity. It’s easy to become discouraged and I understand that, especially when doctors are throwing diagnoses at you, and the 30 second stretches and “glute” strengthening exercises given to you by your physical therapist don’t seem to be doing the trick. I am here to tell you that you do NOT have to resort to surgery or activity avoidance to have a functional knee that tolerates all movements without leaving you on the couch for the next 5 days.
One thing that is important for you to understand before I dive into the steps necessary to manage your knee pain, is that in order to get better you must take your health into your own hands. Nobody is going to “fix” it for you. IF you want results you have to take the tools we give you and apply them yourself. These are not one and done tips. They are daily practices that will absolutely decrease your knee pain if you do them properly and regularly. I would also like to add that all exercises should be performed at your own risk. If anything increases your pain you should stop. If you have any questions regarding how to properly perform any of the following exercises, please contact us! We would be happy to help you with understanding and performing any of our recommended exercises.
In order to run, squat and lunge without knee pain you must have the following:
Basic ACTIVE Range of Motion (ROM) at the Knee, Hip and Ankle
When you perform dynamic movements, such as running, squatting and lunging, this requires a combination of multiple joint movements performed with control. When you are lacking in a certain direction at a given joint your body will find a way to compensate in order to achieve the movement. The problem with movement compensation is that it causes abnormal stress on the joints and the surrounding soft tissues. With repetition and load this will only worsen. So what is the basic ROM required and how do you determine if you have a deficit? Im going to break it down according to joint.
The major motions we are looking at with the hip when performing dynamic movements such as squatting, lunging and running are flexion, extension, external rotation and internal rotation .
Self Test: Straight Leg Raise (SLR) of at least 90 deg.
Lie flat on your back with both legs extended. Slowly lift one leg up in the air while maintaining a locked knee. As soon as your leg begins to buckle STOP you have gone too far. Ideally, you should be able to flex your hip to 90 deg while maintaining a locked knee. Compare both legs. Most people usually have a tight side. usually the tight side is also the painful side. Coincidence? I think not!
If you cannot get to 90 deg then this is something you need to work on. First, determine WHY you can’t get to 90 deg. You either (A) lack posterior chain flexibility, (B) lack hip flexor strength, (C) hip joint restrictions, or (D) a combination. For many, posterior chain flexibility is at least part of the issue. The posterior chain is a group of power muscles located in the back of your body and includes:
Hamstrings - hip extension and knee flexion
Gluteus muscles - hip extension and rotation
Gastrocnemius and Soleus - Plantar flexion of ankle (point down) and knee flexion
Multifidus / External obliques - Spinal support Muscles
Erector Spinae - Back and Spine extension
Exercises to improve posterior chain mobility:
Pancake Stretch/Mobility - Sit with legs out to the side as wide as you can get them while maintaining a straight knee. The stretch is a static hold that should be maintained for a length of 2 min. Begin by slowly leaning your trunk forward directly between your legs as far as you can while maintaining straight knees. It is pertinent that the knees remains locked. For some of you this may mean minimal to no fwd trunk lean in order to maintain the locked knee. After 2 minutes in the center move to the left or right leg. Try to get the elbow on the side that you are stretching down to the ground or resting on the leg and the opposite arm reaches over towards the side you are stretching with the elbow pointed up toward the ceiling. The mobility exercise is performed by actively reaching forward and slowly controlling the movement back up to the starting position. You can hold a weight to make this more of a challenge.
Pike Stretch- This can be performed sitting or standing. With legs together and knees locked slowly bend forward towards the toes. Go down as far as you can while maintaining a locked knee. Hold for 2 minutes.
Windmill Mobility- Stand with legs wide and knees straight. Grab a light weight with one hand (5lb) and hold it up in the air above your head with elbow straight. While keeping your eyes on the weight lower down and try to touch the ground with your opposite hand while maintaining locked knees. If your knees bend before you reach the ground only work within the range that you can maintain a straight knee. Perform 5- 10 reps on each side.
Romanian Deadlift (RDL)- The knees should be only slightly unhinged. The weight should be held close to your body. Keep your back flat and your butt out. If you can perform this exercise pain free without difficulty progress to the single leg RDL. Perform 12 - 15 reps with light to moderate weight and increase as tolerated.
Single Leg RDL- Same principle as the double leg RDL but on a single leg. Keep your eyes on the floor in front of you in order to maintain a neutral neck position. Perform 8-15 reps with light to moderate weight and progress weight as tolerated.
Hip flexor strength is usually not the problem among active individuals. Hip joint restrictions are very much a possibility and that means that a restriction exists between the ball and socket joint consisting of the head of the femur and the acetabulum of the pelvis. If this is a problem you may or may not have hip pain when you perform the SLR test. If you are limited in your SLR and you find that the posterior chain lengthening exercises do not seem to be helping you than by process of elimination the joint may be your issue. If this is the case, I recommend that you consult a physical therapist for proper treatment and proceed from there.
Self Test: Prone Hip Extension
Lie flat on your stomach and slowly lift one leg up towards the ceiling. It is easy to cheat this movement. DO NOT allow your back to arch or your pelvis to raise to increase your hip motion. Also watch for your foot to move out to the side and your pelvis should tilt forward. This is a test of pure hip extension and should not be influenced by spinal compensation. If your back arches or your butt or feet move AT ALL, then you are compensating. Ideally you should be able to get a minimum of 10 degrees relative to the surface. If not, hip extension is a deficit you need to work on.
Common reasons for lacking adequate active hip extension include: (A) tightness of the hip flexors (B) weakness of the gluteus muscles and/or hamstrings and (C) a hip joint restriction and (D) a combination. The following exercises will help address the most common causes for lacking hip extension mobility which includes: Tightness of the hip flexors and weakness of gluteus and hamstring muscles. As with hip flexion limitations, a possible joint restriction should be considered. If you are performing the following flexibility and strengthening exercises and not seeing significant improvements or possibly have hip joint pain when performing hip extension then a joint restriction may be your problem. Again, consult a physical therapist if this seems to be the case for you.
Exercises to improve hip flexor flexibility:
The Couch Stretch - When done properly, this is a great way to stretch the anterior muscles of the hip. Key pointers: (1) knee to wall (2) shin vertical and flush with wall (3) chest upright and (4) Drive front of stretch hip towards the ground. When you are able to get your butt to your heel, lean your trunk forward and allow the front of your hip to drop more towards the ground. Slide your front foot out slightly to the same degree as your pelvis moved. Hold for 2 min.
Spiderman Hip flexor stretch - This stretch focuses more on the iliopsoas hip flexor muscle. The keys to performing this stretch properly include: (1)Get into a deep lunge position with your back leg extended behind you with toes in contact with the ground.(2) Lean forward over your front foot and place arm on ground for stabilization. (3) Drive front of back leg towards the ground. Hold for 2 min.
Improve glute and hamstring strength:
Bridge (double leg and single leg)- Feet should be just outside of shoulder width. Tighten your core by flattening your low back against the floor. Push up with both hips while maintaining a flat back. Pause at the top and slowly lower back down. Your pelvis should stay stable and not tilt to one side or the other. I recommend building up to high reps with this exercise. Start with 2-4 reps of 15 and increase as tolerated. If you can perform 4 sets of 15 easily and without pain progress to a single leg bridge. With the single leg bridge be very aware of your pelvis position. Only move up within a range that you can maintain an even pelvis. If your pelvis starts to tilt then you have a core stability issue.
Quadruped HIp extension- Start on all fours with hands underneath shoulders and knees under hips. Tighten the Core by pulling your belly button in towards the spine allowing your spine to maintain a neutral position and not allow it to arch. Lift one hip up towards the ceiling in a slow and controlled fashion with knee flexed as you lift the leg make sure to keep the core tight so that your spine maintains the same position. Do not let your pelvis rotate. Perform as many reps as you can with good control and form.
Superman- There are many variations of the superman exercise. The most basic is to simply lay flat on your stomach and lift your hip up into the air. Increase difficulty by lifting up opposite arm and leg simultaneously. Most aggressive would be to extend both hips and shoulders at the same time. The goal is to get the thighs off the ground. Begin with performing 10 to 15 reps and progress to holding for 30 - 60 seconds.
Hip Internal and External Rotation (IR/ER)
Self Test: Sitting Hip Rotation
Sit on the edge of your bed or another surface where your feet are hanging and not in contact with the floor. To test IR, move your foot out towards the side as far as you can while keeping your trunk still (no leaning to the side to increase motion). You should be able to achieve at least 30 deg of motion to be considered normal. To test ER, simply move your foot in the opposite direction (towards your other foot). For external rotation, you should be able to achieve a minimum of 40 deg of motion.
If you are seeing limitations with hip internal or external rotation this is usually a result of (A) Decreased strength of the hip rotators (B) Tightness of the rotators of the opposite direction (e.g. limited hip external rotation due to tightness of the hip internal rotators), (C) Hip joint restrictions , and (D) a combination
Hip External Rotators:
Hip Internal Rotators:
Tensor Fascia Latae (TFL)
Portions of the gluteus medius and gluteus minimus
Adductor longus, brevis, and magnus
Exercises To Improve Hip External Rotation
Hip 90/90 Stretch/Mobility- Sit with one leg flexed 90 deg in front of you and opposite knee flexed 90 deg behind you. Lean over the front leg to improve external rotation of that leg. Hold for 2 minutes to stretch. This can be progressed to a mobility exercise by actively switching back and forth between each leg
Pigeon Stretch- Front knee flexed to 90 deg in front of you with knee in line with hip. Back leg behind you with knee slightly bent. Keep chest high with weight on back leg. Hold for 2 min.
Butterfly stretch- Sitting with feet touching each other and pulled as close to your body as you can tolerate. If possible, lean forward at the waist and use hands to press knees down towards ground. Hold for 2 min.
Clamshells- Lie on your side with band tied just above knees, Knees are bent and stacked on top of each other. Raise top knee toward the ceiling while keeping your feet together. Place your hand on your top pelvis to make sure you are not compensating by rotating your pelvis back each time you raise your leg. Your pelvis should stay stable and not move with this exercise. Start with 15-20 reps performed with good form. Build up to 50 reps.
Exercises to Improve Hip Internal Rotation
Hip 90/90 Mobility- With one leg flexed 90 deg in front of you and opposite knee flexed 90 deg behind you. Lean over the back leg to improve internal rotation of that leg. Hold for 2 minutes to stretch. This can be progressed to a mobility exercise by actively switching back and forth between each leg
Hip “W” Stretch- This can be performed on both hip simultaneously OR a less aggressive technique would be to perform on one leg at a time. Start Sitting and position leg so that your foot is next to your outer hip while keeping your bottom on the ground. Lay back if you are able. Hold for 2 min.
Frog Stretch- Upper trunk supported on elbows and legs positioned as wide a tolerable with knees bent and feet OUTSIDE of the knees. Sit in between your ankles by pushing your hips backwards. Hold for 2 min.
The most significant component of ankle and foot motion required for normal performance of dynamic movements are ankle dorsiflexion (DF) and big toe extension. Without adequate ankle DF and big toe extension you will see significant movement compensations up through the length of the kinetic chain.
If you lack adequate ankle DF then there are a number of compensations that will result. The direct result on the knee is an increase in forward translation of the knee resulting in increased stress on the patellar tendon or your knee may deviate laterally inward or outward, which, will place unnatural stress on the medial and lateral aspects of the joint.
Self Test: Kneeling Ankle DF Test
Get in a half kneel position with test side forward and toes 5 inches away from the wall. Hold onto a PVC or similar object to help keep your balance and slowly move your front knee forward toward the wall while being sure to keep your heel flat on the ground. Ideally, you should be able to reach the wall with your knee. If you are lacking, then, you have found a deficit worth working on. As with all of these tests, be sure to test both the left and the right sides to compare.
Lack of ankle DF results from (A) tightness of the gastrocnemius and/or soleus muscles that make up the calf. (B) weakness of the anterior tibialis muscle, (C) ankle joint mobility deficits (posterior and medial glide of talus) and (D) a combination
Exercises to Improve Ankle DF
Calf Stretch off Block- Heel is supported on the ground and top of foot supported on yoga block or step. Lean forward to increase intensity of the stretch. perform with knee straight to stretch the gastrocnemius and with knee flexed to stretch the soleus. Hold for 2 min
Standing Calf Stretch- This one is the least aggressive calf stretch. The stretch leg is back behind you as you lunge forward while keeping the heel of the back leg down on the ground. Hold for 2 min.
Seated Ankle DF with Weight- Sit on a low surface. Pull heel as close to body as you can while keeping the heel flat on the ground. Place heavy weight on your knee (25-50lbs) with towel underneath to decrease discomfort from the weight. Maintain for 5-10 minutes
Kneeling Ankle DF with Downward Pressure- Start in a half kneel position pull heel of front leg in towards body as far as you can while keeping heel flat. Lean over ankle to increase intensity and apply a downward force through your knee using your arms. Hold for 2 min.
Self Mobilization with Strap- Rogue monster bands work great for this exercise. Wrap the band around the front of your ankle where the foot and ankle meet. Allow for good tension in the band. Drop your opposite knee to the ground. You can also perform this by placing banded foot up on a small box and lunging forward. Perform 8-10 reps with 2-3 second hold.
Big Toe Extension
Big toe extension is limited in a lot of people due to the amount of time we spend wearing shoes throughout the day. The standard amount of big toe extension required just for normal gait is 45-55 degrees. A minimum of 60 deg is required for a normal running pattern. Without adequate big toe extension the windlass mechanism of the foot is disrupted. The result is de-stabilization of the foot during forward propulsion and this results in compensations at the ankle, hip, knee and trunk.
Self Test: Raise your Big Toe
This test simply consists of placing your foot flat on the ground and raising your big toe in isolation of the rest of the toes as high as you can. You should have a minimum of 45 deg of extension in reference to the ground. If you run, I would recommend at least 55 deg of extension. Compare left and tight and if you determine you have a deficit treat accordingly.
Exercises to Improve Big Toe Extension
Kneeling Great Toe Stretch- Kneel down in a sprinters position with heels under your behind and toes extended so that the bottom of your toes makes contact with the ground. Can perform with both feet or just one foot. Hold for 2 min.
Great Toe Stretch on Weight- Stand with bottom of toes supported on the shaft of a small dumbbell (2-5lbs). Lean forward until adequate toes stretch is felt. Hold for 2 min.
Great Toe Stretch Against Wall- Same concept as with the weight only your big toe is in contact with the wall. Hold for 2 min
Barefoot Walking- Walking without the restrictions of shoes allows your toes to move through a wider range of motion and it engages the intrinsic muscles of the foot. Spending time barefoot everyday will improve your foot strength and increase your foot mobility.
We can’t ignore the actual knee joint when it comes to identifying the source of knee pain. Adequate knee extension and flexion ROM is necessary for performing the dynamic movements of running, squatting and lunges.
Self Test: Knee Flexion
Sit down and with knees straight in front of you. Slide your heel toward your bottom as far as you can bend the knee and keep your foot flat on the ground. You should be able to flex your knee 135 deg without pain.
If you are lacking knee flexion it is likely due to (A) Tightness of the quadriceps, (B) weakness of the hamstrings or gastrocnemius, (C) a knee joint mobility deficit or, (D) a combination.
Self Test: Knee Extension
Same test position as knee flexion. This time straighten your knee as much as you can. This is where we tend to see more deficits among the active population. You should have 0 degrees of extension at the knee in order to function properly.
If you are lacking full knee extension it is likely due to (A) tightness of the hamstrings, (B)Weakness of the quadriceps, (C) a knee joint mobility deficit or (D) a combination
Exercises To Improve Knee Flexion
Prayer Stretch with focus on sitting back on heels to increase knee flexion- Similar to the prayer stretch only knees are together and you are pushing hips back to increase knee flexion. Hold for 2 min
Goblet Squat Hold- Holding a weight in front of you makes it easier to maintain proper form get into a low squat position with knees flexed as much as you can tolerate. Try to keep heels down if possible. Hold for 30-60 seconds.
Exercises to Improve Knee Extension
Weighted Knee Extension Stretch- Place heel on bolster and place object of weight (ankle weights or a bag of rice) just above the knee. Maintain for 5-10 minutes
Pancakes- Described above.
2. The Ability to Control the Knee with Dynamic Movement Patterns
Once you have achieved the basic active ROM that is required at the hip, knee and ankle it is important that you can perform these desired movement patterns while adequately controlling the knee. In order to achieve adequate muscle control at the knee you need to decrease the load and/or modify the depth of the movement until you achieve appropriate knee control. We will now go through the movements of the squat, lunge and running technique and the proper form required for each movement. If you are unable to maintain the dynamic stability of the knee then we will guide you through various modifications that you can work on until you achieve the control required to perform the full movement without pain or compensation.
Key Form Components:
Feet should be just about shoulder width apart and toes can be pointed slightly out or straight forward depending on your personal preference
Weight should be evenly distributed through the balls of the feet and the heel
When you squat down your back should remain flat but not straight up. Depending on the length of your femurs relative to your torso you will have a different back angulation when squatting. If you have a bar on your back the bar should remain in a vertical line over your midfoot throughout the squat.
When you squat down, think knees out and hips back. Knees caving in during a squat is a sign that something is wrong. Decrease the squat load until you are able to keep your knees out throughout the movement. If you continue to have trouble, place a resistance band around your legs just above your knees. Press your thighs out to maintain tension in the band as you squat down. Go down only as low as you can go while maintaining outward pressure on the band. Maintain the pressure as you extend back up from the squat.
Exercises to Improve Squat form:
Goblet Squat Holds: The goblet squat is great for working on squat mobility (Refer to exercises to improve knee flexion). By holding a weight in front of the body you are better able to sit back into the squat while maintaining a neutral spine and pelvis. The squat hold also works as a sustained mobility exercise for the hip, knee and ankle. Perform 3 - 5 sets of 30 second holds.
Box Squats: This is helpful when learning the foundation squat pattern because you can set the box up so that it limits your depth to the range in which you can maintain proper form without pain. If squatting below parallel causes pain. Work on your technique within a limited range of motion. As you get more comfortable you can begin using smaller boxes to allow for more depth until you feel comfortable squatting the full depth with proper form and without pain
Body Weight Squats: Simply taking the weight away until you can squat with proper form is also a way to decrease the stress on the knees while you retrain yourself to squat properly. If you can perform 10 air squats before the pain sets in or before you feel your form start to deteriorate start at 10 and work your way up.
Key Form Components:
Most of your weight should be distributed through your front leg with heel of your back leg up and parallel to the wall behind you
Your trunk should stay in a straight line, meaning, it should stay centered and not move to either side during the lunge
The spine should be neutral with a slight forward lean onto the heel in front of you
The knee should stay in line with the foot and not translate in or out
Exercises to Improve Lunge form:
Lunge barefoot - There is a surprising amount of foot and ankle stability required when performing lunges. Over supportive shoes do nothing to help us in this department. Lunging barefoot will strengthen the intrinsic muscles of the foot and improve ankle stability
Mini Lunge - If you cannot lunge to full depth without knee pain, then, decrease your range of motion to a pain free range. The key with this is focusing on your form. Once you are more comfortable with the proper form slowly begin increasing the depth of your lunge until you get back to full depth
Single Leg Stance- The lunge requires a lot of single limb balance with most of your weight on the front leg. Practice standing on one leg for a period of 30 to 60 seconds.
Reverse lunges- If you have pain with forward lunges try doing a reverse lunge. Do to the nature of the exercise the movement you are less likely to have issues with form while doing a reverse lunge. If you can do a reverse lunge with less or no pain this means your problem with front lunges is likely due to a flaw in your form.
Key Components of Running Form
Upright trunk with neutral spine
Adequate hip extension is ESSENTIAL to proper running form. Your leg should be extending behind you quite a bit.
Your feet should stay relatively underneath your body. A common issue is for people to step their foot way out in front of their bodies. This is called over striding and is guaranteed to result in knee pain with time.
You strike the ground with your midfoot. Many people tend to strike with their heels (overstriders) or their toes.
Your feet should point straight ahead and not angled in or out.
Shorten stride and decrease bounce. A shorter stride allows for greater running efficiency. The greater you lift your self off the ground the greater the force will be whenever you land.
Exercises to Improve Running:
Run barefoot - Shoes change your running stride. We naturally run better without shoes. Try running bare foot for a short distance and focus on what changes your body makes when you do so. You will likely notice a shorter stride, a faster cadence, and greater push off and an overall more efficient running pattern. Do not attempt to run your usual distance barefoot if you have never done this before. Invest in some minimalist shoes or running shoes that do not have a built up heel. if you have been wearing overly supportive shoes it is important that you ween yourself into the less supportive shoes. If you usually run 3 miles try running half a mile with less support and then change back into your usual running shoes for the duration. Increase by .25 miles with each run until you build up to your usual distance.
Listen to a running cadence playlist- This isn’t really an exercise but it will help to increase your cadence which will shorten your stride and decrease load on the knee with running. They have cadence playlists on most music streaming apps. If you have a fitness tracker device that measures your average steps per minute look at your history. Try increasing your steps per minute by 5 and see how you feel. Continue to increase your cadence at this rate until you feel that you are able to sustain a longer distance run before onset of pain. If you aren’t sure what your average steps per minute are try listening to a playlist set to 90 bpm. A cadence of 90 steps per minute is a good place to start and you can increase fro there if necessary
Interval Running- Running in shorter bursts will help you to work on improving your form without aggravating your knee. Run for a period that is sustainable for you without bringing on your knee pain. Try running for half a mile being conscious of your form. Then, walk for half a mile before running again. The walking rest breaks will allow you to focus more on your form when running and will give your knee a break so you can sustain a longer distance. Build up your intervals as your form and knee pain allow until you can run your desired distance without issues.
Single Leg Stance- Running involves continues single limb balance on alternating legs. If you cannot stand on one leg with the opposite knee flexed to 90 deg for at least 30 seconds then this is something you should be working on. Build up to 60 second holds on each leg.
The two major components of performing dynamic leg movements without knee pain are (1) having basic required AROM at the hip, ankle and knee joints and (2) Having the muscle control to adequately control the knee when performing these dynamic movement patterns. If you are having knee pain with activity the first thing you need to do is determine where you are lacking mobility. Once you are working towards improving your mobility you need to work on controlling your knee when performing the movements that cause the pain. There is a TON of content out there regarding ways to scale and modify exercises and you do not necessarily have to perform the ones we mentioned. The principles to remember, however, is that first you decrease the load and if the pain persists decrease the range or “depth” of the exercise and work on achieving knee control with these modifications. Once you can perform the modified exercises pain free, you can began to progress to performing the full motion, and finally add to the load until you can perform the full exercise without pain. If you continue to have knee pain and difficulty after implementing these concepts, then you may need to seek help from a Physical Therapist. Dr. Kelly Starrett, author of The Supple Leopard, once said that “all human beings should be able and willing to perform basic maintenance on themselves”. We strongly agree with Dr. Starrett on this topic. We are here to provide you with the knowledge and the tools needed to perform maintenance on yourselves. You do not have to resort to a life in pain and you also do not need anyone to “fix” you. The choice is yours.