A Strength Coach’s Guide to Dealing with Pain: Part 2, Knee Pain
By
Andrew Paul
This is part two of a two-part series.
In part 1 of this series, I introduced some ways in which a strength and
conditioning coach can deal with an athlete’s shoulder pain. It’s extremely
important that as strength and conditioning professionals, we stay within our
bounds when working with athletes in painful conditions. While we may be
somewhat limited in the actions we can take, there are some things that we can
do to help the athlete feel more comfortable.
Part 2 of this series will deal with knee pain, which is all too common. When
dealing with knee pain, we must be very specific about exactly where the pain
is. If we know where the pain is, we can create a good game plan for dealing
with it. Let’s take a look at a few very common points of knee pain and create a
game plan of our own.
Pain is right down the middle of the patella
This is, more often than not, textbook patella tendonitis. I’m willing to bet
that every strength and conditioning coach in the country has at least a few
athletes battling this annoying condition. While this condition isn’t
debilitating, it’s more painful than most believe, and it will hold an athlete
back considerably.
- Foam roll the rectus femoris
When dealing with tendonitis, the biggest mistake we can make is to only
deal with the point of pain. Icing the knee will help, but we need to find
the source of the inflammation. More often than not, the source is in the
rectus femoris. Use a massage stick or a foam roller and work right down the
middle of your thigh. When you find a knot, you’ll know. Believe me. If you
have access to a massage therapist, use them as well. The balling up of this
muscle is what is causing the quadriceps to shorten and place a ton of
tension on the patella tendon.
- Stretch the rectus femoris
Once you have done some soft tissue work to remove knots and adhesions
within the quadriceps, you’ll be able to further lengthen the muscle through
active and passive forms of stretching. Always remember to do your soft
tissue work before stretching. The other way around might be
counterproductive.
When stretching the rectus femoris, remember that this muscle acts in both
knee extension and hip flexion. Lunge variations offer the best stretch in
this case. Begin using more passive forms of stretching.
If you’re able to stretch passively with no pain, make the stretch more
active by activating the glutes on your back leg and drawing your belly
button inward. This will actively pull your pelvis into a posterior tilt and
elongate your rectus femoris even further. Once this exercise becomes fairly
easy, move to the next step.
- Perform tempo split squats
A tempo split squat will really lengthen the rectus femoris as well as other
hip flexor musculature. Before beginning the exercise, activate the glute on
your back leg and draw your belly button inward. Maintain that position for
the entire movement. This is done to a 5-2-1 tempo. That is, go down slowly
to a five count, hold one inch above the ground for two counts, and come up
slowly. Ideally, at the bottom of the movement, you’ll have pretty close to
a straight line through your knee, hip, and shoulder while your front knee
stays over your front ankle.
 
Caption: Tempo split squat
Once this becomes fairly easy, progress to an eccentric quasi-isometric
(EQI) lunge. Tony Schwartz has written a chapter on the benefits of these
types of isometric holds in Thibaudeau’s book, Theory and Application of
Modern Strength and Power Methods (2). The EQI lunge is basically a
static hold at the bottom of the tempo split squat for an extended period of
time. Again, be sure to keep your glutes activated and your “core” drawn in.
- Lengthen the pectineus
More than likely, the shortening of the rectus femoris was an after
effect of the shortening of some other hip flexors such as the psoas,
illiacus, and pectineus.
The traditional tempo split squat will aid in lengthening the psoas and
illiacus. However, we need something a little different to lengthen the
pectineus. This muscle is unique in that its main action is adduction of the
hip, but it also aids in hip flexion and internal rotation. A tempo split
squat done at an angle will target this muscle pretty well.
In this exercise, the athlete’s feet are set up just like in a split squat,
except they’re placed about two feet apart in width (as seen below). This
puts your athlete’s back leg in hip extension and slight abduction. Because
of the angle, your athlete’s back leg will want to internally rotate and his
back hip might move forward slightly. Be sure to have the athlete keep
everything square.
Caption: Angle split squat (feet wide)
- Maintain hip flexor length
Once pain has subsided, the athlete may feel as if the problem is gone. While
no pain is present, the imbalance that created the rectus femoris tightness is
more than likely still present. The problem could be weak synergistic
musculature—VMO and psoas in particular—or simply excess pelvic anterior tilt
due to weak glutes and hamstrings. Those can all be strengthened using basic
exercises.
Just remember, for whatever reason, that particular athlete is predisposed to
quad tightness. Lucky for them, it’s as easy as foam rolling and stretching
religiously.
Pain is on the upper, medial portion of the patella
I know from experience that this one hurts. However, it can be taken care of
without resorting to surgery. This is simply a patella tracking problem due to a
strength imbalance within the upper leg. As the IT band balls up and tightens,
the VMO is forced to shut down. This causes a pull of the patella laterally.
There are a few things that we can do to ease this pain.
- Foam roll the IT band and TFL
In this case, the athlete, more than likely, has some massive trigger points
on their lateral thigh. The first time the foam roll is used it is either
going to hurt immensely or have a sensitive, tickling feeling. Either way,
the nerve bundles are sensitive as hell and need to release some pressure.
And, once again, if you have a massage therapist, use them. Soft tissue work
always goes a long way.
- Strengthen the VMO
With a tight IT, comes a weak VMO. As stated earlier, this combination pulls
the patella laterally, causing pain. Strengthen the VMO using single leg
exercises such as terminal knee extensions and Peterson step-up
progressions. Once the athlete is capable, do full unsupported single leg
squats or low pistol squats. Doing Olympic squats from time to time may not
be a bad idea either.
 
Caption: Single leg terminal knee extensions
- Strengthen the psoas
Shirley Sahrmann does a great job of describing the importance of synergists
(1). She makes it clear that if you have a tight or injured muscle, look for
a weak synergist. In this case, our TFL is balled up. More than likely you
will find that the psoas on that leg is also weak. This is a small muscle,
but it becomes very important in hip flexion.
As the hip goes into flexion, the rectus femoris acts as the prime mover.
However, as the rectus femoris shortens, it’s unable to carry the load. As
the knee reaches hip level, the psoas and TFL kick in to finish the job. If
the psoas is weak, the TFL is left alone and dysfunction occurs. Strengthen
the psoas by raising the knee above the hip while maintaining good posture.
High step knee raises are a good choice. Adding resistance aids in
progression as well.
 
Caption: High step knee raise
- Strengthen the glute medius
Once again, if the IT band is tight, look for a weak synergist. In this
case, it may be the glute medius. There are many ways to spot a weak glute
medius, most of which have been written about extensively. There are also
many ways to strengthen it. Be sure your athletes are attempting to “spread
the floor” with their feet while squatting. This is a great way to activate
the glutes. Adding some true single leg movements also helps recruit the
glutes as stabilizers.
Nagging pain on the lateral side of the knee
This type of pain is very common among long distance runners and is usually
diagnosed as “IT band syndrome.” IT band syndrome is a result of the IT band
creating friction against the lateral condyles of the tibia and femur. Follow
the same steps that were listed for the previous condition. There will be some
massive trigger points along the lateral leg. A weak psoas and glute medius are
almost definite. In long distance runners, this is due to repetitive motions of
the legs going through short ranges of motion in the hips along with the absence
of lateral movement.
While chronic knee pain may be one of the most common problems seen in
athletes, it can be manageable. To sum things up, foam roll, stretch, and
activate and strengthen synergists. All of these things can be done without
withholding your athlete from any workouts.
References
- Sahrmann S (2002) Diagnosis and Treatment of Movement Impairment
Syndromes. St. Louis, MO: Mosby.
- Thibaudeau C. Theory and Application of Modern Strength and Power
Methods. In: Kendall F, McCreary E, Provance P, and Rodgers M (2005)
Muscles: Testing and Function with Posture and Pain. Baltimore, MD:
Lippincott Williams & Williams.
Andrew Paul currently serves at the assistant director of strength and
conditioning at the University of Missouri. He works with the football,
softball, and volleyball teams. He can be reached via email at
andrewpaul@mizzou.edu.
Elite Fitness Systems strives to be a recognized leader in the strength
training industry by providing the highest quality strength training products
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