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.

  1. 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.
  1. 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.

  1. 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.

  1. 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)

  1. 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.

  1. 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.

  1. 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

  1. 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

  1. 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.


  1. Sahrmann S (2002) Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO: Mosby.
  1. 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.