Ouch! My knee hurts!

Working in the field of strength and conditioning and sports massage, one of the most common complaints I receive from athletes is “my knee hurts.”

While the knee can hurt for a variety of reasons, some of those reasons requiring surgical intervention, it is not uncommon for the pain to be cleared up with some soft tissue work and corrective exercise.

Patellofemoral Pain, or anterior knee pain, and IT Band Syndrome are two of the biggest complaints that plague athletes, especially athletes like runners and cyclists who perform repetitive movements in training and competition and usually do so over long periods of time and/or distance.

Anterior knee pain is a problem relating to the way in which the patella moves within the groove of the femur, referred to as the trochlear groove.

If, for whatever reason, the patella does not track properly with in this groove during flexion and extension of the knee, the patella will begin to contact other areas of the femur, which over time, can create wear and tear and ultimately pain.

IT Band syndrome on the other hand, is an overuse injury resulting in repetitive friction of the IT Band over the lateral femoral condyle, with the maximum angle of friction being approximately 30 degrees of knee flexion.

IT band sydrome is commonly referred to as lateral knee pain, for obvious reason.

Dealing with these injuries has been a controversial subject as they seem very different with regard to where the pain is felt and the structures involved – IT Band for IT Band syndrome and the patella for anterior knee pain. However, more current research has looked not at the site of pain, but rather the reason for pain.

I emphasize the word reason because in order to truly become pain free you have to deal with the source of the pain and not the symptom. If all you do is go to physical therapy and get ice on your knee, electrical stim, and ultrasound, your symptoms may decrease (or the may not); however, once you start to run or bike again and stress that structure, the problems will surely return if you have not addressed the cause!

Current research regarding both anterior knee pain and IT Band Syndrome is looking at the hip as the cause of the dysfunction. The reason for is that the hip musculature plays an extremely important role in controlling what happens at the knee. While we primarily think of a task like running as a sagital plane event (we run straight ahead), we have to remember that our hip still needs to control for and prevent unwanted movement in both the front plane (side to side) and the transverse plane (rotation). When we are unable to do that, we typically will see the femur bow in (knock-kneed), bow out (bow legged) or rotate either internally or externally.

These excessive positions, especially over time with hard training and competing, will undoubtedly create knee pain due to changes in the length tension relationship of the muscles and the stress that these muscles will cause as they pull structures out of alignment.

A significant amount of the research in dealing with anterior knee pain and IT Band Syndrome has been focused around the strength of the hip abductors, the main muscles being the gluteus maximus, gluteus medius and the tensor fascia lata (TFL). Surprise, Surprise, all three of the muscles create the IT Band (glute max and TFL primarily with some contribution from the glute medius as its main attachment is on the greater trochanter).

If the IT Band develops a lot of tension/tightness, then there is potential for friction to occur, creating IT Band Syndrome. If the muscles that make up the IT Band are weak, then the hip will adduct during running and the knee will collapse inward (knock-kneed) compromising the alignment of the patella within its groove, leaving the athlete with anterior knee pain. This knock-kneed position, may also contribute to IT Band Syndrome as the origin and insertion of the IT Band muscles is being pulled further apart (because it is adducting), creating tension. In addition, the knock-kneed position may be accompanied by some internal rotation of the femur, creating a shortening of the TFL and the anterior fibers of the glute medius (and glute minimus), as they are internal rotators of the hip (while the glute maximus and posterior fibers of glute medius are external rotators).

Okay, enough of all the nerdy anatomy…WHAT DO I HAVE TO DO TO GET BETTER?

The basic program I will lay out follows my 4-step process for dealing with soft tissue problems and dysfunctions. Those steps are:

1. Soften the tissue
2. Lengthen the tissue
3. Activate weak muscles
4. Integrate movement patterns

Step 1: Soften The Tissue

The goal of this step is to decrease muscular tension, decrease myofascial adhesions, decrease trigger points, and enhance overall tissue quality.

It is important to remember that the IT Band is a long tendinous sheath, almost like a cable. Trying to improve the density of this structure can be a difficult task and is usually made easier by first addressing the muscles which make up this structure – glute max, glute minimus and TFL. In addition to the IT Band muscles, researchers Fredericson and Wolf documented trigger points in the vastus lateralis, piriformis and the distal biceps femoris in patients with IT band syndrome.

Getting soft tissue work done by a licensed practitioner is a great way to enhance the healing process. However, this may not always be a viable option and, you should learn how to perform your own self-care strategies as a means of preventing injuries. So, we will be using either a foam roll or a tennis ball to address the above structures. Roll on the tissue and when you come to areas of increased tension or an area that may send a referral pain to a different site other than the one you are pressing on, be sure to stay on that site with direct pressure for about 8-10 seconds before rolling back and forth to help promote blood flow to the area and break up myofascial restrictions.

Glutes/Piriformis:

Sit on the foam roller, crossing one leg over the other.  lean into the glute of the leg that is up and roll back and forth over the tissue.

IT Band:

Assume a side lying position on the foam roller.  Cross the top leg over so that the foot is in contact with the floor, offering you support and the ability to control the amount of pressure you put into the foam roller with the bottom leg.  Roll from the top of the hip down to just above the knee joint.  Use caution, this can be an extremely tender structure to roll.

Quads, Vastus Lateralis:

Lie face down and position the roller on the quadriceps muscle.  Roll the entire muscle slowly from the hip down to just above the knee.

The vastus lateralis can be rolled by turning your hip inward while rolling the quadriceps group.  This will move the lateral portion of the quadriceps (vastus lateralis) directly in contact with the foam roller.

Hamstrings/Biceps Femoris:

Sit with your legs outstretched in front with the roller positioned at the bottom of the hips, just below the gluteal fold (ischial tuberosity).  Roll from the bottom of the hips down to just above the knee joint.  To work the biceps femoris, rotate the hip outward to place the lateral portion of the hamstrings in greater contact with the foam roller.

Tensor Fascia Lata (TFL):

The TFL is a hip flexor, abductor and internal rotator of the hip.  It originates just posterior to the Anterior Superior Iliac Spine and then feeds into the IT-band.

To roll the TFL, you may use a tennis ball or a foam roller.  Sometimes, because a foam roller is big and broad, the tennis ball may work better for more specific work on this muscle.  First locate the ASIS, which is the bump on the front portion of the hip (the pelvis) (as pictured above).  Next, lie onto the tennis ball so that it is positioned just posterior to this bump (ASIS) and you will be contacting the TFL.  Roll the muscle up and down to decrease tension and tone.

Step 2: Lengthen the Tissue

Once we have addressed the quality of the tissue, we need to them attempt to restore optimal length. There are a variety of stretching methods that you can use – static stretching, contract-relax, Active Isolated, or dynamic stretching.

Below are some stretches for the involved structures. If you want to perform static stretching, hold the stretch for approximately 20-30 seconds and repeat for 2-3 sets. For active isolated stretching, move into the stretch position, hold for 1 second and then relax back to the start position. Repeat this for 12-15 repetitions for 2-3 sets.

Hamstring

Glutes/Piriformis:

Assume a quadruped position on the floor with your hands positioned under your shoulders and your knees positioned under your hips (perfect 90 degree angles).  To stretch the right glute/piriformis, cross the right ankle over the left.  Gently sit back and down towards the right side until you feel a stretch in these structures.

TFL Stretch:

To stretch the TFL, we must extend, externally rotate and adduct the hip.  In a standing position, first locate the ASIS, which are the two bumps on the front portion of the hip (the pelvis).  To stretch the left TFL, place the left foot behind the right and externally rotate it so that the feet create a 90 degree angle.  The left hip is now externally rotated and extended.  Make sure you stand up tall and focus on shifting your hips towards the left side as your torso moves towards the right (limit excessive side bending and focus more on shifting the hips over).  By shifting the hips towards the left, you will adduct the left hip and stretch the left TFL.

IT Band Stretch:

To stretch the IT band we need adduct the hip.  Lying supine on the floor we can use a stretch rope (a belt works fine if you don’t have a stretch rope) and place it around our foot.  Lift the leg up and then over, across the body, adducting the hip to stretch the IT band.

Quadriceps:

Lying prone (face down), place the stretch rope or belt around the foot and genetly pull, flexing the knee and lengthening the quadriceps.  It can be helpful to first contract the hamstrings, brining the heel close to the glutes, before giving a gentle pull on the rope.  By contracting the hamstrings, the quadriceps will automatically decrease their tension via the process of recipricoal inhibition.

Psoas Major:

To stretch the Psoas major, assume a half kneeling position. Make sure that the back knee is aligned under the hip and the front foot is aligned under the knee. Tense your abdominal muscles (this is key!) to make sure that you do not arch your lower back and extend your spine (doing this will not allow you to stretch the psoas properly). Lean slightly forward – if the abdominals are contracted enough it should not take much of a forward lean to meet the barrier of resistance. To intensify the stretch, once you are in position, raise the arm opposite the forward knee overhead (Ex., if the left knee is forward the right arm is overhead).  Side bend toward the knee that is in front.

Step 3: Activate Weak Muscles

Now that the tissue length has been restored, we need to strength or “turn-on” the muscles that are weak and not doing their job. Since out main focus is on those that abduct the hip (the gluteals and TFL) the exercises below will help get those muscles firing again.

Supine Clam Shells:

Lying supine, place a min-band around your thighs, just above your knees.  Lift the feet off the floor, flexing the hips to 90 degrees and bending the knees to 90 degrees.  Keeping your feet together, push your thighs apart, externally rotating and abducting the hips.

Lateral Tube Walking:

Place a mini-band around the ankles and assume a shoulder width stance.  Stride out to the side for a short distance and then replace that distance with the trail leg, bringing the feet back to shoulder width.  Do not let the feet come together, as this will take tension of the muscles.

Step 4: Integrate

At the end of the day, if we do not begin to re-learn proper movement patterns, our training program will be all for naught. So, the last step is to integrate everything back into something that is useable.

The first exercise is a single leg excursion exercise, which focuses on hip stability (on the standing leg) while the other leg moves through all three planes of motion.

Single-Leg/1-Leg Excursion:

Take your weight onto one leg.  Slowly extend one foot out directly in front of you and hold for 3-5 count before returning back to the start position.  Do not touch the floor when you are back at the start position.  From here, slowly extend the foot out directly to the side (laterally) and do so without allowing the torso to side bend (the torso must remain upright).  Hold that position for a 3-5 count before returning back to the start position, again not allowing the foot to contact the ground.  Finally, extend the leg back and at a 45 degree angle (halfway between out to the side and directly back).  Hold that position for a 3-5 count before returning to the start position.  Repeat the sequence for a desired number of reps before returning to the start position.

The second exercise is a 1-leg RDL. I like this exercise because it does not include active knee flexion and extension (which initially may be painful for those dealing with one of these two conditions), but rather hip extension – a movement that requires a strong contraction from gluteus maximus – and also focuses on hip stability.

Single-Leg/1-Leg RDL:

Take your weight onto one leg and slightly bend the knee of the stance leg (do not leave the leg straight).  Although the stance knee will slight bend, this bend should not increase or decrease during the movement.  There is no active knee flexion or extension; rather, focus on hinging at the hip.  Keep the shoulders back and do not allow the back to round.  Hinge at the hips, lowering the torso towards the floor and attempting to maintain a straight line from the back heel (the leg that is not in contact with the floor) and the head.  Do not allow the hips to rotate.

Once you have perfected this movement using your own body weight, you can progress to using dumbbells for some external resistance.  Hold the dumbbell in the hand that is opposite of the stance leg (IE, If you are performing the movement on the left leg, hold the dumbbell in the right hand).

It is important to use the single leg excursion and RDL exercises in the initial integration phase because they limit active knee flexion and extension (which can be painful at this time) and effectively strengthen the hip stabilizers, which translates to better knee function. DO NOT progress to the next two exercises if there is pain. Disrupting the tissue will delay the healing process. If there is pain with the single leg excursion and single-leg RDL, do not perform them and only perform the activation exercises until these movements can be performed pain free.

Finally, once your pain has subsided, you can begin to re-train movements that require flexion and extension. My two favorites are the Split Squat with Medial Pull and the single-leg squat with band around the knees. Both of these movements are great because, aside from the single leg stability requirement, they also add an element of biofeedback. When the tubing is pulling your knee inwards, towards the dysfunction (the way your knee wants to go anyway), it causes the weaker muscles (in this case the hip abductors) to “turn on” and keep the leg in alignment and prevent any further inward movement.

Split Squat with Medial Pull:

This exercise is performed with the same technique you would use in a split squat.  Step the leg you want to work forward.  The heel of the back leg is up off the floor, leaving only the back toe in contact with the ground.  The front foot stays in contact with the floor at all times.  Lower yourself down until the back knee is just above the floor and the front knee is at approximately a 90 degree angle.  Hold for a second and then raise back up to the starting position.  The only difference is that we are placing a long band around the outside portion of the knee so that it will pull the knee inwards.

Now, most people are probably thinking, “My problem is that my knees already cave inwards, how is this going to help?”  Pulling the knee inwards, towards the compensation, will force us to use the hip abductor muslces to push against the bad and keep the knee aligned properly - otherwise, we will fall over.  The band will help us to retrain the hip abductor muscles to work efficiently during dynamic tasks.

Single-Leg Squat with Band Around the Knees:

The final exercise will also use a band to pull the knee inwards, again forcing the hip to stabilize and control knee position during the movement.  You can perform this movement either standing on a small box, aerobic step, stool, or the side of a treadmill as I am doing (just make sure the treadmill is not on or that no one is using it - that would be really weird!) or you can perform the movement squatting down to a bench or box.  I prefer to start people off having them perform the exercise standing on a small aerobics step because there is less range of motion and as they become more comfortable with the exericse, we can use a bench to squat down to, which increases the range of motion and complexity of the exercise.  Place the tubing around your thighs, just above the knee joint.  Squat down to the desired depth - If you are standing on an aerobics step that will be until the heel of the non-working leg touches the floor, and if you are using a bench it will be when your butt makes contact with the bench.  From there, fire your muscles and push yourself back up to the start position.

As you can see in the pictures below, I reach my hands forward during the descent.  This is helpful for maintaining balance and it also provides us with a countermovement which helps to re-enforce the act of sitting back and engaging the hip musculature.

Conclusion

The goal of this this article was to give you some ideas to help either prevent knee pain/injury or to help you take care of your current knee problems. If you are a clinician, strength coach or massage therapist, hopefully the information on this article will help to breath some new life into your treatment plans and give you some ideas for helping your patients/clients who suffer from knee problems.

The information here is not intended to over rule any sort of orthopedic or physical therapy assessment. Before beginning any training program, you should consult your physician to make sure that it is right for your individual case.

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References

Ireland ML, Wilson JD, Ballantyne BT, Davis IM. Hip Strength in Females With & Without Patellofemoral Pain. J Orthop Sports Phys Ther, 2003 Nov; 33(11):671-76.

Fredericson M, Wolf C. Iliotibial Band Syndrome in Runners: Innovations in Treatment. Sports Med, 2005; 35(5):451-459.

Powers CM. Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint Dysfunction: A Theoretical Perspective. J Orthop Sports Phys Ther, Nov; 33(11): 639-646.