Article #2
Source of Knee Pain - Solutions

Pain in the knee, particularly the front, is rising up to be one of the top complaints among the lifting and fitness industry. It is prevalent among both male and female populations diagnosed as chondromalacia, patellar tendonitis, jumper’s knee, etc.

Let’s point to some factors that can lead to knee discomfort and overall hinder activity and performance. Because the knee is located smack dab in the middle of the hip and ankle - poor hip and/or ankle mobility can lead to knee pain. Other aspects that aggravate the knee include muscle imbalances from overly tight and weak muscles to synergistic dominance. 
 
As stated, knee pain can come from any number of sources, however, we’ll focus on a few typical forms of exercise.


Improper Squatting Technique
Squats. Most people can’t squat. Most people have a hard time squatting just their bodyweight. But they’re back in the saddle loading the bar up with tons of weight and guess what? They quarter squat maybe and still have valgus knees (knees migrate inward) AND as they descend they’re practically on their tippy toes! My knees hurt watching you…Find a good coach to help figure your movement patterns out to determine your faults and restrictions. 

Leg Extensions
Compressive forces are the greatest at 90 degrees or more of flexion. This means per say that in a sitting position the initial movement to straighten the leg  is a huge culprit in the chronic development in anterior knee pain.  Fitness folks love to go to town on this machine. It’s not a mass builder, but the amount of weight people try to lift with this exercise is ridiculous. If it is a must in your workout begin with a higher placement of the lever (start exercise at higher angle) and focus on a reduced load and a slower return to the start position…I guess, but this exercise is terrible.

Increased Valgus Angle of the Knee
Just touched on this above…it has been suggested that the train (patellar) is rolling over the track (femur) so to speak. This can be another article, but I will say it’s the track (femur) moving under the train (patella). This valgus angulation at the knee is suggested as a patellar mal-tracking issue. When the knees move inward, the patella will track laterally and come into contact with the femur. The result is wearing of the cartilage under the patella, which can be quite painful. From my standpoint the femur is controlled by the gluteals particularly the Glute Medius. Should the Glute Medius be weakened or inhibited the risk of valgus angulation increases enormously. 

These are key issues as to why repetitive forces add up. Hinting about stability and mobility above we can look at some dysfunctions that are causing limitations and, therefore, pain. 

Limitations in Soft Tissue and Density: The hip flexor muscles and TFL are frequently short and overactive. Since they are opposing muscles to the glutes, they can inhibit the glutes by reciprocal inhibition. Further, trigger points in the gluteals can lead to knee pain by pulling on the IT band causing IT Band Syndrome.

Glute Dysfunction: The glute complex is responsible for hip extension, abduction, and external rotation. When attempting a squat, they resist femoral adduction and internal rotation (valgus knee). If there is no glute activation, that femur is headed in the wrong direction.

Limited Ankle Dorsiflexion: Poor ankle mobility is not a common thought to knee pain. To check ankle mobility, start in a standing position facing a wall with the ankle in a neutral position. Place the foot about an inch from the wall. Drive the knee forward to the wall while keeping the heel down. Some figure 2-3 inches foot placement from the wall is a good indication for mobility.

Core Dysfunction: If the stability strength in your core is non-existent then as you squat, lunge, deadlift you will have forward migration during your lift that can also lead to back pain.

Solutions to our Pain
Here are some known exercises to start you on your way. I would go in order.

A) Foam Roll the hip flexor group and TFL and the glutes to reduce increased tension on the muscles to encourage these muscles to lengthen.



B) Improve ankle dorsi-flexion through mobilization and mobility work. To work mobility, drop into a half kneel position and place the stick just outside the outside toe, but it should be touching the floor next to the fifth toe. Glide the knee forward, keeping it outside the stick. Do not allow the heel to leave the floor.

C) Hip extension activation.  Your glutes can be strong and not functional. Depends on what your recruitment patterns are: glute dominant or quad dominant. Most people are quad dominant. In a quad dominant squat, let’s say, movement begins by flexion at the knees instead of the hips. More knee stress.

D) Bridge. There are variations that build awareness and strength. Start with both heels pressing into the floor, toes up and lift the hips until a straight line could be drawn from your shoulder through the hips and to the knees. Should your hamstrings start screaming then your hams are trying to do the glutes work. This is known as synergistic dominance (second string playing instead of first string).  To avoid this, initiate contraction of the glutes before lifting.
 
 

Evaluate Movement Patterns to determine root causes. I prefer to assess an individuals movement patterns from a variety of sources to find the weak link in the system. Some times it may be just a teaching of the correct movement but in today’s society there are a lot of present dysfunctions.

E) Hip Musculature – Activation and Strength: Critical to maintaining knee alignment is the Glute Complex and the smaller hip external rotator muscles. These muscles control adduction and internal rotation of the femur. 

There are several exercises used to generate some strength in the hip abductors. 

-      Clamshells -They target the external rotators of the hip in isolation. From a side lying position with the hips and knees bent, lift the top knee. The feet stay together. Try not to roll back as the knee comes up. Progression: add band or tubing resistance around the knees.
    
-      Side lying hip abduction is another isolated exercise but requires good form. The top leg should be slightly extended at the hip and in a slight external rotated position. As you lift the leg, the hip is to initiate the movement, not at the waist.

-      Lateral band walks are done with a band or tubing around the knees for    beginners and progressed to the ankles for a greater challenge. The athlete will abduct the lead leg and then eccentrically control the back leg as it adducts back in (effectively working the abductors on both legs simultaneously). Try to stay upright while doing this exercise. Perform one set right and left standing relatively straight and the second set in a quarter to half squat position.

-      Reactive Neuromuscular Training is a known technique designed to activate the hip musculature and prevent valgus migration at the knees during the squat by using tubing around the knees pulling the knees inward. This brings awareness to the problem and works to activate the hip muscles to keep reoccurrence of valgus knee migration from happening.

-     Core Stability - an absolute must. Developing trunk stability through planks (prone/side), quadruped stance as well as, hip mobility exercises such as hip circles and abduction work the trunk and deep spinal muscles and the lumbo-pelvic region. 

This sums up our look at anterior knee pain from an exercise enthusiast and those that train with weights point of view, Again, included are some corrective exercises you may want to give a try. Visual awareness is huge in your quest to reduce pain.