The Smart Approach to Training Through Knee Pain, and Overcoming Injury
What would life be if it didn’t throw a monkey wrench at you from time to time? Where’s the fun in living if someone didn’t pull the rug out from under you, literally, and made you tear your ACL? Well, all of that’s horse crap and injuring your knee isn’t fun, especially since it screws up your lower-body strength training.
Fortunately, a simple understanding of the anatomy of the knee allows us to create a training program that works around our injuries. You can take a trip to snap-city and keep your gains, too.
The key is to understand the nature of the injury. We need to make sure that the training program doesn’t strain the injured tissues too soon during the healing process. So, if the goal is to continue training through knee pain, we’ve got to understand the anatomy of the knee and know what movements stress which parts of the knee.
Don’t actually train through the pain, but train AROUND it.
“Rome wasn’t built in a day.” Such a phrase has never been so true. Given the fact it takes weeks or months for ligaments to heal after they are damaged, we can be assume that our bodies aren’t built in a day, either (Hefti F, et. al). Saddle up and enjoy the ride, because this stuff takes time.
The Anatomy of the Knee (for Non-Scientists Out There)
Let’s review the structures of the knee. We want to know about the bones and soft-tissues, and how the soft-tissues resist certain movements.
The knee joint is formed by the heads of the femur (thigh bone) and tibia (shin bone). Also the fibula (other shin bone) and patella (kneecap) “participate” in the knee joint through shared ligaments.
There is cartilage on the surfaces of the heads of the tibia and femur, which come into contact with each other. Cartilage serves as a “cushion” during weight-bearing activities. The cartilage found on the tibia is known as the meniscus, and forms a bowl-like shape. There are two of these in each knee – the medial meniscus being on the “inner side”, and the lateral meniscus being on the “outer side”. The medial and lateral mensici serve as anchoring points for the ACL and PCL, respectively.
There are four primary ligaments in the knee, divided into two groups: the collateral ligaments and cruciate ligaments. Additionally, there is a fifth one – the patellar ligament.
The collateral ligaments consist of the lateral collateral ligament and the medial collateral ligament, or, the LCL and MCL. They are found at the sides of the knees, resist lateral flexion, or side-to-side movement, and are also taut in full extension, or when the knee is locked out. An abrupt impact, such as a tackle, to the side of the knee would damage the collaterals.
The cruciate ligaments consist of the anterior cruciate ligament and the posterior cruciate ligament, or, the ACL and PCL. Both ligaments are found inside the knee joint, between the femur and tibia. The cruciate ligaments resists tibial shear – or, when the tibia is being pulled forward or backward. The ACL resists shear caused by the quads contracting, and the PCL resists the shear from the hamstrings.
Both the ACL and PCL resist rotation of the knee – or, when the femur twists one way and the tibia twists the other way.
Rotating the tibia inwardly would stress the PCL (as well as where it attaches to – the lateral mensicus) and rotating it outwardly would stress the ACL (and medial meniscus)
Also, there is the patellar ligament, which connects the bottom of the patella . The patellar ligament (or, patellar tendon) helps transfer the force of the quads contracting over to the tibia, so it can lock the knee out.
Which Ligament Injury Determines Your Training Program
So, we understand that the knee’s ligaments resist movement to help stabilize the joint. A ligament undergoes strain when it resists a particular movement. If you injure a ligament in your knee, it’s important to cut out any movements that would strain those ligaments, and (when cleared by a doctor) slowly re-introduce them overtime.
Also, we can have faulty movement patterns or posture that twist or bend the knee unnaturally, which further damages the injured ligaments if they’re the ones resisting this faulty movement. It’s bad enough that a movement, like a squat, will make our knees hurt. We don’t want to have walking hurt our knees, too, because bad posture causes our knees to collapse.
Your Injury, Your Training Program
Now that we understand the basics of the knee, some general guidelines for training around an injury can be established. First, we must look at what movements will be initially “problematic.” These details will be the basis of training through knee injury.
- Folks with LCL and MCL tears must avoid side-to-side bending of the knee, as well as using the quad-dominant movement, such as squats and leg extensions.
- ACL tears and PCL tears are aggravated by twisting of the knee. The ACL would not tolerate quad-dominant movement, and the PCL would not tolerate hamstring-dominant movement, such as leg curls or glute-ham raises.
- Meniscus tears can be irritated by weight-bearing – anywhere from squatting 500 lbs to walking. Also, because the cruciate ligaments attach the the menisci, theoretically anything that strains those ligaments can strain the meniscuses.
- Patellar ligament issues can be exacerbated by quad-dominant movements.
As you embark strength training program again, removing exercises that would strain your injured knee would be prudent. The bold points above give us a general idea of what to remove initially and then slowly reintroduce. The ligaments may be too messed up to take the strain of certain movements, so we must work with non-problematic movements at first, then we can focus on building up our strength in those problematic movements. As always, pain is a damn good indicator of what you shouldn’t be doing.
Correcting any faulty movement patterns or postural issues must be addressed as well.This is incredibly important because faulty posture or movement forces the knee into unnatural positions that do nothing but strain the ligaments. Twisting and side-to-side bending of the knee is not “normal”, and can only injure the knee eventually.
Letting the knees “cave in”, also known as valgus collapse or valgus knee, is a common issue for strength trainees and lay people, alike. It can happen during squats, or it can even happen while walking.
The usual culprits behind collapsing-knees are a lack of activation in the glutes and anterior pelvic tilt. Both of these “causes” result in the hips not externally rotating and abducting, which would then allow the knees to cave in.
A good exercise to activate the glutes is “the clamshell.” Lie on your side, keep your knees and hips slightly flexed, and “open” your legs as if they are a clam, close them again, and repeat. This exercise works both external rotation and abduction of the hips. A band wrapped around the legs will make this exercise harder.
The typical hip flexor stretches will help discourage anterior pelvic tilt, because tight hips cause this faulty posture. The picture below is an example of a hip flexor stretch.
My Program for Pain Associated with Quad-Dominant Movements
Squats are all the rage, and they very damn well should be. They strengthen the lower-body like no other and allow your legs to move stupendous amounts of weight.
As awesome as squats are, they sometimes cause issues for our knees if done beyond our capacity to recover, or if done improperly. Folks in pain will back off and do other movements, but sometimes the pain remains. As a quad-dominant movement, knee injuries from squats seem to cause issues with other quad-dominant movements too.
Being one of those people who gets knee pain from squats occasionally, I have a protocol, with squatting as both the MEANS and the END, when pain flares up. Here is what I use:
- First of all, a list of squat variations in order quad-dominance, from least dominant to most: box squats, low-bar back squats, high-bar box squats, front squats. Start with the most “quad-dominant” squat that can be performed without pain. For example, if front squats cause pain, regress to high-bar, and if high-bar causes pain, regress to low-bar squats.
- Use a weight that is pain-free as well, even if it is barbell-only, and slowly add weight over the span of the training sessions.
- Do not increase volume, frequency, or weight too quickly. I usually work up to 5 sets of 10 reps, adding 5 reps or a set each session, then add 5-10 lbs each session after I hit 5×10. Sessions are twice to 3 times per week.
- If there’s no pain after a few sessions, move on to the next squat variation (going up in quad-dominance). The first session with the next squat variation will usually be a “test” with light weight. For example, if I worked up to 300 lbs with 5×10 for low-bar back squats painlessly, I’ll try out high-bar the next session, using 135 lbs at first to see what happens, and then take it from there.
- During this whole time, work on hip mobility to prevent anterior pelvic tilt, and do the “clamshell” exercise to activate the glutes. This prevents the knees from collapsing, and minimizes stress on the knee ligaments. Also, keep doing hamstrings-dominant movements, such as glute-ham raises and leg curls, as they most likely won’t cause any pain or damage.
An understanding of knee anatomy allows us to design a smart training program that won’t wreck our knees while they recover from injury.
To summarize: the best way to continue training through knee pain is to identify what part of the knee is injured, cease movements that stress that certain structure, and slowly reintroduce those movements overtime while avoiding pain.
Bros, it’s time to study, plan, and conquer our knee pain. Now go get after it!
Hefti F., et. al. “Healing of ligaments and tendons”. Der Orthopäde. 24.3 (1995): 237-245. Web.