“You need knee surgery. You’re out for the season.”

Knee problems can be devastating.

Serious knee injuries can be career enders that require expensive surgery and months of rehabilitation.

Even if serious surgical intervention isn’t required, knee pain and knee injuries can be enough to stifle an athlete from performing at 100%, due to worries about reinjury or from altered movement patterns.

Fortunately, there are many prevention and treatment strategies we can use to address knee problems. And these can go a long way toward getting both athletes and everyone else moving confidently again.

In the following article Jeffrey Tucker, a chiropractor based in Los Angeles, shares injury prevention, treatment and rehabilitation strategies for common knee problems.

If your clients suffer from knee problems, this article will help you not only get them back in action more quickly, but also help minimize the risk of problems occurring in the future.

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[Jeffrey Tucker] I’m going to talk about how you can help your clients stop knee problems from playing out, and help them return to life physically and mentally robust in as short a period of time as possible, and help them avoid common injuries in the future.

Whether you’re a doctor or a personal trainer, knee pain is going to be one of the most common complaints your clients have. It’s important to understand how to manage this, treat it and prevent it.

Why knee injuries seem to have long-lasting impacts

People who have injured a knee in the past will often say something like, “My knee doesn’t hurt anymore, but it feels different” or “It doesn’t hurt anymore, but I’m more aware of it.”

For athletes, that “I’m aware of it” feeling can lead to anxiety, which can cause poor execution or poor movement patterns. A player hesitates, becomes tentative and even unwilling to perform at full speed. Or people compensate by adopting sloppy form, and this can lead to frustration.

This heightened degree of awareness is the brain’s natural increase in attention on the harmed area after experiencing trauma. It’s the body’s way of doing extra surveillance to reduce the risk of further injury or reinjury.

If you’re working with a client who has experienced a knee injury, your end goal should be to help the person get to the point of not worrying about a knee injury reoccurring. You want to decrease the brain’s attention to the harmed area so people can reach the maximum levels of performance they’re capable of.

In the rest of this article, we’ll look at some things you can do to facilitate this process, but first, let’s look at how to prevent knee injuries from occurring in the first place.

Look at posture

Posture is at the root of many knee issues. The knee especially can become inefficient when restrictions limit the potential energy stored for that elastic recoil, and forces are dissipated improperly. Underlying it all is posture.

I’m a big proponent of doing a visual posture analysis. Having proper posture ensures that the muscles of the body are optimally aligned, and are at the proper length-tension relationship necessary for efficient functioning.

This is what neuromuscular efficiency is all about. It’s the ability of the nervous system to properly recruit all of the muscles in all planes of motion.

To do a postural evaluation, have your client stand up.

Poor posture can reduce the efficiency of the knee

If you see the head sits forward, you’ll want to help the person improve body awareness. If you see a thoracic kyphosis—or hunching in the upper back—you know there will be stiffness in the upper and mid-back. If you observe increased lumbar lordosis, or saddleback, it could be due to a lumbopelvic-hip complex problem.

In any case, try to naturally restore and maintain good posture in order to keep the knees working efficiently.

Evaluate the patella

While you’re performing the postural evaluation, look at the patella.

Look at the position of the patella

At rest, the patella should be in the center of the knee, pointing straight ahead. If you were to drop a plumb line from the center of the patella straight down, it should line up directly with the second toe.

What you’ll typically see is an increase in the Q angle. Ideally, the Q angle should be about 14 degrees in men and 17 degrees in women. If the femur or the tibia is too angulated, the Q angle will be greater than 14 or 17 degrees.

The Q angle is formed by drawing a straight line down the femur, with a corresponding line drawn along the tibia. The Q angle is where these two lines bisect at the knee.

The most common reasons for a patella to sit too far toward the lateral side are an increase in the Q angle, tight lateral structures or a weak medial structure.

The main reasons for an increased Q angle are wide hips, which is why women tend to have more kneecap pain; a femur that comes inward when the foot strikes the ground, which could be due to a weak gluteus; or a tibia that comes inward on the foot strike, which could be due to overpronation of the foot.

Tight lateral structures—tightness in the iliotibial band, lateral hamstrings or the lateral retinaculum of the knee—can cause the kneecap to drag to the outside of the knee.

Another cause of the patella sitting too far laterally are weak medial structures—weakness in the medial quads, the vastus medialus oblique (VMO), or a particularly loose or flimsy medial retinaculum, which could be due to a previous patellar dislocation.

If you see a lateral patella in the postural analysis, focus on loosening the tight lateral structures, particularly the iliotibial band, the lateral hamstrings and the lateral retinaculum. Then work on strengthening the weak VMO and glute muscles. You could have your patient foam roll the lateral structures, and then teach VMO and glute exercises.

My favorite VMO and glute exercise is the band lunge. To do it, wrap a Theraband around the patient’s upper shin to direct the force so the band pulls the knees inward. Have the patient lunge, keeping the patella over the second toe, for three sets of 20 repetitions. That’s an old-school treatment. Foam roll the lateral structures, and then do the band lunge.

Other problems commonly associated with knee pain

Knee pain is not usually the primary complaint we hear when a patient comes in. Patients usually come in complaining of low back pain or a shoulder problem, and then mention, “By the way, I’ve had chronic knee pain,” “When I play golf, my knee bothers me,” or “When I go out for a run, my knee hurts.”

Knee pain is highly linked with the joints above and below the knee.

When we see a patient with pain in a joint, we get the most information—and the most relief—from looking at the joints both above and below the affected one. Joints don’t live in isolation; everything is interlinked. When someone’s knee hurts, you need to check the ankle and hip as well.

The angle the ankle bends at affects the angle at which the knee bends. Restrictions at the hip force the knee to take on a greater load than it’s designed to do.

And as a professional, you have to be aware of this and be able to explain this to your patient.

It is also important to look at the front functional line and the superficial front line. The front line is the pec, the rectus and the adductor—particularly the adductor magnus. The superficial line is the tibialis anterior, the vastus group and the quadriceps, on up to the rectus abdominis, the sternalis and the SCMs.

Using the Functional Movement Screen to assess the knee

There are so many different knee orthopedic tests available. In my practice, I use the Functional Movement Screen and perform the seven tests.

The seven FMS Tests

The most important test for the knee is the flexion-extension assessment, where we use the squat, hurdle step, lunge and rotary stability.

We then break it down further. We check ankle dorsiflexion, the toe touch, the squat, the one-legged squat, the TFL, the iliotibial band, hip internal rotation and hip external rotation.

Normal ankle dorsiflexion is 20-30 degrees. So have your client heel walk. If the movement is dysfunctional, painful or both, but functional and non-painful when passively tested, there’s either a dorsiflexion stability issue, a motor control dysfunction, or both.

If the dysfunction is consistent between active and passive testing of the ankle, there’s a joint mobility problem or tissue extensibility dysfunction—or both—limiting dorsiflexion. If passive testing is painful, stop and treat it.

In a healthy ankle joint, when the ankle dorsiflexes and the toes come up toward the knee, the bodyweight compresses the tibia and fibula. That causes them to spiral downward, opening the ankle and creating space for the talus, which actually has no bony attachments at all but is merely suspended in a finely tuned tensile sling of tendons and ligaments that allows the talus to roll forward.

Opposite the ankle joint is the knee, connected through the same bones—the tibia and the fibula. A dysfunction at the ankle, leaving the tibia and the fibula unable to open to allow space for the talus to roll as it should, will affect the function of the knee joint.

If there are hypertrophic muscles and restrictive fascia blocking ankle joint function, what happens? The ankle must flex with each knee bend. The ankle will work hard to get a knee bend—even if that means twisting, collapsing the arch, or “paddling” the foot from the hip and the knee. A twist in the ankle means a twist at the knee and hip, too.

The second ankle dorsiflexion check is to passively dorsiflex the ankle with the client on a table. If the ankle range of motion is limited, but the client does not report a stretch-type feeling in the gastroc, the issue is mobility—not flexibility. That client will respond to ankle self-mobilization instead of stretching.

Mobility issues require manual therapy and re-patterning exercises. A flexibility issue will require soft tissue and fascial therapy to get it to stretch.

Myofascial release points for knee problems

For self-myofascial release at the knee, you can use foam rolling or stick work. I like to use the deep muscle stimulator. You could use an ART-type of maneuver, instrument-assisted tools, or get in there with skilled hands.

We use pressure to stimulate the golgi tendon organs and inhibit the muscle spindles. You can do some tissue work at the apex of the gluteus maximus. Work on the side of the coccyx to get the deep six rotators. Make sure to get the TFL, the iliotibial band and the adductors. Work around the patella, the shin and the whole anterior tibialis. Get behind the knee at the popliteus, and get the bottom of the foot.

The most important myofascial release points for a knee problem are the apex of the gluteus maximus, the side of the coccyx, the iliotibial band and the TFL. Emphasize the TFL. Get the adductor. Work around the patella. Do the anterior tibialis. Get behind the knee into the popliteus and do the bottom of the foot.

Correctives for knee problems

Ankle mobility dorsiflexion corrections include a staggered stance holding both hands in front, then rotating the body side to side. You’ll see the ankle moving side to side in pronation and supination.

Another option is step sweeps. Have the client stand, then step one leg out to the side into abduction, and sweep the leg forward as far as possible. Have your clients roll on their feet, doing seesaws side-to-side, or forward and backward to create dorsiflexion.

I also have my clients do a toe touch to check the hamstrings. The forward bend will put the hamstrings on greatest tension, whether the movement is done correctly or incorrectly, because those muscles are in the most direct position to gauge tension, the rate of change for feedback and perception.

You can also check the hamstrings with the active straight leg raise as we do with the Functional Movement Screen.

There are three hamstring corrections I especially like: Have your client sit upright on a chair, and straighten the knee to the best of your ability. Once you straighten the knee, lift the knee as high as it will go.

The second correction is leg lowering with a band. The patient is supine; both legs are elevated with the heels toward the ceiling. Wrap a Theraband or yoga strap around the right foot and hold it upright. Lower the left leg slowly, and repeat about 10 times on each side.

I also like the standing hip rotation with a foot on a chair. Have your client put the right foot on a chair, then internally and externally rotate at the hip to get the hamstring to loosen.

Next you want to check the squat.

Make sure the knees track over the second toe. Oftentimes, they’ll go inward. That’s the typical compensation we’ll see—the knee moves inward. It’s a dysfunction if the patella moves over the first big toe toward the midline of the body.

If you see this, concentrate on inhibiting and lengthening the gastroc soleus, the biceps femoris, the adductors and the TFL iliotibial band.

It’s not as common to see the knee move outward in the squat, but if you do, you still want to lengthen and inhibit the gastroc soleus, the biceps femoris and the piriformis muscles.

Functional testing of the TFL iliotibial band

You will need to spend time on the functional testing of the TFL. This is a difficult muscle, and you have to get comfortable with it. We have strategies for soft tissue work, as well as for teaching clients specific stretches to do at home.

There are nine common causes of TFL-iliotibial band syndrome. The first is tightness in the TFL-iliotibial band itself.

One test we do is called the Modified Ober’s Test—try this yourself now.

Lie down in a side-lying position with the unaffected side down. The pelvis and spine are in  neutral alignment and the bottom leg is flexed for support. The upper leg is extended, although the leg may be flexed as much as 10-15 degrees and the test will still be valid. But the leg needs to be above horizontal.

The hip is laterally rotated and extended as far as it can be extended with no lumbar extension. Keep the lumbar spine in neutral. Actively flatten the waist toward the floor and hold the leg in slight abduction and lateral rotation.

Those are the keys: keeping the waist toward the floor and holding the leg in slight abduction and lateral rotation. The knee doesn’t have to be locked. Keep the foot relaxed.

Slowly lower the leg toward the floor until the iliotibial band hangs on the greater trochanter and cannot lower more. The key to an accurate test is not letting the pelvis move into lateral tilt, anterior tilt or rotation. As long as the leg lowers, the hip should not flex or medially rotate. It’s essential to maintain the laterally rotated position of the hip.

Ideally, the leg should lower into at least 10-15 degrees of adduction—which is approximately two to three inches above the floor for women and approximately one to two inches above the floor for men—without the loss of proximal control of the pelvis or hip.

An iliotibial band lacks extensibility if the leg does not adduct sufficiently. That’s the Modified Ober’s Test. It’s a great test to determine tightness in the TFL and iliotibial band. It can also be used as self-stretch homework.

Myofascial restriction in the hip and thigh muscles

The second cause of iliotibial band syndrome is a myofascial restriction in the hip and thigh muscles, which increases tension on the IT band. The IT band only becomes sensitive to mechanical stretching in the presence of inflammatory pathology. A client will describe fascial inflammation as a burning sensation in the outer thigh.

In manual palpation, you’ll be able to feel the tension in the band. In a visual postural analysis, with the client standing so you can see the thigh exposed, if the band is tight there will be a deep groove along the IT band.

Get the client into a Modified Thomas Test position.

Check the tensor fasciae latae by adducting the horizontal thigh until the pelvis moves. It should be about 15-20 degrees, but if the iliotibial band is tight, there will be a restriction in the passive extension adduction of the thigh when the knee is flexed to 90 degrees.

The third cause of iliotibial band syndrome is a weakness in the hip abductors. This is very common in distance runners. It’s especially common if they run in the same direction around a track or the same direction on a crowned road. Get clients to mix up the running direction to balance the way their feet hit the ground.

The fourth cause is weakness or poor control of the knee muscles.

The fifth cause is dominance of the anterior hip muscles—the TFL’s dominance over the posterior hip muscles and glutes. Tight flexors cause the pelvis to rotate while walking, and this leads to a shutting down on one side of the abdominals and one side of the gluteus medius.

The sixth cause is excessively flat feet or high arches. Poor instep strength is a cause of Achilles’ tendon inflammation and chronic knee pain from the iliotibial band attachment at the knee.

The seventh cause of iliotibial band syndrome is bow legs or knock knees.

The eighth cause of TFL-iliotibial band syndrome is leg-length inequality.

And the ninth cause is limited ankle range of motion.

When the feet or toes externally rotate during the overhead squat, this is usually associated with decreased ankle dorsiflexion and lateral gastrocnemius muscle tightness. If you observe the feet turning out, you’re likely to see knee valgus—the knees turn inward. Movement of the knees inward is due to increased hip adduction.

We resolve this through mobilization, inhibition and muscle-lengthening procedures before moving up the kinetic chain. Get into the biceps femoris and the TFL with your hands, because those cause the lower leg to abduct, which can perpetuate eversion of the ankle and foot.

Treatment for TFL-iliotibial band syndrome

Now let’s talk about treatment for TFL-iliotibial band syndrome. I’ll break it up into the acute phase and the sub-acute phase.

If a person is having knee pain without hip pain in the acute phase, ice the area. I usually tell people to use ice in a baggie with a piece of paper towel under the ice for a solid 15 minutes.

Introduce your clients to an anti-inflammatory diet like the Paleo diet, and supplements like Omega-3 essential fatty acids and curcumin.

The acute phase

Clients with an acute problem in the TFL or knee, have them take three grams of Omega-3s and three grams of curcumin daily. This recipe seems to be the best in the acute phase.

You also have to modify their activities. People have to stop the perpetuating factors that cause irritation.

One recommendation I often make is sleeping with a pillow between the knees to decrease tension on the IT band.

After the acute phase

Once out of the acute phase and into the subacute phase, it’s time for massage and myofascial release techniques. Address those tight areas. Work on the trigger points. Get the client to foam roll, use the balls, do stick work, and then get good at stretching the TFL and iliotibial band.

First, I recommend the Thomas Modified Maneuver as a good way to manually stretch the TFL-iliotibial band.

Second, I suggest a standing self-stretch.

Third,we use a gluteal bridge with the feet wider than hip-width apart and toes raised with adduction. Get into a bridge position, with pressure on the heels, put a pillow between the knees and squeeze when bridging up and down. There are lots of standing self-stretches you can show the client.

The stability phase

Once in the stability phase, I give clients three or four exercises as daily homework.

I get them to bridge with a single-leg raise. They’ll repeat the movement up and down, building up to one to two minutes of slow, continuous movement.

Secondly, I prescribe the clamshell to target the gluteus medius.

In the beginning, allow the client to keep the heels in contact, but don’t let the pelvis rotate forward or backward—that’s the biggest mistake I see. Lift the thigh from the hip to maximum ability, hold it there for 10 seconds and slowly bring it back down. I have clients perform 10 of these 10-second holds.

The third move is standing with an elastic band around the knees to perform a single-leg or thigh abduction, one at a time in a semi-squat position. Have your client get in a semi-squat position. Wrap a band around the knees to do a single-leg or thigh abduction, one at a time, keeping the big toe on the ground. Build up to one or two minutes of continuous movement.

The fourth exercise is the step-down. Step-downs are done from a two- to six-inch stable step, performed very slowly. Get your client to track the center of the patella over the second toe.

Those are four good exercises to have clients perform at home during the stability phase.

Checking hip rotation

The next thing we’ll do is to check hip rotation, which is extremely important.

You have to know how to check and assess the hip in a prone position. You could place a pillow underneath the pelvis if needed, and have the client keep the knees together and the hips neutral.

This is based on the Craig’s Test. The knee is at a 90-degree angle. Passively assess rotation range. Ideally there should be 35 degrees of lateral rotation and 35 degrees of medial rotation from neutral.

That’s important—35 degrees of rotation in the medial and lateral direction is ideal. Less than 10 degrees difference is not clinically significant. However, it’s best to measure internal and external hip rotation in a prone position, rather than in supine.

Make sure the work is at the hip and do not allow any movement in the pelvis. The pelvis has to stay still as you passively move the hip into internal and external rotation.

If you find excessive medial rotation of the hip—more than 35 degrees of medial rotation—this tells you there’s poor stability or excessive length of the capsule or the lateral rotator stability muscles—the posterior gluteus medius and the intrinsic hip lateral rotators. If you see this, give the client specific exercises. The clamshell is a good place to start.

If you see excessive lateral rotation of the hip, it coule be due to poor stability function or excessive length of the medial rotator stability muscles—the anterior gluteus medius and minimus. Those are the biggies of poor stability or excessive length of the anterior gluteus medius and minimus. You can start with some clamshells in this case, too.

You also have to see if there is any decreased lateral rotation or decreased medial rotation. If there’s decreased lateral rotation, that’s tightening or shortening of the capsule or the TFL-iliotibial band. You’ll need to get in there with your hands, do the foam rolling and deep tissue work, and loosen up that capsule with manual therapy.

If there’s decreased medial rotation, it could be a shortening of the capsule or myofascial structures like the piriformis or the gluteus maximus fibers. It’s usually the superficial ones. Again, get in there with deep tissue work on the piriformis and gluteus maximus. This makes a significant difference for those who have lumbar pain or knee pain.

Quick and simple knee rehab

We’ll close with some quick and simple knee therapy rehab. Get your client to do a quad exercise—it could be seated with a Theraband as the resistance, using one of the machines, or something you find a little more functional. Lunges are great if the client can do it.

The second exercise I give clients is hip abduction, preferably standing. Standing hip abduction using a Theraband as resistance around the ankle is a great knee therapy exercise.

Make sure to include an exercise for hip extension. Usually, standing is better than from the floor. Again, wrap a Theraband around the ankle and have the client do some hip extension exercises.

I also like to have patients do balance work on unstable surfaces, like stability pads. I have my client put one leg on each of the stability pads.

You just want them to stand there to get a sense of what it feels like. Eyes are open at first, and then have them try it with eyes closed.

Let them get comfortable with that. Once they’re good at that, take them off of the pads and have them stand on one leg. Do a one-legged stand with eyes open. Test this for 10-30 seconds.

Then, get them comfortable with doing the same stance with eyes closed for 10-30 seconds. Once they’re good at that, have them progress to doing a stability pad on one leg. It’s the same routine—eyes are open at first, then eyes are closed.

I like to use a squat movement in knee rehab. You can teach clients how to sit back into a chair. If they’re more advanced, use full overhead squats, and progress into different types of kettlebell moves from there.

Do step-ups—going up stairs, tracking the knee over the second toe. Then do lateral step-ups, facing the side of the stairs and stepping up into adduction-abduction.

Get clients to do that routine twice a week for a few weeks. It will make a difference in successful re-patterning.

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If you’d like to improve your client’s movement quality and lower the risk of injury—including knee injuries—here are some resources you may find useful.

Movement

If you’re looking for the missing puzzle piece to help protect your clients from future injury and to eliminate the roadblocks that hold them back from greater performance, you’ll find Gray Cook’s Functional Movement System as detailed inside the Movement book invaluable.

Inside you’ll discover a system that not only helps you screen and assess a person’s movement quality, but also a system that helps you identify the corrective strategies needed to help protect your clients from injury and help them move better.

If you’ve ever wanted to—

• understand why people get injured, and why their pain keeps returning
• improve your patient’s recovery process
• give people a strong foundation before loading them with weights
• eliminate training mistakes that delay results
• improve your client’s chances of making it through the athletic season without suffering a non-contact injury
• restore the quality life in people who have suffered in pain due to movement problems
• build more functional, longer lasting athletes
• avoid frustrations and improve patient outcomes when working with other healthcare and fitness professionals by learning a standardized language to communicate

… then Gray’s Functional Movement System outlined in Movement may be just what you need.

Click here to learn more about Movement.

Prehab/Rehab 101

Restoring fundamental movement patterns can go a long way in unlocking performance and reducing injury risk. In Prehab/Rehab 101, Mark Cheng teaches five groundwork progressions based on the neurodevelopmental sequence. These progressions will help you form a solid foundation for more challenging movements and activities.

Click here to learn more about Prehab/Rehab 101.

Tap Into the Brains of Some of the World’s Leading Performance Experts

FREE Access to the OTP Vault

Inside the OTP Vault, you’ll find over 20 articles and videos from leading strength coaches, trainers and physical therapists such as Dan John, Gray Cook, Michael Boyle, Stuart McGill and Sue Falsone.

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