A GUIDE TO TRAINING WITH KNEE PAIN FOR PERSONAL TRAINERS & STRENGTH COACHES
GENERAL GUIDELINES FOR TRAINING WITH ANY INJURY
1. Refer out!
We are strength coaches and personal trainers, NOT doctors. We do not make medical diagnoses. Anything that is painful, please refer out to a doctor or specialist in your area. Do your best to make this person a part of your network as it’s about helping the individual, not about egos. In the end, everybody should win: you, the doctor, the therapist, and most importantly the client/athlete.
2. Ask them: Does it hurt?
Only a yes or no answer will suffice. “Kind of,” “not really,” and “only when I…” are a yes. Refer out, and then regress or eliminate any exercise that causes pain. Read Coach Boyle’s “Does it hurt?” article for more information.
3. Use an assessment.
At MBSC, we use systems from Functional Movement Screen like the FMS and SFMA. We find these to be the best systems currently available to look at gross movement quality and identify entry points for improvement in training.
When using the FMS, specifically for pain-free clients, the simplified scoring system allows our coaches to put clients into buckets based on their movement quality. Scores of 2 or 3, don’t raise any red flags meaning they can continue training the associated pattern normally. A score of 1, would signify a limitation in gross movement quality, warranting a regression to an simpler movement and further investigation into local joint movement quality. A score of 0 means there is pain associated with the movement, meaning we refer the client to a medical professional for treatment and continue to train the non-painful patterns. Generally speaking, non-specific back pain clients could use more mobility in their hips and thoracic spine and improved motor control of their hips and core musculature.
If you are not familiar with the Functional Movement Screen, you can employ the “Does it hurt?” method above and set up your programming from there. *Note: There are always exceptions to the rule. Think young pliable athletes and yogis. Usually, they’re a case for getting stronger, not more mobile!
4. Manage your expectations.
Training age, chronological age, previous injuries, joint replacements, and surgeries are all variables that could negatively effect training outcomes, although they’re not an excuses for in-action. Braces, sleeves, ice, heat, taping, compression, NSAIDs, and passive care are just band-aids. Their purpose is to minimize inflammation, stabilize the injury, and help the healing process. Once a cut (injury) heals, you wouldn’t keep wearing a band aid (modalities & passive care) would you? These modalities are meant to be used sparingly, not relied on.
5. There is always something…
we can be doing while an injury heals. If your right arm is broken, you have three other limbs and a core to train. The positive systemic benefits of exercise on the human body will aid in the rehabilitation of (X) body part or segment even if you are not training it directly. Movement is Medicine.
6. Knee Forward vs. Vertical Tibia Debate
A healthy knee is meant to travel forward over the toes. If it wasn’t, we wouldn’t be able to walk, run, or jump. With that said, when training someone with knee pain it is best to stay “Hip Dominant” where there is minimal to zero forward translation of the knee/tibia. This will spare the knee and put most of the focus on the hip complex. While this is not how the knee joint necessarily works, it is a good way to continue training the legs and hips while pain/inflammation are decrease and motion of the knee is restored. This is where it is important to be working with a medical professional.
CONTRAINDICATED EXERCISES FOR CLIENTS WITH KNEE PAIN
Explosive Lower Body Plyometric Work
High Box Jumps & Hurdles
All Single Leg Plyometrics
Heavy Cleans & Snatches
Heavy or Explosive Rotational Work where the knee is planted (due to twisting on the knee)
Standing Rotational Medicine Ball Work
Dynamic Rotational Keiser/Pulley Work
Heavy Knee Dominant Exercises
All Bilateral Squat variations
Single Leg Squats
Rear Foot Elevated Split Squats (usually the back leg due to a lack of quad length and/or hip extension)
Explosive or High Impact Conditioning
Sprinting or Long Distance Running
Heavy Sled Work
Slideboard due to the explosive lateral nature of the exercise
The Rower due to the repetitive knee flexion
Stay away from most Met-con work. It leads to serious fatigue where the client is usually trying to beat the clock or focusing on quantity, not quality.
Stretching into deep knee flexion
Sitting butt to heels (Yoga: hero pose)
Aggressive quad stretching
Linear/Lateral Warm up
the walking stretches that are part of the MBSC warm up are generally ok, but the linear and lateral track drills can be too much
THINGS TO TROUBLESHOOT WITH CLIENTS WHO HAVE KNEE PAIN
Note the word “troubleshoot” here. Anything below could be contraindicated depending on the individual. We have found through our experience that the information provided below has worked well for our knee pain clients. Please consult with a good physical therapist, chiropractor, or doctor who understands the importance of quality movement to get a second opinion on your programming. We see this as “best practice” for any injury: everyone working together for the sole purpose of getting the client healthy.
Easy Plyometric Work
Ladder drills
Battling Ropes for the upper body
Light hang cleans & snatches under 60% (caught with a slight knee bend, not in a full squat)
KB Swings
Jump Rope with feet together
Start with low box jumps or depth drops
Body Weight or Assisted Bilateral & Single Leg work
Ensure a 2/2 Active Straight Leg Raise, Toe Touch, Hip Hinge Pattern then move to a Kettlebell Deadlift
Bodyweight or Assisted Single Leg Deadlifts
Assisted Squats
Assisted or Body Weight Split Squats, Reverse or Slideboard Lunges, and Lateral Lunges
If you are going to load with resistance begin in a goblet position as having the load in the front of the body reflexivity activates the core and encourages good posture without having to cue it.
Use RNT (Reactive Neuromuscular Training)
By feeding the mistake (usually a valgus collapse of the knee), we re-train the brain to do what we want it to do. The band does the cueing for us.
RNT is great for all squatting variations and single leg exercises.
It’s a wonderful teaching tool but don’t rely on this as a crutch. As the client/athlete improves try to use it less and less.
Non-Impact Conditioning or Warm up
Airdyne Bike for time or distance, slowly integrate interval work
WALKING – get outside and walk every day, done preferably on their own time
Light sled pushing or dragging
Bike & rope are great ways to elevate heart rate without putting strain on the knee
An elliptical in this situation would be a valuable tool to get the lower limbs moving in a somewhat running motion without impact
Half Kneeling core work can be your best friend as it takes the bad knee out of the equation (unless it’s both knees). Just be sure they have an airex pad or something similar to kneel on. Also crossing the midline like this is candy for the brain.
½ Kneel Chop & Lift, Row, Chest Press
½ Kneeling Dumbbell Press
½ Kneeling Landmines and Anti-Rotation Holds
½ Kneeling Medicine Ball Work
When working with the joint-by-joint approach the knee sits between the ankle and hip. If the ankle lacks mobility, the knee more than likely will have to pick up the slack. If the hip lacks the stability to absorb ground reaction forces, the knee will end up absorbing those forces instead. Herein lies the problem.
Below are some of our favorite ankle mobility drill & hip stability drills:
Ankle mobility:
1/2 kneel ankle mob
Eccentric foot drops
PNF Wall calf stretch leg straight
PNF Wall calf stretch knee bent
Stability Ball Anterior Tib Activation
Hip Stability & Glute Function:
a. Hip Lifts – Bilateral & Single Leg
b. Lying Hip Flexion
c. Isometric Split Squat Work
d. RNT (see # above)
e. Quadruped Hip Extension Progression
f. Mini-Band Walks and Single Leg Holds maintaining spinal position first and foremost
g. Clam Shells w/ back flat against a wall
h. Leg Curls
Quad Length
a. Foam Roller or Tiger Tale
b. Lax Ball
c. Couch stretch
d. Box Hip Flexor Stretch
Do not forget the core as an integral part of any rehabilitation. If the knee is left to support a non-functioning “core” or malpositioned rib cage & pelvis, then it is likely that progress will be slowed or stall completely.
a. Breathing Drills
b. Carries
c. ½ Kneeling core work (See #5)
d. Use the ground as your “core”. You’re able to put your spine in a good position and take the knee out of the equation completely
e. Crawling Variations
f. Body Saws/ Stability Ball Work/ Rollouts/ Planks
g. Anti-Rotation & Push/Pull
*Note: these mobility, flexibility, and low-level stability drills are done for breaths and NOT for time. Breathing is the only way we can consciously regulate the autonomic nervous system to relax. Coach breathing during the initial phases of your training and it will carry over into everything else you do.
CONCLUSION
Slowly begin to add in more explosive and heavy work as the client progresses. Some exercises may never again be possible and will always be contraindicated for that individual. That is the reality. Set your goals high but have realistic expectations. Trial and error will be a part of the process. Use our Phase 1 Intro Adult Program and regress or eliminate from there. Remember when someone has knee pain in training to decrease impact forces, do your best to maintain a vertical tibial, all the while working with a good doctor, therapist, or both to restore function.
PROGRAM EXAMPLE
The accompanying example program is our Intro Phase One Adult Program. The contraindicated exercises have been replaced with exercises that may be a better choice. Remember, each person is different. There is no timeline on when it’s appropriate to progress. The provided program is a great place to start. Regress and progress as needed, with the end goal being to get every client into our Returning Adult Program pain-free and without any compensations.
CFSC Knee Pain Example Program Download
Interested in learning more? At our Certified Functional Strength Coach course you will experience 8+ hours of hands-on coaching. We will take you through each of the regressions and progressions mentioned above and share with you the system we use to train large groups of clients and athletes.
This article was written by Coach Brendon Rearick the author of “Coaching Rules: A How-to Manual for a Successful Career in Strength and Fitness” and creator of “Building Exercise Checklists for Successful Training” . He can be contacted at brendonrearick@gmail.com