From The Eyes of a PT - Knees

Introduction 

Over the years, we CrossFit coaches have noticed many behavioral trends among our athletes. One of the most common trends we see involves their willingness to take to heart our opinions on building strength, increasing range of motion (mobility) or healthy eating.  We are often seen as experts in these fields thanks to thousands of hours of real world practice and learning.  However, one of the areas that we often get scoffed at is that of injuries, whether they are the nagging or serious variety.  We’ll be the first to admit that we are certainly no experts in this area of health and wellness as we have never received a sports medicine or physical therapy degree, nor practiced as a licensed physical therapist.  Having said that, through the years we have come to develop a pretty good instinct for when athletes are pushing too hard and entering the window of overuse injuries.  Unfortunately, our words of wisdom oft fall on deaf ears.

As CrossFit trainers and coaches, we promise an elite level of fitness (“CrossFit – Forging Elite Fitness”) as compared to other common exercise routines.  This is an elite level of fitness that is usually only reserved for professional athletes and military personnel.  To achieve this level of fitness, gym members must come to understand that they are making a commitment to themselves and a healthy lifestyle that has often (unfortunately) been seen as too time consuming by a great majority of the population.  This commitment includes making daily choices that improve the healthiness of the athletes’ lifestyle.  One of these choices is beginning to look at fitness as training for life and not simply exercise that can be performed each and every day.  When an athlete trains for elite fitness, the athlete is taxing his/her body more than a general exercise routine and thus requires a greater level of recovery than the casual exerciser.

Knowing their own limits and lack of attentiveness to recovery is one of the main reasons why CrossFit athletes can find themselves experiencing nagging injuries and issues from time to time during training.  To hammer home the importance of this attentiveness and provide a greater understanding of these issues we asked Stephanie Romich, a CrossFit Sixth City member, to provide us with some insight into common injuries and nagging issues that athletes experience.  In this edition she addresses the knees. 

Let’s Get Physical (Therapy)! 

OK guys - let’s get real with our current injuries and nagging issues with training and working out so we can begin to understand how to fix them. I want you to ask yourself these questions:

• Am I getting inside of the knee pain or pain right under the knee cap?

• Do I have pain at the top, back, or front of the shoulder or into the deltoid?

• Do I have mild to severe pain at the mid/low back with possible radiating pain into the leg? 

If you answered yes, then you might be suffering from some of the most common overuse injuries we see in athletes, especially those in the CrossFit community.

If you don’t know me personally, I am a sports specialist Certified Athletic Trainer and Doctor of Physical Therapy currently practicing in a sports outpatient facility for University Hospitals in Mentor, Ohio.  I have worked with several high level athletes over the years, including state and national champions, current pro athletes, as well as your usual weekend warriors.  Throughout my time with CrossFit I have noticed a trend in the athletes who frequent our gyms, usually among the more frequent members, that fall in common overuse painful patterns.  The following is a little education for each of these areas where we, as athletes, could all use a little more focus.  This post will address everyone’s favorite issue - the knee. 

Why Do I Have Knee Pain?  
There are a few very common overuse injuries which tend to happen in those who do a lot of heavy lifting, squatting, or running related workouts which tend to include general wear and tear at the knee.  Most often, these injuries when assessed by doctors will be diagnosed as “Patellar Tendonitis” or “Runners Knee.”  These types of injuries are caused by abnormal stress being placed at the knee from either a mechanical movement issue or muscular imbalance.  I have found that in CrossFit, the cause can usually be traced back to one of three things: poor squatting/functional mechanics, glute weakness or inactivation, or a muscular imbalance which has developed between the quads and hamstrings.  It is rare that these problems are happening in isolation of each other.  Instead, it is very common these patterns are present in combination and have lead to more chronic knee pain overtime.

A good place to start looking for causes of knee pain would be with the athlete’s squat form. This is particularly important as we continue to work with heavy weights and progressions which can include high reps or sets during the gym programming.  The main things to be aware of when squatting are as follows: 

• Limiting knee valgus - Most knee related issues lie when people allow their knees to go into valgus (a movement of then knees in towards each other) instead of keeping them in neutral alignment over the foot and ankles. This is most common at the transition point from full depth squat to the accent back up, or throughout the entire squat when your feet are too wide to start the movement. When you allow for this knee alignment you are putting the stress of your entire body weight (plus any extra weight you might have on your back or shoulders) onto a very small point of pressure at the medial (inside) knee. This pressure will stress and irritate the structures at the medial knee including the muscles, ligaments, tendons and bones. Lack of control of this valgus force is often traced back to weakness and lack of activation at the gluts or with a stance that is too wide to perform the squat properly.

• Proper alignment - The second common mistake is the excessive forward knee position at the beginning and full depth position of a squat.  This is when people allow their knees to drive forward and over their toes instead of sitting back into their hips and driving the butt back FIRST to initiate the movement and follow through to full depth.  This will cause you to put all for your body weight, as well as any extra weight you might be lifting, into the knees alone and cause the movement to be performed predominantly at the quads.  When you engage the hips and initiate the movement posteriorly first, then you are allowing all of the muscles of the lower extremity to assist versus putting all of the pressure solely at the knee joint.  This will limit the quads from becoming too dominant and bulky and encourage a unison activation of the quads, gluts, and hamstrings to achieve the movement with good control and fluid form.

• No “butt winks” - We will address this concern again in the back pain section, but it involves what is known in CrossFit gyms as the “butt wink.” This happens when flexibility becomes too limited in the bottom of the squat or due to the inability to maintain a neutral spine position due to core weakness.  This lack of mobility or core activation can cause the back to flatten or pelvis to excessively tilt back instead of staying in a neutral lumbar spine position.  This flattening or rounding of the back in the bottom of the squat places a lot of stress at the low back and can irritate the muscles protecting the spine.

Muscular imbalances and joint restrictions throughout the lower chain can also cause the resultant pain we feel at the knees.  Another common cause of medial (inside) or anterior (front) knee pain is found in those who have become quad or hamstring dominate, which is very common to do without realizing it.  Be weary of the person who says they have been doing heavy squats for years, has a ridiculous 1RM (one rep max), yet has no gluts.  More often than not, athletes with imbalances have become quad dominate, more so than hamstring, due to the aforementioned common form mistakes.  Based on the fact that you have to activate the gluts and keep them active to maintain neutral alignment at the knees throughout the squat, there is minimal chance your gluts can remain small if they are an active participant.

Muscle tightness and restriction at the calves can also limit the ability of the shin to move forward normally over the ankle which can inhibit the depth in which we can squat and can throw the lifter more anterior onto the toes to make up for the limitation. Below you can see a good exercise which can help specifically with the ankle mobility when the knee is in a squat position to allow for great depth.  Other imbalances we should consider involve the mobility and movement of the lumbar/thoracic spine to ensure the torso can remain upright and strong enough to hold the barbell load.  We will discuss ways to ensure the spine is in a good alignment for lifting in another post. 

I Have Knee Pain, Now What? 

So, now we have knee pain and many of the things listed above sound familiar…now what? Not every knee pain is the same and not everyone needs to focus on all of these to help, but chances are a combo of these will lead to the quickest route for pain relief.  There are several exercises and retraining tools you can do to help decrease the medial knee stress and hopefully decrease your pain overall.

• First and foremost, if you have gotten to the point of constant and pretty intolerable knee pain - TAKE TIME TO REST.  There is no shame in resting and recovering, but continuing to push through pain is not usually going to resolve it and will only further the problem or damage being caused. The body responds to stress with pain for a reason, so LISTEN to it.  If the movement hurts, then stop.

• Reassess your form!  Take the time to drop your weight, take off the weight belt, grab a coach or someone like me and have them look at your squat form to tell you where you might be having trouble.  To a trained eye, these impairments can be very obvious, but it might not be as clear to you because it’s the form you have trained your body to perform.  Some of these impairments might also not be clear with light weight or without stressing mobility limits.

• Back down your weight and focus on PAIN-FREE, full ranges of motion with consistent proper form for high reps.  This needs to be worked on until you can move without hesitation through the skill with proper form and is completely pain-free before more weight is added. 

• Strengthen your weaknesses in isolation.  While we realize most movements in CrossFit are more functional and involve all the muscles to work in unison, when we have gotten to the point of pain we are usually activating our stronger muscles to perform all movements and might have issues activating the weaker ones. More often than not, you need to focus on hamstrings, gluts and external rotators to ensure you have the strength to engage the proper musculature, especially when you are under a greater load.  We have been adding these often to our accessories as a gym, but if you ask for an analysis from the coaches or myself we can direct you to more specifically to exercises which would fit you individually. Below you can see some of the more effective exercises for hip and glut activation and can be a good place to start.

• While squats have been the main focus of this blog, they are not the only things that cause knee pain.  We also must reassess our form with squatting related activities like box jumps, wall balls, double unders and walking lunges to make sure we have good form and proper muscle activation throughout.  These are all sources of knee pain when the same mechanical fallacies are occurring which we have talked about above (i.e. knee valgus, excessive anterior knees to toes, lack of posterior hip engagement, etc.).

• Finally, and I can’t stress this enough – CrossFitters and athletes alike always need to be focused on mobility!  Unfortunately, this tends to be one of the biggest issues we ignore in the gym.  A lot of common squatting issues, which lead to resultant knee pain, can be traced back to limited mobility and can cause poor form like excessive forward torso, rounded upper back, heels rising from the floor, toes excessively rotated out, etc.  We need to be taking the time to focus on mobility all the time, not just when you are painful or limited, with a specific emphasis on post WOD.  We need to ensure the hips have the mobility to move into external rotation, the hamstrings and quads allow for depth on the squat, calves and ankles are mobile enough to allow the shin to translate forward, and thoracic/lumber mobility allow for the chest to remain upright and stable. Without the proper mobility, the knees will tend to find themselves as the monkey in the middle where the pain is most prominent and will be prevalent.