If you suffer from knee pain you know how miserable it can be.
Not only can it stop you from exercising, but it can stop you from doing other things you enjoy like hiking or playing sports with friends.
Worse still, it can also negatively affect your mental health and wellbeing.
Recent research by Versus Arthritis with Public Health England found that people with long-term musculoskeletal conditions, such as knee pain, are almost twice as likely to suffer from anxiety or depression compared to those that don’t have joint pain.
But the important thing to remember is that knee pain can be treated.
Every day, I work with clients that have, at some point, suffered from knee pain.
As a biomechanics coach and personal trainer, many of them come to me looking for a solution to their knee pain problems. They want to do everything possible to reduce the risk of surgery or to improve their recovery after having had a knee replacement.
By having them perform specific stretches and exercises consistently, my clients are able to make great improvements in movement and pain levels.
This guide lays out my step-by-step process.
If knee pain is preventing you from exercising and being as active as you would like, then this guide will give you a clear route forward.
Let’s start by looking at the most common causes of knee pain…
Chapter 1: Common causes of knee pain
Weak glute and hip muscles
An inability to control the level of adduction and internal rotation of the upper leg (femur) when walking or running has been shown to increase the stress that the knee cap (patella) is exposed to.
The term used to describe this is ‘knee valgus movement’. It is often linked to a type of knee pain called patella femoral pain.
Weak quadriceps
The quadriceps are a key stabiliser of the knee joint.
This creates more instability at the knee joint and leads to abnormal load distribution.
Anatomical knee position
The Q angle is measured from the ASIS (anterior superior iliac spine) to the midpoint of the patella, as shown in the image above.
Women typically have a wider pelvis than men, which results in a greater Q angle.
Studies have found an association between knee pain and larger Q angles.
Ankle joint restriction and over-pronation
“If you’re missing ankle range of motion, you have no choice but to compensate into an open foot position, meaning that you walk, run and move with open knees and collapsed ankles. When this happens, you can’t expect everything to be okay.” – Dr Kelly Starret, The Supple Leopard
Research shows that people with reduced dorsiflexion (moving your toes toward your shin) in the ankle joint self-report higher levels of knee pain when tested for joint movement.
It has also been noted that when the foot rolls inwards (overpronation) knee pain is more likely to present itself.
Overuse in activity and/or sport
Research by Fairbank et al and Thomas et al found that females, in particular, are at risk of developing knee pain when involved in physical activity and sport which is classed as highly repetitive.
There is also evidence that a drastic increase in activity can be a leading factor in developing knee pain.
Chapter 2: Self-myofascial release techniques to improve knee pain
The first step in addressing the aforementioned causes of knee pain is self-myofascial release.
Self-myofascial release is a way of reducing the tightness in a muscle by using either a foam roller, massage stick or massage ball.
When the muscles of the hips, thighs and lower leg get tight they can restrict movement at the knee joint, hip joint and ankle joint which in turn leads to altered movement patterns often resulting in knee pain.
Self-myofascial release helps to break down knots in the muscle fibres and helps to reestablish muscle tissue quality. Research has shown that using the approach of self-myofascial release prior to exercise will create a short-term increase in joint range of motion. This will enable more effective stretching to be done in the next step of this process.
The key areas to focus on when using a foam roller, massage stick or massage ball are the muscles around the ankle, thigh, knee and hip area.
Foam rolling the Gastrocnemius (calf muscle)
Foam rolling the Quadriceps
Foam rolling the Gluteus Medius / Piriformis
If you don’t already have a foam roller, we highly suggest you get one. It is an invaluable tool that can be picked up relatively cheaply. This is the one we recommend.
Alternatively, you can improvise with anything from a rolling pin to a broom handle to plumbers piping. I’ve used them all with my clients and they do the same job.
Chapter 3: Key stretches to help improve knee pain
Having released muscle tightness and improved tissue quality using a foam roller or massage stick, you can now move on to stretching.
This will help to continue the process of taking pressure away from the knee joint and allowing more range of movement in the ankle and hip joints.
These are the 5 key stretches for you to focus on.
Stretch 1 – Gastrocnemius Stretch
Hold for 45-seconds each side.
Stretch 2 – Kneeling Ankle Mobilization
Perform 15 reps (touching knee to box) each side.
Stretch 3 – Kneeling Hip Flexor Stretch
Hold for 45-seconds each side.
Stretch 4 – Standing Quadricep Stretch
Hold for 45-seconds each side.
Stretch 5 – Supine Glute Medius Stretch
Hold for 45-seconds each side.
Chapter 4: Strength exercises to improve knee pain
After restoring range of motion through foam rolling and stretching, you now have a stable foundation from which you can start building strength.
It is important, however, to focus not just on the muscles that surround the knee joint itself but also to include strengthening exercises for the hips, buttocks and core, too. This helps to create a more stable lower body foundation to support the knee joint in the long-term.
Here are the top 5 strength exercises for knee pain to include in your routine…
Exercise 1 – Seated Leg Extensions
Perform 15 each side.
Exercise 2- Glute Bridge Hold
Perform 15, 5-second, holds.
Exercise 3 – Clam Shells
Using a resistance band:
Perform 15 each side.
Without a band:
Perform 15 each side.
Exercise 4 – Box Squat
Perform 15 reps.
Exercise 5 – Static Lunge
Perform 10 each side.
Chapter 5: Modifying exercise technique for knee pain
If you are actively working out with knee pain there are often some simple technique alterations that can reduce or eliminate the amount of knee pain you are experiencing.
The most common exercises that I see being performed with incorrect technique are the squat and lunge.
The technique tutorials below will coach you through the key concepts of each movement such as how to ensure your feet remain in a strong position to guide the movement of the knee joint.
Squat
Lunge
Summing up
The presence of knee pain can often be traced back to biomechanical issues or muscular weaknesses such as;
- Valgus knee position, which increases the amount of force placed on the knee joint.
- Weak hip and glute muscles, which lead to instability at the hip translating down to the knee joint.
- Restriction in ankle mobility, which causes the knee to overcompensate and creates more pressure on the joint.
- Weak quadriceps, which leads to lower levels of shock absorption at the knee and a greater level of instability.
It should come as no surprise that the above biomechanical issues are aggravated by exposure to activities like running, exercising or sports that place greater demands on the lower body.
In order to improve these issues you need to attack all angles of possible weakness and instability to create a stronger foundation for the knee joint to function.
That includes:
- Self-myofascial release.
- A variety of stretches.
- Strengthening exercises for the hips, knees and core.
- Focus on your exercise technique to ensure you are limiting your exposure to irregular pressure of the knee joint.
Bonus chapter: Exercise substitutions for knee pain
If having followed all the steps listed above you are still struggling with knee pain while exercising, then it would be wise for you to replace the exercises that are causing you trouble.
Here are 3 substitutions for you to try.
Squat substitution
The hip thrust is a great exercise substitution for the squat as it can be executed without adding stress to the knee joint (as long as it is performed correctly).
This exercise recruits the glutes to a very high degree which is a huge benefit for building strength around the hips to help stabilise the knee joint. It will help to get you back into doing squats when the time is right.
Lunge substitution
The lunge loads your legs in a unilateral fashion (one leg at a time) so a good replacement is the single-leg deadlift.
The focus of this movement is to load the glutes and hips while also testing out single-leg strength. It is a great way of improving both your strength and balance at the same time.
If you struggle for balance try placing your hand on the back of a chair to start with for added stability.
High Knees Substitution
High knees are a great exercise to get your heart rate up and burn calories.
They often show up in bodyweight training sessions. But with bad knees, this exercise can do more harm than good. Instead, try incorporating this low-impact jack exercise.