How to program for clients with knee pain

By: Ben Pavlovich, SUF-CPT. Santa Monica Personal Trainer.

Hey guys my name is Ben Pavlovich and I am a Show Up Fitness – CPT in Santa Monica and I've completed the esteemed mentorship program for elite trainers (Show Up Fitness – Mentorship Program.) I have worked with some of the top physical therapists in the country, gone through internships and courses on knee pain, as well as read basically every published medical study reviewing knee pain I could get my hands on. This is not medical advice and is intended for education purposes only.

Pain is multifactorial and before you try to self-diagnose your knee condition, schedule a consult with us at Show Up Fitness to eliminate red flags and if need be, we can make a referral to our partners at the Pre Hab Guys& read more on how to assess your knee pain HERE

Now that's out of the way let’s dive into knee injuries.

There are a number of types of knee pain you may encounter working with clients such as Patellofemoral Pain Syndrome, Patellar Tendinitis, or Iliotibial band syndrome to name a few.

Working around these injuries can be a challenge. Fixing them can be even more of a pain in the ass knee.

We're going to go over 3 of the most common knee injuries you may experience, we'll review the current science on how to address them, as well as how to create a program working around these injuries.

Most Common Causes of Knee Pain

Patellofemoral Pain Syndrome- Anterior Knee Pain

Patellofemoral Pain Syndrome or PFPS for short is the most common knee injury in adults. It's an umbrella term for anterior pain around the patella and is sometimes called “Runners Knee” as runners are the most common victims of PFPS. PFPS is characterized as a dull anterior knee pain usually above the knee.

What is it Caused by?

There are a number of theories as to what causes PFPS or anterior knee pain as a whole including but not limited to overuse, injury, muscle imbalances involving the Vastus Medialis, weak hip abductors, and/or improper training techniques.

How to treat PFPS?

According to a meta analysis in 2018 reviewing 14 trials and 673 participants concluded that “Hip and knee strengthening is effective and superior to knee strengthening alone for decreasing pain and improving activity in persons with patellofemoral pain”

Rather than focusing solely on quads, we should incorporate compound movements that involve the hip as well. A second study found that when comparing quad only to hip only exercises, the hip only group was able to resolve their anterior knee pain one week faster.

So when Chubbs says “It's all in the hips” in Happy Gilmore, he's not lying!

Iliotibial band syndrome – Lateral Knee Pain

ITBS is the second most common knee injury. The pain is felt on the outside of the knee proximal to the lateral condyle of the tibia where the IT Band inserts into.

What is it caused by?

The general consensus is that with ITBS, the IT band is inflamed and swollen applying pressure on your knee cap or the lateral condyle of your femur which causes compression or friction leading to pain.

How to treat ITBS?

A study done with 24 (10 M, 14 W) runners suffering from ITB syndrome were found to have weaker hip abduction in the affected leg.

In addition, these runners completed a 6-week rehabilitation program focused on hip abduction to strengthen the gluteus medius which resulted in 91.7% of the athletes being able to return to running at the end of the program.

So once again we see a trend where weak hips are correlated to knee pain.

Patellar Tendinitis – Lower Knee Pain

Also known as jumper’s knee, Patellar Tendinopathy is inflammation of your patellar tendon from overuse or injury. The pain is typically felt right below your knee cap where the patellar tendon is located.

What is it caused by?

The injury is caused by microtrauma in the tendon and risk factors include jumping sports or being overweight. Repetitive overloading exceeds the body’s natural healing and doesn’t allow the tendon to fully recover.

Patellar Tendinitis vs Tendinosis

Acute Patellar Tendinopathy or Patellar Tendinitis is when the patellar tendon is subjected to extreme forces such as jumping, rapid acceleration/deceleration, or overuse due to recurrent heavy load squatting. Read more about the difference between the two HERE

Chronic Patellar Tendinopathy or Patellar Tendinosis is pain due to the deterioration of collagen in the tendons. There is no inflammation typically as the actual issue is the degrading of the actual tissue.

How to treat Patellar Tendinitis:

A study conducted in 2001 with athletes suffering from patellar tendinitis compared squats to leg extension/leg curls for 12 weeks. “Over the 12 week intervention, pain diminished by 2.3 points (36%) in the leg extension/curl group and 3.2 points (57%) in the squat group.” PMID:11157465

See a trend here?

As we have seen from the previous knee related injuries the exercise involving hips was more effective than isolation exercises like leg extension/curl.

Programming for clients with Knee Pain

I believe when structuring a training routine we should focus on 3 things:

– Reteach proper squat form and slowly progress the movements to the client’s ability.

– Find knee dominant exercises that don't recreate or cause excessive pain.

– Train the muscles of the hip.

Start with body weight to own the movement and then slowly progress the load. Be aware of the clients facial expressions. If they say they are not in pain, yet they grimace, you need to regress the movement or switch it out completely. MAKE SURE TO CHECK WITH YOUR CLIENTS THE NEXT DAY. This is part of the professionalism that we teach in our fitness mentorship. If you're looking to improve your streams of revenue, you need a fitness mentor. Show Up Fitness Mentorship Program (SUF-MP) is the most cost effective mentorship in fitness!

Workout Routine Template

1. Core Movement
a. Core Movement
b. Accessory

2. Core Movement
a. Core Movement
b. Accessory

3. Core Movemet
a. Core Movement
b. Accessory

Here is a full body workout routine you could follow for a client dealing with knee pain.

Full Body Routine with Lower Body Focus

1. Lateral Step Up – Knee Dominant

a. Cable Row- Horizontal Pull

b.Side Plank – Accessory lift

2. Romanian Deadlift -Hinge Pattern

a. Incline Press – Horizontal/Vertical Push

b. Calf Raise – Accessory lift

3. Split Squat – Knee Dominant

a. Lying Leg Raise- Leg Abduction

b. Squat Throw – Throw a ball to your clients, have them catch it, squat down, and then throw it back

Some other exercises you could experiment with are

Isometrics- Wall Sits, Spanish Squat, Alternating Wall Sits,

Isolation: Cable Hip Abduction, Hamstring Curls, Quad Extension,

Compound- Lateral Lunge, Deadlift, Barbell Hip Thrust

If you want to learn more about how to program as a new and/or aspiring personal trainer, sign up for the WORLD'S BEST PERSONAL TRAINING CERTIFICATION HERE: SHOW UP FITNESS CERTIFIED PERSONAL TRAINER (SUF-CPT). We have daily calls that are live and on-demand with our APP.

Sources:

PMID: 19771287

PMID: 2039064

PMID: 29034800

PMID: 21041965

PMID: 10959926

PMID: 10959926

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