Do you know how to train, and deal with a client that has a knee injury, or structural concern? Many trainers simply avoid the issue and work around the injury which needs to be addressed, and as a trainer, you will come across clients with previous and current musculoskeletal implications more often than not.
Some of the most common knee injuries or conditions that you will encounter are, patellar tendonitis, patellar tracking dysfunction, chondromalacia patellae, torn meniscus, ACL, LCL, PCL, repair or reconstruction, knee replacements, genu recurvatum, etc…
Typically during your initial assessment and musculoskeletal evaluation with a new client you want to get as much information on the injury or injuries, but for now, we are going to focus on the knees since this is the topic. Find out when and how it happened, and what was the exact procedure and protocol for taking care of the knee. Did it require surgery, and did they go to physical therapy and for how long? Find out if the knee is still symptomatic, or maybe it is asymptomatic at this point.
If the client had a surgical repair or physical therapy, find out their progression from then until now. Contact the surgeon or physical therapist that worked with this client, as you can find exactly what was done, and how far their progression in physical therapy was. If you get a client that is still in physical therapy, then you’re in good shape, as you can work in conjunction with the therapist. As a Strength and Conditioning Coach you want to take the client to the next level, beyond restoration. Your job is to strengthen and stabilize the knee, so it is more mechanically efficient and stronger than it was previously, and to minimize the likelihood of re-injury.
As the client steps down from physical therapy, and you take over, your job is to get the knee as stable as possible by focusing on strengthening all of the musculature of the hip girdle, core, and ankles. By this I mean that you need to strengthen all of the supporting musculature of the knee, not just the ones around the knee, but the musculature more proximal to the core, where the root of knee stability comes from. For example if I wanted to build a table with four legs, and each leg had a movable joint much like a knee, and I needed to attach the legs to the table top with nails and bolts. If I attached three of the legs with only one nail from the top, then attached the fourth leg with glue, a thick bolt from the top going down through the leg, and secured it with braces, the fourth leg would obviously be much more stable then the other three. Let’s just say that all of the joints on the table legs were equally as stable, still the fourth leg would be much more stable than the others. Makes sense right? Well let’s apply that concept to a client’s hip and knee. You need to strengthen the hip adductors, abductors, hip flexors, hip extensors, gluteus maximus, gluteus minimus, gluteus medius, and all core musculature as mentioned in an earlier article “The Lowdown on Abs”.
If these muscles are not strong then it is impossible for the knee to have good stability, even if the knee musculature is strong.
Typically seated machine leg extensions are contraindicated, because all of the pressure, and sheer force are directly on knee. Also any type of plyometric is as well, such as lunges and jump squats. As a note, utilizing knee wraps while training will only end up detraining stabilizing musculature. Some good choices of exercises to perform are hip flexion/ extension, hip abduction/adduction, standing TKE’s, and proprioception drills on one leg. Don’t forget about the ankle either. Perform soleus raises, calf raises, dorsi flexion, ankle inversion/eversion, and utilize a BAPS board.
If the client is still symptomatic and has a limited range of motion in the knee, less than 60 degrees, then you want to focus on strengthening all of the stabilizing muscles as mentioned above. As their range of motion increases, start incorporating compound multi joint exercises that include knee flexion. A good place to start is with a body weight ball squat, mini squats with adduction or abduction, light weight supine leg presses, and straight leg deadlifts. Another thing to keep in mind with compound lower body movements are to ensure that the clients feet are in the natural position in which they stand, and the feet stay flat on the surface you are working on. Make sure that the knees also follow a straight line in relation to the toes, and that they are not buckling in or outward. This is a good way to tear a meniscus. Take a look and evaluate their mechanics of how they initiate movement in the knee. Watch your client perform a ball or simple squat if they can do so and make sure they are initiating the movement from the hips, rather than the knees. You always want to place the greatest load on the bigger muscle groups first. Initiated from the hips and the knee follows. The knee can go slightly past the toe in flexion, as long as the heel is not lifting up off the floor. If you watch an athlete perform a front squat, the knees will most likely pass over the toe somewhat at the bottom range of the exercise. This is normal mechanics. If you try doing a squat below 90 degrees it is almost impossible not to do so, especially with individuals with long femurs. Try doing a single leg squat, and see what happens. If you want to believe otherwise about the toe not allowed to surpass the knee, then enjoy moving around like a robot.
You also need to ensure that the client has a proper quadriceps to hamstring strength ratio of 3:2, and testing the flexibility ranges of the lower extremities so they are within biomechanical norms. A good way to test lower body flexibility is to utilize the Thomas Test Position, and supine position on a treatment table. If you cannot make a good estimation of degrees, utilize a goniometer. Normal minimal ranges of motion are as follows, hamstring flexibility 90 degrees, glutes 135 degrees, abduction 45 degrees, dorsi flexion 20 degrees, quadriceps 135 degrees, knee extension should be at least 0 degrees or up to 10 degrees past 0, and internal/external rotation of knee is normally 10 degrees to each side. In a Thomas Test Position, hip flexors knee just below line of anterior illiac crest, quads 90 degrees ROM, and Iliotibial band where lateral side of knee is in line with hip.
As the client progresses in strength and flexibility, and can perform compound multi joint exercises with a full range of motion without pain, then it is a good time to teach them eccentric loading techniques. A good place to start is by doing step ups and enforcing good eccentric loading in the landing phase of exercise. Once mastered then they can move into lunges and entry-level plyometrics as discussed in “The Rules of Gravity: Plyometrics”.
In the end, tight or weak muscles will ultimately compromise knee stability, and most likely lead to some kind of injury, and as a final note, these are just basic guidelines for working with an injured knee. If you are not sure what to do, talk to a physical therapist and Strength and Conditioning Specialist.
Jon Torerk, CSCS
