Never Miss Twice: Strategies to Train around Knee Pain

As a disclaimer; this is not an attempt at diagnosing specific knee pain or a suggestion to ignore pain and not seek out medical guidance when necessary. The body is a complex system where mobility and stability in one joint can have a significant effect on the performance of another; and although you experience pain somewhere, the issue could be stemming from a different muscle or joint. There is even a trend in the physical therapy world showing how an understanding of what pain is may be more efficacious than treatment modalities like massage and stretch.

This post will be the first of a four part series where we’ll cover knees, hips, shoulders, and lower back. The intention of these write-ups is to provide you with a few strategies to remain active and continue training when you don’t feel 100%. If you train hard for an extended period of time, it is likely that some aches and pains will rear their ugly head. This does not necessarily mean that there is structural damage (however keep in mind the first sentence of this blog) that warrants complete rest. Knees, hips, shoulders, and lower back are the most common discomforts that we have to address. Today’s post will cover three ways to train around knee pain.

1. Maintain a Vertical Shin Angle in Lunging and Squatting movements

Having the knee translate over the toes during squatting and lunging is not inherently bad as it was once believed to be. With many of our athletes we perform exercises in low volumes that encourage this. You would be hard pressed to break down the movement of an athlete on a court or field sport and not observe a “knees over toes” action. However, in our athletes experiencing anterior (front) knee pain, this specific knee flexion range of motion during a squatting and lunging movement typically exacerbates symptoms. However, there are a handful of ways to continue squatting and lunging without putting athletes in this position.

During Forward Lunges, dorsiflexion of the ankle is often maximized, placing the knees in front of the toes. This increases pressure on the knee and could result in pain. However, if you were to perform Reverse Lunges instead, you’ll notice that as you step backwards with your left leg the shin in your right leg remains vertical with minimal ankle dorsiflexion. This reduces tension on the Quadriceps, places more of the burden on the hip, and typically leads to less knee pain.

Other examples of modifications that you can make to maintain a more vertical shin angle include:

- Wide Stance Box Squats instead of Front/Goblet Squats

- Parallel Wall Sits instead of Goblet Squats

- Single Leg Touchdowns instead of Step-ups

Next time you squat or lunge, take note of how your knee moves in relation to a fully planted foot. Don’t be afraid to make modifications when necessary to minimize pain and allow for more consistent training.

2. Train the Posterior Chain (Hamstrings and Glutes) more than the Quadriceps

For some individuals, the onset of knee pain can coincide with excessively training the quadriceps with popular movements like Squats and Lunges and placing less of an emphasis on the Hamstrings and Glutes. By simply incorporating more hinging and bridging movements to even out strength imbalances and training ratios, you may notice less discomfort in your knees. When performing these posterior chain exercises, knee flexion is minimal and the shin remains relatively vertical.

Some of our favorite movements include:

- Banded Good Mornings

- Single Leg RDL Variations

- Dumbbell RDLs

- Barbell Hip Thrust

- Dumbbell Glute Bridge/Frog Pump

- Med Ball/Ultraslide Hamstring Curls

Next time you notice squats or lunges bothering your knee/s, try focusing on the movements above instead when training your lower body.

3. Warm-up Longer, Reduce Intensity, Volume, or Range of Motion

If you need to perform a given movement that is causing some discomfort, there are a few modifications you can make within the structure of a workout to reduce the likelihood of knee pain. Sometimes, performing a longer warm-up that incorporates some light cycling, mobility work, and regressed movements can be what the joint needs to be prepared for the demands of training.

Intensity refers to the weight that you’re lifting in respect to your maximal capacity. For example, if someone can Back Squat 200lbs, an intensity of 80% refers to using 160lbs. Volume refers to the total amount of weight that is lifted during a workout. If you perform 5 sets of 3 reps with 160lb, then you performed 2,400lbs of volume (5 x 3 x 160). Not all volume is created equally as 3 sets of 10 reps with 80lbs would have equivalent volume but may be functioning at too low of an intensity threshold to create much of a training stimulus. When you’re returning from a period of inflammation or discomfort, it may be best to reintroduce the painful movement with a period of low intensity and low volume.

Lastly, a specific range of motion may be what exacerbates pain. You may be fine squatting to 100 degrees of knee flexion, but as soon as you descend below parallel, you feel an ache in your knee. You can continue to train in the comfortable range of motion while simultaneously making additional recovery efforts. Box Squats are my favorite modification as they allow the athlete to squat to a consistent range of motion every rep while also addressing the protocols in the first two sections of this post.

My role as a strength and conditioning coach and personal trainer is to instruct, help you cultivate a love of fitness, form lifelong habits, and “meta-analyze” the influx of information that I’m exposed to into something comprehensible for you. Writing blog posts like these are tough as they walk the line between my scope of practice and that of a physical therapist. However, there is so much outdated and incorrect information that finds its way to the masses that in the small sample size of my mailing list, I’m comfortable sharing a few suggestions.

When you train hard, days of rest and recovery are deserved and aches and pains may be inevitable. Like James Clear, one of the best researchers and authors on habit formation states, “Never miss twice”. Don’t allow aches and pains to derail your routine and training progress.