The KNEE PAIN Thread

Ok, I liked VROOM’s idea so much with the beginner thread that I’m going to start a new thread for knee pain. I figure with all the experts on this site, if we can organize all the info it would make people searching for answers a lot happier!

Now I’m sure some of you are wondering, why is Mike starting a thread like this? Well, unfortunately, the unthinkable has happened: The injury prevention guy has gotten injured! Don’t worry, this wasn’t something weight room related or something I could’ve prevented.

This past February my good friend convinced me to go snow skiing for the first time. Needless to say a 200 pound powerlifter going down steep hills with no friction probably ISN’T a good idea, but I thought I would be fine. After some crazy falls that would’ve made any “Blooper” reel, we headed home and I proceeded to ice my body down for the next week.

As the weeks went on, I realized my knee was still really sore and my ROM was atrocious. Being the powerlifter I was, I kept doing all the recovery things like icing, supplementing, etc., but recovery was slow. Since I was gearing up for a meet, this wasn’t the time to get mental.

I started my normal squatting cycle about 8 weeks out and things were rough; weights that I would normally punish were coming up slower than molasses. The second week is my high volume, moderate intensity session and I was ready to quit…things were just not right. I realized that if I didn’t get this workout done, I could kiss my previous 3 months of training goodbye. I got through it and as the weeks went by, things started to loosen up. All the massage, stretching, ART , chiro adjustments, etc. seemed to be coming around.

As I got into my gear phases I thought the knee was 100%; 10 days out from the meet I’m warming up for my last heavy squat workout, and every time I hit the hole my knee would click. Got it adjusted, and then went ahead and competed the next weekend. The clicking was still there, but the adrenaline got the best of me on meet day! I squatted a 15 pound PR, with the strength to go another 10-20 pounds. Now, I would finally have the down time to let things heal.

Fast forward to this week: The knee was still clicking, so I had an MRI ran. The MRI confirmed a torn lateral meniscus, which the doc said probably happened while skiing 4 months earlier! I’m set to meet with a surgeon next week.

So how does this help you all? Since that time I’ve done even more research on the anatomy and injuries of the knee joint. My goal is to help ANYONE who has knee pain so that they can train pain-free and feel good again. Nothing has felt worse than not knowing what was going on.

As well, I’m going to document my entire treatment and rehab process so that the T-Nation members will have an idea of how I get myself fixed up.

So there it is; if you have any questions regarding knee pain, feel free to post them here. Who knows, if this goes well maybe we can even start other threads for different injured areas…sound good?

Stay strong
MR

Sounds great. I just had my medial meniscus and lateral meniscus repaired. I am one week into recovery.

-Machine

Mike, the best of luck with your recovery and thank you for starting this thread.

I was diagnosed a number of months ago with a partial patella tear.

Pictures of my knee now indicate that almost all noticable damage is gone, and the hospital has been analysing my walking and running patern(I also sprint, besides lifting).
While this is nice and dandy, I have pain when squatting.

Not so much during, when my form is correct, but afterwards.
As long as I keep my shins mostly vertical, I can train without pain, however, I feel it coming on whenever I add weight, and I my knee is swollen and painful afterwards.
Since the start of my recovery(almost 7 months now), the time I’m in pain after training has been severely cut down to being subsided within the day.

I recently started deadlifting(conventional)light again, for sets of 10.
DB Snatches cause pain afterwards when I start then from between my legs, not from in front.
Power Clean&Presses work, but I have to be careful.

I also started jogging slowly about twice a week again.

Since the pictures show that there’s no more damage, is is just a matter of building up again and sucking up the pain ?
I am being careful now as I’m very unsure about what I can and can’t do.

I am stretching every day to keep my flexibility in order.

Also, how can I build back up to doing full squats without pain ? I can do them easily butt to floor, but I’m in pain even after sets with bodyweight(although it’s been a few months since I actually did them)

Is this just scar tissue that needs to break down while I exercise ?

Thanks in advance

Mike,

I’ve had pain in both of my knees for over a year now. It hurts while squatting and even while sitting in the same position for a long time. I’ve just started taking chondroitin about a month ago, but so far the pain hasn’t ceased. I do need to start icing them though. Any information you could provide would be very helpful.

Oh, thank you, thank you, THANK YOU! OK, I will now try a third time to get some input here (I was apparently a little late to Dr. Ryan’s Q&A thread).

I have been having pain in my right knee for several weeks now that seems to be primarily associated with squatting. After a squat workout the pain lingers for several days before fading.

I have been able to pinpoint it to the ligaments behind the right knee (lateral and medial collateral ligaments, I believe). When I bend the knee under weight, as in a squat, I can feel increasing discomfort in that area as I go down. The discomfort continues from there down into the calf, primarily on the lateral side. Again, this is most notable under knee flexion.

I haven’t squatted in two weeks hoping that it will heal, but I’m going to try again soon. Any thoughts or recommendations on possible causes and remedies would be most welcome!

I was diagnosed about 3 1/2 years ago with “patella femoral dysfunction” where the knee cap doesnt track straight. it is grinding down on the underside of the knee cap causing a very sharp pain during knee flexion. while the glucosamine, chondroitin, and msm seem to help, from time to time it flares up.

recently its been almost unbearable though. Ive been avoiding surgery because of the horror stories Ive heard from others about knee surgery in general. Ive tried about every advice Ive heard about trying to strengthen the outside of the quads to bring the tracking back into balance, but really nothing seems to do much good.

about the best thing ive tried so far is squating with a narrow stance with toes pointed straight forward. this seems to aleviate the pain somewhat, but Im not going to win any powerlifting meets this way either. knee wraps seem to help also.

so Id be interested in hearing any advice or experience from this surgery for patellar tracking problems .

You got the repair, eh? What kind of time frame did they give you for full recovery? Also, did the immobilize you and/or put you on crutches?

Good luck with the rehab!

Stay strong
MR

[quote]machine514 wrote:
Sounds great. I just had my medial meniscus and lateral meniscus repaired. I am one week into recovery.

-Machine[/quote]

Leeuwer,

Thanks for the vote of confidence!

As for you, do you mean you partially tore the patellar tendon? If so, what grade was it?

If the MRI showed that the tendon is pretty much fully healed, I would suspect that you still have some scar tissue built up in there Have you had any ART done? The fact that the pain subsides very quickly now is good, but I would continue to ice post workout to get rid of any lingering inflammation. As well, EPA/DHA and glucosamine/chondrotin should be staple supplements in yours (and most!) arsenals.

Glad to hear you are stretching. Not sure if you mentioned this, but how much are you warming up pre-workout? Does the warm-up help keep the pain at bay? Also, have you considered knee sleeves to keep the tissues/joint warm? These could be an invaluable tool in your arsenal.

The pain is telling you something; whether it’s just scar tissue or something worse, you’ll have to find out. Good luck and keep us posted!

Stay strong
MR

I will try to help, but we need more info. For instance:

  • Where in the knees does it hurt?
  • What movements/motions provoke the pain?
  • Are you doing a fair amount of posterior chain work in your program?
  • Are you making sure to stretch the quads/hip flexors/ITB/adductors?

Give us more info and I’ll try to help!

Stay strong
MR

[quote]wwatts11 wrote:
Mike,

I’ve had pain in both of my knees for over a year now. It hurts while squatting and even while sitting in the same position for a long time. I’ve just started taking chondroitin about a month ago, but so far the pain hasn’t ceased. I do need to start icing them though. Any information you could provide would be very helpful.[/quote]

Posterior knee pain can be tricky, especially in the postero-lateral corner that you describe. A few questions:

  • What’s the flexibility like in your glutes, hams, calves?
  • Do you have any palpable adhesions back there? (Possible Baker’s cyst)
  • It could be something in the lateral tissues as well, such as the peroneals or ITB. Have you tried foam rolling?

Let us know the answers and we’ll try to get this figured out!

Stay strong
MR

[quote]Fonebone wrote:
Oh, thank you, thank you, THANK YOU! OK, I will now try a third time to get some input here (I was apparently a little late to Dr. Ryan’s Q&A thread).

I have been having pain in my right knee for several weeks now that seems to be primarily associated with squatting. After a squat workout the pain lingers for several days before fading.

I have been able to pinpoint it to the ligaments behind the right knee (lateral and medial collateral ligaments, I believe). When I bend the knee under weight, as in a squat, I can feel increasing discomfort in that area as I go down. The discomfort continues from there down into the calf, primarily on the lateral side. Again, this is most notable under knee flexion.

I haven’t squatted in two weeks hoping that it will heal, but I’m going to try again soon. Any thoughts or recommendations on possible causes and remedies would be most welcome![/quote]

Alpha,

First off, it’s VERY rare that you have an imbalance that pulls the patella laterally. Typically, the lateral tissues (VL, ITB/TFL, and lateral retinaculum) overpower the VMO. This imbalance pulls the patella laterally and can lead to crepitus (clicking/popping), as well as the grinding you describe.

Now, most would say to “recruit” the VMO, which is great, but you need more. Foam rolling of the ITB and VL is a good start, and then ART for the VL, ITB and lateral retinaculum will really work to loosen the tissues up. THEN, after you’ve inhibited these, try doing the terminal knee extensions and other VMO recruitment exercises. Deep tissue massage on days off will help speed the process as well.

The surgery you discuss is called a retinaculuar release; it may work, but I would take a stab at the exercises/rehab stuff I mentioned with full force before taking it into consideration. Good luck!

Stay strong
MR

[quote]alphamonkey wrote:
I was diagnosed about 3 1/2 years ago with “patella femoral dysfunction” where the knee cap doesnt track straight. it is grinding down on the underside of the knee cap causing a very sharp pain during knee flexion. while the glucosamine, chondroitin, and msm seem to help, from time to time it flares up.

recently its been almost unbearable though. Ive been avoiding surgery because of the horror stories Ive heard from others about knee surgery in general. Ive tried about every advice Ive heard about trying to strengthen the outside of the quads to bring the tracking back into balance, but really nothing seems to do much good.

about the best thing ive tried so far is squating with a narrow stance with toes pointed straight forward. this seems to aleviate the pain somewhat, but Im not going to win any powerlifting meets this way either. knee wraps seem to help also.

so Id be interested in hearing any advice or experience from this surgery for patellar tracking problems .[/quote]

I’ve dislocated my left knee 3 times in the last 15 years or so.
I’ve had 2 lateral release surgeries the latest about 2 years ago.
My left leg is significantly smaller and weaker than my right.
Rock bottom squats are hard for me from a technique stand point and sometimes there is some pain and a “creaky feeling” in the joint.

I guess I’m not real sure how to approach rehabbing it or if I should be using some kind of wrap to prevent further injury. Also I guess I get a little scared using it, I don’t want another dislocation. Any ideas Mike?

[quote]Mike Robertson wrote:
Alpha,

First off, it’s VERY rare that you have an imbalance that pulls the patella laterally. Typically, the lateral tissues (VL, ITB/TFL, and lateral retinaculum) overpower the VMO. This imbalance pulls the patella laterally and can lead to crepitus (clicking/popping), as well as the grinding you describe.

Now, most would say to “recruit” the VMO, which is great, but you need more. Foam rolling of the ITB and VL is a good start, and then ART for the VL, ITB and lateral retinaculum will really work to loosen the tissues up. THEN, after you’ve inhibited these, try doing the terminal knee extensions and other VMO recruitment exercises. Deep tissue massage on days off will help speed the process as well.

The surgery you discuss is called a retinaculuar release; it may work, but I would take a stab at the exercises/rehab stuff I mentioned with full force before taking it into consideration. Good luck!

Stay strong
MR

alphamonkey wrote:
I was diagnosed about 3 1/2 years ago with “patella femoral dysfunction” where the knee cap doesnt track straight. it is grinding down on the underside of the knee cap causing a very sharp pain during knee flexion. while the glucosamine, chondroitin, and msm seem to help, from time to time it flares up.

recently its been almost unbearable though. Ive been avoiding surgery because of the horror stories Ive heard from others about knee surgery in general. Ive tried about every advice Ive heard about trying to strengthen the outside of the quads to bring the tracking back into balance, but really nothing seems to do much good.

about the best thing ive tried so far is squating with a narrow stance with toes pointed straight forward. this seems to aleviate the pain somewhat, but Im not going to win any powerlifting meets this way either. knee wraps seem to help also.

so Id be interested in hearing any advice or experience from this surgery for patellar tracking problems .
[/quote]

McConnell taping techniques work well in conjunction with the stretching, deep tissue work and rehab exercise. Find a PT that has done the courses.

As a former PT from Australia, I found this to be the most effective. But you need somebody who knows what they are doing. Further, foot biomechanics often play a role, and if necessary orthotics will help.

[quote]Mike Robertson wrote:
Posterior knee pain can be tricky, especially in the postero-lateral corner that you describe. A few questions:

  • What’s the flexibility like in your glutes, hams, calves?
  • Do you have any palpable adhesions back there? (Possible Baker’s cyst)
  • It could be something in the lateral tissues as well, such as the peroneals or ITB. Have you tried foam rolling?

Let us know the answers and we’ll try to get this figured out!

Stay strong
MR[/quote]

Mike, I will answer your questions in the order you asked them:

  1. Flexibility in my hams is poor. I’m not sure how to gauge flexibility in the glutes and calves, but I would imagine it too is lacking.

  2. I don’t know if I have any adhesions and I’m not sure how I would be able to tell.

  3. I have not tried foam rolling, and am not familiar with it.

I apologize for the dearth of information, but I hope it’s enough to start with anyway.

Thanks Mike!

http://images.t-nation.com/forum_images/./1/.1117748468546.post-3-1112751228.jpg

[quote]alphamonkey wrote:
I was diagnosed about 3 1/2 years ago with “patella femoral dysfunction” where the knee cap doesnt track straight. it is grinding down on the underside of the knee cap causing a very sharp pain during knee flexion. while the glucosamine, chondroitin, and msm seem to help, from time to time it flares up.

recently its been almost unbearable though. Ive been avoiding surgery because of the horror stories Ive heard from others about knee surgery in general. Ive tried about every advice Ive heard about trying to strengthen the outside of the quads to bring the tracking back into balance, but really nothing seems to do much good.

about the best thing ive tried so far is squating with a narrow stance with toes pointed straight forward. this seems to aleviate the pain somewhat, but Im not going to win any powerlifting meets this way either. knee wraps seem to help also.

so Id be interested in hearing any advice or experience from this surgery for patellar tracking problems .[/quote]

Often the site where the pain develops is not the site where the problem is. You might want to look up and down the kinetic chain for some answers. Do your feet over-pronate (flat feet)? Do you have internal rotation of the femur, with or without squatting? These are two common causes of patellar femoral pain. They can also cause a change in the relationship between the femur and the patella. EC and MR did a great job of showing you how determine if you have either one of these problems on their NNM series.

There is also a really simple test to determine if your femur is internally rotation while you squat. Basically all you need to do is find a step op box that is 8-10 inches high. While standing on the involved or injured side, do a slow controlled step-down. If once you get to the bottom position you can’t see your big toe, you know you A) have over-pronation of your ankle, B) have excessive internal rotation of the femur. Where you should see your big toe is on the inside of your knee, not infront of it as everyone’s knee will go foward past their big toes with this test. However, if the knee shifts towards the other leg and covers your big toe, you know the test is positive.

Either one of these problems can cause changes in the way the patella tracks. If the above happens with the step-down test, you can be pretty sure that your patella is tracking more laterally than it normally would if your knee was not in a valgus position (knock knee).

Attached is a picture of one of my patients doing step-downs with dumbbells. He is in the bottom position of the step-down with weights, however the motion is the same with the test as it is with he exercise, without the weights however.

It is often very difficult to determine if it is the hip causing the problems at the knee (pain and faulty biomechanics) or at the foot (over-pronation) however. The good news though is that the exercises I use to help correct these problems usually help address both problems.

Below is a study that shows that hip weakness, particularly hip external rotation and hip ABduction, can affect patellofemoral.

J Orthop Sports Phys Ther. 2003 Nov;33(11):671-6.

Hip strength in females with and without patellofemoral pain.

Ireland ML, Willson JD, Ballantyne BT, Davis IM.

Kentucky Sports Medicine Clinic, Lexington, KY, USA.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To determine if females with anterior knee pain are more likely to demonstrate hip abduction or external rotation weakness than a similar, asymptomatic, age-matched control group.

BACKGROUND: Diminished hip strength has been implicated as being contributory to lower-extremity malalignment and patellofemoral pain. The identification of reliable and consistent patterns of weakness in this population may assist health care professionals establish a more effective treatment plan.

METHODS AND MEASURES: Hip abduction and external rotation isometric strength measurements were recorded for the injured side of 15 female subjects with patellofemoral joint pain (mean +/- SD age, 15.7 +/- 2.7 years; age range, 12-21 years). These were compared with strength measurements from the corresponding hip of 15 age-matched female control subjects (mean +/- SD age, 15.7 +/- 2.7 years; age range, 12-21 years). All strength measurements were made using hand-held dynamometers.

RESULTS: Subjects with patellofemoral pain demonstrated 26% less hip abduction strength (P<.001) and 36% less hip external rotation strength (P<.001) than similar age-matched controls. CONCLUSIONS: The results indicate that young women with patellofemoral pain are more likely to demonstrate weakness in hip abduction as well as external rotation than age-matched women who are not symptomatic.

Good stuff, Mike. Specific to your own situation, I remembered to save the emails among you, Bob, and I from when nobody really knew what was going on with your knee. Hopefully, they’ll be of help to others:

Eric Cressey, meet Trainer Bob…the best damn PT I know. Bob, meet Eric Cressey, one of the most knowledgable strength coaches I know. I wanted to write you both and see if you have any ideas as to what can be causing my newest ailment.

So you both know I went skiing about a month ago; sprained my R MCL and LCL. After an extensive course of ART, manipulations, battling the inflammation and restoring proprioception to the joint, things felt great. About 2 weeks ago, however, I started getting a TON of tension in the L quadriceps. Now granted my quads have always been a LITTLE tight, but this is off the charts; once I get to around 90 degree of flexion the brakes get turned on. The end feel is very rigid, and it feels as though if I were to break the barrier I would tear the quad/tendon.

For this I had been getting ART, icing like a madman, taking anti-inflammatories and even had some massage done yesterday (which actually has made things worse). To be totally honest, it doesn’t feel like ANY of this has changed what’s going on. Dr. Monique did a knee screen on me the other day and said that the joint is solid and that there doesn’t appear to be any damage to the ligaments, meniscus, etc. The only thing she can think of is that there’s a lot of inflammation in/around the joint that’s restricting the range of motion (no apparent swelling, however). I would agree with her, but the anti-inflamms, ice, etc. doesn’t seem to be doing any good and the ROM is consistently poor day-to-day.

I guess what I’m asking you guys is this: Do you have any ideas what this could be? I have done a ton of knee research over the past week or so and haven’t found anything that sounds similar to what I have. It’s very frustrating as I haven’t been able to train legs intensely for almost a month now. Any thoughts would be greatly appreciated!

And my response:

Two thoughts, in no particular order:

  1. Did anyone check your PCL? You didn’t mention the nature of your injury, but if it was a dashboard-type impact, I’d suspect that the PCL is injured (especially since the LCL went, and losing the PCL always wipes out the LCL among other structures). If your PCL is out of commission or just weakened, the quads are going to have to work overtime (just as the hamstrings would in the case of a weakened/torn ACL). I know it’s somewhat of a longshot, but it seems to be worth at least a mention.

  2. The 90-degrees of knee flexion issue raises a red flag for me in light of the MCL. It’s going to be the primary restraint to valgus force, which is going to increase as knee flexion increases. Essentially, I think it’s fair to say that the quads and MCL work together in preventing/decelerating valgus stress and knee flexion. If one is out of commission, it stands to reason that the other would be firing on all cylinders and potentially locking up.

Then again, I might just be spinning my wheels due to sleep deprivation! Obviously, I’d love to hear some other thoughts on this one.

At which point Bob chimed in with:

]Mike,
As far as the right knee goes, see how it responds to the work Dr. Monique did on the capsule. However, the fact that the left quad tension came on later (2 weeks after the fall) and in the uninvolved knee is a little puzzling.

You might have hurt it at the same time you did the right, but weren’t aware of it because the right was worse. It happens, but I doubt it in your case.

With the trauma to the right knee, you may have changed your gait mechanics or torqued your pelvis in the wipe out. Has Doc taken a look at your ASIS and PSIS levels? Any signs of an ilial rotation or obliquity? I see lots of that in my patellofemoral patients and the fact that the knee came on kind of insidiously makes me wonder if there’s something mechanical that is pretensioning either muscle or neural tissue.

Eric’s right on about the PCL being a bit of a sneaky son-of-a-gun so be sure Doc checks that. In most cases, it doesn’t cause a hemarthrosis like an ACL tear and it can be a lower load injury. By the way, how the heck did you get the MCL and LCL? That fact also feeds into Eric’s concern about ACL/PCL injuries.

Any signs of a chondral defect that might create a little synovitis. Not necessarily swelling, but just enough irritation to mess with your neuromotor firing and cause a protective spasm? I’ve blown both ACLs through the years and have had a couple of pretty decent chondral contusions/defects that have been buggers, particularly until I worked out how much and in what manner I could load the surface while it healed.

This is just my personal opinion, but I’d look into a glucosamine/chondroitin/MSM supplement. Give the body what it needs to try and heal. I’d also see if you can get away from anti-inflams before too long since they can inhibit chondrocyte activity. www.consumerlab.com evaluates supplements to be sure they contain what the label claims. They don’t comment on the validity of the claim of the supplement, just that it is what it says it is.

How about anything going on up at L2-4? Maybe from the fall, maybe compensating for gait mechanics. If you’ve got a rotated segment or a locked up facet, it can start playing inhibition/facilitation games.

Also, if contract/relax for the quads isn’t working, try it for the hamstrings first; then the quads. See if you can get a little reciprocal inhibition going.

Just a couple of thoughts. You sure don’t make anything easy! Let us know how things go. If we come up empty with these ideas, we go back to the drawing board with some new information.

See what happens when you let a powerlifter out of the gym?

It hurts at the front of the knee. My knee tends to click as yours do. Any bending beyond 45 degrees provokes the pain. Walking and standing does not hurt. Performing sprints is very painful. As I mentioned, even sitting causes a pain that is only relieved by stretching out the legs.

I primarily follow any quad exercise with a hip or hamstring exercise, and vice versa. I tend to stretch my hips flexors more than my quads because any bending of the knee involved in stretching the quads causes pain.

[quote]Mike Robertson wrote:
I will try to help, but we need more info. For instance:

  • Where in the knees does it hurt?
  • What movements/motions provoke the pain?
  • Are you doing a fair amount of posterior chain work in your program?
  • Are you making sure to stretch the quads/hip flexors/ITB/adductors?

Give us more info and I’ll try to help!

Stay strong
MR

wwatts11 wrote:
Mike,

I’ve had pain in both of my knees for over a year now. It hurts while squatting and even while sitting in the same position for a long time. I’ve just started taking chondroitin about a month ago, but so far the pain hasn’t ceased. I do need to start icing them though. Any information you could provide would be very helpful.
[/quote]

Can wide squats lead to tracking issues?

I’ve been doing wide squats for about 2 weeks and recently picked up some knee pain.

This is the only thing really new with my regimen.

Distances is running/cycling/swimming all the same.