9 Training Strategies for Knee Pain
There's no such thing as a "good" or "fun" injury. While some are definitely more severe than others, all injuries basically suck, especially if they keep you from training hard or just enjoying life. And in my case, training hard and heavy is the very essence of enjoying life.
Although I have a long history of back problems, recently my knees have become the bane of my training existence. I've recently gone through two painful knee surgeries – the last of which was just a few months ago – so I know firsthand how much a knee injury can suck for an iron junkie. You work so hard for so long, only to have it all seemingly taken away in the blink of an eye.
(One day after surgery)
Neither of my injuries was lifting related, but they've obviously affected my training in a big way.
But an injury doesn't have to be a death sentence to a training career – unless you let it be one.
Here are some tips to help you move past your knee issues and make it nothing more than a speed bump on your road to long term success.
1. Let pain be your guide
This is one of those tips that gets repeated ad nauseum but often gets overlooked. I know I've blown it off more times than I can count, and I also know that I've paid the price every time.
Trying to train through pain is a guaranteed losing battle. Even if you "win" and are able to tough it out in the short term, it always comes back to bite you in the ass, and usually much worse than if you'd just surrendered at the onset of the pain.
Now keep in mind that surrendering doesn't mean shutting it down completely, giving up, and turning in your man card. It just means avoiding what hurts and listening to your body.
That last part bears repeating: listen to your body.
For example, some people swear by Peterson step-ups for improving knee pain, but whenever I've tried them, they've hurt.
Does that make them a bad exercise? For me it does, but if they work for you, keep doing them.
Don't get caught up in doing something just because you've heard it's good. If you try it and it doesn't feel right, pull the chute and choose a different approach.
2. Include more hip dominant work
A lot of gym-related knee pain stems from unbalanced programming that overemphasizes the quads and neglects the glutes and hamstrings, leaving people with woefully weak and underdeveloped posterior chains.
It may seem illogical, but to achieve the desired balance we're shooting for, we actually want to continue on with unbalanced programming – only the balance should be in favor of hip dominant work over quad dominant work.
Moreover, hip dominant movement patterns (deadlifting, bridging, etc.) are generally better tolerated by folks with wonky knees, so it's a good way to get a lower body training effect in the presence of knee pain when squatting and lunging are problematic.
A simple place to start is just to do your hip dominant work first in the workout. This will allow you to give it your full attention so you don't blow it off, and it will also serve as a sort of pre-exhaust for your legs so you won't need as much weight for your quad dominant exercises, which will further help to take stress off your knees.
3. Make your quad work more hip dominant
If you came to me saying your goal was landing a leading role as Quadzilla in an upcoming blockbuster movie, I might tell you to start bombing away at rock bottom squats with your heels elevated, lunges and split squats with a short stride, and maybe even some sissy squats for good measure.
That'd definitely get you some ginormous quads, but it might not be long before your knees give out and you find yourself on the shelf pounding Ben and Jerry's and lamenting as you watch your once burly legs wither into toothpicks.
Some people can get away with doing those exercises for years without issue (and usually have big thighs to show for it), while others get knee pain just from watching them. For those in the latter category, stop trying to target your quads with an anterior weight shift and learn how to sit back and share the load with your hips, keeping more of a vertical shin.
If you're worried about your quads not getting sufficient stimulation, remember that the most important factor in building muscle and getting stronger is consistency, which means that your primary goal should be to stay healthy for the long haul.
4. Use bands when necessary
Bands can be extremely useful to facilitate a solid posterior weight shift and safely strengthen the quads.
Here are some different ways you can use them to serve your needs.
For true single leg work like one-leg squats and skater squats, attach one end of a band to a sturdy post (a power rack works great) and loop the other end behind your knee. From there, perform the exercise as you normally would. See the video below.
The band forces you to sit back to avoid being pulled forward, thereby loading the hips and taking stress off the knee at the bottom portion of the rep.
Here's the cool thing. As you come up, it shifts from a hip dominant movement pattern to a more quad dominant terminal knee extension (TKE), allowing you to strengthen the vastus medialis (VMO) within a more knee-friendly range of motion.
You can also do something similar to split stance work like split squats and Bulgarian split squats, only it's better to attach the band to a belt rather than putting it behind your knee just to make it easier to get into position.
Make sure to set up with a longer stride such that your tibia is perpendicular to the floor.
The band increases the demands on the quads because you have to continually push through your toes to grip the floor and maintain stability, but it does so within safe joint ranges because it's simultaneously driving you to sit back and maintain a vertical shin to keep from getting pulled forward.
To help groove a good bilateral squatting pattern try cable hip belt squats, which I wrote about in more detail here. A band also works in a pinch, but it'll be difficult to get enough
The cable doesn't drastically alter the squatting pattern but still allows you to practice free squatting while reflexively teaching you to sit.
5. What about lunges?
Lunges generally aren't something I like for individuals experiencing knee pain.
The worst knee offenders are forward lunges and walking lunges due to the high amounts of deceleration and eccentric stress involved. But even reverse lunges, which are more accelerative in nature, can be problematic.
Instead, I'd recommend starting with static exercises like split squats and then Bulgarian split squats which offer a fixed base of support so you can set up with a vertical tibia and maintain that position throughout the set.
The one exception may be slideboard reverse lunges, which is really a hybrid exercise.
While it ostensibly looks like a knee dominant lunging pattern and you're certainly using your quads to some degree, when done correctly it's actually more hip dominant – you're pulling yourself back up to the starting position using your posterior chain.
Furthermore, the back leg never leaves the floor, so there's a higher degree of stability than with other lunging variations.
You can also try placing a band or bench just in front of the working leg to serve as a physical reminder to keep your weight back on your heels and prevent the knee from traveling too far forward.
That all being said, remember rule #1.
6. Reverse Sled Drags
Reverse sled drags are a great bang-for-your-buck exercise that serves as both a rehabilitative tool and a muscle/strength builder.
Since making them a staple in my program, my knees have felt significantly better. I've even started to gain back some of the muscle I lost in my right quad to the point where my legs are fairly even again. I'm not out of the woods yet by any means, but it's been a big step in the right direction.
In fact, at the time this picture was taken, I was doing nothing but reverse sled drags and hip dominant work.
Sled drags certainly won't replace heavy lifting, but it's better than nothing, and at the very least can help stave off losing muscle in the interim.
Here's how I've implemented the sled dragging into my program when I haven't been able to do any significant knee dominant work:
- Do it four times a week, so basically every workout. If I feel like I need to take a day off, I take it.
- I use a very simple method for choosing the right weight. I'll keep adding weight until it starts to bother my knee, and then I'll take a plate off. That's my weight for the day. Some days it's heavier than others, but I'm not really too concerned about it.
- On upper body focused days, I'll pair the reverse sled drags with my main lift for the day: chin-ups, presses, etc. Between every set of that exercise (including warm-up sets), I'll walk down and back the length of the gym with the sled, which is approximately 25 yards each way. Again, I'm not too concerned with the weight and just focus on keeping it pain-free.
- On lower body focused days, I'll do them at the end of the workout after hip dominant work. Here I use a timed method where I'll allot a certain amount of time and just keep walking until the time expires. I started with three minutes and have slowly worked up to 10-15 minutes. This is a lot harder than it sounds.
They burn like crazy while you're doing them, but since there's no eccentric component, they don't leave you crippled with soreness so you can employ a higher frequency.
If you're doing them along with other knee-dominant work, 1-2 times a week is plenty. In this instance, I'd do them before squatting and lunging to help warm up your knees and pre-exhaust your quads.
Most of the time I'll do them with a belt so I'm not limited by my grip, but here's a nifty variation that I like using from time to time to also get some bonus work for the upper back. I couldn't think of a clever name for it so I went with "Batwing" Reverse Sled Drags since it sort of mimics Dan John's batwing idea.
Row the sled towards you, then keep your elbows pulled down and back and keep your hands pinned to your sides as you walk backwards.
No sled? Check out this article from Tim on making your own sled.
If that's still not an option due to space limitations, try walking on the treadmill facing backwards with the belt turned off and set at a slight incline.
7. Band stomp TKEs
This is a great exercise that can be used either for rehab purposes or as part of a warm-up.
Band stomps are typically thought of as a posterior chain exercise driven by hip extension, while TKEs are meant to strengthen the quads (specifically the VMO) through terminal knee extension.
Combine the two and you've got one heck of a combo: hip extension, knee extension, and a nice full range of motion.
Setup is key for this one. With a traditional band stomp, you place the band closer to your heel and focus on pushing with your heel. With this version, put the band closer to your toes and consciously think about pushing through your toes. As your foot nears the ground, squeeze both the quads and the glutes.
To encourage greater hip extension, the toes should land slightly behind the heel of the other foot.
You can adjust the difficulty by choosing a thicker band or increasing the height of the bar. I like to do it where the bar is set to about mouth level, as that puts me in a starting position where my femur is parallel to the floor.
Try adding a few sets at the start of your lower body workouts as part of your warm-up, or on upper body days for some low-load supplement work.
8. The bike is your friend
The days of hopping on the bike for 5-10 minutes before the workout seem to have gone by the wayside in favor of stretching, self-myofascial release, activation drills, etc.
I definitely think that stuff is important and I do it all myself, but I also think that 5-10 minutes on the bike can go a long way towards feeling better and having better workouts by helping to increase overall tissue temperature and "lubricate" the knee joints so to speak by decreasing the viscosity of the synovial fluid.
I'll generally get on the bike as the last part of my warm-up right before I lift, but if it's particularly cold outside or early in the morning and I'm having trouble getting moving, I'll do it first thing before I get into the rest of the warm-up.
9. Train the good leg
I've heard conflicting arguments whether you should train your uninjured limb. I've tried both ways, and I'm in favor of training the good leg.
Some research studies have shown that training one limb can increase strength in the contralateral limb, but I mainly do it for my state of mind.
When I focus on what I can do as opposed to what I can't do, I feel better, and I honestly believe that positivity has a big effect on recovery. Whether you choose to believe the same is up to you.
As for the worry that training the healthy leg will create and exacerbate size and strength imbalances between limbs, in most cases we're talking about a few months, tops. Realistically, you aren't going to pack on much muscle in that amount of time anyway, so it probably isn't going to create major discrepancies.
Onward and Upward
I hope I've given you a few good tips to take with you and apply to your own situation so your knee pain doesn't stop your dead in your tracks.
Proceed with caution though. It's easy to get excited and overdo it. Even if you're doing "good" knee-friendly stuff, you can still do too much of a good thing.
Less can often be more when it comes to dealing with pain, so remember that as you push forward. At the same time, an injury isn't an excuse to throw in the towel.
Find that balance and get crankin'!