Rehab to Performance is Dr. Joey's experience with different patients on the clinical side of Engineered Per4mance. In this context he will walk you through common issues he is seeing in the clinic and how to fix it in a case study format.
Rehab to Performance: Weekend Warrior with Knee Pain
This week we will discuss a patient that presents with a very common complaint of knee pain. This weekend warrior belongs to the local YMCA and is attending the "body pump" class at least twice per week. I'm not entirely sure what the class entails but he reports doing plenty of lunges and loaded squatting. He is super active otherwise going on hikes, enjoys running, and recently returned from a vacation in Colorado beat up from an accident down the alpine slide. He presents with knee pain that he describes as tugging and nagging pain on the base of the patella near the patellar tendon but often just lateral to it. He reports walking without pain but when he goes for runs it always acts up a couple miles in and he will pay for the run for a couple of days.
After comprehensive orthopedic testing it is clear his knee is structurally sound and no passive movement could reproduce the pain experience. The functional exam is where it always gets interesting. With knee presentations like this I like to do a single leg depth squat to evaluate dynamic hip strength controlling the knee, but also limitations in mobility at the ankle and hip. What do you see?
If you answered KNEES COLLAPSING you would be correct. Every competent strength coach and clinician in the world can tell you we want to avoid this position especially while working under load. Where the exceptional coach shines is in the correction. "Knees out" just doesn't resonate with most people. It makes sense but the athlete knows they shouldn't be in this position, they might not have the ability to prevent it.
1. Stop the aggravating behavior. I am the last person to tell someone to stop exercising, instead we suggest some alternatives. Right now we will build a "rehab" protocol to work for the next couple of days. For the following week we want to unload the squat and lunges done in class and focus on quality movement first. Having someone to watch the movements is instrumental.
2. Normalize pelvic positioning. A study published in the American Journal of Sports Medicine shows us someone presenting with anterior pelvic tilt of just 10° can contribute to a decrease of 6-9° of hip internal rotation and, intuitively, if the pelvis is anteriorly tilted the hip flexors tend to become hypertonic as they stay in a shortened position limiting hip extension. The thomas test and ascension drop test (pictured below) clearly demonstrate an anterior pelvic tilt positioning. In the ascension drop test, if the pelvis was in a neutral position the idea is that the femoral head would clear the acetbaular rim and the knees would be able to drop to touch the table. As demonstrated below the knees are well above the table indicating the pelvis is tilted anteriorly and the femoral head is running into a boney block at the acetabular rim. Fixing this is one of our "party tricks" because it doesn't take many passes of soft tissue work or reps of an exercise, as soon as the pelvis is back at neutral you clear space, the knees drop, and the patient can conceptualize exactly what is happening. My preferred approach to normalizing pelvic positioning is a plethora of exercises by Postural Restoration Institute. I typically start with the "all four belly lift" or "90/90 hip lift".
3. Normalize soft tissue ROM. Next we attack the indicated tissue elasticity dysfunction. In this case I used Active Muscle Pumping to the hip rotators in both directions targeting the lateral rotator group, glute max, min, and finally the piriformis. A few passes here tends to clear up the left over range we are looking for.
4. Introduce core-lower quarter control exercise to improve dynamic control of the hip and knee. Starting with Kolar dying bug against the wall as pattern assistance, clam shells, and progressing to standing mini-band monster walk sequences and kettle bell suitcase carries.
5. Return to functional exercise. At this point the patient has no more pain experience and is demonstrating baseline levels of strength and control in all planes of motion. We can now safely move back to functional exercises that he enjoys including bodyweight supported squatting and lunging with PNF valgus input at first, and progressing back to the loaded movement.
6. Maximize functional stability with plyometric control. We didn't get to this phase due to resolution of pain but if I were to see the patient further this is where the treatment plan would lead starting with jump squats, diagonal squats, and agility ladder/banana step drills asking the patient to dynamically control the core and lower quarter in a reactionary environment.
7. Build power by adding triple extension exercises including Kettelbell swings, and olympic lift pulls/variants. This is where our practice shines as we have the ability to move patients directly into functional performance and fitness training within the facility and with direct collaboration of clinicians and performance specialists.