If you’ve stumbled across this article, chances are you, athletes you work with, or someone you know has knee pain that has hurt their ability to function athletically. If so, you are in the right place now.
5 years ago, I wrote an article on getting healthier knees for athletic performance. Although it had a lot in mind in regards to getting the knees to feel better, in hindsight, it was not a “performance friendly” article. It also was missing out on a huge world of knee muscle and tendon strength training means that are absolute game changers.
It’s fun to look back on things occasionally to see where new ideas have landed you and how your thoughts evolve as influential coaches and ideas permeate your mindset. There is a lot of dogma in the sports performance industry, and a lot of things that relate to lifting barbells are actually in complete opposition to the biomechanics of athletic performance.
“Knees out” while squatting is the fundamental opposite of what happens in the loading phase of jumping, change of direction, throwing, hitting, accelerating and the list goes on.
“Hips back” is the fundamental opposite of what happens in essentially every single athletic movement where the force is distributed through the feet, knees, and hips as athletes drop straight down into movement.
Things we do to alleviate our knees, in many cases, detract from performance, and set us up for pain and injury when we do get in those athletic positions where knee strength is required.
In the old list from the prior article I wrote, I’d throw out the following points:
4. Learn to squat with slowly, and with the correct knee hinging motion.
(this ignored the action of the feet in the frontal plane)
8. Be aware of your shin angles.
(emphasizing sitting back more in jumping movements, or taking away forward shin angles… something that is fine if your feet are working well)
9. Strengthen your feet
(needs a different term and in the process, a higher priority on the list)
I also wanted to consolidate two points in the old article into one:
6. Foam roll your IT band, erring on the side of the quadriceps.
7. Use a voodoo band.
6 and 7 were basically the same thing, “Use SMR techniques that help you feel good” but it’s important to keep them in context of what they can and cannot do (hint “getting knots out of the muscle/fascia” is NOT something they can do).
In the last few years, great minds such as Dr. Keith Baar, Jake Tuura, Ben Patrick and his ATG Gym, Adarian Barr and more have turned around my take on what it means to have good knees, and how training in this regard should really work.
With all of this updated information in mind, it demands I update my works on how to overcome knee issues while being able to jump higher and perform better in the process, so here we go:
10 UPDATED Knee Health and Performance Commandments:
- Optimize your foot function
- Be smooth
- Build up the VMO
- Have good hip strength and control
- Do extreme ISO’s and tendon-health isometrics
- Supplement with Vitamin C and collagen
- Gradually expose yourself to sharper shin angles
- Optimize your plyometrics
- Use slower barbell tempos
- Use SMR but do so in the context of what it actually does
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Optimize Your Foot Function
I’m starting to notice a trend with athletes I find have knee problems, and that trend is related to what is going on with their feet. The common process in sports performance/strength and conditioning is to look at the hips first when looking at knee issues (which makes sense due to the fact that strength and conditioning revolves around hip-dominant lifts). The trend I see in athletes with knee issues is that they over-grip with their toes and don’t pronate well (Adarian Barr and David Weck both had a large impact on my thought processes on toe-gripping).
Athletes who don’t pronate well (for simplicity’s sake, think of flattening the arch and spinning towards the big toe, you can also call pronation “unlocking the foot”) will compensate by gripping the ground with their toes, which locks the foot into the sagittal plane and sends forces directly upwards into the knee and hip. Learn to pronate and avoid gripping the toes down in athletic movements, and you’ll be in a better place as far as knee health is concerned.
Stay tuned for an upcoming book of mine on foot training and performance to this end.
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Be Smooth in Your Movements
Here is a concept I did save over from my last rendition of this article. It is simple, but effective, especially in jumping oriented work and plyometrics, and that is the concept of smoothness. If you ever look at elite level triple jumpers, especially in person, you will have a newfound appreciation for the stretch-shortening cycle, and moving in fluid harmony with the ground.
https://www.youtube.com/watch?v=RhR0R43u2bg
Smoothness can also be a moniker for matching the vibrations of the foot with that of the playing or training surface. Resonance of waves is key when it comes to the appropriate transfer of force. At the very least, having some portion of work devoted to “quiet” movements in the jumping, landing, and direction-changing realms are important for building this quality of elite performers.
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Build up the VMO (Lower Quad)
Building up the Vastus Medialis Oblique (VMO) is a very trendy means of improving one’s knee strength. Enter “VMO” activation into a search engine and you’ll get a ridiculous amount of exercises, tips and “activations” to do. This has caused the VMO as a stand alone muscle to get some hate-mail over the years (I remember Mark Rippetoe writing a lengthy article for T-Nation saying how VMO activation or isolation was crap several years ago). I actually agree with a lot of the article, but not so much the VMO part. I’ve worked with a lot of athletes with a big vastus lateralus but not much of a VMO. For that matter, just look at the leg structure of an Olympic weightlifter versus an athlete who doesn’t bend their leg as much in their sport (like a water polo player).
After being a skeptic for years, I’ve come to realize recently that the VMO and lower quad do get selective hypertrophy depending on how you train them, and do play a role in protecting the knee from injury. Many of my clients and athletes with regular knee pain tend to have relatively little size going on in the VMO region.
Ben Patrick of ATG really took me over the top of this idea of working the VMO, along with acquiring a direct current electrical stimulation system (think of a typical Compex or Power-Dot, but one that works with your body’s natural currents and electrical signals instead of fighting them in a tetanic contraction). The DC stim showed me that I have serious compensation patterns around my VMO’s compared to the other muscles in my quad, and this helped relieve pain in short order.
Doing Ben’s progression in sissy squats, as well as some of my own creations, such as sissy squat variations on the kBox, have been tremendously helpful in myself and my athletes in building knee strength while restoring leg power.
https://www.instagram.com/p/BxLGFXknpVE/
When it comes to VMO activation, I shy away from terminal knee extensions as doing much, simply because there is relatively no lengthening of the muscle under load, the entire focus is on the neural drive to shorten the muscle, which can “activate” it, but it won’t create any sort of hypertrophy stimulus. When you can get everything in one shot with sissy squat oriented progressions, your biggest bang for the buck is by far found there.
If I was going to do a shortening based VMO exercise, I’d just go with the reverse sled drag that Ben Patrick recommended to me (his work coming up in point #7), since it offers way more exposure than “TKE’s” (you’ll get hundreds of reps in, versus 10-20 TKE’s you might do in a traditional warmup) and these reps are garnered at a much sharper knee angle than what happens in a typical TKE.
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Have Strong Hips (Glutes, Psoas and Rotators)
Having strong hips can definitely help in terms of preventing knee injury and issues, but it’s not everything, in fact, I wouldn’t even say it’s in my top 3 anymore, wherein many people’s thoughts on knee injury prevention, it’s the first priority. In my original article, I spoke on the importance of strong glutes, and gave ideas on various exercises that would help improve strength in that region.
At the end of the day, “just get stronger glutes” is an extremely general statement, and a blanket thrown on any upstream, and downstream problem that exists in an athlete.
Bad back?… Weak Glutes
Bad knees?… Weak Glutes
Bad pinkie finger……………….. Weak Rotator Cuff…. And Glutes!
Athletes are a lot more complex than this, and there are a lot of muscles that control the hip. After taking Neurokinetic Therapy courses, I’ve been through procedures testing and assessing the function of a myriad of muscles around the hip. The glutes can also be locked “on”, which is also a problem, and adds to the potential confusion if “weak glutes” are a cause of every ailment.
For my purposes, strong hips means being able to hold an ISO lunge in a good position for at least 3-4 minutes straight, being able to do a good ISO straight leg raise for at least 2 minutes, being able to squat around one’s bodyweight without pitching the torso forward on the concentric phase, and being able to do dynamic movements such as squatty runs well. Hip thrusts obviously can help get strong glutes, but other important elements for hip centration and control such as hip circles and psoas work can be important. Hip circles are something I picked up from Dr. Tommy John that covers a lot of bases.
https://www.youtube.com/watch?v=kHFusc4QCQo
The “seated psoas” raise that Kelly Baggett wrote about many years ago works the iliacus which has a powerful role in hip centration.
Both these muscles develop strength and control of the hip, which impacts pretty much everything.
One thing that is pretty simple in situations where knees have been hurt is athletes can do a lot of work on their hips, but they must always remember to be aggressive in strengthening the knees through increasing ranges of motion and loads as well, or they’ll be a different type of athlete when they return to play!
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Do Extreme ISO’s and Conditioning Isometric Sessions
As I alluded to in my last point, extreme ISO’s are an important part of my training regime. I’ve heard way too many anecdotes of athletes with tendon pain getting better using this training method than I can remember, and the anecdotes are so good, I’ll never go back on using this method as a way to help overcome the barriers of tendon pain (as well as improve performance on a lot of other levels in the process).
As Dr. Keith Baar mentioned on podcast #156, when we perform an isometric, the muscle contracts while the tendon lengthens. This lengthening is called “creep”, and this creep helps to increase the compliance of the tendon, as well as give the signal for which direction for tissues to align themselves. Injured tissues in the absence of load will just go in chaotic directions… scar tissue.
For the sake of knee training, the ISO lunge and ISO sissy squat are my two go-to favorite movements. Dr. Baar recommends several holds of 30 seconds in length, so if you have issues, this type of work is the first priority.
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Supplement with Vitamin C and Collagen
Another Dr. Baar gem on episode #156 was supplementation for tendon health. His two go-to supplements were Vitamin C and Collagen. You can even take them together, throwing collagen into orange juice. If you are dealing with a tendon issue, collagen is a key factor in strong tendons, and Vitamin C is very important as well. As Dr. Baar said on the last episode:
“The reason Vitamin C is essential is it is a mandatory co-factor in this prolyl hydroxylase reaction where we are making collagen”
Collagen can be taken, not only as a supplement, but it also can be taken in the “hyena diet” or in eating the connective tissues in meat, such as the edges of a cut of steak. This supplementation is best taken right in the primary, and then secondary tendon-helping (isometric) workout window.
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Gradually Expose Yourself to Sharper Shin Angles (ATG and Ben Patrick’s work)
My podcast with Ben Patrick of Athletic Truth Group was one of my personal favorites. In the show, Ben went in detail on how he overcame debilitating knee pain through a progression of sissy squats and related work that he originally learned from Charles Poliquin. Ben has transformed not only himself but also a great many athletes in terms of their own knee health and performance. Ben’s “foot and knee first” mentality of training really struck a chord with me, as if it was an idea I was searching for my whole life and made perfect sense.
If you go through your training “steering away” from the foot and knee by getting more hip dominant over time (as I have) you really start to change what type of athlete you are, and it shows up particularly in vertical reactivity and running speed.
As Dr. Ebonie Rio said on podcast #144 “tendons love load” and work the stresses knee range of motion is an epitome of progressive load. Dr. Rio mentioned that if your tendon doesn’t feel worse 24 hours after performing exercise, then you selected the overload correctly.
Ben does an awesome job of being very transparent in his training on his Instagram channel, @kneesovertoesguy. Here are a few of his go-to exercises in progressing the knees-over-toes ideology: Reverse sled pulls and sissy squats
https://www.instagram.com/p/BzQtnArH8MP/
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Do Plyometrics on Small Surfaces, Watch Volumes, and Do Waveform Work as a Portion of Your Plyometrics
This was a point in my original article on the topic. In my old post, I wrote:
“Plyometric exercise involves an extremely high rate of force production, so it is important to watch the surface that these are done on. I would always favor grass or field turf if it is available here. The second place is rubber mats. Avoid doing plyos on concrete or wood flooring at all costs. If you have no history of knee issues, you can do plyos in very small volumes on these harder surfaces, but if you are having any knee issues at all, relegate your elastic work to as soft of surface as you can manage. If you don’t do plyos, try and shift some of your jumping work to grass if this is possible.”
This is good information, but I’d finish this idea with something Adarian Barr taught me on the level of doing more plyometrics that deal with “waveforms”, particularly on using more waveforms that we see in sport itself and the natural function of the human body. The “vertical-vertical-vertical” waveform in something like a hurdle hop is fairly intense in terms of repeated vertical loading. Doing something that is more “horizontal-vertical” in nature can do a great job in mitigating these impact forces, and should represent a portion of one’s plyometric training. Below is a sample video of this type of work that helps mitigate vertical loading forces and can be more specific to sport:
https://www.instagram.com/p/Bldv7XdD9o3/
Although this stuff is cool, at the end of the day, simply doing different jump variations, such as planting to jump in a “right-left” fashion if you normally jump “left-right” would also utilize this mechanism, and do so more specifically.
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Do Barbell Work with Full Ranges of Motion and Slow Tempos
I already talked about range of motion in point 7. The range of motion is an interesting thing. On one end, the range of motion is specific in the weight room when we are talking transfer. As I go in extensive depth in Speed Strength (link) partial squats have numerous advantages over deep squats from a specificity perspective, and research (when looked at in the context of the actual program design in the study) and anecdotal experience confirms this.
The full range of motion work absolutely has its place, however, since it is key in developing the extensible tissue qualities of an athlete. Even when it comes time to ditch deep squats in a program, you can still keep sissy squats in to maintain the knees.
In terms of training tempo, we need to remember what Dr. Keith Baar mentioned on podcast #156, as well as Jake Tuura on #157, and that is that slow barbell work is great for tendon health. This can be slow work as a function of heavyweight, or function of a training tempo (such as 5 seconds down, 5 seconds up). I tend to lean towards sub max percentages and tempos for most athletes, but those with the right nervous system can tolerate much more of the former (heavy work).
In doing strength coaching for as long as I have, combined with all of the education I’ve gotten by doing my podcast and speaking with many mentors and great coaches, I’ve almost come to look at the barbell more for it’s potential for tendon enhancement than muscle or at least the “sheet” like quality of the muscle tendon unit for a great many athletic populations.
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Do SMR (Self-Myofascial-“Release”) But Keep it in Perspective
In the old article, I mentioned doing things like foam rolling the IT band and using a Voo-doo band. When we learn more about the nervous system and various advanced techniques on treatment and the human body, it becomes a lot easier to scoff at stuff like foam rolling, but the fact of the matter is… SMR does provide acute pain relief that helps people get through training sessions more easily. I certainly have found this to be true.
SMR is a fine tool, but I would just encourage people to use it as a last resort… work on everything else on this list first to the point where hopefully you don’t need to even think of, or waste time with these tools. That’s definitely my goal and I would hope it is yours too.
There isn’t much worse in terms of workout “vibe” than needing to spend 10 minutes sitting around on a foam roller before you start training (to me, this really signals that I’m not ready or excited to start my workout, or I’m probably too stressed out to do the workout that’s on the sheet today), but I get it in terms of working with large groups where more advanced techniques or personal interaction isn’t available.
Conclusion
Having healthy knees has always been popular in the community of athletic performance. It has even been conjectured that humans evolved in a way that left the knee as a vulnerable side-effect of bipedalism. Maybe so, but there is definitely a lot that can be done to prevent problems here, and I know this list has been highly effective for me and my athletes, I know it can be for you too.
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