Build Strong Knees

author : AMSSM

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Techniques and exercises to prevent knee injury

Member Question:

I've started doing a lot of extra sports this year since signing up for my first triathlon. I have also been learning about technique and stretching the hard way, as I have had a couple of injuries with my knee. I have changed my swim stroke to free style (and gone to a swim technique class), started stretching more, as well as doing a couple of other things. Simply though, I think it is running that is the culprit with my sore knee & tendons.

My question is: Do you recommend any certain strength exercises to build up your knees or connected muscles? Is there something simple I should be doing? Some particular stretches perhaps?

Answer by Dusty Marie Narducci, M.D.
Member AMSSM

As a triathlete, your participation in running, cycling and swimming make you vulnerable to multiple musculoskeletal injuries. It is not uncommon for triathletes to experience overuse or overtraining injuries as well as injuries from poor flexibility and/or deficits in muscle strength. Runners in general have a high incidence of lower extremity injuries with the knee being the most frequently injured body part. Common causes of knee pain include patellofemoral pain syndrome (PFP), medial tibial stress syndrome (“shin splints”), patellar tendinopathy, iliotibial band syndrome and osteoarthritis. Knee injuries can be attributed to both intrinsic and extrinsic risk factors. Intrinsic risk factors include anatomical variables, age and gender. Training, stretching, footwear, gait strength, biomechanics, psychological factors as well as nutrition are extrinsic factors that can lead to injury.

Providing appropriate recommendations is challenging without knowing the exact cause of your knee pain. The research surrounding stretching prior to and after exercise is conflicting as is the association between inflexibility and injury. Increased hamstring, quadriceps and iliotibial band flexibility is thought to decrease the stress placed on the patellofemoral joint which may help to relieve knee pain. Although some studies refute this theory most knee rehabilitation programs do recommend stretching.

Patellofemoral pain (PFP) is a common knee injury associated with running. Risk factors for developing PFP include genu valgum (“knock knees”), overtraining, being overweight/obese, pes planus (“flat feet”), pes cavus (“high-arched feet”), deficiencies in core strength and insufficient quadriceps strength and flexibility. Hip abduction weakness is the most common deficit, even among elite athletes. Most athletes benefit from exercises focused specifically on correcting these deficits. Although many randomized clinical trials assessing treatments for PFP have been performed, the results do not support any specific rehabilitation protocol. Most rehab protocols do recommend improving mobility, strength and range of motion of the proximal muscles.

Treatment regimens for PFP should routinely address potential deficiencies in the interrelated group of muscles including hip abductors and adductors, iliotibial band, quadriceps, hamstrings, and core muscles. Strengthening of the gluteus minimus, medius and maximuis is advised in most rehabilitation protocols. The glutes medius is the main hip abductor and external rotator of the hip where the gluteus maximus assists with similar movements but primarily functions to extend the hip. Hip exercise programs for injury treatment and prevention should include straight leg raises, inside leg raise, calf raises, clamshells, lunges, bridging, and wall squats. Air squats without bending forward at the waist or allowing your knees to move over your toes should be possible before advancing to weighted squats or single leg squats. Below is a list of resources that explain these stretching and strengthening exercises in greater detail.

• https://uhs.berkeley.edu/sites/default/files/PatellofemoralPainSyndrome.pdf


• http://orthoinfo.org/PDFs/Rehab_Hip_3.pdf


• http://www.goodfellowunit.org/sites/default/files/events/mercy_ascot/hip_abductor_exercises.pdf

If you continue to experience knee pain I would strongly recommend that you see a sports medicine physician and consider gait analysis as well as formal physical therapy. Although running is most likely the cause of your knee pain you should also consider an inappropriate bike seat position as well as your transition from cycling to running which are common reason for knee injuries in triathletes. It addition I recommend assessing your footwear and avoiding overtraining. Good luck with your training and competition!

Dusty Marie Narducci, M.D.
Mayo Clinic Florida
@NarducciDusty

References

Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician 2007; 75:194.

Witvrouw E, Callaghan MJ, Stefanik JJ, et al. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013. Br J Sports Med 2014; 48:411.

Souza RB, Powers CM. Predictors of hip internal rotation during running: an evaluation of hip strength and femoral structure in women with and without patellofemoral pain. Am J Sports Med 2009; 37:579.

Noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. Med Sci Sports Exerc 2013; 45:1120.

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date: May 31, 2017