The first time I met Bob,* he had just finished a ten-mile run. This would have been impressive even if he hadn’t done it in under 70 minutes.
After running that fast for that long, most people would have been tired, covered in sweat, and ready for a nap. Bob was upbeat, chipper, and eager to talk about his many plans for the remainder of the day.
At the time, Bob and I were at a fitness-related social event and not planning on working together. Bob left an impression as the type of buoyant, energetic man who never slowed down.
But a year later, when I met Bob again, something had slowed him down.
Bob, like many runners, was struggling with chronic knee pain. Specifically, he was having show-stopping pain in his left knee. The pain had been off and on for years, but now it was worse than it had ever been. He’d tried resting, and he’d tried some physical therapy exercises from a past PT visit, but none of his old tricks seemed to be helping. Now, Bob was struggling to run at all. Even bending his knee without weight on it could cause pain.
Once Bob had laid out his struggles, I said I felt we could help him recover function in his knee without losing significant fitness.
Step 1: Testing
In order to help Bob, we first had to figure out what might be the source of his pain.
Usually, physical pain — particularly pain that builds up over time and isn’t the result of an acute injury — is caused by the way we move. Generally, pain signals that our body has fallen into an unsustainable movement pattern. For example: our knee may be turning slightly too far in when we run, which, over time, results in knee pain.
When thinking about movement patterns, there are two major factors that determine healthy movement:
- Mobility: If we don’t have enough mobility to move through our desired range of motion, our body will compensate in ways that will often cause pain.
- Stability: If our muscles aren’t strong enough and coordinated enough to create stability during our movements, we may also experience pain.
Our first step was to test Bob’s mobility and stability in order to see if we could pinpoint what was causing his pain.
What Our Tests Found
When looking at knee injuries, it’s important look beyond the knee itself and also test the tissues around the hips and ankles. That’s because pain in the knee is often connected to an imbalance in the hips or ankles.
Our tests revealed a few key findings:
- Bob had limited mobility in both his left and right ankles
- Bob had limited internal and external rotation in his right hip
- Bob’s left knee was caving slightly inward when he ran
When I explained the findings to Bob, he was surprised. Specifically, he was surprised that his right hip lacked mobility when it was his left knee that was in pain. But this is not uncommon: sometimes, our body compensates for a lack of mobility on one leg by putting more weight on the other. As a result, our more mobile leg is often under more stress than our less mobile leg. This added stress could easily contribute to his knee pain.
The other findings made more sense to Bob: instability in his left knee suggested a lack of strength and/or coordination in that area. This instability could, in turn, translate into pain.
And then there were his ankles. Strong, mobile ankles help absorb the force of impact during exercise, including during running. Stiff ankles make the feet less able to absorb impact, which, in turn, results in more stress further up the leg.
What We Did
In order to address Bob’s pain, we were trying to accomplish three goals:
- Increase the mobility of Bob’s hips, particularly his right hip
- Increase the mobility of Bob’s ankles
- Increase the strength and coordination of the muscles surrounding Bob’s knees
In order to accomplish these goals, we tried a variety of exercises. Not every exercise helped Bob, and that’s perfectly normal — every body works a little differently. That said, most of the exercises did help. Here are the ones that worked best for Bob:
- 90/90 Hip Shift with Breathing. This exercise helps the pelvis access a more neutral position and larger range of motion, which in turn increases mobility of the hips.
- 90/90 Side-Lying Hip Shift with Foam Roller: This exercise helps our hips access both internal and external rotation in a gentle, low-stress way.
- 90–90 hip rotations. This exercise is great for mobilizing hips through internal and external rotation as well as warming them up for future exercises.
- Active pigeon pose pulses. Rather than using the passive pigeon pose stretch, we had Bob use active pulses in this position to increase his hip external rotation.
- Internal/External Rotations against a wall: This exercise helps activate our internal and external rotators in a low-impact way.
- Kneeling split squats. These help increase ankle dorsiflexion (which is whether the toes bring closer to the shin), which is important for minimizing impact on joints up the leg.
- Glute bridges with cross-legged hip stretch: These help strengthen the hamstring and glute muscles, which help stabilize the knee. The simultaneous cross-legged stretch helps increase external rotation.
- Calf raises on an elevated platform: These exercises help strengthen the calves while also increasing ankle mobility in plantar flexion.
- Toe-taps. These help strengthen the muscles on the front of our lower legs (anterior tibialis). Runners often have relatively strong calves but relatively weak tibialis anterior muscles. This imbalance can lead to instability and pain in the ankle, knee, and even the hips and back
- Deep lunges with internal rotation. These help activate the internal rotation pathway, while also strengthening the muscles around the knee.
- Goblet Squats with light weight. This exercise helps increase hip mobility, strengthen the muscles around the knee, and increase ankle mobility.
Results
By the end of our first session, Bob had increased his pain-free range of motion to the point where he was able to completely bend his knee without pain, and was able to jog lightly with significantly less pain.
Of course, chronic pain doesn’t disappear overnight. But after several sessions, Bob was able to return to light jogging. And within a few months, Bob had managed to string together another series of sub-seven-minute miles, pain free.
If you are struggling with pain and injury — or just looking for a training plan — I want to help! Schedule a free consultation or reach out via our contact page.
*Names changed to protect the innocent