Guess what? Physical therapists sometimes have pain and dysfunction too! We are only human. Often times, people will see me wrapping a voodoo band here and there, or digging a lacrosse ball into my shoulder. It usually strikes up a conversation starting with, “What would you do if…..?”
My ol’ volleyball knees tend to get creaky and achy sometimes, just as many athletes and patients often describe. So, what do I do if I have knee pain?
These are my 5 favorite “quick fixes” for knee pain. Obviously, management of knee pain is more comprehensive than 5 quick tips. However, these are for when you are in the middle of weightlifting, running, playing your sport and you get that nagging knee thing. Ideally, you would consult a PT or watch a video of yourself moving to see what is causing the knee pain. But understandably, sometimes we just need it to feel better RIGHT NOW.
#1 Modified Couch Stretch- This is a great stretch for the front of the hip! It is important that you stay tall and do not let the band pull your hips forward so that your back is banana shaped. Propping the foot up on a ball takes up more slack in the quad and intensifies the stretch. If you squeeze your booty, you will feel the stretch even more. Please kneel on something soft! Prolonged pressure on the front of your knee will only exacerbate the issue.
#2 VooDoo Band- Using a voodoo band, wrap your knee beginning below the knee and leaving a gap for your kneecap. Be sure it wrap it tightly! After it is wrapped, any knee movement will be beneficial. I like to do air squats and butt kicks to get deep knee flexion. You could also sit down and bend and straighten your knee. Leaving it on for up to 2 minutes will give you the best bang for your buck.
#3 Soft Tissue to quad- Often times, tension in the quad will cause knee pain right at the top of the knee cap or on either side. Pressure to the soft tissue in the thigh area can help the quad relax and allow more pain-free range. My favorite tool for this is the handle of a kettlebell. It allows more direct pressure than a foam roller and you can easily push down and then move it side-to-side for some release. Another option is a lacrosse ball. Just lie on your stomach, pin the ball on a sore spot on your quad, then bend and straighten your knee. Spend at least 2 minutes on this one.
#4 Knee Gapping- Everyone’s favorite! We like to use Yoga Tune Up Balls for this (as seen in the photo) but a double lacrosse ball or even a towel rolled up will work. Simply put the balls in the bend of your knee, then use overpressure form your arms to bring your heel towards your booty. This should feel good- like a stretch to your knee. Two minutes of oscillating between overpressure and releasing it will do the trick.
#5 Modify- Some days, the knees just aren’t on board. If you have completed a thorough warmup and tried some self-management but the knee still feels iffy--- modify, modify, modify. Don’t work through the pain! There are plenty of ways to change a workout that will still be beneficial but not aggravating to the knees. A great example is the box squat. If I have knee pain, it’s usually with heavy back squats- ol’ volleyball knees, remember? Box squats are a good option. I am still loading in the pattern I want, hitting the lumbopelvic muscle groups, but allowing my knees to stay back further so that the shear force is less.
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Whether you are looking to PR your squat, want to squat without pain or are just sick of nagging lower extremity pain—this is where the change needs to begin.
This week I posted a picture on social media of a patient who started the session with a squat that deviated to the right and then after some mobility she was centered. This started a lot of conversation from athletes asking for help with this exact issue. First, check out your mobility. Remember: symmetry is important in a squat so be sure to check both sides and compare!
Pain and dysfunction in the back, hip and lower extremity can absolutely be caused by a laundry list of issues, but sometimes we make it more complicated than it needs to be. The best way to begin to decrease pain and improve function is to find the low hanging fruit and start there.
At Athletes’ Potential we use a group of movements to screen every patient with lower extremity complaints. The last movement is always a body weight squat. Not because every patient we treat is a weightlifter and wants to improve their squat, but because it is a foundational movement that everyone should have the requisite mobility and strength to perform.
The first two places to look for a mobility restriction are the ankle and the hip.
A few indicators of ankle restriction during the squat often comes in two forms: the people that feel like they will fall backwards if their chest is up any higher (pic 1) OR those who look like they have a solid squat but on closer look, their ankles are collapsed and spin outward (pic 2&3).
Ankle dorsiflexion is essential to have a deep squat with an upright torso. The best way to check your own ankle mobility: place your foot a hand width from a wall (in a lunge position), with the foot in that position drive your knee toward the wall making sure that your heel stays down. Can it touch the wall? If yes, move on to checking hip mobility. If no, your ankles are limiting your squat!
Our favorite ankle mobility drill uses a band to distract the ankle and then move it through range. Check it out-- Ankle distraction and dorsiflexion
Ankles can be a frustrating joint to mobilize because they are slower to change. It is important to work ankle mobility into your warm up and/or cool down as much as possible! As you begin to chip away at ankle restrictions, check out this older blog post about the best way for you to modify a squat until your mobility is improved: Is squatting bad for my knees? Part II
To self-check hip mobility there are a two hip movements that are important to check- hip flexion and hip internal rotation. When you are missing hip flexion and/or internal rotation, there may be a pinching sensation at the front of the hip during a squat or you have a “butt wink” at the bottom. To check hip flexion, lay on your back and pull your knee towards your chest. Ideally, you will be able to get your knee about a fists width from your chest. As you apply overpressure with your hand, you might notice your pelvis start to lift off of the floor. This is actually lumbar flexion, which is synonymous with a ‘butt wink’. The athlete below is experiencing this a bit, I think he was trying to show off for the camera. ☺
When checking internal rotation, sit on a table or box so that your feet are not in contact with the ground. Internal rotation is the motion when your foot moves outward from your body when your hips and knees are bent. We like to see 40-45 degrees, as in the picture below. Be sure that as you rotate your hip, you don’t bring your booty off the table and lean to make it go further!
Lacking hip flexion? Here is a great sequence to work through-- Hip Flexion Mobility
Is your internal rotation less than ideal? Is one side much less than the other? Give this a try-- Anterior Hip Opener with Internal Rotation
Maybe you check all of these areas and you have the ideal mobility. What else could it be??
Really bendy athletes are on an opposite end of the spectrum from more immobile athletes. In fact, banded mobility and banded distractions won’t help you at all! If this is you—stay tuned for Part II that covers the limiting factor of the squat for flexible folks.
Thanks for reading,
Often times, external rotation is the focus in athletic movements. When the shoulder is externally rotated, it can be packed into the back of the capsule to improve stability and congruence. It also rotates the humerus in a way that the anterior structures of the shoulder have room to move without being pinned between bones. Many of the stretches people gravitate towards for the hip involve external rotation: sitting figure 4 stretch, pigeon, etc.
What is internal rotation and why do I need it?
Internal rotation is one of the movements of a ball and socket joint, such as the shoulder and hip. In the shoulder, it allows you to reach behind your back and pull your wallet from your back pocket or tie your bikini behind your back. More importantly for athletes, it allows you to keep the bar close to the body during Olympic movements and arrive at the bottom of a ring dip safely. Hip internal rotation is needed for athletes for proper biomechanics during any form of a squat or while running. Without full internal rotation, you will likely have a “butt wink” or your low back will slightly round at the bottom of the squat. It is also important for runners to have full internal rotation, coupled with extension, to allow correct biomechanics in the trail leg.
During internal rotation, the ball of the joint (humeral head and femoral head) will glide posteriorly and roll anteriorly. This movement can be restricted with a tight posterior capsule or muscles around the joint. Unfortunately, many people will have issues here due to increasingly sedentary lifestyles and desk jobs. As you sit all day, the hip rarely reaches full extension, allowing the posterior capsule to become tight. This in turn decreases the posterior glide and thus decreased internal rotation. The same deal happens at the shoulder when you sit all day at the computer with terrible posture.
Interestingly, hip internal rotation deficits have been correlated with low back and sacroiliac pain. It is better to start improving internal rotation now rather than trying to manage back pain!
How to check internal rotation
It is easiest to accurately check internal rotation of the shoulder with a buddy. Lay on your back, arm straight out to the side and elbow bent (as in the picture below). Your buddy should provide solid but comfortable pressure to the front of your shoulder to avoid it from raising off of the ground. Now move your palm down towards the ground. Ideally, you would be able to get at least a fists-width from the floor! Be sure to check both sides because noting an asymmetry is important. Also, be sure to do this same test after practicing the mobilizations below!
To check hip IR, lay on your stomach and allow your feet to drop out to the side. Again, we are looking for asymmetries and major deficits. Ideally, your leg will move about 40 degrees or roughly halfway down toward the floor.
Mobilizations to Improve Internal Rotation
Below are a few mobilizations for the shoulder and hip to improve internal rotation. They are by no means an exhaustive list but merely a starting point.
Bully stretch- used to mobilize the humerus into the back of the shoulder capsule, which increases internal rotation.
Pec smash- nearly everyone has a tight pec minor due to the poor postures we often keep throughout the day. This muscle is located in the front of the shoulder, so if it’s tight it can easily restrict the posterior glide!
Internal Rotation Stretch- start with your foot flat on the ground and the other leg crossed over. Slowly walk your foot out to the side until you feel a strong but comfortable stretch in the hip. You should feel this in the bottom leg.
Lateral Hip Opener- this does not have to be banded if you do not have access to one, you will still feel a stretch!
I hope this gives you a better understanding of what internal rotation means, how we achieve it and why it is needed. More importantly, I hope these videos give you a good idea of how to begin to manage internal rotation deficits!
At Athletes’ Potential we want to help every athlete remain healthy and meet goals. You don’t have to be in pain to come see us. If you find asymmetries with tests such as these or know you have movement deficits, we can help you with proper movement and self-maintenance. We also have recovery options to further augment your fitness and health. We look forward to hearing from you!
Thanks for reading,
If you're in Atlanta and you have questions about our Physical Therapy or if you're frustrated with your current situation, contact us and let us help you!
Flexibility is an important aspect of fitness, along with muscular strength and endurance, and aerobic capacity. However, it is not uncommon to find athletes who are unable to bend over and touch their toes! This is most likely due to sitting most hours of the day and attempting to reverse the changes by ten minutes of stretching at the gym.
In the past decade, there has been much discrepancy in recommendations about stretching: how long, what kind, which muscles? Does it depend on your sport of choice? Before or after a workout?
There have been countless studies published, even in the past year, with varying results. However, they all agree on one thing: Do not perform static stretches prior to exercising.
Static stretching alters the (microscopic) length of the muscle which can alter, and likely decrease, its firing potential. Stretching may also activate tendon structures that inhibit muscle action. Both of these proposed mechanisms will decrease power output.
“Then how should I warm up?”
Warm-ups are essential to performance and injury prevention. They are useful for increasing the core temperature to decrease stiffness of muscles and alerting the neurologic system to the events about to take place. This should be achieved with specific, dynamic exercises rather than static stretches or laying on the foam roller.
Runners—Studies found that a dynamic warm-up increased performance of endurance runners, meaning they ran longer without exhaustion1. This warm-up consisted of movements such as high knees, butt kicks, leg swings and hopping. Total time: 4 minutes.
Notice, I said nothing about running. Those athletes warming up with running had comparable results to those not warming up at all. Check out Dr. Danny’s post specifically addressing running warm-ups.
Weightlifters—Other studies found that just ONE set of static stretches decreased 1RM performance by 5.4%2. That would decrease your 400 lb back squat by 21.6 lb!
When performing sets for reps, static or ballistic stretching decreased amount of reps by 17-20%3. That’s 2 less reps in your 10 rep set. The most effective was a specific warm-up of 20 reps around 30% 1RM, then appropriately building to working weight.
For Olympic Lifts, additional dynamic warm-ups may be warranted, specifically for the overhead movements. One of my favorite drills is thoracic rotation4, performed in between light warm-up sets:
CrossFitters—You fall somewhere in between; Choose your warm-up type based on the workout of the day. The same theme holds true: specific, dynamic warm-ups!
Sport-Specific Athletes—Dynamic, sport specific warm-ups are the most effective to prepare for practice or competition. This includes running, cutting, jumping, ball handling, throwing or whatever your sport demands. Begin at a slower pace and then work up to competition speed movements.
Your workout is over, you ran your fastest 5K, PRed your back squat or scored the winning goal... NOW you stretch.
To address the earlier question: When, how long, what kind, which muscles?
To receive any benefit, hold static stretches for at least 30 seconds but 2 minutes may show better results. Static stretches can work but they take a few weeks for sustainable differences.
PNF (proprioceptive neuromuscular facilitation) stretches have been shown to be superior to static stretching. These can be done with a buddy or by yourself using bands or straps. A common form of PNF to increase range of motion is contract-relax. You have likely seen it before:
This would also be the appropriate time to work with the foam roller or PVC pipe on the muscles that are sore or may be lacking flexibility.
Of course, the cartoon at the top is wrong. Touching your toes IS everything. Every athlete should have the flexibility to bend over and touch their toes whether or not they are warmed up. Inefficient muscle length can lead to compensation by other muscles. This causes joint pain, tendonitis, faulty movement patterns, poor form and then decreased performance or injury. Stretching is also great to incorporate into rest days. A light warm-up, then your favorite stretches or maybe your least favorite if you have some restrictions.
Self-management is 100% possible when it comes to flexibility and recovery! Take the time to take care of your body and it will perform better. Remember, at Athletes’ Potential you can supplement your stretching and take recovery to the next level with full-body cryotherapy and NormaTec compression boots. Call us anytime to schedule an appointment!
All too often the answer is “I just run my first half mile slower and then get into my running pace”.
Paula Radcliffe, one of the greatest female marathoners in English history, does a warm up for 45-50 minutes before a marathon race! That’s longer than most of us will run for our work out.
So why is it that elite runners and athletes put such an emphasis on warming up and we do not? There are a few factors that can lead to the lack of using a warm up.
We’re going to try and solve these issues with the warm up and put something together that you can do in a short period of time (15 minutes) before your next run.
Here’s the strategy in a nutshell: we need to get tissues opened up that can be primary limiters of running mechanics and we need to get muscles firing that need to be working for proper movement. Let’s start with opening up the tissues we need for running.
One of my favorite pre-run mobilization for runners to do is a quick pressure-based technique for the bottom of the foot. All you need is a lacrosse ball, baseball or some other type of hard ball to step on. Do not use a racquetball or a tennis ball, it’s a waste of your time because it’s not enough pressure. We want to open this area up before running because every little bit of increased ankle dorsiflexion will be a mechanical advantage for us in particular on hills.
Do this technique below for 1 minute on each foot
Next, we want to open up the hips, in particular hip extension. This allows us to get our leg behind us while we run without having to compromise our back to do so. This is also a huge area of emphasis because of the amount of time most of us spend sitting. When we sit we are in a hip-flexed position. When we run, we drive into the opposite range, hip extension. If you sit all day in hip flexion, your tissues get tight in that range and cause you to lose hip extension.
This is essentially a hand brake that you have with your forward movement. By opening up your hip extension, it allows increased ease of movement in the running gait. Here is what you’re going to do. This stretch is called the world’s greatest stretch and it really might be!
Perform this sequence twice on each side. It should take you about 1 minute to go through this sequence on each side. This gets things moving at the upper back, front of the hip and hamstring/calf. It’s really a catch all for many athletic movements but in particular running.
Alright, we should have those done in about 5 minutes. On to the priming of the movement that we want to perform.
I’m a big fan of working on the skill of running. That’s right, running is a skill and if you treat it that way your body will thank you and your finish times will be better. Practicing certain movement prior to running can help us ingrain good moving patterns while we are running.
The first drill is a pulling drill that I use all the time with my athletes. Do 1 minute of pull drill work like Nate explains in the video. After that, run for 1 minute trying to emphasize the same exact pull feeling that you got doing the drill.
The last drill will be to work on your cadence. Cadence is how many foot strikes you have in a minute. Coaches and researchers have found that having a cadence around 180 foot strikes per minute is a very efficient place to run. This allows for you to pull your foot quickly off the ground and minimize some of the elongated ground reaction force that happens with a very slow cadence.
Download a free metronome app on your phone. Put the beats per minute at 90. You’ll try and have your right foot hit the ground every time it bets. This will equal 180 foot strikes per minute since you’re only counting the one side. Run for 1 minute at this cadence but try and keep a slow to moderate pace. Don’t go bananas and try to run a 4 minute mile because you’re increasing your cadence. Stride length plus high cadence is what allows us to run really fast efficiently. Shorten your stride and keep your cadence high during this drill. You should imagine you’re running on hot coals.
In summary your warm up should look like this:
Don’t be surprise if you’re breathing a little harder after your warm up. That’s why it’s called a warm up! You’ve got to prime your body for what you’re about to do. This could be the single most important thing you can do to maintain your body as a runner and improve your skill of the movement.
If you’re a runner, triathlete or CrossFitter that wants to improve your running or are dealing with a run-related injury let us know. We’ve literally helped thousands people with knee, foot, hip and back issues related to running. Don’t wake up every morning wondering if this is the day your knee will stop hurting when you run. There are answers out there and we can help.
Contact us below if you would like to set up a free talk with one of our Doctors of Physical Therapy to see how we can help you run pain free
Thanks for reading,
Dr. Danny and Dr. Jackie's views on performance improvement, injury prevention and sometimes other random thoughts.