Knee Pain In Powerlifters
A look into the knee pain in Powerlifters and how to solve it.
Knee Pain In Powerlifters
Knee pain is pretty common in Powerlifters, the large volumes of squatting and sometimes high frequency can lead to knee pain. Powerlifter’s generally are good dealing with pain and completing the prescribed work but if left unchecked you could find yourself in a situation whereby you have to stop training altogether and this can have a large detrimental effect on strength first and foremost but secondly really scupper any longer term goals that you have. As we all should know consistency is the key to this game and having a frequent specific stimulus is one of the main drivers for adaptation. I’ll explore this concept further in the future but for this article we will dive into knee pain.
Defining Knee Pain
In my experience working with literally 1000’s of athletes over nearly 20 years of professional Strength and Conditioning and Performance coaching I think you can boil down knee pain in Powerlifters broadly into 2 types.
1 - Patella Femoral Joint Pain (PFJ Pain)
2 - Tendinopathy
PFJ pain is a fairly general term for knee pain under load. For me in reference to a lifting population we are likely talking about changes to the cartilage on the underside of the patella and/or tracking issues of the patella as you flex the knee. These changes or mechanical tracking issues lead to aggravation and inflammation of the PFJ and lead to pain. Essentially the more knee flexion you get the greater the forces and pressure acting on the knee. The long term effects of will be the hyper-sensitisation to pain under load and through flexion leading to pain inhibition, atrophy and altered firing patterns during the squat.
Tendinopathy is the term used for any inflamed or degenerative tendon, either through acute overloading i.e. a very large volume of squatting in a single session compared to your normal routine or chronic overloading i.e. an increase in overall load over a longer period of time that is just beyond what the turnover and repair rate of what your tendons can currently cope with. Essentially the collagen that makes up the tendon will become disorganised and not allow for adequate force transmission. These will most likely be in the Patella tendon and possibly the quads tendon.
How To Self Diagnose
Now for most lifters they will not really care a great deal about diagnosis rather they want to know how to get back to plan A, getting back on track and being out of pain. The problem with this is that these two issues require different interventions
I think the process of self diagnosis for these two conditions is fairly straight forward, although I would say if you are ever at a loss you should consult with a qualified professional and get a diagnosis and potentially some further investigation.
The below would be my cheat sheet to begin the process and allow you to make great training based decisions.
PFJ
Knees that ache most of the time
Crepitus in the knee joint (crunching) which causes no pain
Pain at the bottom of the squat
As you lift more through knee flexion (inc leg extensions etc) the pain gradually becomes worsened
Possibly carry a small amount of swelling on the knee at all times
Tendinopathy
Knees are sore upon waking in the morning
Walking up and down stairs is painful
The descent on the squat is painful
As you warm up pain subsides and you can become pain free during training
As you cool down the pain returns
How To train
This can be dependant on a few factors, severity of symptoms being one, the other would be the amount of time you have been training in pain and battling through. Early detection and intervention is key and the next segment is for lifters who are potentially at the beginnings of this pain. If you are reading this and you have been in pain for a long period of time and the condition is fairly chronic you must consider rest first and foremost plus some work on pain re-education as you have likely hard wired yourself to feel pain now.
PFJ
Training Volume and Frequency
The first and most obvious thing to do would be to reduce some of the training volume and frequency, you are dealing with an inflammatory condition that is aggravated by lots of knee flexion. A reduction of 10-20% initially would be a good starting point and then re-asses.
Squat Style
If you are a squatter who allows knees over toes and beyond plus you have sign of PFJ related pain you must consider adopting a modified squat style to preserve the knee and also allow again for higher volumes and frequencies of training. Using a period of very controlled box squats, which promote a more neutral shin angle is a great place to start this re-education.
Quad Strength
With pain comes inhibition, with inhibition comes atrophy, with atrophy comes more pain. You must find way to limit quads atrophy and the logical thing would be to use leg extensions for this and or look to the bodybuilding world and use some version of quad dominant squat. These are both contraindicated due to the knee forces, pressure and contact areas when performing these exercises. They will make you worse. My personal favourites to counter this process of pain/inhibition/atrophy/greater pain are Blood Flow Restriction or BFR training, for this you can use the leg extension as the load will be much lighter, forces much less but the anaerobic environment created by the BFR starts a cascade effect which leads to great hypertrophy. The we go the other way with the flow. pain/hypertrophy/activation/less pain.
Hip Strength
Reduced hip control is found in sufferers of PFJ pain, by incorporating some hip stability work in both the open chain and closed chains would be a big benefit although not entirely solving the problem. Exercises such as lateral lunge, banded clams etc would help develop the lateral chain and improve frontal plain control.
Tendinopathy
Pre-Training Strategies
Long Duration Isometrics
As mentioned earlier tendinopathies generally improve with warming up. There is a small amount of evidence for the the use of longer isometric holds in decreasing pain prior to loading. This is a very individual strategy but once tried and you feel it is a benefit, keep it in. If you receive no benefit in terms of pain reduction then remove it form the program.
Single Leg (Leg Press) Isometrics;
2-3 sets x 45s Holds
Performed with a single leg at a pain free knee angle
Soft Tissue Release
When thinking of the tendon we must think of all the structure that potentially act on it and not just about the external loading on the bar. The resting tone of the quads muscles will play a role in tendon tension and decrease the need for that tendon to experience load and allow for a more even distribution of force when squatting. My absolute favourite soft tissue release exercise for this is using a hockey ball on the lateral aspect of the quads where it blends into the tendon.
Distal Quads Release (Hockey Ball);
1-2 rounds of 90-120s
Maintain pressure and don’t roll around
Wait for the muscle to decrease in tone.
Post Squatting Strategies
Eccentric Overload Training
By increasing the load on the muscle and tendon during lengthening we achieve two things
1 - An increase in strength of the muscle and activity of type 2 muscle fibres. A stronger muscle can offload the tendon to some degree
2 - An improvement in collagen alignment which is not achieved as effectively with a concentric biased approach (uncontrolled eccentric phase)
The exercises used here would be the leg extension and leg press. You want to isolate the knee flexors as much as possible to stop other muscle groups facilitating the movement.
2 Up 1 Down Single Leg leg Press;
4 x 4 Tempo 4s ECC
2 Up 1 Down Single Leg Leg Extension;
4 x 4 Tempo 4s ECC
Programming Strategies
Again you must strike the balance between how and when you load. Collagen turns over at a much slower rate than muscle can due to the poorer blood supply. This must be respected so allow 48 hours between loadings of the specific structures to ensure you get limited flare ups and you start to generate a good amount of collagen which has good alignment.
This is where higher frequency squatting and deadlifting become a potential issue. Squatting back to back days can be achieved but you must be very conscious of intensity, this should be undulated quite aggressively if within a 48 hour window to mitigate the risk of a flare up.
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