Go back to about a year ago, and ask me what the number one injury that I’m seeing in Crossfit is. I probably would tell you some type of shoulder pain or injury. Fast forward to today, and I can undoubtedly say that it is knee pain. That dreaded, never-goes-away knee pain. If you don’t think it’s common, then pay attention to how many knee sleeves you see on squat day at a Crossfit gym. I’d bet if you asked, the majority of those knee sleeve wearers sport them to try and keep their knee pain at bay.
At least once a day, I have a conversation with a friend or patient at the gym about the nagging knee pain that they have been experiencing. It’s usually the same story from all of them too: it gets temporarily better with rest, ice numbs the pain, ibuprofen helps a little, and it is worse with some type of squatting movement. The one other commonality is that they haven’t sought help and just hoped that it would go away on its own. By the way, I have personally struggled with knee pain from Crossfit and could check off that list the same as many of you readers, so don’t play the empathy card.
So quick anatomy lesson: what does the knee do? The knee is mostly a hinge joint (it predominantly flexes and extends) even though it does allow for a small amount of internal and external rotation. This is important to remember as we discuss some of the things that are causing knee pain in the Crossfit community.
To be clear; we are talking about general knee pain around the kneecap (referred to as Patellofemoral Pain Syndrome) and not a ligamentous or other structural injury to the knee area.
What’s causing the knee pain?
In short, it’s complicated. This type of pain can be caused by many factors. To date, there isn’t much research pinpointing a single cause of this type of pain, but there are definitely patterns and similarities among cases.
Hip (Abduction) Strength - The biggest and most consistent finding among similar cases is a decrease in hip abduction strength/stability on the same side as the painful knee (or bilaterally for bilateral knee pain). A 2013 study in the Journal of Strength and Conditioning Research demonstrated a much higher hip adduction strength to hip abduction ratio in those with knee pain compared to those who did not present with knee pain.1 In plain English, you are much stronger moving your leg towards your midline than you are moving your leg laterally to the outside of you.
Quad Strength- It was once thought that this type of knee pain was caused by a lack of strength of the VMO (or a small portion of the inner quad). However, studies are telling us now that it is correlated with a decrease in thickness/size of all quadriceps muscles. Literature in the Journal of Orthopedic and Sport Physical Therapy demonstrates that Patellofemoral Pain Syndrome is associated with a decrease in the thickness of all quadriceps musculature. On the painful knee, the quads have been shown to be over 8.5% smaller than on the non-painful side.2
Ankle Dorsiflexion- Proper ankle biomechanics when squatting requires considerable ankle dorsiflexion. Essentially, this is when the distance between the shin and the foot decreases. If we don’t have this range of motion, our foot will over pronate (or roll inward) when we squat. This leads to problems up the kinetic chain as the mechanics of our knee are compromised and now more likely to collapse. For this reason, a 2010 study showed a correlation between decreased ankle mobility and ipsilateral (same side) patellofemoral knee pain.3
Poor movement/athlete development-Then there are some cases where the athlete needs to relearn the movement pattern. In the Crossfit world, I often see athletes catching Olympic lifts or even squatting by crashing to the bottom position and then bouncing back up. This type of movement relies on connective tissue strength/durability instead of depending on your muscles to absorb the load. If coaching cues are not helping to place the athlete into a more correct position, then the movement or lift needs to be regressed so that the athlete can perform the exercises correctly. Sometimes squatting to a box or performing a wall sit is necessary to relearn how to move effectively. Focus on proper knee tracking and controlling the weight.
Do you see anything off with the first two photos? If not, take a look at the position of the knees. In squatting patterns, our knee should be tracking over our 2nd toe. When this doesn’t occur and our knees cave in or move to the inside like in the lunging photo, we call this valgus collapse. Many of you are probably looking at these photos thinking, “I do not do that when I squat.” You may be right, but what if it is just a subtle lack of stability every time you catch a snatch, come off a box jump, or perform a lunge. That accumulative instability can add up!
How to Fix It
Get evaluated- I don’t like to waste time, and I doubt you do either. Trying to self-diagnose is pretty tough and usually ends without any improvements in symptoms. So, have a professional evaluate your knee and determine what is causing the issues. The clinician will be able to rule out other, more serious conditions and also pinpoint the root of the problem.
Alter programming- This type of knee pain can be described as a tendinopathy. Tendinous pain is most often an issue of loading and the tissues’ ability to adapt to its stressors. When you experience tendinopathy, you get disorganized collagen, increased ground substance, and increased nerves ending and vasculature (i.e. hypersensitivity). So use the concept of mechanotransduction to heal this thing. Simply put, expose the tissues to mechanical loading to create a cellular/structural change. If back squatting was causing knee pain, find an alternative until your tissues can handle the load. The alternatives are endless: front squats, belt squats, Bulgarian split squats, zercher squats, etc. Additionally, regress the movements. Spend time working on eccentric strength. Mastering a decently heavy eccentric squat will improve tendinous strength and help teach you to control weight using your musculature and not just the connective tissues.
Increase Hip Stability/Strength- Monster walks are great, but it’s unlikely that you are experiencing knee pain because of your walking or lateral stepping. Therefore, use bands to create hip stability during movements like squats and lunges. The perturbations caused by the bands will require your hips to be stable and able to react in a squatting or lunging position.
Increase Quad Strength- My favorite exercise for these patients is a reverse sled drag. The reverse sled drag is very easy to teach and can be loaded as heavy as you want. This is an awesome way to build strength in your quads. Try a few sets, and you’ll know what I mean.
Improve Ankle Dorsiflexion- Google search ankle dorsiflexion stretches, and you’ll find a lot of ways to improve upon this range of motion. If you feel tightness in the back of your calves, spend time doing basic calf stretching and foam rolling. If you feel pinching in the front of the joint, hook up a band to a rig and mobilize that joint. Watch my Facebook video titled “2 Drills to Improve Ankle ROM” for questions on how to do that one: https://www.facebook.com/palmierisportschiropractic/videos.
Consider the points made if you’ve been struggling with a nagging and recurring knee pain. Doing nothing and hoping that the pain goes away is more than likely not going to help you improve or reach your goals. Rest for Crossfitters is not a great solution because musculotendinous strength decreases in 2 weeks, which is not recommended for lifting heavy weights. The main take-home point is to remove abusive loads (change something) and use loads that are tolerable and helpful. This doesn’t mean you should go super light. It just means make a modification.
1. Isometric strength ratios of the hip musculature in females with patellofemoral pain in comparison to pain-free controls. Eduardo Magalhes et al., The Journal Of Strength & Conditioning Research, 2013
2. Atrophy of the Quadriceps Is Not Isolated to the Vastus Medialis Oblique in Individuals With Patellofemoral Pain. Lachlan S. Giles, Kate E. Webster, Jodie A. McClelland, Jill Cook. Journal of Orthopaedic & Sports Physical Therapy 2015 45:8, 613-619
3. Foot and Ankle Characteristics in Patellofemoral Pain Syndrome: A Case Control and Reliability Study. Christian J. Barton, Daniel Bonanno, Pazit Levinger, Hylton B. Menz. Journal of Orthopaedic & Sports Physical Therapy 2010 40:5, 286-296