Hooper’s Beta Ep. 89

INTRODUCTION

Do you force yourself to downclimb everything because jumping makes you cringe? Does the thought of a deep drop knee give you nightmares? Do long hikes to the crag leave you walking like Hank Hill’s dad? If you’ve been experiencing frequent pain right around [zoom into knee] here, then you KNEED to check out this video!!

In this episode, we’re talking about the causes, tests, and solutions for anterior knee pain, so you can stop asking your friends to carry your heavy crashpad for you and start hiking, climbing, and jumping like a true kneesovertoesguy fanboy.

AN IMPORTANT NOTE

Before we begin, I need to make one thing clear: the causes of anterior knee pain range wildly, making an exact diagnosis difficult to impossible without evaluation from a professional. As such, this video is not meant to diagnosis a specific pathology, but rather to first explain the most common biomechanical and behavioral causes of anterior knee pain for climbers, then to demonstrate functional mobility and strength tests so you can narrow things down a bit, and finally to provide a set of exercises to help mitigate the issues highlighted by those tests. If you have or suspect a more severe issue like patellofemoral pain syndrome, instability of the patella, or even a big word diagnosis like Chondromalacia Patellae, then please get help from a skilled provider.

PART 1: CAUSES OF ANTERIOR KNEE PAIN

Biomechanical Causes

Anatomical and/or biomechanical causes of anterior knee pain include: limited range of motion, low or untrained tolerance to high loads placed on the knee, imbalances in the strength of the hamstrings vs the quads, and finally imbalances and/or weakness in the foot/ankle as well as the hips. Let’s start with the slightly less common ones and work up to the most common and thus most important. 

Let’s start with discussing muscle imbalances. First, the quad to hamstring ratio, then we will move on to foot/ankle and hip imbalances. 

Reason 1: Having appropriate hamstring to quad strength is important. Though the knee is a simple joint, it requires balance in the connected structures to function well. Just as the extensors in the hand and wrist need balance from the flexors (and vice versa), the quads need balance from the hamstrings. So, disproportionately weak hamstrings cause imbalance in the knee, which can lead to joint pain. Weak hamstrings also tend to become inflexible, which can increase load on the quads and exacerbate the issue. 

Reason 2: Climbers unfortunately tend to avoid appropriate foot/ankle and hip exercises that would help stabilize the entire lower extremity, for risk of “weighing themselves down” with “too swoll of legs”. But, without any training and without this control at the foot / ankle and hips, the knees will be subject to rotational, varus or valgus forces (AKA your knee may be stressed inward or outwards). These unwanted forces while climbing, hiking, jumping, etc. will create additional stress on the patellar ligament, which will lead to anterior knee pain.  

Reason 3: Climbing is a sport that demands full range of motion of the knee, particularly with knee flexion. When climbing at higher levels, we will often find the need to maximally flex the knee to place the foot as high up on a small chip as we can. If you do not have adequate range of motion of the knee at that time, you will be forcing an elongation of the quadricep muscles and patella ligament beyond what it can normally tolerate. The quads may be able to more easily adapt to this, but the patella ligament cannot do so as quickly which can cause pain. 

Reason 4: Typically, if we do train the knees we don’t work them through the full range of motion. This is generally safer and causes less impact on the knees. But, it does not prepare them for the demands of the scenario we just mentioned where we perch on a high foot, because we often rock our weight onto the foot and then stand up, using the full range of motio. Without adequate training, you are now generating significant force to tissue that is elongated to its end range, has less muscle fiber overlap, and may not be ready to safely handle that much force. This is an immediate recipe to cause irritation that presents as anterior knee pain.

Reason 5: The final reason for knee pain is actually related to our typical behavior as climbers. We’ve established that lack of training of the lower extremities, whether it be strength- or mobility-related, is often the underlying source of your knee woes, but these woes usually present themselves as a result of specific activities and habits which we should be aware of.

For example, when you’re hiking uphill, do you notice your knees pointing inwards? What about on the walk back down? Did you engage your hips or glutes to help out? If not, you’re placing all that force on the knee without using the surrounding structures to help it out. You create a huge contraction of the quads, likely with limited hip extension, so the hamstrings can’t balance things out, which causes increased strain and stress on the anterior knee.

Another common example is the falls we take while climbing. The continuous jumping from bouldering gym walls, the unexpected falls from the proj -- again, this is a huge shock to the knee, creating high loads, and without adequate training: your patella ligament may not be ready to absorb that force, your hamstrings may be too weak to create balance at the knees, and your glutes may be on vacation still, not helping one bit which creates a huge demand to the patella ligament which it is not ready to absorb. With repetition? This will definitely create discomfort.

PART 2: TESTING FOR A STRENGTH VS A MOBILITY ISSUE

Now, you may be thinking to yourself, I feel like I do have some of those issues, and I have had knee pain before, but I don’t really know exactly what caused it! Was it the hike, was it the high foot I kept doing, do I have terrible mobility, or am I just a chicken legged jabroni?! Well don’t worry, I’m going to take you through a few tests you can do to help identify your potential problem areas! Step 1 will be an easy mobility test. Step 2 will take you through a strength test. And then step 3 will combine mobility AND strength to see if your knees are truly up to par.

Range of motion check

As with anything I need to remind you to do these tests at your own risk and if you think it may cause pain do them slowly and safely. 

The first check we are going to do is a deep knee bend in a sitting position. 

1. Start on your hands and knees with a mat on the ground

2. Walk your hands back towards your knees as you begin to bring your butt down towards your heels

3. Use your hands as support as needed, otherwise try and sit completely on your knees. 

Now assess how this made your knees feel. If you have pain or feel limited in these positions, you likely need to work on your knee mobility.

[OPTIONAL] A second test to look at mobility of the knee will be a catcher's squat test. To perform the catcher's squat test

1. Start in a standing position with a sturdy object nearby to hold onto if needed

2. Start to lower into a squat position pointing your knees out

3. As you lower shift your weight onto the balls of your feet

4. You should end up with your heels off the ground and your knees fully bent. 

Again, assess how this made your knees feel. Do you have pain or tightness in this position? 

Strength Testing

For an easy strength and stability test we will perform a single leg Y Balance Test (YBT). This is best performed in front of a mirror or just with a camera/phone so you can watch yourself to monitor your form. You’ll also need 3 cones (or just items you can push around easily) and a tape measure. 

Note: if you already have knee pain and can’t do a regular double leg squat without pain, you may not want to do this test. 

To perform the Y Balance Test

1. Start by marking “home” position with a piece of tape

2. Place 1 of your objects directly in front of you, and the other two behind and to your side (to make a Y)

3. Stand on a single leg with the tape directly in front of your toe

4. Try to keep the weight in the middle of the foot as you use your opposite foot to push the objects as far as you comfortably can. 

5. You should not be placing this foot down on the ground while you do this, the control needs to remain in the centered foot. 

6. Once you have pushed all 3 objects out into the “Y’ shape, measure the distances

Results:

So, how did this test feel? Did you have pain on one leg and not on the other? Was there a greater than 10% difference between your limbs in the distance you could push the objects? While it may be normal to have a slight difference with your dominant leg having better results than your non-dominant, a >10% difference would be an abnormal finding, meaning one leg has a more significant strength deficit compared to the other and can lead to issues with that knee. What if you had no pain and both numbers seemed great, how do you know what is normal? For an easy check, go to your camera! Were you able to get at least 70 degrees of knee flexion with every test? If so, you are looking good! But go deeper! See just how far you can comfortably go. For all of the nitty gritty details (AKA, the true science with amazing research and normative values!) check out the show notes as we have charts from wonderful resources.

Strength and mobility test

Now that we have checked our strength and mobility separately and in a safer, more controlled manner. We now need to check them together! You see, it’s one thing to have some basic strength and range of motion, But having strength throughout that range of motion is even more important. Now, there are numerous ways to test your strength AND mobility, but I’m going to include a basic one that will really test your strength through a large range of motion. It’s going to look similar to the previous mobility drill we did but this time without the use of our hands. This will be the Active Heel Sit Test. 

To perform the active heel sit test

1. Lay a mat on the ground

2. Kneel on the ground keeping your body upright 

3. Start to lower yourself towards your heels, keeping your chest up the entire time.

   1. Your hands should be by your side in case you have pain and need to pick yourself back up

4. Rest on your heels momentarily, and then use your quads to lift yourself back up, returning to the original position 

Results: what did you feel here? Were you able to go through the entire motion without pain? Did this feel easy? Could you do multiple repetitions? If so, great! YOu should be able to do multiple repetitions without pain. That would be a sign of a healthy knee with good mobility and end range strength. Note: there are many other more challenging progressions with this test, but we are going to leave it there to cover the basics, not elite end range mobility. . 

Summary of mobility and strength testing

OK, so we now have a way to test our mobility and strength. If you found some, or all of those tests to be painful or just challenging, how do we go about fixing it? 

PART 3: HOW DO WE FIX IT?

The truth to fixing knee pain is that it is a simple, yet complicated process. What I mean by this is everyone’s solution is going to be slightly different. For some it may be focusing more on mobility. For others strengthening the quads, glutes, and/or hamstrings may be more important. In some cases, it may also just be improving awareness of your behaviors! And for the lucky few, it may be a combination of all the above! For an individualized plan to really get after your issues, see a skilled professional. BUT! I’m going to do my best to provide you with a guide map that you can use to help correct your issues. We will look at some of the most important stretches and strengthening exercises you can do to correct knee pain. But first, we will talk about some important behavioral corrections. 

Correcting Behaviors

Making slight changes to a few of your habits can go a long way to reducing knee pain. These changes include: 

1. Downclimbing rather than jumping off the top

2. Rolling onto your back rather than landing flat footed every time (if you’re in a gym).

3. Paying attention to your knee positioning while hiking. In particular, avoiding the knee falling inwards

4. Engaging your glutes while hiking. In particular, using the glutes to help you step up and also engaging them lightly while downclimbing to help reduce some stress on the knees

Now, let’s review some stretches and strengthening exercises you can work on to improve your knee pain. 

Stretching

Foot Up Against The Wall half Kneeling Stretch

This is one of my all around favorite stretches. It hits the rectus femoris, quads, and hip flexors. It will not only help your knees, but it will also help with lower back pain. It’s an amazing stretch that also can be done if you have some limitations in your range of motion. But, don’t worry, if you can’t do this or are really limited, I will provide you with some options coming up after. 

Wall Rec Fem Stretch

To perform the Wall Rec Fem stretch

1. Start by placing a pad down at the wall. 

2. Next, go into a half kneeling position while facing away from the wall. 

3. Lean forward, placing your hands on the ground 

4. Bend the leg that is closer to the wall and point your toes

5. Scoot back until the top of your foot is on the fall

6. Continue to slide back further until your knee is as close to the wall as you comfortably can

   1. You may need to adjust this once you get into the stretch

   2. If you are newer or have less mobility, keep your knee 6-12 inches away from the wall 

7. Place one or two hands on the front leg for support, and raise your chest up

8. Next, keeping your chest upright, shift forward to really get into the stretch

9. You may need to adjust your placement of the knee once again as you shift forward. 

If this was impossible, or you’re just too afraid to try it, start with a standard quad stretch and a hip flexor stretch to build up your confidence. 

Perform 2 or even 3 sets, 30-45 seconds each. This can be done multiple times a day

Strengthening

The subject of strengthening the knees is vast. There are so many exercises you can do that would be beneficial. I could list off a dozen awesome exercises. Rather, I am going to provide an exercise that will address most of the underlying anatomical deficiencies that typically cause anterior knee pain, though if you’ve figured out specifically what is causing your symptoms you can of course focus on exercises that only target that issue. This means doing side steps with a band at the feet to work the foot/ankle and outer hips, doing nordic hamstring curls to strengthen the hamstrings and glutes, and finally doing some deep anterior lunges to work on loading the knee and improving functional tolerance to deep knee positions.  

To perform the Side steps with the band at toes

1. Start with a circle band, or simply tie a band in a circle

2. Place the band around the balls of your feet

3. Create mild tension in the band

4. Take a small, 4-6 inch step to the side with one leg. 

5. Match the step with the trail leg BUT make sure to move this in slowly and with control

6. Place the leg back down and continue to move to the side

Perform 10-12 steps, 2-3 sets. This should be done once or twice a week, but can be performed more frequently as needed. 

To perform the Nordic hamstring curls 

1. Place a pad up against a wall

Note: we are going to do a modified form that also works the toes / calf to really add benefit to this for climbing. 

1. Kneel on the pad with both knees and back your feet up to the wall so the entire foot is touching the wall

2. Keep your trunk completely upright

3. Engage your core, glutes, and dig your toes into the wall (it’s OK if the heels come off of the wall now)

4. Start to lean forward keeping the trunk straight (don’t bend at the hips to try and go further)

5. Fight to go as deep as comfortable, holding for 1 second, then return!

6. Repeat. 

Perform 10-12 reps, 2-3 sets. This should be done once or twice a week, but can be performed more frequently as needed. 

To perform anterior lunges with knees over toes 

1. Start with your feet hip distance apart

2. Step forward with 1 leg

   1. The step distance matters. If you take a shorter step you will force a lot more knee over toe action which means you need to have good range of motion and strength in that leg. If you take a longer step you will feel a large pull in your hip flexors on the posterior leg

3. Try to keep your posterior or back leg straight throughout the movement for an added stretch of the hip flexor

4. Start to lower down as safe and comfortably as you can with the end range goal being to fully flex at the knee

5. Hold briefly

6. Push through the forward leg to return to a standing position. 

7. Repeat

Perform 8-10 reps (depending on intensity / depth of each lunge), 2-3 sets. This should be done once or twice a week.

Note: on step 4 there are a few modifications that can be made

1. You may use to yoga blocks by your side to use your hands to help take some load off of the foot

2. If you don’t have good ankle mobility, you can shift from a flat foot position to the ball of your foot

3. If you really want to work on your mobility and strength, go deep into the position with added weight

On The Wall Drills

For a simple on the wall drill

1. Pick a high foot

2. Rock onto that foot going through maximal knee flexion and weighting the foot/leg as tolerable. 

   1. This should be a rather large hold so you don’t worry about the foot blowing. 

3. Grab onto a secure hold above with the opposite hand

4. Push through the leg on the hold using the hand as much or as little as required to allow you to stand up.

5. Repeat on the other side. 

Perform 2-4 repetitions as this is a larger range of motion and may place more force on the knees. Also, not many climbs will require 12 high knees so let’s keep the reps functional. Perform 1 or 2 sets each time your climbing. 

Note: if you’re having difficulty with this drill due to hip limitations, definitely check out our video on how to improve this technique! The Most UNDERRATED Climbing Skill (3 Steps to Improve High Feet, Open Hip Mobility)

OUTRO

In summary, here are my honest thoughts about the knees. There is no one size fits all video to solve knee pain. There are loads of reasons why people develop knee pain, and a professional evaluation may be needed to create an individual plan. There are also loads of different opinions about the knees. There are plenty of reasons why people say that your knees shouldn’t go over your toes (higher force to the knee itself, less help from the glutes), and there are certainly scenarios where the knees should be trained to go over the toes (such as with climbing). The simple truth is this: the body is amazing at adapting to the training we do. If we train it right, and if we train it with the right volume you can certainly fix and even prevent yourself from having knee pain. 

RESEARCH

Alnahdi, A. H., Alderaa, A. A., Aldali, A. Z., & Alsobayel, H. (2015). Reference values for the Y Balance Test and the lower extremity functional scale in young healthy adults. Journal of physical therapy science, 27(12), 3917–3921. https://doi.org/10.1589/jpts.27.3917

Disclaimer

As always, exercises are to be performed assuming your own risk and should not be done if you feel you are at risk for injury. See a medical professional if you have concerns before starting new exercises.

Written and Produced by Jason Hooper (PT, DPT, OCS, SCS, CAFS) and Emile Modesitt

IG: @hoopersbetaofficial