Preventing knee pain and injury

Most of you reading this would have at some stage experienced a training or sport related knee injury, if not you certainly would know someone who has. Unfortunately training and sport related knee injuries are far too common. As a personal trainer having contact with close to 100 clients each week I regularly encounter complaints about knee injuries sometimes of an unknown origin, or otherwise due to an obvious and very painful trauma. Every active person is aware of, and would like to avoid the feared 'pop' of an anterior cruciate ligament (ACL) tear.

This issue was made very relevant to me during a wrestling match in November 2008 when I ruptured my ACL which required surgery and a lengthy 9 month recovery. leading up to my injury I had maintained a consistent strength and conditioning program. Looking back I can see that my training was not optimal for reducing the chances of a knee injury occurring and I often wonder if it could have been avoided had I been more understanding of the importance of injury prevention training. As a result of my own experience I am very passionate about preventing knee injuries where possible.
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Training specifically for the goal of preventing an injury is referred to as prehabilitation. Most sporting teams and athletes, not limited to only the elite or professional level, include prehabilitation routines in their training programs to avoid common injuries. Prehabilitation to prevent knee injuries rank highly among these. Their is no guarantee that prehabilitation will definitely prevent an injury, however it can maximise the chances of an injury being avoided. Key areas to focus on are outlined below.

Improve Strength of Muscles that Stabilise & Support the Knee
Supporting the knee joint with strong surrounding muscles is the  best insurance against a knee injury. Strengthening exercises should focus on the quadriceps, hamstrings and calfs. Correcting muscular imbalances between the muscles that support the knee is equally important. This includes maintaining an appropriate strength balance between the hamstrings (which often become dominant) and the quadriceps and ensuring the strength of the medial and lateral muscles of the quadriceps are balanced appropriately to allow correct tracking of the knee cap. A weak vastus medialis oblique (VMO) and dominant lateral quadriceps can result in mal tracking of the knee cap, pain and injury.

Improve Strength of Muscles that Stabilise & Support the Hip
Strengthening exercises to stabilise and maintain alignment of the hips are also important to prevent knee injury. These strengthening exercises should focus on the gluteus maximus and medius and the tensor fascia latae (TFL). Increasing the strength of hip stability muscles helps to give better control over the leg in dynamic situations. Special attention should be given to hip alignment during the strengthening of these muscle groups to maximise activation and strength development.

Improve flexibility of Muscles that Stabilise & Support the Hip & Knee
It is important that the muscles supporting the hip and knee are flexible to avoid mal tracking of the knee cap, maintain correct alignment of the hips and knees and improve biomechanics during dynamic situations. Flexibility is of particular importance for the quadriceps, hamstrings, calfs, glutes, adductors, TFL and ITB. Flexibility can be improved in these muscle groups using self massage, myofascial release, deep tissue massage and stretching. There is evidence to suggest that static stretching may increase plasticity in the muscle which reduces its ability to produce force.

Improve Proprioception at the Hip, Knee & Ankle
Proprioception is the ability to sense the position, location, orientation and movement of the body and its parts. Increasing proprioception at the hip, knee and ankle joints can help to reduce injury by helping to recognise when adjustments are required to maintain balance and more importantly when adjustments are required to avoid injury in potentially dangerous situations. This includes positioning of ankles, knees and hips on landing from stepping or jumping and positioning when moving laterally.

Improve Core Strength & Stability
Core strength and stability is important for maintaining correct posture, positioning and alignment at the hips in both static and dynamic situations. Improving core strength and stability involves strengthening the muscles of the back, abdominal and glutes.

Improve Foot Speed, Coordination and Skills
Foot speed, coordination and skill development can help to reduce the incidence of a knee injury by improving the speed and control of a response to a potentially dangerous situation. Training and improving these components relies on skill training which is in most cases specific to the sport or activity. Specific skills to reduce knee pain and injury during running and other dynamic activities  include; reducing pronation at the ankle, keeping the knees bent and not to straighten, reducing rotation at the knee, not landing ahead of the body and to land on the mid foot or ball of the foot not the heel. Each sport may introduce its own additional skills requirements.

I regularly incorporate these aspects of knee injury prevention in my clients training programs. This is particularly the case for clients that participate in sports or activities that put the knee at risk. As previously mentioned, there is no guarantee that prehabilitation will 100% prevent knee injury, a direct hit to the knee at the wrong angle will cause injury even to the most well conditioned athlete. Despite this, it appears to be a smart option to spend the time developing these various protective fitness components to reduce the chances of knee injury occurring. I believe that I may have been able to prevent my own knee injury had I have been more diligent with this training in the past.