To keep things focused and direct, the knee pain that is commonly felt just above the knee cap and or throughout the patella tendon is caused from a few specific muscle imbalances; some muscles being strong, others weak, some may be strong but not active at the right time and others overactive. This then leads to inadequate R.O.M. (range of motion) of a few key joints of the body (hips, ankles) and excessive stress on the knee itself, particularly the patella tendon.

The goal is to inhibit overactive tissues, lengthen the appropriate one’s, strengthen your overall stability and then reintroduce the area to sound movement patterns, showing no compensations. This thought process needs to be with every workout that you do, even when the knee pain has subsided. If its not, the pain and knee issue will return. In others words, even when the injury is no longer present by following the guidelines below, you will need to include the proper warmup & movement prep before each workout. Sometimes your warm up can be quicker and simpler than others but if you find yourself sitting down for a significant amount of time and the body has become stagnant, then your time spent foam rolling, stretching, activating, along with movement prep just increased 2 fold.

Remember, the body is very susceptible to losing its flexibility, creating muscle imbalances and falling back into bad habits, if your training program does not include the proper warm ups, cool downs & maintenance program to specifically address your current or past issues.  By following the guidelines below, you will be able to increase the intensity and demands of the workout as you move forward and minimize the chances of re injury.

Step 1: Foam Rolling

Foam roll to inhibit over active tissues, lengthen specific muscle fibers, increase blood flow to the area and reduce tension on the tendons insertion and origin points (basically where the muscle meets the tendon and tendon meets the bone). Imagine a large rubber band that has several large knots in it, its length will be reduced and the elasticity of that band will be severely compromised. Now undo those knots (foam rolling & massaging out the tender areas of your muscles), you will begin to bring back the full length of the band (body tissues) and begin to re-establish the necessary elasticity. But you're not done yet! In order to fully restore the length and elasticity of the muscle fibers, you have to now further lengthen them with proper stretching, then activate them, strengthen and integrate full functional movement patterns. There is a process to this and each step works off of the previous one. 

Articles to read - How to Foam Roll & Why, About Foam Rolling, Rest & Recovery

* The primary area to focus on when foam rolling is your Quadricep (thigh muscle). There are 4 major muscles of the Quad, all tying into the Patella Tendon, which is where your problem lies and time must be spent on each one of these. You may find your most tender points are the mid & lower quad. Be sure never to roll directly on your patella bone but do get close to the area. Remember to pause on a tender spot for 30-60+ seconds and also roll the full length of it slowly many times over until some, if not all of the tenderness has subsided. The secondary areas to address are your Gluteals (butt muscle & piriformis), Adductors, IT-Band, Calves, Short Head of Bicep Femoris (lateral aspect of lower hamstring) and Lats. Each of these muscles or muscle groups have an influence on the knee and determine overall with all other body structures and movement patterns whether you walk, run, squat, push, pull, lunge, reach or throw in an efficient manor or injury prone way. This is why you have to address your movement patterns and look for signs of imbalances and or weaknesses.

Step 2: Stretching

Once you have worked out much of the tenderness of the muscle tissues with foam rolling, you now must take advantage of this and further lengthen the muscle with Stretching. There are several ways of stretching but we will focus on 2; Static & Active Stretching.

  • Static Stretching is when you take a muscle and joint to its end range of motion and hold for a minimum of 30 seconds on up to a few minutes.

  • Active Stretching is when you actively take a muscle & joint to its end range of motion, hold for 3 seconds, return back to a resting length and then repeat several times over.

Areas to target are your, Lats, Hip Flexors, Quadriceps, Adductors, Hips & Glutes, Calves and then Hamstrings; in this order. Remember, every muscle influences another and the quality of its joint mechanics. Example, if your shoulder ROM is poor and is caused from a shortened Latissimus Dorsi (the long wing like muscle of your back, running from your shoulder to hip), this can cause a lower postural distortion leading to poor mechanics of the pelvic area since the Latissimus originates on the Iliac Crest of the Hip Bone and inserts on the Lesser Tuberosity of the the Humerus (upper arm bone). So again, you must look at everything and not just focus on the knee!

  1. Latissimus Dorsi Static Stretch with Stability Ball - Using a Stability Ball or something head height from a kneeling position, place 1 arm fully extended in front with hand on the center of the ball and thumb up. Sit the hips back and place the other hand on the floor for support. Drop through the shoulders, keeping the arm straight and not arching the low back. Hold for 30-60+ sec. ea. side.
  2. Kneeling Hip Flexor Static Stretch - Place 1 knee on the ground with the other foot out in front and inline with your hips. Keep your chest tall & back straight. On the side that the knee is down, engage the glute. Shift your weight & hips forward while keeping the spine tall. Hold for 30-60+ seconds, complete 1-3 times.
  3. Side Lying Quadricep Active Stretch - (video) vimeo.com/48707459 - 1x10 reps ea. leg, 3 second pauses.
  4. Standing Adductor Active Stretch - From a standing position similar to a lateral lunge. Place both feet outside the hips & as wide as your flexibility will allow. Sit the hips back, place both hands on each knee, slowly squat to 1 side, keeping the opposite leg completely straight. The focus is on keeping the spine neutral (no rounding forward), hips back & squatting to a 90º depth. Hold each stretch for 3 seconds. 1x10 reps ea. leg, 3 second pauses.
  5. 90/90 Floor Hip Static Stretch - From the floor, place front leg in a 90º angle directly out in front of you with the knee flat on the ground. Do the same with the other leg behind you. Place hands on the floor on each side in front leg. Slowly bring your chest towards your knee, keeping your shouldrs squared to the mat. Don't drop to the elbow unless both can be on the floor equally. Hold for 30-60+ seconds, complete 1-3 times.
  6. Standing Calve Active Stretch - Having proper mobility in your ankle joint is essential. - Place both hands against a wall, feet placed in a lunge position distance apart, with front foot 1+ feet from the wall. Gently lean into the stretch while keeping the back leg straight & heel on the ground, keeping the foot neutral. Relax into the stretch, you should feel the stretch slowly increase & then decrease. Hold each stretch for 2-3 seconds & repeat. 1x10 reps ea. leg, 3 second pauses.
  7. Floor Hamstring Static Stretch - Lie supine on the floor. Place a rope or similar around the bottom of your mid foot. Keep your head & shoulders relaxed on the ground. The opposite leg is bent at the knee to start with, as flexibility improves straighten that leg so its fully extended on the floor. Walk the leg up hand over hand using the rope while keeping leg straight. Start with holding for 30 seconds and work your way up to 60+ relaxed seconds at the end range of motion. Be sure the hips do not come off the ground and don't force it.  Hold for 30-60+ seconds, complete 1-3 times ea. leg.

Step 3: Strengthen & Activate

Once the muscles are at their proper Length Tension Relationship or close to it, its now time to strengthen specific areas, correctly activate & educate others and then take them through a full range of motion against resistance. The goal is to recondition movement patterns by isolating some of the weaker or inhibited areas.

  1. Floor 2 Leg Glute Bridges - (video) https://vimeo.com/34759630. Be sure to feel the full range of motion driven from the gluteals (butt muscles) and not the hamstrings, this is essential!  Pause for 1-2 seconds at the top range of motion for each rep. 3-5 sets of 10-20 reps, 1-3 min rest interval (Ri).
  2. Single Leg Glute Bridges - (video) https://vimeo.com/34756311. Once you establish good strength with the above 2 Leg Glute Bridge, progress to this movement but when doing so be sure to always do at least 1 - 2 sets of the Floor 2 Legged Bridge before. This will allow you to properly warm up into the more challenging movement. Be sure to feel the full range of motion driven from the gluteals (butt muscles) and not the hamstrings, this is essential!  Pause for 1-2 seconds at the top range of motion for each rep.
  3. Mini Band Side to Side Shuffles or Hip Walks - Video, Side to Side Shuffles. Video, Mini Band Hip Walks. You can purchase mini-bands by clicking here, buy 2 yellow, 1 green & 1 blue. 2-4 sets of 15-20 reps, 1-3 min Ri.  If you don't have access to Mini-bands or until your purchase them, you can perform these 2 movements  in place of the exercises, (1) Side Lying Adduction Raises, Inner Thigh (2) Side Lying Abduction Raises, Outer Thigh.
  4. Core Planks - (video) https://vimeo.com/9337614. Have fun with these and vary the exercises up that you see in the video. Be sure that your abdominal region feels the most fatigue and not your lower back. You can do most of these movements from the elbows or with straight arms. Be sure to keep the head, neck and spine neutral. 2-4 sets of 30 to several minutes, Ri 1-3 min.
  5. Wall Facing Squats - Only do these if no pain is felt in the knee or pain decreases with each rep. This will teach you how to squat properly. Facing a wall, stand with toes 0 - 6 inches away from the wall and perform a bodyweight squat with your hands reaching towards the ground between your knees. As your mobility and strength improves, move your feet as close to the wall as you can. The focus is to keep your spine neutral, hips back and not touch the wall or round your back. Keep your head and neck neutral with eyes straight forward, be sure not to look to the side or up. Watch for the knees don't move inward or out, keep good alignment and absolutely no compensations. The goal is to get parallel to the ground. 2-4 sets of 10-20 reps, 1-3 min. Ri.
  6. Single Leg 1 or 2 Arm Reaches - (video) https://vimeo.com/8768740. The goal here is to stabilize the knee and strengthen the hips. You will feel this from the foot on up through the core. Be sure the knee does not collapse inward or out and only bend it to 120º max. Primary target to fatigue is the gluteals, secondary would be the hamstrings & foot and ankle complex. As with all the exercises listed, be sure to draw inward your navel (belly button) to stabilize the core, which will allow proper engagement of the muscles specific to each movement. 2-4 sets of 10-20 reps of ea. leg, 1-3 min Ri.
  7. Prone Opposite Arm / Leg Extensions - (video) https://vimeo.com/48631247. 2-4 sets of 10-20 reps ea. side, 1-3 min. Ri.

There are several other movements & exercises that you can do in addition to the one's listed here but these are essential to begin with. Take your time learning them and be sure to practice each movement. Once the pain has subsided completely you will need to begin working on fully body integration movements, see Step 4. 

Step 4: Integration with Compound Movements (multi-joint).

Now its time to make the body work together. The focus is for your muscular, nervous & skeletal system to efficiently work together to effectively move against any given resistance or demand. This can be done with Olympic Lifts, Kettlebell Movements or exercises such as the Squat to Dumbbell Shoulder Press. We will focus on 2 movements in particular here, the Squat to Press & Kettlebell Swing.

  1. Squat to Press - (video) https://vimeo.com/9046293. Form is vital, make sure its perfect. Reps are kept lower here and the focus is on strength. If you have any shoulder issues be sure to condition them with Shoulder External Rotations, Ball Combo One Y's, T's & Cobras, and Standing Back Dumbbell Rows. Be sure to stretch your chest & lats as well. 2-4 sets of 6-12 reps, 3 min. Ri.
  2. Kettlebell Swing - (video) https://vimeo.com/13519420. There are a lot of KB movements out there but we are going to keep it focused and true to what kettlebells are about. The driving force here are your hips, while pivoting from your hips and keeping the entire spine neutral from beginning to end. Weight and Intensity is the goal of the movement. The heavier the better, however, you must perfect the movement before proceeding to higher intensities. 2-6 sets of 6-20 reps, 1-3 min. Ri.

Bringing it all together:

You must follow the order listed above, beginning with Step 1 and moving along to Step 4. Complete Step 1-4 every other day or every 3rd day. You can and will need to do Step 1 & 2 every day or as often as possible. Consistency will be the determining factor as to whether or not you fully eliminate your knee issue. The workout and protocol above will also help build a solid foundation to build upon and will help eliminate any other lower body postural issues, injuries or pain.

Whenever you go for a run or trek be sure to do as much of step 1, 2, 3 as you can. Minimally you will need to perform Gluteal Bridges, a few mini-band walks and some Standing Marching Drills or 100ups Minor. Another good way to get the body prepared quickly and warmed up thoroughly once your feeling better is to complete the Medicine Ball Chop & Reach Circuit before a workout, run, etc.