Knees

The torrid, record-setting summer was finally drawing to a close. The air was much less humid and the sun more merciful. The gym was less of a hot box because a steady breeze found its way in the windows, so training was more enjoyable. I had finished my workout and was sitting in my car with Jason, sucking down a cold Miller and listening to the music coming from the bandstand in the park directly behind us. The band was quite large and they were belting out a series of John Philip Sousa standards.

A gust of cooling air rushed in the car windows, causing Jason to lean back in his seat and mutter, “Aaaah, that feels sooo good. I’m so glad fall is almost here. I hate training in the summer.”

“Me too,” I agreed, watching an older couple unload lawn chairs from their car, then hurry across the street to the park. Jim came out the gym door, looked around, and we waved at him. After putting his gym bag into his pickup truck, he joined us. I noticed he limped slightly, so when he climbed into the back seat, I asked, “Something wrong with your leg?”

“It’s not my leg,” he grumbled, “It’s my knee.” Jim weighed 215, so he squirmed around a bit to find a comfortable position, then opened a can of beer.

“How did you hurt it?” asked Jason without looking back.

Jim sighed, then exulted, “It’s my own stupidity. I try to make my running shoes last a month longer than I should. The heels wear down on the outside, but the rest of the shoe is in perfect shape. I keep running in them and I also squat in them and invariably I get trouble in my right knee. Never in my left one. Weird, isn’t it?”

“I think everyone favors one side over the other. Notice how some lifters always have trouble with one shoulder and not with the other? I pull the same stupid stunt with my running shoes. I try to make them last just a little while longer, and I always end up paying the price for being cheap.”

“Well, I’m going to the mall from here. I don’t want it to get worse, because my squat is just starting to move again,” he provided, rubbing his offended knee.

“Stop and get some ice. That worked wonders for me,” I suggested.

“I plan to,” he replied sullenly, then added, “You know, there are so many ways we can irritate the knee that it’s really a wonder we don’t have more problems than we do.”

“You’re right,” I said, nodding. “The knee joint is really an amazing piece of work. It is the largest and most complex joint in the body. Every step we take involves an intricate interplay of bones, muscles, ligaments and tendons. Just think of all the stress we put on our knees when we squat heavy, or do a lot of jumping playing games like basketball or volleyball, or the lateral stress we put on them playing racquetball or tennis. The knee is extremely strong. It is made up of two large bones, the femur from above and the tibia from below. In addition, three major muscle groups – gastrocnemius, hamstrings and the quadriceps – attach above and below it, and it is literally surrounded by a host of very durable ligaments and tendons.”

Jason ventured, “I guess I’ve been sort of lucky. The only time I ever had any knee trouble was when I fell off my bike and twisted my leg real bad. The doctor said I had a slight pull in the medial collateral ligament. It hurt when I walked or tried to run or jump, but I was still able to squat light. I wrapped it when I trained and that helped too.”

“Worst problem I ever had with my knees was the time I played two hours of basketball right after my heavy squat day.. I knew it was too much but our team kept winning and they didn’t want me to quit. I got my bursa sac right under the knee cap irritated and it gave me a fit.”

“Did you have to stop squatting?”

“No, I never did. It didn’t bother me after I got warmed up, but it ached like a toothache at night. I lived on aspirin for about a month. What does the bursa do?”

“Bursae are located at sites of moving tissue, and they help permit friction-free action and also diminish inflammation. To once again point out how complicated the knee joint is, there are eleven bursae in various parts of the knee.”

Jason asked, “Why is it so many guys in the gym constantly complain of having some sort of knee trouble, but none of us really has any problems, except when we do something stupid?”

“The most important thing that we do and they don’t is squat correctly. From the very beginning you learned proper form, and that’s saved you a great deal of grief. When you squat correctly, and systematically, you strengthen the knee joint, but when a lifter uses faulty form, he’s running the risk of injuring the knee.”

“I don’t know why some of those jerks just don’t do what they see us do. I’ve tried to explain to some of them that when you go below parallel in the squat, you’re actually putting less stress on the knee than you do when you stop right at parallel, but they just ignore me. That’s what you taught us and none of us has any real problems. I am telling them right, ain’t I?”

“Absolutely right,” I returned. “Once the top of the thighs goes below the parallel position, the stress is transferred to the larger muscle groups – the leg biceps, glutes and the powerful hips – but when a lifter stops above parallel or at parallel, most of the stress is conveyed to the knee joint. So many beginners will do half or partial squats to avoid irritating their knees and in the process do much more harm than if they did full squats correctly. The only precaution in full squats is not to bounce at the bottom. This can be potentially dangerous, especially if the legs are tired. Another problem, which is often overlooked, is allowing the knees to turn inward during the movement. I’ve seen lifters wrap their knees until they looked like mummies, then let their knees turn in, and, sure enough, they were soon complaining of knee trouble.”

“There’s a guy who comes in on Thursdays, when you’re not here. He lets his legs turn out. I’ve told him he’s asking for trouble, but he ignores me,” Jim said bitterly.

“About the only thing you can do with that type of person is wait until he does hurt himself. Then maybe he’ll listen to sensible advice,” I suggested.

“Why do some lifters’ legs turn in or out like that?”

“It’s an indication that the muscles that control abduction and adduction in the leg are relatively weak.”

“Try that again, in simple English?” asked Jim with a laugh.

“Alright. The act of bringing you legs together is called adduction and the main muscles that do this run from your hip down over your knee – the vastus lateralis. When you pull your legs apart, this abduction and the major muscles that perform this task are the vastus medialis, which also run from the hip to the knee. It is quite important to keep these muscles strong, for they play a major role in protecting the knee joint.”

“Those machines are good for that, aren’t they?”

“Excellent. The abductors and adductors are rather difficult to overload with free weights. I can get some results with very wide-stance squats, but the machines are so much more effective because they can isolate these groups. I had about a dozen of my football players at school with this problem of their knees turning in when they squatted. A few benefited from wide-stance squats, but not many. Then we got an adductor machine and after only a few sessions on it, their knees stabilized and their squats improved tremendously.”

“What really happens when the legs move like that?”

“The knee is forced to move around when it should be stable. The side-to-side movement puts an undue stress on those ligaments on either side of the joint, the lateral collateral ligament and the medial collateral ligament, and over time they will be traumatized – and hurt like hell!”

“That’s the one I dinged when I fell off my bike,” interjected Jason, “and I can sure vouch for the pain part.”

Jim said, “My boy is wanting to play football this year and I’ve been having him squat. Light and plenty of reps. His form is good, better than mine in fact. What else could I have him do to make his knees stronger? I know that if he takes a direct hit, he may get hurt anyway, regardless of his leg strength, but I’d like to keep the odds in his favor.”

“There’s no doubt in my mind that a lot of major knee injuries have been prevented because the joint was extra strong. True, there are situations where he will not be able to avoid injury, but if the knees are strong, the injury will be less severe and he will come back much faster during therapy.”

“I said earlier that the knee joint was extremely complex, involving a great number of ligaments, tendons, bursae, bones and muscles, but some trainers overlook this very simple fact. There are twelve different muscles acting on the knee, but some trainers are content to work the front of the thigh with some partial squats or leg presses, throw in a couple of sets of leg extensions, and assume that this is enough.

“Not only do all the muscles have to be strengthened, but they also have to be strengthened proportionately. If, for example, you only do partial squats and get your quadriceps 400 lbs. strong, but have neglected your hamstrings and they remain 100 lbs. strong, then you’re asking for trouble. Here is yet another reason I advocate full squats. When they are done correctly, they involve all of the muscles that house the knee. Even the calves get involved during full squats.”

“I’ll second that,” blurted Jason. “Two or three weeks ago, I pushed my triple up to more than I’ve done in a year. Two days later I could hardly walk around the house because my calves were so sore. I had never realized they were part of the movement before – I guess because I never pushed them like that before.”

“The calves are extremely important because they, along with the leg biceps, help support the back of the knee. To get back to your question, Jim, I’d have your boy do lots of things to strengthen his knee. Squatting you mentioned, which is the core exercise. Add in leg extensions, leg biceps curls, calf raises, and, if there is an adductor-abductor machine available, by all means have him use it. Keep the reps rather high on all the auxiliary exercises, two or three sets of 20-30 on the calf raises. Plus, I would add in one or two specific exercises for the leg biceps, because it’s very easy for the quads to get considerably stronger than the leg biceps. Good mornings or stiff legged deadlifts will do the trick.”

“And lots of variety?”

“Sure, it should be fun for him. I’d even vary his foot stance on his squats, at least one day a week. By going a bit wider, he will involve different muscles. The same thing applies if he takes a narrow stance.”

“Sounds good,” Jim offered, then said, “Let me out. I want to go buy some shoes. Thanks for the brew.”

We watched him go to his pickup, listening to the brass echo off the building in front of us. Jim waved and drove down the street. Jason opened another beer, asking, “Why is it so many guys seem to get knee trouble right after they come back from a layoff?”

“They come back too fast,” I responded, trying to identify the song the band was playing. I’m not very good at recognizing big band music, but I did know some of Sousa’s stuff. “The same thing is often true for a lifter coming back from a slight injury, or a bodybuilder or competitive lifter cycling for a contest. They move too fast, leaving some muscle groups behind. There are so many muscled involved in the knee that it’s easy to forget one or two, but those one or two omissions will result in an injury. The basic concept of “make haste slowly” really applies when the knee is involved. This is why I advocate squatting three times a week rather than two. The gains will come a bit slower, especially at first, but this is a plus, not a negative. The additional work will build a firmer base and ensure that some of the smaller muscles are getting stronger at the same pace as the larger ones. It’s the rapid increases that get lifters in trouble, going from a triple with 325 to 350, instead of taking a moderate ten-pound increase. When you’re on the move, it’s very difficult not to take all you can get. It’s simply the nature of the animal.”

“But you’re not talking about going heavy every workout, are you?” You mean going heavy, light, and medium for three times a week.”

“That’s right. One of the reasons that people start using steroids or lifters who put on a great deal of bodyweight rapidly get sore knees is that they take the gains much slower than the muscles. In other words, the joints adapt to strength gains much slower than the muscles. In other words, for whatever reason, you may be able to elevate your squat 40-50 lbs. in a couple of weeks, but your knees cannot adjust to this rapid a gain and will lag behind. Too many trainees do not go through a preparatory stage where they adequately condition all the parts of their body to get ready for the more severe overloading stage.

“Lately the trend has been to squat heavy, then take as much time as necessary to rest completely before squatting again. This may be four or five days. At the net session the lifter may be able to handle more weight than he did previously, but unless he’s taken the time to strengthen all the muscles that protect the knee joint in between, he is actually raising the risk of damaging his knees even more. So while it may seem paradoxical to suggest that you’re making you knee joint stronger by squatting more often, rather than less, it is true.”

“I always do my best when I squat three days a week, but I have to make sure one is a heavy day. What about those guys who put blocks under their heels? It looks to me like this is putting more stress on the knee joint.”

“You’re right – it is. But for some trainees, the block is necessary until they gain the flexibility in the back of their ankles which will allow them to go low enough and also to assume the correct position. After a few months the squatting movement itself helps them to go lower, and I encourage them to get rid of the block. Since most have only been using relatively light weights in the beginning stage, they don’t have any problems.”

“Wraps? What’s your opinion about them?”

“I don’t encourage their use, unless the lifter has a history of knee trouble or has had surgery. A lifter has to realize that the wraps, while supporting the knee, also do what the tendons and ligaments of that joint normally do. If they are used constantly, the muscles will grow proportionately stronger than the attachments and sooner or later there will be problems, wraps or no wraps.”

“But anyone entering powerlifting competition has to use them.”

“That’s right, he does, for they can add many pounds to his lift, but, again, I encourage lifters not to use them all the time – only on heavy days and even then only on the top end sets, not on the warmups and the back-off sets. I encourage that they keep the knee as strong as, or stronger than the large muscles of the leg.”

We sat listening to the music for a time. Then he asked, “What’s the name of that piece?”

I laughed, “The only march I know is ‘The Stars and Stripes Forever’, and they haven’t played that yet.”

“I once read that Sousa used to have two bands, each playing different music, start marching at opposite ends of the street and come together so he could hear what it sounded like when they converged. Sounds like something you’d do,” he added with a laugh. “I know all this stuff you said is right and useful, but still, if a person trains for any length of time and trains heavy occasionally, he’s going to get some sort of knee trouble – little aches and pains, if nothing else. Of he might just do something stupid like what you and Jim did. Besides, any athlete in a contact sport always runs a higher risk. So what’s your advice when someone gets a ding?”

“This is assuming that the injury isn’t serious enough to go to a doctor?” He nodded, so I went on, “Then I would recommend the standard RICE therapy: Rest, Ice, Compression, and Elevation. Ice is invaluable, so use it as many times a day as possible. When you’re not icing, keep the knee wrapped, and, if you can, elevate it. If the injury allows you to train on it, be sure to spend some time warming up the knee joint. A good warm-up is a couple of sets of high rep, twenties, leg extensions. Then apply some muscle rub and wrap it. You want to make sure the joint is always warm during exercise. Then ice it as soon as your finish the workout.

“Also be very careful when you perform any exercise that pouts the knee in a position where it might move laterally. Sometimes a movement like the bentover row will irritate the injured knee more than squats themselves. Even seemingly harmless movements such as inclines or EZ-curls can put stress on the injury if the lifter twists the bad leg. Avoid any jamming motions – no power cleans or power snatches – and stay away from playing basketball, volleyball or racquetball. The controlled up-and-down movement of the squat is the best rehab exercise. If you are not able to go low in the squat because of the injury, utilize the power rack. Set the pins at a position high enough so the movement does not irritate the injury. Slowly squat down to the pins and allow the bar to rest on them. Bring the bar up deliberately – no herky-jerky motions. Keep the reps high, 12’s to 20’s, for two to three sets. Once you get stronger in this pin position, lower the pins and start from square one.”

“I used that a few years back and it worked.” He opened the car door and climbed out, saying, “See you tomorrow. Listen!” he shouted. “That’s ‘The Stars and Stripes Forever’!”

I laughed and drove off, humming along with the music.