Less is More: Returning from Injury (Runner’s knee)

I love America, but we do everything here to the extreme.

We’ve always been taught more is better, but, when it comes to training – less is more and better is better.

Every year, I get referred athletes in pain or have to consult with injured athletes trying to get back on the field. If I wasn’t having to do this so frequently, I wouldn’t feel the need to write this.

Background: Track and field athlete

• Program was incredibly high volume (up to 70+ miles a week!)
• Little recovery (No off days)
• Minimal weight training (almost zero)

Practically the entire team is hurt, no surprise right…

Outcome: Runner’s Knee or Patello-femoral Pain Syndrome (PFPS syndrome)

• Told to keep running same program
• Pain worsened until it became intolerable.
• Sent to see PT and Trainer at school

PT’s and Trainers at school see “knee pain” and say it’s due to tight IT bands. Certainly it’s not the running 70 miles a week with no off days. “Roll IT band and we’ll do Cupping, Ultrasound, Stim.”

Lol. Awesome, we’re back in the 90’s.

Step 1: STOP RUNNING (aka eliminate the irritant)

This might seem like common sense, that’s because it is. But seriously, people miss this. You need to eliminate the stressor initially and break the pain cycle. That doesn’t mean you don’t train, because if you want it to heal quickly – you must train (intelligently).

BUT, you need to get away from the activity that is producing pain first. The trainers did some cupping, had her roll the IT band, and back out on the track…

And right back to pain and being unable to continue after a few minutes of running.

Is the act of running the issue per se? No. It’s the load or the total volume of running that is the problem. In her case this was an overuse injury. The body’s ability to tolerate this stress was exceeded.

We can argue about why it happened – inefficient mechanics, lack of overall hip strength, poor knee stability, all fine and good. It doesn’t change the fact that whatever you were doing, clearly wasn’t working. So it’s time to start over.

I’m a firm believer that we truly can’t predict and prevent injuries (the research currently supports this ). There are just too many variables at play, I prefer just focusing on the things we can control – proper training, nutrition, and smart load management.

We know there is some correlation between “knee pain or PFPS” and strength of hip musculature, or poor control of dynamic knee valgus, lack of strength in the extensor muscles (quadriceps), and so on…

We can list all of the “risk factors,” but a solid training program should check all of these boxes regardless.

Step 2: TRAIN and MOVE

              Your body, or how you move, is your instant feedback into what’s happening. Pay attention to this. Remove the fear and anxiety attached to movements – this is huge when it comes to dealing with pain. A little bit of discomfort is ok, a ton of pain is not. Be smart.

In this case, a runner can still develop the proper energy system of their sport/event through other non-painful means.

• You can bike, use the pool, perform medball workouts, or various circuits. All of these can help you develop and maintain your fitness.

What we did and you can still do during this time:

Bike workouts:

• Tempo intervals (aerobic development)
• Acceleration (alactic-anaerobic), higher resistance, shorter bouts of work, 6-10 seconds
• Speed (lactic-anaerobic), higher seat height, low resistance, up to 30 seconds of work

*We also used continuous circuits (blend of lower/upper/ab workouts) for anaerobic training and circuits with recovery for more aerobic training.

Strength/Movement Training

• Thorough, Purposeful, Active/Dynamic warm-up (to reintroduce pain-free movement and improve dynamic flexibility)
• Walking power-speed drills to maintain form – eventually progressing to low intensive drills
• Upper-body training (use this time to get your upper body strong)
• Lower-Body training with proper progressions

Movement is important and can be restorative. This particular athlete needed strengthening of hip musculature and just overall strength. The training is general in nature, the exercises you choose to use aren’t all that important. Find pain-free (within reason) strengthening exercises and progress them.

• Isometric quadriceps exercises, TKE’s, Hip/glute strengthening (side-lying abduction, isometric band holds, bridges, etc.), single leg stability.

• Eccentric leg press, Isometric and Iso-dynamic Peterson step-ups, re-groove squat/hinge patterns, general hamstring development (train it as hip extensor AND knee flexor).

We went – bodyweight squat (ecc/iso) -àgoblet squat-àbox squat-àbarbell squat.

• Continue to progress strengthening exercises. Begin to teach/reinforce proper jumping and landing mechanics.

• Re-introduce running while controlling total volume. DO NOT resume right where you left off. We used tempo runs (Charlie Francis), to control the volume, beginning with 20-30 seconds “on” at 65-70% effort with ab work in between as “recovery.” Eventually we progressed this to 3,500m total volume with no pain.

She was one of 3 left who was healthy enough to run in the first meet (no shocker). She ran her best race of the year after doing significantly less total running for the week and not even being sure if she could compete this weekend.

Take home points:

• Devil is in the dose (control the amount of total work you are doing, you aren’t the terminator)
• Stop doing what hurts
• Maintain fitness through non-painful means
• Train intelligently
• Progress slowly and don’t be afraid to regress if your body tells you to
• Train to feel good, not to feel dead
• Less is more