Knee pain is one of the most common injuries affecting people of all ages. It can cut down many young sporting athletes suffering with patella-femoral problems and more severe ACL injuries and it can greatly affect adults and people with a more sedentary lifestyle. If the cause of the problem is left unchecked it will develop into a much bigger problem and eventually begin to create injuries at other joints of the body. According to latest research, frequent knee pain affects 25% of adults, and osteoarthritis is the most common cause of knee pain in adults 50 years and older. Rates of knee replacements have tripled in women in the United Kingdom and have increased 8 times in the United States among those 65 years and older. In the early stages of treatment people are often told they have a weak vastus medialis muscle (VMO) that needs to be strengthened and it will make their pain go away. Unfortunately, it is not as simple as that as there are many factors you need to consider with correcting knee pain. While it is true that the VMO plays a massive role in stabilizing the knee, the methods you use to strengthen this muscle is the secret to finding the solution to your knee pain. In this article I explain the 5 steps you need to follow to get this right.

 You Must Find The Cause Of Your VMO Weakness

This is the MOST IMPORTANT thing you must attempt to find out before you implement any corrective program. If your knee pain is not from a collision injury or a traumatic event like a car accident and evolved over time then you can safely assume you have muscle imbalance and a movement dysfunction.  

The big question that needs to be answered is, are you moving poorly because you are in pain? Or, are you in pain because you are moving poorly? 

Trying to remove the pain and not addressing this question will only lead to more problems and a lifetime of treating symptoms. But this is exactly the current model of the modern health approach to knee pain. We are trained to think that pain is bad and it must be removed and once it is gone everything is okay. But with these injuries that develop over time the problem was there long before you had any pain signals! Take for example patella tracking knee pain or ITB Friction Syndrome, both of these are caused from poor alignment of the leg and muscles working either too hard, vastus lateralis and ITB, or too little VMO (vastus medialis) you end up having a problem with your knee.

You cannot treat these problems with anti inflammatory tablets, using knee braces or taping and definitely not with surgery! Even focusing all your efforts on strength training on the area around the knee is a waste of time! Why? Because you have not established why these muscles are either working too hard or not enough and causing you to have poor alignment in the first place. You must find the answer to this question in order to really solve the problem. These muscles did not just stop doing their work for the fun of it. There is a reason behind this, if you find out what it is and correct it, your problems will be gone forever!

Often the two biggest causes of VMO weakness and knee pain is linked to restricted mobility with the HIPS and the ANKLE. If you have poor movement in combination with this you are guaranteed for trouble. Let me explain why this is often the first things I look for when I see a new client with knee pain.

It is funny because these areas that rarely have pain so nobody bothers to look there. This also explains why most treatments fail people for they are treating the symptoms and not the cause. It is inevitable that problems will resurface if the cause is not addressed. I want you to take a good look at the picture below as this will give you great insight into how a knee problem is so easily caused by either the ankle or the hip.

Let me explain this picture.

This picture gives you a great image in learning what is known as the "Joint by Joint" approach which was invented by Mike Boyle. The leak in the pipe often starts with the feet that leads to compensation all the way up the chain through every joint. What you will see is that every second joint will need flexibility and mobility, while the other joints require the exact opposite being stability and strength.

Here is how it works. 

1. Feet - The feet have a tendency to being lazy, and easily losing strength and motor control. From poor footwear to sitting too much, and even the lack of barefoot walking, the feet need exercises to make them stronger and more stable.
2. Ankle - The ankle tends to develop stiffness very easily and needs more focus on mobility and flexibility.
3. Knee - The knee like the feet becomes weak and sloppy easily, (VMO for instance completely shuts down with as little as 10ml of fluid present). This, in turn, creates severe knee injuries and if left untreated eventually chronic stiffness in an attempt to stabilize it. Stability and strength work is needed for this joint.
4. Hip - This joint is often the cause of many problems. The hips have a tendency towards stiffness and as a result, benefit from flexibility and mobility work.
5. Lumbar Spine - The lumbar spine needs stability to prevent unwanted flexion or extension.

The most vulnerable of these joints is the knee and the lumbar spine as both these joints need stability but when they are forced to move into positions they cannot perform due to the joint below or above being restricted is when all the problems arise. 

The knee is caught in a crossfire and dependant on the ankle joint (below) and the hip joint (above) to perform their roles correctly to maintain perfect alignment. If any of these joints are unable to complete their role effectively it disrupts the optimal alignment of the patella in the knee and now you are set for trouble as it will be impossible for the patella to track correctly when the knee is fully flexed.

When you lower body into a squat position the knee cap engages into the trochlear groove (track) and is guided down the femur and as you straighten the knee when you begin to stand up the patella tracks back up the groove. This is what is known as patella tracking.

The inside of the joint is covered in articular cartilage designed to reduce the stress that occurs in the joint created by the quadriceps. However, if you lack the correct alignment of the patella in the trochlear groove you can end up with increased stress within the joint usually on the outside or lateral part of the knee as the larger more powerful quadriceps muscles begin to take over the work from the VMO. And eventually this stress becomes pain! This is where you see foam rolling on the outer part of the thigh, (ITB) to release this tension. This may help to some degree.

However, on its own it will do little for it isn't just tightness on the outside of the leg that can produce issues. Weakness and or timing issues of the medial stabilizers can also cause the knee cap to track incorrectly when you move. This is where many people are told to strengthen the VMO in the belief that isolating this muscle with strengthening exercises will automatically correct the problem. Once again though this will do very little if this is all you do.

Why?

Remember the knee is not really the problem. It is the joints above and below forcing it into faulty alignment to begin with. Okay, so what do you do about it?

To fully grasp this concept I suggest you read our articles below

• Why Poor Ankle Mobility Can Cause A Chain Reaction Of Injury
• How to complete a Knee Pain Assessment
• When You Have Knee Pain Rarely Is The Knee The Problem

Surgery & Medical Drugs Should Be A Last Resort

We have been taught in today’s modern world to treat symptoms.

What we must recognize is that unless your injury was due to a traumatic accident it is a POSTURE and MOVEMENT problem. It is pointless to just take away your pain without addressing the original cause. I have literally worked with hundreds of clients who at some stage were told, "never to squat" or "don't ever run" or "do resistance training on your legs", as it will ruin your knees and you will need a replacement. Only for these clients to apply the principles I am going to show you in this article, and within months be able to not only do all of the things they said they will never be able to do but also go back to playing netball, football or even 7-day hikes in the mountains!

We must become more educated about how to apply good principles of health using a proven formula of strength training, nutrition and lifestyle habits to prevent injury and also overcome chronic pain. To see pictures and videos of some of these incredible stories go to our Testimonials page.

Okay so now that you have a better understanding of what to look for let's take a look at how to correct or prevent this problem.

Step 1 - Assess Mobility & Release any Tight muscles

This must be your first step as tight muscles (Tonic) can disrupt the entire timing and firing of muscles within a movement that will produce weakness, instability and compensatory patterns that in turn, create more pain. The concept of loosening a tight muscle first is, that a tight muscle will cause a weaker nerve signal to be sent to its opposing muscle. Again your areas to look at the most are often the hips and ankle.

From a mechanical perspective, a tight muscle will limit the range of movement through which its opposite muscle can move. For instance, in the case of the gluteus maximus (your big butt muscle), a tight hip flexor muscle at the front of the hip mechanically will limit hip extension (backward leg movement) and neurologically will decrease the force of the nerve signal to the buttock. In other words, the tight muscle at the front of the hip will make the rear hip muscle less efficient and weak, which in turn will significantly affect the function of the kinetic chain, increasing strain on the lower leg.

I regularly use this method in sessions when we are working on movements like lunges which typically cause pain. Foam roller release and Quad stretching are crucial here. So many people make the mistake of using strength exercises first without weakening the dominating muscles. This leads to frustration later when the corrective exercises don't work even though they are the right exercise. Never skip this step!

For more information on this mobility read the articles below.

• How to identify mobility restrictions affecting how you move 
• How tight quadriceps weaken the knee

Step 2  - Tape The Knee

I don't always do this but for some people it can be useful. This is very simple to do and research has proven that it is extremely effective at increasing the nervous system firing of the weak VMO muscle on the inside of your knee.

Many people report that they instantly feel better when the tape is on, almost as if the muscle has been awoken and starts to do some work! To do it correctly make sure you put the tape on the outside of the leg and pull it inwards ensuring that you see a little skin fold crease as you do it. Having said that there is also plenty of literature proving that by just putting tape on the knee in some way will activate the Proprioception within the VMO significantly, even if it is done wrong! So the point you want to take out of this is to make sure you put tape on.

Below is a quick video on how to do this.

Step 3  - Improve Joint Stability

Often this step is ignored, but make no mistake you WILL NOT DEVELOP STRENGTH WITHOUT IT!

Stabilizers are so different to prime mover large muscles in that their job is to fire first and react within a split second to correct faulty alignments of joints and positions of the body. They are not strong enough to produce movement but they ensure the integrity of the movement is maintained so the big movers can do their job.

I like to start with simple brain exercises such as single leg standing exercises with eyes shut. Kneeling exercises and hip extensions can also be very useful as you can teach good hip mechanics that will be critical with standing movements. I like to focus heavily on the deadlift and the toe touch drill exercises in this stage working with body-weight only. Watch the videos below where you will understand why these two movements are so important.

The floor based exercises and mobility work will complement my approach to help the brain learn a more efficient way of moving that avoids putting pressure into the knee. More importantly it teaches the weaker muscles how to coordinate their workload to maintain joint alignment between the ankle, knee, and hip. 

Do not underestimate the importance of foot stability here and working barefoot will be invaluable for many people..

Great articles to read with additional information about stability training for this stage are shown below.

• Stability Training What Is It Really & How To Do It 
• How to use the single leg squat as an assessment tool

Step 4  - Isolate & Strengthen Weak Muscles

This stage is where use isolated exercises to strengthen specific areas that are known to be weak. 

These exercises help to activate muscles that may have been dormant for a long time. But don't fall into the trap of where most rehab programs fall over as they focus so much on muscles and forget to teach movement. The body does not know it's little finger from it's big toe, it only knows movement patterns. Strength without this is a waste of time but it does have relevance if you can tie it together.

Common weak areas with knee pain are often within the glutes and calf. This is where I might use hip extensions and clams for the glutes and perhaps some VMO activation drills lying down. However, I don't like to stay here for too long and prefer to use a method of combining the isolated exercise with the more integrated movement based exercise. More or less trying to take the information from the isolated exercise and transfer it to the standing up integrated version. I like to use some strange looking exercises called iso-integration to do this as seen in the video to the left below.

The video on the right shows some of the simple isolated exercises you can use.

I do suggest to grab a copy of our FREE glutes checklist below as this will help you to navigate easily around the complex nature of the glutes and hips. This includes links to detailed videos and articles to help get this part right.

Step 5  - Integrate and Strengthen with Full Body Functional Movements

The last step is arguably the most important.

The worst thing you can do is use machines to try and strengthen your body. Remember back in step 3 we looked at stability, well machines basically tell your body you don't need stabilizers! Not a great idea. So don't do it. Any strength or muscle you add is giving you a false sense of strength. In many cases, it is the brain that is the problem and not the muscles. Faulty patterns of movement can only be trained by using exercises that target the nervous system and the way you move. These exercises are often complex and require great skill and teaching methods to change them. 

Read our article Squat vs Leg Press Which Is Better to see more detail about exactly why machines are so bad for knee rehabilitation, and basically exercise in general.

Without learning how to complete Functional movements in a standing position you are not yet fully rehabilitated.

There will be a chance that you will have to go back to rehab. This is a delicate time as there may no longer be any pain however your body is not quite ready to go back to what you want to do. Without a doubt the best exercise to use is the Single Leg Squat as this brings into play all of the weaknesses with flexibility, stability and strength all at once! It is possibly the best glute strengthening exercise you can do. It is also the same movement pattern most people hurt their knee with! Learning how to do this correctly and improving your skill and strength is critical for the prevention of further injury or getting rid of your pain.

Squats, Deadlifts, and Lunges are all great exercises to help achieve the same goal but they are nothing compared to the single leg squat or the single leg deadlift. The two videos below give you some great ideas to explore here as I take you through these functional patterns and how they relate to knee pain and VMO weakness.

Over the years I have come across many people who were experts at everything lying on the ground, but when they stand up and try a lunge or a squat it is a different story. This is because although they have worked the muscles in isolation correctly, the sequential timing and stability has not been taught in the right order, meaning the movement that is likely to hurt them is still compromised. Look at it this way, how many people do you know that have hurt themselves lying down versus how many people do you know that have hurt themselves standing up? 

The body thinks in terms of movements, not in terms of muscles. Isolation training will eventually lead to a dysfunctional body. Unfortunately, this is also true with many rehab programs as once again they fail to provide a method of progressing from the ground to standing. Pilates is a perfect example of this.

Your program MUST include various types of lunges, squats, deadlifts, step ups and standing upper body movements to train the body for everything it encounters in life. Remember exercise technique is absolutely essential here if you want to build good movement and muscle. 

For more detail on functional movement read the articles below.

• Functional movement is everything and this is why
• 7 Best squats for bulletproof knees

Knee Pain Download, DVD & Toolkit

Due to the overwhelming number of questions I have received about our Knee rehab program I decided to document ALL of my assessments, stretches, stability, strength, power exercises and programs and put it all into one big bundle so anyone could follow the path I had spent many years developing. If you want to see a quick trailer video of what is inside click here.

Below are both of our options and I highly encourage you to at least get the 60-minute video as this has over 60 exercises with instructions and detailed explanations on how we have helped hundreds of clients in the past few years.

CLICK HERE to get both the 60-minute download video and PDF report complete with 6 months of programs to get you started right now!

Conclusion

I hope that this report provides you with enough information and knowledge about how to go about strengthening your VMO and your legs as a whole unit of muscles. We must move away from looking at areas in isolation for this is not how we move. Important for everyone from sporting athletes to people just wanting to have toned legs and look great. But even more important to those needing knee rehabilitation to address pain and dysfunction. Using an intelligent method of program design based on the principles I have just shown will help build strength like never before and help almost every type of injury. You cannot rush the process, you must be patient and aim for perfect form and movement before progressing to the next phase. It is not more exercises that will make you better, rather better quality.

The most important points to remember are:

• Assess don’t guess
• Mobilize first before attempting to strengthen
• Isolate then Integrate within the Strength Phase
• Always aim to improve MOVEMENT PATTERNS in a standing position and not just focus on muscles

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 200 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily.

If you do need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Movement - By Gray Cook
• Corrective Exercise Solutions - by Evan Osar
• Athletes Acceleration Speed Training & Game Like Speed - by Lee Taft
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Stuart McGill
• Knee Injuries In Athletes - by Sports Injury Bulletin
• The ACL Solution - by Robert G Marx
• Understanding & Preventing Non-Contact ACL Injuries - American Orthopaedic Society For Sports Medicine
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek
• Twist Conditioning Sports Strength - By Peter Twist
• Twist Conditioning Sports Movement - By Peter Twist
• Twist Conditioning Sports Balance - By Peter Twist