I’ve had an influx of youth athletes with anterior knee pain recently so I’ve been reading and searching for some answers. The wheels in my brain have been spinning at 7000rpm so I decided to just jot down some of these thoughts to make more sense of them and decided to share them with you. Not all of this is backed up by research, this is me thinking out loud
Here are some of those thoughts:
- There is still not a lot of youth athletes who strength train. Most just play sports. And some just play one sport and play it A LOT. This means their basic movement variety will be low and basic movement development may be biased towards the sport they play. Most of them do not know how to properly hip hinge, squat, lunge, jump, push, pull, etc.
- This may lead a lot of young athletes to become quad dominant. They never learn to use their posterior chain, therefore they are always pulling from the knee instead of pushing through the ground. This can put increased stress on the patellar tendon, and compresses the infrapatellar fat pad under the patellar tendon as well as the patella itself into the intercondylar groove.
- Some athletes such as hockey and soccer players are known for having tight quads and hip flexors, just the nature of the movement of the sport. This agonist tone in the quads and hip flexors can lead to antagonist inhibition in the glutes and hamstring.
- Because they never learned or their posterior chain is inhibited, they have weak/inactive glutes and hamstrings. This hamstring weakness can be masked into “tightness” when in reality they are just very weak and overworked.
- The knee is anatomically one of the most unstable joints in the human body. Most of the stability of the knee comes from hip control and co-contraction of the quads and hamstrings. However, if the hamstrings are weak/inhibited, the quads will have to compensate to make up for that weakness. This creates a quad:hamstring ratio in favor of the quads, which can cause the quads to get even tighter and overworked even though they are strong.
- In an athletic position is when we get the most co-contraction between the quads and hamstrings. In this position of approximately 30deg of knee flexion with both feet planted on the ground, the line of pull from the hamstring is posterior to the axis of rotation in a closed chain movement. This set up allows the hamstrings to contribute to extension of the knee by pulling the tibia posteriorly for running, jumping, lunging, etc. which should almost double the extension strength at the knee by combining hamstring and quadriceps strength
- With a lack of posterior chain strength or activation, youth athletes are overusing their quads creating pathologies like patellar tendopathy, patellar chondromalacia, etc. and creating complaints of anterior knee pain in youth athletes.
Here are also some thoughts on what we can do to help these youth athletes:
- I think one of the big ones is monitoring workload. Some kids are simply playing too much to the point that by the time they turn 14-15 years old, their tissues are already tired and need a break. Kids are not mini adults, so we can’t treat them like adults.
- Kids should have an off-season from their sport where they have the opportunity to try different sports. If they don’t want to do different sports, they should be training – learning fundamental movement patterns such as the hinge, squat, lunge.
- Strengthening and activating the posterior chain. Teach them hip hinge movements that strengthening the glutes and the hamstrings, especially in quad dominant sports like soccer and hockey.
- Quad: Hamstring ratio might be something to pay more attention to with youth athletes with anterior knee pain. Strength coach Mike Boyle says that in terms of functional anatomy, muscles prevent the body from flexing at the ankle, knee and hip in order to stand upright. That being said, if the Q:H ratio is biased more towards that quads, the quads are working harder to prevent the knee from bending, eventually getting tired, tight and inflamed at the knee joint. Strengthen/acitvate the hamstring, share the work of maintaining an upright posture between the quads and hamstring, reduce the strain on the anterior knee structures.
These are some thoughts on anterior knee pain in youth athletes. There are lots of other things to consider by looking up and down the kinetic chain. Again, not all of this is supported by research, this is just where my train of thought takes me on some factors playing into anterior knee pain. If you guys have other thoughts, ideas, comments, think I’m way off on all this, don’t be shy.