In the last last article  we covered three common knee injuries: ITB, patella femoral knee pain and osteoarthritis of the knee. To help prevent these injuries, we bring you six exercises to activate your glutes and strenghtening and flexibility around the pelvis in order to unload the knee.

There are hundreds of exercises that can be chosen. I have focused on ones that have the highest gluteus maximus and gluteus medius activity based on the research. In all exercises quality trumps quantity.

If any exercise is too difficult or you struggle with form, see a physiotherapist to assist with an exercise programme. There may be factors beyond weak glutes causing your knee pain. Strenghtening both the glute medius and maximus can help with the prevention and recovery of knee injuries.

Preventing Injuries

As well as execises there are also a few other tips that help you deal with an existing injury, or help you prevent one.

Personal Stress: Assess all the stressors in your life. If work is very busy, your training load is demanding and you have family stress, something has to give. You might need to reduce your training for a week or two.

Physical Stress: be wary of physical stressors like always wearing high heels then going for a run in relatively flat shoes.

Get mobile: If you are sitting with your hips and knees bent thoughout the day, make sure to get up and walk and even do some back bends in a standing position to stretch your hips, knees and back every few hours.

Best Impact: It is often not necessary to do many exercises. Focus on three exercises whihc will make the biggest impact, and progress from there.

Review Mistakes: If injured, go back abd look at your stats (with running apps like Strava). You can sometimes see where you had a spike in distance, intensity, or hill work, which can be related to your injury. Also review heart rate and recovery times. Sometimes a run that should have been easy shows that you worked too hard, perhaps an easy run is needed rather than pushing a hill or speed session. Even work on your walking speed, cross train or take a rest day.

Impact of weight: Consider the weight of the pack that you will race with (for trails), and train accordingly. An extra 3-5kg in a pack will impact the load through the knees. Trekking poles can help take the weight off your knees.

Walk it out:Walking during runs is a great way to decrease the load on your knees and to improve your walking speed ahead of your next event.

Running form

Improvement of running form in novice runners can reduce the risk of injury by 62% (Chang et al 2018)

• Aim for a cadence above 165 steps per minute. Elite runners have a cadence of 180-200 steps per minute.
• Any change in running forms should be gradual, for even a 100 meters within a run, or running lamp posts
• Running barefoot or in minimalist shoes for short periods can help improve form (see point above)
• Starting slowly with a run/walk programme is a good way to rebuild fitness after an injury
• Focus on making your feet land lightly below you- cues that help this are thinking “land softly”, “shorten your stride”, or “quick steps”

Get Off You Butt

These 6 exercises are the best for glute activation based on a literary review  by Reiman et al (2011). For strengthening exercises you want to aim to do strengthening 2x per week, aim for 3 sets of 8-12 reps.  Quality always trumps quantity. Click on each exercises for a video link to the exercise. Any exercise can be made more challenging by introducing weights and unstable surfaces. Training on a Bosu ball is great for trail running and getting used to an i=unstable surface

1. Forward step up– Stand about 20cm away from a box, step, bench or pavement. Step up onto the step with your right leg. Now pull up using the right leg (don’t push with the left leg). To make this harder use a higher step, stand further away from the step, drive your opposite knee up, use a weight in your hand.
2. Wall Squats – start with feet hip distance apart. Your feet should be away from the wall, such that when you slide down your hip and knees are 90-90. Your middle of the knee should be in line with the middle of your second and third toes. If you get knee pain don’t go down as far. Hold for 3 seconds and then push back up. To make it harder, you can hold for longer e.g. up to 10sec hold. If you get knee pain don’t go gown as far. You could add a band around your knees and pull against this for more glute activation.
3. Single-leg deadlift– stand on one leg, keep your standing leg straight and bend from your hips. Keep your hips level and your back straight, and avoid rotation of the pelvis. Aim to form a T shape with your body. If your pelvis starts to rotate, then don’t bend as far as your hips. Keep looking forward as it help keep your back straight. The work of gluteus maximus is bringing you back up to standing. The work of gluteus medius is keeping the hips level. One-legged exercises are great as you can see if you have a weaker side. Aim for 3 sets of 8-12 reps on each side . Once you are stronger you can add an weight in.
4. Single-leg Squat– stand on one leg. Squat and touch the floor with the opposite hand. With the bent knee make sure you keep the middle of your knee cap in line with the second and third toe. To make this harder you can progress to a piston squat with your straight out in front of you.
5. Side-plank – Lie on your side, your shoulders, hips and heels aligned. When you lift your hips into side plank, your elbow should be directly under your shoulder. Once in position, lower your hips to the ground and come back up. Aim for 3 sets of 8-12 reps per side.
6. Side-lying hip abduction– Lie on your side with your head supported. You can bend your bottom knee for support. Make sure you head, shoulders and heel are in one line. If not sure then lie against a wall. Now slide your heel up a wall, or think of sliding it up an imaginery wall. The tendency in the exercises is to let the top leg sneak forward, key is to keep the leg back.

Talking to the Healthcare Professional

When consulting a healthcare professional, be honest about your training. You also need to be thorough. Even if you think you are only seeing them for your knee, they may ask about other injuries in order to see how everything links together. Physiotherapists are first line practitioners who are trained to assess and diagnose. They can appropriately refer you on for further investigation if needed.

Consult a physiotherapist if you have pain that is not improving, or you notice you have a lack of range of movement in joint. You can also see a physiotherapist to do an assessment of your muscle strength and flexibility and help you put together a program that is tailored to you.

Happy  Trails!

Thank-you to the South African Society of Physiotherapy for the opportunity to write the article, and to Trail magazine (www.trailmag.co.za) for publishing it in their Appril/May/June 2018 issue.

References:

1. Chang Z, Zhang JHW, Au I.P.H, An W.W., Sum G.L.K, Ng G.Y.F, Cheung R.T.H (2017) “Gait retraining lowers injury risk in novice distance runners: a randomized controlled trial” The American Journal of Sports Medicine.2017. In press. AMJSPORTS/2017/221127 DOI: 10.1016/j.clinbiomech.2016.03.010
2. Reiman M, Bolgla L, Loudon J (2011) “A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises” Physiotherapy Theory and Practice, 28(4):257-268 DOI: 10.3109/09593985.2011.604981 · Source: PubMed