Knee pain from running: why hip dominant strength matters

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show's for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. In prior episodes, I went over some aspects of strength and how it helps with various different types of conditions.

I think the last time we talked about a knee condition and just kind of the overlying theme of how strength actually works with changing the individual, which changes movement patterns. It changes compensations and so on. There's other ways to change it, but if you're working on yourself, which is really the main thing that you can control, adding strength and some mobility, especially when there's deficits, is a huge win. But remember what I said there, if there's a deficit, I get asked quite often about, should I increase my hip mobility or my knee mobility? I need to be more flexible. Well, why?

You look generally symmetrical side to side and you're within normal ranges. I want to be a ballerina and I can't move that high. Then yes, you need more for your activity, but we kind of need to see what is a normal amount of mobility or strength for the task or sport that you're trying to accomplish. It's all about your unique sport or task or what you're going to explore on a monthly basis. So I'm going to talk about knee conditions today again, mainly regarding hip dominant lifts and how they can help. I'll talk about a little bit of anatomy associated to it as well as some of what the literature may say.

I'm going to go off the cuff here with some of the literature that I've seen over the years and I'm not going to be necessarily listing them and I'll let you guys use all your Dr. Chats and Dr. Clods and stuff to look up what I'm saying and see if there's any validity to it. So I hope I remember them correctly, but knee conditions generally for runners and other types of athletes, if non-trauma-based, which is the key, typically revolve around up and downstream mechanics. So it's going to be the hip, the core, the hip core, we'll call them the same thing today, and the foot angle. So yes, you can, we can talk about foot ankle if we want to today.

I'm choosing not to. In my experience working with people, usually starting at the hip is the easiest win unless there's a bigger, if there's a bigger highlight reel of ankle things or we see things like a long history of, I've had an ankle turn, I fractured my ankle, I was in a boot for a year. It's like, these are, oh, okay, then maybe we'll start at the ankle today. But generally we look at the hip. And so when I do an assessment with people, at least for range of motion, I do a passive range of motion one first and we look at active. Passive means someone does the movement for you or the movement does not require any physical exertion.

It doesn't require any muscular contraction. And that looks to see like, what is the quality of movement within the joint capsule itself? Meaning, is it a meniscus issue? Is there a cartilage issue? Is there a, I'm sorry, I guess I'm talking about, mixing the two up, I'm talking about knee and hip at the same time. So we'll talk first about hip. So the, is there a labrum issue, which is cartilage, or is there a joint issue, which could be arthritic chain and so on? Or is there something, which is more of a guarded nature, which will generally show as a lack of range of motion with active range?

Reasonably so, there's usually less with active range anyways, but in the passive range is generally normal or normal side to side for the person. For knee conditions, it's the same thing. Like usually we see a lack of flexion extension as well with passive range of motion if there's an internal joint restriction. But also too, a lot of these things don't necessarily need mobility interventions. Sometimes just building strength can help out quite a bit with even passive joint motion. And so I don't want to push people towards a mobility solution if it may actually need some strength instead. So I'm not going to focus any more on mobility today, but the strength part, I think is the important part that people are generally lacking.

Recently, there was a position statement by the American College of Sports Medicine 2026. You guys can look that up as well. I think they estimate that 60% of the U.S. does not really strength training, or resistance training rather. Resistance training is using resistance. Strength training is building strength and there's power training. There's all these different types of training. But overall, let's call this resistance training or weighted training. Majority of people don't do it. And so that is the low-hanging fruit for most people with non-trauma knee conditions, even if they are doing recreational sports like running or baseball or soccer.

Most people don't do resistance training. So the way this works is, at least from a knee mechanic perspective, is the knee is a really good hinge joint. It moves a lot in flexion extension, which is bend, unbend, or straightening, right? But it really doesn't tolerate a lot of lateral force, which is side-to-side, or rotation. Yes, there are components of it in there. I think if you look up online, like how much lateral flexion or rotation does the knee tolerate, I want to say it's in the small degrees. I want to say rotation is five. And I want to say lateral bend is probably three or something.

It's very low. With flexion extension, it's almost heel to butt. It's a ton, right? And so there's a ton of range of motion in the knee with flexion extension, but it doesn't tolerate really lateral bend and rotation too much. The other joints or areas surrounding it usually absorb those forces. The hip is a ball and socket. It twists and turns about. It does lateral bend within normal ranges of motion. Yes, can we all do the splits? Probably not. Do we need to? Probably not, right? But we should have a general, like normal range of motion with rotation. Most people lack internal range, internal rotation at the hip, especially in flexion.

And so that is an outlier, especially side to side for most people that can be combated with mobility or strength. With ankle, usually they lack other ranges of motion. There's a ton of range of motion in the ankle, which can be restricted. Most of the time it's dorsiflexion and eversion, which is kind of like the, it's kind of like toes to your face and then outward flaring, which is probably the most common lacking. But there's other specific things that are down there too. Now, when you are lacking function, especially command over the amount of internal rotation drift in the hip, which could be from strength of the hip or core issues, then it leads the knee into internal rotation, knee across midline, which is known as hip adduction, as well as rotational forces too.

And so if you look at some of the mechanics online, go ahead and do Dr. Claude for this. Look at knee valgus force and hip drop. Just put all that in there and just see what it comes up with. And you'll see a picture of single leg stance mechanics. And you'll see that hip drop plus pelvic drop plus hip adduction plus internal rotation and knee valgus or knee knock knee all goes together. It's all the same thing. Although we may demonize one or the other, generally they are all the same thing. And they're from usually a lack of hip strength or core complex strength. So if you want to look up lateral forces of the knee, like the hip adduction or thigh going across midline, people will break this down a little further and say, well, it's an issue with the IT band.

The IT band is not early holding its ground, which is a lateral stabilizer of the knee. It keeps the knee tracking generally-ish below the hip. And it helps out with force management in a lateral bend type of plane. And so if we think, well, why would the IT band not do its job? Well, what attaches to it? If you look up at the hip, well, it's the TFL. Well, that muscle is really small. So it probably doesn't do a lot and it doesn't. And then there's the glue max. Yeah, the glute max attaches to that baby. I think they estimate that over half of the glute max fibers actually insert into the IT band.

Now, does the glute medius matter? Yes, but look at the size of them in comparison. The glute medius and minimus, they're small. The glute max does most of the work. And if you look at the fiber orientation of the glute max, it goes from the sacrum or midline of the back, let's just say, and it wraps around rotationally to attach to the fibers on the backside of the IT band. If you contract that in your mind's eye and you let it shorten, it outwardly rotates the knee and reverses all of those things that I just talked about. Now, how do you get the glute max to work with? Some people have this, they call it glute amnesia.

Like the glute doesn't really contract really well. By the way, when we talk about glute amnesia, we're usually talking about glute max, but all the other glutes are included in that too. How do you get that glute max to turn on if it won't, quote, turn on? By the way, it is always on. It's just latent or lazy. Normally, it can be from poor core support. It can be from a lack of core function. It can be from current back issues, whether that be pinched nerve in origin or it's just discogenic or it feels like your back is tight. They've observed in a lot of the research studies over the years that the glutes turn off when the person has episodes of low back complaints.

And then all the other muscles that turn on a little bit higher to compensate for that, which is the TFL, the glute med, the hip flexor, iliopsoas, these are all ones that tend to help out in that process. And to be fair, these are all the ones that most people talk about are tight. Why are they tight? Well, they're probably taking over that work for the glute max and a poor core. Now for a quick pause before we keep going. Hey, everybody, it's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working, and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity.

The link's in the description. It only takes a few minutes to fill out the form. Okay, back to the show. So, how does this look from a strength training perspective? Like, how do we solve something like this? Well, number one, if you have not really performed core exercises, like isometric ones, which are the easiest to implement for most everybody, not sit-ups, not crunches, not V-ups, not Russian twists, like those ones are ones that can help, but also, too, they don't really fare well with everybody. Like, the asymmetric ones usually work a lot better, and there's less spinal load or spinal power with it.

So, if you're not doing any of it, we can start implementing that, right? Usually do that for about, like, four to six weeks, and all of a sudden, things get a lot better, and the glutes turn on a lot better, and the knee pain just kind of dissipates on its own. Now, from a glute max perspective, how do you strengthen that? Is it clamshells? Nope. Not clamshells. Is it hydrons? Nope. Those are all corrective exercises or ones that facilitate contraction in the glute max as well as the other glutes, but they're not really strengthening ones. The load's not high enough. Remember, the goal is to develop strength.

In order to do that, you have to have something that's actually physically hard that usually gets hard usually well under 20 reps. Now, are clamshells hard? Yes, they're very hard. They burn like heck, and so do hydrons, but they don't really carry over because the reps tend to get too high. Also, too, we've got to consider mimicking what type of human activity most people do, which is closed-chain or foot-on-ground contact. And so, usually the exercise needs to be, number one, lower in reps than you'll do with hydrants or clamshells or even sumo minivan walks or monster walks and things like that.

And number two is they need to be foot-on-ground, ideally. So, what does that leave us with? Deadlifts with different types of implements, which is going to be the barbell, a kettlebell, a dumbbell, usually flipped on end, hex bar, track bar, pin pulls, banded lifts, which are higher resistance, usually heavy bands, not therabands because they're usually too light, so there's all these different options, and those are all double-leg options. Then we have single-leg options, which more closely mimics things like running, which is going to be single-leg deadlifts, 1.5 deadlifts, which are going to be with a, or sorry, the other names for those are going to be kickstand or 1.5 stance or B stance, they're all kind of the same thing.

And then we do it with different implements, which is going to be the same, barbell, kettlebell, dumbbell, hex bar, track bar, landmine, like there's all these different implements, but also like these all provide slightly different stimulus to the person. So there's also different leverages and different planes of movement, which not to make it super complicated, but I've had people plenty of times say, well, this B stance deadlift or this kickstand deadlift doesn't feel really good on my knee. And so how should I change it? And I say, well, you're doing it with a kettlebell right now, right?

And they say, yeah. I said, that doesn't feel good. Have you tried it with a dumbbell flipped on end? And they say, no. And they try it and they say, oh, that feels a lot better. Why does it feel better? It's different leverage. It's just a different implement. It's kind of like carrying a TV, which is 20 pounds, which they used to be back in the day versus a very massive Amazon box, which is also 20 pounds, but quite a bit larger. They're different things with similar weights. So those automatically train you into different movements, which may automatically offload some parts of the knee. So those are the things that I like to really have people do from a hip dominant lift perspective.

Now, can you do stuff from a local knee perspective? Because I didn't talk about the quads and the hamstrings or anything like that. Yeah, you can. And one of the first things that I usually have people do who have sensitive knees and are worried about squatting, which is generally squats are going to be, some form of a squat is going to be the exercise that I usually pick from them over the long term. I'll have them do isometrics in the range they can tolerate. So if you can't squat down below parallel because your knee hurts, we'd stay above that and we do a really hard wall sit, a really hard wall sit.

And we do a really hard hamstring one and a really hard calf raise, which all help out support the knee locally. But remember the local knee stuff, the quad things, the hamstring things, those calf things, they don't control rotational forces from the hip that are being shifted to the knee. If your hip is deficient, you need to work on hip things to control the rotational force. We talked about that glute max attached into the IT band. So how are we supposed to control that if we never really challenge it? So think of these in two camps. It's not really like one or the other. It's like usually we do a little bit of both, but one is scaled back appropriately because we don't want to get the person to have any pain.

Most of the time, they don't have any pain with hip dominant movements anyways for the knees, but they could. And so we may scale those a little bit as well. So normally we do an offloading protocol, taking load away and the types of load that it doesn't tolerate, which is usually rotational or lateral forces, which is going to be a hip protocol or an ankle, right? They're kind of like, I'm only talking about hip today, but it could be ankle-based ones. And we get a whole different podcast on that if you want. But also step two is we still need to challenge local support at the knee and more important than anything else, you have to keep the brain and muscle connection between the quads and between the hamstrings and the calf.

Because what do people do when they have knee pain? Unintentionally, they avoid using it. They don't bend their knee. They don't start using it. It almost feels like the leg is kind of, quote, dead. It's almost like the muscles just start not working that much. And over the short term, that's fine. Like a couple weeks, like a month or so, like you're fine. Like you won't lose anything there. But I've met people who have had 20-year history of knee issues. And I say, what? I see your, it looks like your quad is a little smaller on this side. Do you have any reason for that? And they say, oh yeah, I had this 20-year-old knee issue.

And by the way, I'm here for my hip today. You know, I'm like, well, this knee is a big part of it. Like you see your quad, like not to say they are not strong equally because we don't know that we didn't test it yet, but visually they're different. Can you tell me a story about like what, like how have you fared with this knee condition over the course of 20 years? Well, you know, every year I have this knee condition and so I just don't do any exercise with it for usually a couple months and then it gets better. And then a year or two later, I feel like I want to use it again. And then it just, I always have this fallout with it.

So I just kind of stopped doing that. Well, what do we learn about grandma's phrase? You don't use it. You lose it. This is what's happening here. And so it's a feedback cycle. Like there's not a, really a strong relationship to first occurrence knee issues with quad weakness and having a reoccurrence really, or sorry, of having an initial knee issue. But if we're talking about reoccurrence, yeah, the weakness of the quad or hamstring or soleus, the thing that stabilize the knee from a local perspective, weakness in those does not help. And it creates more of a positive feedback loop. But normally it initially starts from other things, weakness in other areas, over demand or under fueling or under recovery.

There's plenty of reasons why the initial knee injury occurs. But the major thing that we can control, at least from a habitual perspective, is usually going to be adding some strength training in, especially if you're not. Now, how do you do that? If you're not strength training at all, you're not resistance training at all because you don't know how or like you don't have gym access. Number one, go to the gym, buy a membership, go two days a week. What do you, what do you, what should you do? It doesn't really matter. You can do bicep curls and calf raises and leg presses and whatever you want.

You can do it with less weight than is recommended. You don't have to be optimal. At this point, most strength coaches and healthcare professionals will recognize that you just have to do more than what you are. You're literally doing nothing. And we have to get you to do something versus nothing. Now, after a while, once you get more more accustomed to it and you have the habit involved, then we can optimize things a little bit more. If anything in today's episode resonated with you, visit the link in your podcast player. There you'll find any free resource that we mentioned in the show, any guest links, and a link for a free discovery call with us.

We're licensed to work with our outdoor active people via telehealth across many states in the U.S. at this point. In fact, we cover almost half of the population in the U.S. and we add more states every year. Thanks for listening. Subscribe to the show and we'll see you in the next one.