“Pain is a liar.” Have you ever heard that phrase? What most people mean by this phrase is that pain does not truly tell you where the cause of your problem may be located; it only tells you where it ended up. This couldn’t be any truer than when you are talking about knee pain in runners, especially female runners. Knee pain is very common in female runners and can be due to all sorts of inadequacies throughout the knee, hip, foot, or ankle. We will discuss one common cause of knee pain seen in female runners: weak hips and buttocks. Yep, that’s right. The buttocks are not just for show; they have a very important function, and a deficit here can lead to pain in the knee.
It is a very well known fact that the male and female body is not architecturally similar. The female pelvis, for example, is wider than her male counterpart. While this architectural difference between males and females is something one cannot change, there are muscular influences throughout the hips and legs that can be changed with proper training and exercise. Through proper training, the female (and male) hip and pelvis can function better with less chance of injury to the knees.
Let’s look at some of the muscles in this area that influence the knee. One of the largest and most powerful muscles in the human body is the gluteus maximus, which is the biggest of the three gluteal muscles that make up your buttocks. The gluteus maximus functions chiefly to extend (move back), abduct (move out to the side), and externally rotate (turn out) the leg, and it also helps stabilize the pelvis and lower spine. The gluteus medius and minimus function to abduct and internally rotate (turn in) the leg, and also help stabilize the pelvis. This means that these muscles not only help control the movement of the leg, but they also help control the pelvis, which is the foundation to which many leg muscles are attached. Two of the three gluteal muscles have a direct connection into the infamous iliotibial tract (also known as the IT band), while all three of them functionally influence the IT Band.
The gluteals nowadays act as a cushion for sitting rather than an explosive lower-body muscle used for walking and running, as they were designed. This lack of use leads to atrophy and weakening of this muscle group. A weakened gluteal area can lead to a pelvis that moves around too much during running, which in turn puts more strain onto hip and thigh muscles that cross the knee. It can also lead to an unstable knee that will drift inward, causing increased tension onto the patella and IT Band, which causes pain to the kneecap and outside of the knee.
There is another group of hip muscles that are extremely important to the function of the leg: the six external rotators of the hip (they turn the leg outward). These tiny muscles are deep in the hip, extremely difficult to touch, and are rarely talked about in comparison to the bigger, more popular gluteal muscles. For all intents and purposes, these are grouped in with the gluteal muscles. This external rotation is needed to counteract the influence of such things as the Q Angle and over-pronation of the feet, which both lead to the drifting of the knee inwards. As with the gluteal muscles, weakness in these external rotators can lead to increased pain at the knee. Some of us in the sports medicine field feel that these muscles are as important to the hip as the rotator cuff muscles are to the shoulder. And as the rotator cuff in the shoulder needs to be strong for the shoulder to function properly, these hip rotators need to be strong in order for the rest of the leg to function better.
Several recent studies found that female runners with IT Band syndrome showed significant weakness in the abduction of their involved leg as compared to their healthy leg and as compared to other non-injured runners. A study done at the University of Delaware showed that in a group of 18 female distance runners with IT Band syndrome, all demonstrated an increase in the adduction (inward drift) and internal rotation (turning in) of the involved knee, which can be counteracted by strengthening the muscles that abduct and externally rotate the legthe glutes and external rotators. Most patients in this category report full pain relief did not occur until strength was improved in their injured leg.
This information should encourage you to take another look at your current “nagging knee pain” (if you are unlucky enough to have it) and reconsider if you are doing all you can for it. These problems are not just tightness issues that need stretching and ice; you need to ensure you have adequate strength and control in the muscles of the hip, or the tightness and pain will just keep coming back. So, yes, all athletes, even distance runners, need to strength train and get “buns of steel.” It could be the answer you are looking for to get rid of chronic knee pain.
Michael Silva, MS, PT, CSCS, the president and founder of FOUNDATIONperformance sports medicine, has been working in fitness and physical therapy since 1995. Michael has been involved in the endurance athlete world most of his career and specializes in running injuries. From high school athletes to Olympians, Michael has worked with thousands of runners. With offices in Pawtucket, RI; Plainville, MA; and Warren, RI, FOUNDATIONperformance has been providing fitness, physical therapy, and performance enhancement services since 2003. [email protected]