Do you struggle with knee pain in your training? Joining me on the show today is Dr. Jon Gardner, the Regional Director and Sports Physical Therapist at True Sports Physical Therapy. The knee is a tricky joint and when pain is present, it can be a huge setback in your training and even in your normal daily routine.
Most knee pain can be preventable, which is why I wanted Jon to sit down with me to unpack the tactics and strategies you should utilize to ensure you are pain-free. What a lot of this comes down to is focusing on what’s going on above the knee (at the hip) and below the knee (at the foot and ankle). Jon and I dive into a bird’-eye view of the hinge joint and how the hip, foot and ankle impact function and pain performance. We also discuss tips you can use to build ankle, foot, and calf strength, which will ultimately help strengthen your knees.
We then do a deep dive into how the hip complex contributes to knee pain and ways you can reclaim your range of motion in your hips. We then share a handful of exercises you can do to improve motion and control. In a lot of cases, many people are stuck managing pain symptoms instead of fixing the true underlying driver. So, listen in as Jon and I unpack what you need to do to build yourself bulletproof knees.
What You’ll Learn in This Episode:
- [04:45] Intro to Dr. Jon Gardner
- [09:25] Bird’s-eye view of the hinge joint
- [11:01] The layering effect
- [13:05] Tendinopathy type pain versus general PFPS
- [15:39] The hip, foot and ankle’s impact on function and pain performance
- [18:25] Strategies you can use to build ankle, foot, and calf strength
- [21:43] Unstable surface training
- [27:35] How the hip complex contributes to knee pain
- [34:41] Reclaiming the range of motion in your hips
- [37:50] The impact of variations on split squats
- [41:10] Utilizing the step up to improve control
- [44:57] Where to find Dr. Jon Gardner
James Cerbie: I think you’re really going to enjoy the episode of the day, so let’s jump in with Dr. Jonathan Gardner. All right, fantastic. There we go. And we are alive with the one and only Dr. John Gardener. John, what’s going on, man? So glad that you jumped on this morning with me.
Dr. Jonathan Gardner: I appreciate you having me, James. I mean, I’ve listened to the podcast since you started it, so it’s a blessing to be able to pop on the thing and actually talk and act like I know what I’m talking about.
James Cerbie: So I just play make believe every time I do one of these. It’s the best. It’s the best. Take it until you make it right. That’s what everybody tells me. Yeah. I told people when I first started this. It was really just an excuse for me to be able to talk with my friends for an hour and then call it work.
Dr. Jonathan Gardner: Exactly. Exactly.
James Cerbie: Just try to tap into that Joe Rogan, that Joe Rogan system as much as possible. I’m like bro. You made a hundred million dollars, and you just sit around and drink Scotch and smoke weed and just have awesome conversations with people. What am I missing?
Dr. Jonathan Gardner: Exactly? How did I not think about this?
James Cerbie: Yeah, brilliant were brilliant. But we wanted to dive in and talk about knee stuff today.
Dr. Jonathan Gardner: Absolutely.
James Cerbie: Because one we haven’t talked a lot about the knee on the podcast previously. Actually, I don’t know if we’ve ever actually really talked about it. And so the people at Rebel that we’re training are 25 to 50 year old former high school College athletes. They probably have a job, and they want to still maintain this total package, performance, physique, athleticism, and still live at their peak. Right. And we end up running into issues with some of them. We’re having a hard time managing this, and we talked a little bit off air.
We kind of have this prehab performance rehab realm where we’re trying to blend these three worlds together so we can build this bulletproof need that’s happy, healthy, pain free performs at a high level. And so that’d be really cool to have you on the show to chat about this because you’re a physical therapist who wears all of those hats very well in terms of seeing high performing athletes training them for performance, as well as having to deal with more of that prehab rehab world because you and I both know that those worlds are not separate.
They are all meshed and integrated very tightly. So I think the best way to start is before we dive into all the new stuff, let’s actually just give the quick elevator pitch on who you are, what you do, give everybody the background on John, and then we can dive in and just have a little coffee chat about knee fitness.
Intro to Dr. Jon Gardner
Dr. Jonathan Gardner: Yeah. So I’d be remiss if I didn’t introduce myself as Jonathan Gardener. I tell everybody I’m John, but my mom will kill me if I introduce myself as John on the podcast. So I’m Jonathan Gardener. I’m a sports physical therapist and strength and conditioning specialist for True Sports Physical Therapy in the Maryland area. I am a regional director now, and I’m covering. I mean, if anybody knows anything about Maryland, I’m in Frederick, like the Western side of Maryland and then down to 70. So I have another clinic in Gaithersburg and then Besada, which is another suburb in Maryland, just outside of DC.
I’ve been practicing physical therapy for let’s see, three years now, mostly in the Maryland area. I started off at a nice outpatient facility that had sports in the name, but no sports actually coming into the facility. So then randomly found a job posting on, indeed, got hooked up with True Sports, and it’s kind of been going from there. More background. I was a College basketball player at Coker College, now Coker University. Very fancy change. Small D2 schools down in Hartsville, South Carolina, about 30 minutes out of my hometown in Florence, so I played my five years there.
I’m a basketball guy. So I’ve had the knee pain type stuff and ankle sprains and all that good stuff. So we’ll dive into a little bit of that as we move forward here. But, yeah, like, you were speaking to the whole goal of, like, True Sports is to provide the best holistic sports medicine approach to athletes, whether that’s prehab rehab or just, like, some performance. Two nuts and stuff like that. So that’s kind of where I’m at now.
James Cerbie: Fantastic, man. So what position did you play in basketball?
Dr. Jonathan Gardner: I was like a shooting guard, small forward when I was in College. And then I think, like, the open court dribble drive offense started to really pick up my junior and senior in fifth years. So then everything essentially became position less. Right. You’re running your five best players on the floor, no matter a size, like those traditional positions went out of the window. So I had times where I was bringing the ball up the floor. And then I also had times when I was guarding a guy who was entirely too tall. But other than that, mostly shooting guard, small forward.
James Cerbie: Okay, nice. I played up through my sophomore year in high school and then realized that there just wasn’t really a room on the floor for, like, a high effort defensive player that really wasn’t very good offensively, right? I was just athletic, and I tried really hard.
Dr. Jonathan Gardner: So it works sometimes it’s all you need. I mean, in College, like, my role definitely shifted. I went from I think that’s the nature of, like, College sports. Everybody was the best player on their team in high school, right? And then you get to College. And these guys are like, you’re not the best player anymore. So you quickly figure out what’s going to get you playing time. Mine was becoming, like, the defender effort glue guy as opposed to, like, trying to be the 30 point per game guy anymore.
So I shifted that route pretty quick to get myself on the floor.
James Cerbie: You kind of have that, like, adjustment from high school to College and then another adjustment from College to pro.
Dr. Jonathan Gardner: Oh, exactly.
James Cerbie: And it’s funny. You see it at every level, like, I can remember a football guy at our high school that was really good a line-backer and he went and played in the ACC and remember chatting with him and ask him one time, like, how things are going and fall ball and spring ball and stuff like that. And he was like, Dude, it’s so fast. Everything happens so fast. He was like, by the time I read my key and I take a step, everybody’s fucking gone.
Dr. Jonathan Gardner: Exactly.
James Cerbie: And that’s the thing that changes as you move up levels of sport. The speed in which everything takes place is just tens and 20 X’s. There’s not this gradual increase of, like, stair stepping. It’s an order of magnitude change from high school to College, and then another order of magnitude change from College to professional.
Dr. Jonathan Gardner: Right.
James Cerbie: And, yeah, the speed factor is just unreal.
Dr. Jonathan Gardner: I mean, I’m lucky enough to work with some, like, NFL, major League NBA guys and, like, even like, their ability to just process stuff, like in our sessions quickly and how in tune they are with everything that’s going on around. Truly just bonkers like, it’s one of those things, like, where you see it. You’re like, oh, that’s why I’m not the pro.
James Cerbie: Because I can’t figure stuff out that quick without question then. So let’s dive into the knee. Sure. The best place to start is let’s just get a bird’s eye view of this joint, right? Just a basic knee 101. What is this joint? What’s happening at the joint? What are some of our contributing factors? So we have this really interesting hinge joint here that tends to be really impacted by things happening both above it and below it. I’ll let you kind of give us the background in terms of how we want to think about this point just from a 101 textbook understanding potential?
Bird’s-Eye View of the Hinge Joint
Dr. Jonathan Gardner: Sure. So, I mean, when you dive into the knee again, like you’re saying, like, it’s a hinge joint. So a lot of people think all it does really is like, flex and extend and that sort of thing. So, I mean, you’ve got your basic tibiofemoral joint where your tibia is meeting that femur. And again, it’s just giving you, like, that nice hinge. And then you’ve also got the patellofemoral joint. And that’s the one that will give people some trouble. It’s just where the patella is able to glide back and forth over that triple that sits on.
So again, the main movements are flexion extension. However, you’re also dealing with some tibial internal external rotation depending on which direction you’re moving and stuff like that. So there’s a little bit more involved with it, then just flexion extension. But, I mean, for the basis of the conversation, it’s basically a flexor and extender. You get your quads hamstrings cast popularity. It’s a bunch of little things running through that area. But for the basis of what we’ll talk about, we’ll just kind of stick with the flexion extension type stuff, unless you really want to dive into the weeds.
James Cerbie: Yeah. Exactly. It’s such an interesting joint because just from, like, a musculature standpoint, like you mentioned, we have muscles that come up to the joint, and then we have muscles across the joint. And like, there’s this, like, layering effect that takes place almost right. And I always think of the knee in particular when we start having people complaining of knee pain, and that could be a decent first place to start is we have this hinge joint. And like you mentioned, there is more going on there, but just kindergarten one on one level.
The Layering Effect
It’s just a flexion extension hand joint. And I always think the femur coming down on top, tibia coming up from the bottom, etc. And we want these things to kind of mesh nicely. But what you start seeing with knee pain or dysfunction at that joint is when you end up with torque at the joint.
Dr. Jonathan Gardner: Right. Right.
James Cerbie: It’s like when these things aren’t lining up. Well, when one thing is going one direction and the other ones going the other or it’s like, sure, it’s this torque at the joint that’s not really wanting to be torqued, right. That is causing problems for people when we start getting repeated exposures and Loading and velocity over time on that underlying structure per se. Is that a fair sort of, like assessment?
Dr. Jonathan Gardner: Yeah. I mean, I think that’s the biggest thing for me, like, you constantly get these kids and adults coming in and seeing you. And the first thing I tell you, I got, like, tendonitis in my knee, and I’m like, you probably don’t like if I’m looking at you and and you come in and you make that complaint unless you’re a basketball guy, a volleyball guy, a high jumper or a volleyball girl, like, just a young jumping athlete. You probably don’t have tendon tendonitis type stuff like that’s.
Like you have to be able to load the tendon and be almost overloaded to get those kinds of symptoms. And I mean, you can typically see pretty quickly when they come in like, you’re not a tendinopathy kind of person. Like you don’t participate in running, jumping sports, like you’re on a bike or you’re having trouble stairs, like, very low load activity. So I think that’s the first thing, like when you start diving into the knee stuff is it actually like a tendinopathy type pain or we are dealing with your classic, like, Patel ephemeral pain syndrome or PFPs or whatever people want to call.
Tendinopathy Type Pain Versus General PFPS
And that’s where you’re starting to look at more of, like, the torque on stuff and stuff being, quote, unquote, like misalign or whatever the case may be. And that’s where you have to really that’s where you do start to dive into the weeds because it’s not so much a let’s just get their quad stronger. Let’s just get their hamstring stronger. Like then you’re looking at, like, their hip move. Well, can they control their feet and ankles? Do they have enough sensation, like when their foot is on the ground to, like, know where the pressure is all that kind of stuff?
So I think that’s the first place to start is whether it’s a tendinopathy type thing or more of, like, your general Patel ephemeral pain syndrome type stuff that most people end up coming in with. And that requires a lot of education on my part to be like, it’s not topsy type stuff. Like, we need to address some different stuff that’s going to help with this anterior knee pain, because I mean, that pain, like in the front of the knee that everybody complains about. That’s, like, right on the tendon, like, there’s studies that show that’s the most painful spot and people who have arthritis or people who have fat pad syndrome and all that kind of stuff.
I mean, there’s tons of different pathologies that can happen at the knee, even though it is such a simple joint, because it’s like you’re speaking to earlier, you have so much stuff happening above it at the hip, so much stuff happening below it at the foot and ankle. And then there’s a whole coordination aspect of stuff as well.
James Cerbie: Yeah. Really glad you mentioned, because that’s right. The PT for Dummies book, what you get depending if you don’t see a good physical therapist, you walk in with knee pain and it’s like we quads, right? That is classic old school PT for the need. You have weak quads. Let’s just go and just make that quad stronger and that knee pain is going to go away. I’m, like, broke. And I think you said it perfectly right. Especially when you get athletes. Our population is not going to be people with small quads.
They’re not going to have small quads. Your quad is not weak. What’s probably more likely happening. As you mentioned, I would love for you to impact this more if let’s go look at what’s happening at the hip and let’s go look at what’s happening at this ankle and foot, because those are the things that are actually going to be impacting above and below. What’s then taking place at a hinge joint because the knee is kind of a dumb joint? It’s going to do whatever is happening above and below.
It is essentially right. And so can you unpack that a little bit more in terms of let’s look at what’s happening at a hip. Let’s look at what’s happening down at the foot, ankle and how that’s actually been impacting, this presentation of function or pain performance, etc.
Sure. So I mean, we’ll start with, like, I’m a big foot and ankle guy as well. So we’ll start down at the foot and stuff like that and you get these kids who walk in and again, I’m not one to dive in and be like, oh, like this whole kinetic chain thing like, you have bad feet. So you have bad nice. You have bad hips or whatever. But, I mean, there is something to be said, like when you look at these kids and they have either very high arches where they have very flat feet, you’re looking at that stuff and their ability to control loads, like with that foot and ankle complex.
And if they’ve got no sensation of, like, where the pressure is and their foot or they have no calf like, that’s a big thing for me. It’s just general foot, ankle strength. Like you get these kids again, like high performing athletes, and we have, like, age related norms for, like, calf strength. Like, you should be able to knock out 30 reps of a single leg calf raise, like, no issue all the way up all the way down a piece of cake. And you get these kids coming in and they’re playing eight games in a weekend, whether it’s basketball across or whatever the case may be.
And they can’t do ten calf rays before they’re cast on fire. So then you’re looking at that kind of stuff and I’m like, well, you can’t absorb force properly with your foot and ankle. So where do you think that stuff is going? And then again, you start adding in, like, over prorating and collapsing your foot or over supinated and stuff. And then you’re changing, like, knee position with it. And they wonder why they feel it all up there. So I mean, that’s typically the first place I will go is looking at general, like, gas rock strength and then solely as strength as well.
Strategies You Can Use to Build Ankle, Foot and Calf Strength
James Cerbie: Let me interrupt you super quick while we’re and then we can go to the hip. What are some things that you like to do from a protocol standpoint to help with this foot and ankle both strength and then control, right? Because it’s just going to be a combination of both. And I think the distinction between our people that are super high arched or the people that maybe have lost that arch and our super flat footed. There’s an element there meaning to regain Cal strength, all those little intrinsic muscles of the feet and just being able to actually understand, where are you in space?
Like when I’m on this foot can actually appreciate where I am in space and control position? Or am I the person that goes to stand on 1ft? And then I just see my entire foot do this. I just pronate and the tibia follows. My knee just goes, oh, okay. Like all classes and internally rotate essentially, what are just some basic ways that people can start working on that in their training. You can throw it into a warm up or back in the day, a crafty performance.
One of the things we would do on a super set with a dead lift. We would give you ankle mobs, like, little things like that, because your rest or two minutes anyways. So it’s an easy place for us to get more work like this. So what are some things people can do there to start helping with that ankle, calf foot strength and control.
Dr. Jonathan Gardner: Right. So I mean, the first thing that I’ll have them do. And again, it’s going to vary, like, the level of the athlete. We provide as many constraints as I can to start off with so that I don’t have to over ce, I guess, because, like, once you start, like, telling these Liebig to find your peak, to find your heel, like, create that arch, like, they’re so lost, like, they don’t have a sense of, like where their foot is in space in general. So again, I’ll use more, like physical constraints, like I will put them on a Slam board and have them be what I call like, an active foot or heel float kind of thing where I just have that foot hanging off.
And I’m like, you have to keep your foot parallel with the floor, but your heel has to stay up and elevate. And once we can, like, determine where they’re finding pressure in their foot and ankle and stuff like that, then they can find their cap. And I’m like, oh, that’s what that feels like. And then again, you can change the angle of a slant. You can put them in pronation. If they’re an over-supinated person, you can put them in Super Nation if they’re an over pronated person, like, whatever you need to do from that standpoint and just get them rocking and rolling.
Unstable Surface Training
I’m not a huge fan of, like, the RX tad phone stuff or the bozoo ball type stuff like the ground isn’t made of foam and the ground doesn’t wobble. So like this whole idea that you’re going to recreate, like, ankle stability and strength by putting them on these unstable services. You’re just cheating them, like, bad compensation patterns, because all they’re going to do is they’re going to hide that foot and ankle and they’re just going to use their hip and stuff like that. So again, the biggest thing for me is like keeping them on flat ground and then making them more aware of, like, where that foot is in space and where they’re feeling pressure.
And then from there, then I’m just I’m sending those kids home with single leg calf raises. I’m sending them home with seized calf raises and basic stuff like that, like, sometimes it’s just not as complicated as we try to make things. Sometimes it’s like you can’t do 30 single Gal raises. So let’s go home and do single calf raises. And again, I think a lot of kids are surprised when that starts to fix, quote, unquote like their knees and stuff like that simply by figuring out where their foot and ankle is in space and how to manage pressure and load and ply metrics, like, with more foot ankle strategy as opposed to making everything knee and hip dominant.
James Cerbie: I’m glad you mentioned the ARX Pad bozoo ball stuff, because that is just such a I don’t spend that much time in that role anymore. So I just kind of assume, like, oh, we’re done with that, right? We’ve moved past that as a thing, like, ten years ago, when I was 22 23, I was like, this is done. Why are people doing this? I thought we’ve accomplished that. This is not doing what we wanted to do. I’m going to take somebody who already has a really hard time orienting and finding position in space.
And then we’re going to put them on an unstable surface so that it becomes even harder for them to try to Orient and find position in space. And they’re just going to go into alarm mode. And they’re just going to fall into some type of, like, they’re going to find whatever reference they can. And it’s not going to be the one you want.
Dr. Jonathan Gardner: No.
James Cerbie: Right. I remember way back in the day, I actually think cresses, like, master thesis had to do with unstable surface stuff and how it just was not he’s like, why are we doing this right?
Dr. Jonathan Gardner: Like, you think you’re challenging all these, like, foot and ankle strategies. And then the more you dive into research on the topic, people just increase their hip strength and their hip control. Their ankle doesn’t get any stronger in terms of, like, force output or ability to absorb forces and stuff like that. They’re just that’s the thing about the human body. They’re going to find a way to compensate. And again, I think that’s part, like, where this knee pain comes in and stuff like that is your body is going to do whatever is the most efficient movement strategy.
So if you don’t have proper strength and coordination in certain areas, like, your body is going to figure it out somewhere else. So that’s when you start over using quads and not finding your hamstring and not finding your calf and your Solis and intrinsic in your foot. And like, those little hip stabilizers and stuff like that. And instead, all you’re going to do is use your giant lateral quad that you see on all these guys. And that’s where we start to talk about, like, that little bit of, like, torque sensation on that knee where it’s kind of altering, like, path of the patella on that truly a little bit. Yeah.
James Cerbie: Because essentially, once you get somebody to a point where they have this baseline strength of being able to do the 30 calf raises, I can feel calf. I can actually kind of get Pinky big toe heel, right. And in a very safe, very restrained, very watered down environment, then as opposed to trying to throw them on unstable services, it’s like, okay, well, now let’s start to challenge that with either, like, Loading or velocity positioning. There are so many other places to go next for people. Right? Like, okay, awesome.
You can do this thing now, can we actually do this, like, can you skip rope? Can you do jumps? Can you do, like, little single leg hops and actually keep what we’ve started to maintain and you can work your way up in terms of the complexity and the demand or the intensity of what we’re trying to do? Okay. Cool. Can I drop from a six or twelve inch box and land in a good position and feel like that strong foot ankle complex? Do what I am supposed to do or when I do that, do I fall apart again?
It’s like, okay, cool. Well, we found our tipping point. Let’s come back and figure out what a lower level sensation I can give you once we get that, and then we can start to ramp up. There are so many other tools you could use, because eventually I want to be able to get you to say, okay, can we fully jump? Can we fully sprint? Can I have you come and cut in and out of turns and corners and have this maintain itself and not go back to this previous strategy that you were using?
Dr. Jonathan Gardner: Exactly. exactly. I mean, I think that’s the biggest thing is you start with as many constraints as possible, and then you gradually start to remove those and then make it more of, like, a coordination, sport, performance based type of thing. Again, like we were speaking to earlier, it’s not more often, not like it’s not a strength issue. It’s more like coordination and timing and stuff like that. So again, that’s where the baseball and Arpad kind of go out of the window, get it strong first and then gradually start to remove constraints and then work on more of the coordination aspect.
James Cerbie: Yeah. Right. Just like the basic progression is has to be able to just from, like, the safest standpoint. It needs to be able to absorb force, stop force, produce force. And then it has to be able to repeat that.
Dr. Jonathan Gardner: Exactly.
James Cerbie: If we were going to make it as simple as we possibly can. And the issue is most people totally ignore the first two, and they just go straight to production and repeatability. The foundation that you’ve built this on is total trash. Right.
Right. As a totally random other example, when I spent a lot more time in the baseball world, you see this a lot with pictures of people who would get elbow or shoulder pain, and then you watch them throw. You do table tests. You do things you’re like, oh, well, it’s pretty obvious why we’re getting shoulder pain, right? Like, you literally can’t move your Scap. We get no upward rotation, you know, scapula, there’s so many problems, but then they don’t really work on those things because the team doctors like, oh, well, we should just do surgery on your shoulder.
James Cerbie: They go to get surgery, and then I’m just like, Ro, your shoulder is gonna hurt again. Give it six months, maybe twelve months. You haven’t fixed the underlying problem here.
Dr. Jonathan Gardner: Exactly.
James Cerbie: A prominent example.
Dr. Jonathan Gardner: That very much the same thing with, like, knees and stuff like that. Sometimes it is as simple as occasionally. There’s just a general strength deficit more often. Not like somebody changed stimulus. They went from not doing anything over the course of Cove to all of a sudden be like, well, I’m going to start running or they used Cova to start running and they hadn’t run for years or whatever the case may be. I mean, it’s a very multifactorial approach to the thing in terms of the amount of load you’re putting through it and all that sort of thing.
But again, just having systems in place to know what you’re going to look at not only just the knee joint, but then the ankle and the hip as well to make sure that you’re sure. And all those things up is super important when you’re looking at that joint, because again, more often than not, it’s not just a weak quad or a weekend string or whatever the case, it’s a full kinetic chain, like coordination issue.
James Cerbie: The running one’s. Funny, because you see that here in Utah, you go drive up the canyons, Legit Canyons, and you see people running up and down these things. And I’m just like; we’re driving on the road. I’m watching them run down. I’m like, bro, you’re doing like a five mile down, like legit downhill grade, just like decelerated run. And I’m like, you don’t even look like you run very often. This maybe like the second time you’ve been out here doing this.
Dr. Jonathan Gardner: Exactly.
James Cerbie: And then you’re going to be surprised when your knee feels like it got hit with a baseball bat tomorrow.
Dr. Jonathan Gardner: Yeah.
How the Hip Complex Contributes to Pain Performance
James Cerbie: Okay. So let’s transition and go above the knee and let’s chat more about some things going on with that hip complex and how that’s potentially contributing. And then what are some ways we can maybe start to attack that as well.
Dr. Jonathan Gardner: Right. So I mean, the biggest thing for me that I’m going to look at is the ability to get proper rotation and stuff like that. So again, I think in the PT world, particularly like people, they’re obsessed with glutes and external rotation and driving your knees out and keeping them out over your Pinky toe and all this stuff. But I mean, when you’re in a general, like, squat pattern, your hip has to move from er to er to er constantly. So you’ve got to have both.
So this whole idea that you’re just going to work glutes and you’re just going to work external rotators like that’s not necessarily the case by any means. So I mean, I’m looking at can they actively internally rotate their hips? Do they even have the passive hip internal rotation to get into these positions? Because if you don’t, then you can’t put the proper stretch on the proper muscle, so then you can’t fire them. And that’s when you’re starting to get into more like that compensation stuff, whether you’re going to again, your body is going to do the most efficient movement pattern it can to accomplish the task.
So if you’re not making sure that you’ve got your kicking those prerequisite boxes of, like hip internal rotation and proper strength and those positions, then it’s not going to matter. You can queue knees out all you want, but that’s a conversation for a different day. Everybody over with mini bands and all this kind of stuff. Again, if it looks so bad that I can’t stand to watch it. Yes, I will come in and recreate and fix
somebody’s knee August, but like, your hip has to internally rotate like your leg is going to rotate inward and pronate and all those things like when you’re going to do, like an explosive jump and stuff like that.
Valgus, I think, is more like a shearing type thing. Anyway, this idea that your knees can never go in, they can never go over your toes and your foot can never pronate and you can’t internally rotate. That’s very old school thinking like your old classic, like snap down and keep your knees out and sat and push your knees way to the side. And then again, those are the kids that come in and complain of like lateral knee pain into your knee pain type stuff. So again, making sure that they’ve got internal rotation and abductors has been a huge thing for me.
Moving in the last I’d say probably a year or two, like finding those as opposed to just crushing hip external rotation as well. So making sure you’ve got the range of motion prerequisites and then also just general Hi adductor strength is super important then obviously the hamstring is super important in terms of, like finding, like, true hip extension, not over using, like, lumbar extensors and stuff like that as well. That’s typically where I look at, like, hip internal rotation and then just general strength testing.
James Cerbie: Yeah, this is a big one. I hate the whole knees out movement and it’s still a thing, and it drives me insane. I guess that probably goes back to a lot of the Kelly Starrett CrossFit mobility wad stuff, where it’s you’re going to torque into the ground and drive our knees out super hard. It’s like this dumb. I’m like one if you can’t internally rotate the hip and you can’t open your pelvic outlet, which isn’t going to come into what’s going on with an adductor, right? You will not be able to squat.
You may not be able to squat. Well, you may fake your squat, but it’s like you also won’t be able to go into a cut and come out of a cut because you have to be able to internally rotate and absorb before, so you can then turn it around. Right. But for whatever reason, there’s this huge story, like driving your knees out and external rotation, external rotation. I’m like, Well, if you put an athlete or even any of our people, like people that train. If you put someone that actually trains on a table, here’s what they’re going to be missing 99% of the time.
They’re not going to have IR. They’re not going to have extension, and they’re not going to probably have the ability to add duct. They’re going to be really good at abducting, and they’re going to be great at externally rotating. Yep. And then we just pile more of that on. Exactly what are we doing? We got to fill the empty bucket. This is what they need if we think about trying to reclaim some of that for people.
Dr. Jonathan Gardner : Sure.
James Cerbie: What are some things that people can do? Because if you’re listening to this and you’re still in the knees out camp, please, for the love God, just stop. Even if we just want to think about a squat, it makes no sense. I’m trying to put force into the ground so that I can push myself back up. Why would I want to drive force rotating laterally when I’m trying to put force straight down into the ground? That’s like, okay, I want you to jump as high as you can, but I want you to think about trying to push your feet out to the side when you do so exactly like that. So stupid.
Dr. Jonathan Gardner: I know. And then they wonder why they come in and they have like that again. It’s like that lateral knee paint and everybody’s going to tell me it’s ten. And I’m like, no, it’s like the Tel ephemeral type stuff because you’re not using the whole system because you’re driving like, a compensation pattern and stuff like that. And the other thing that I always tell my athletes and stuff, cause, like, isn’t it bad for, like, my knees to go, like, and I’m like, I’ll show them videos of, like, Michael Jordan jumping, and when he takes off, his knees are touching.
Like, if he’s able to fly like that, then I don’t think it’s time for me to tell you to drive your knees out as far as you can just to stick a landing? Like, your body is very smart and it knows how to decelerate. So for most of these people, it’s a little bit like, you’re going to use your doctors and you’re going to allow that leg to internally rotate to create a more stable base. So that whole drive your knees out thing is for me anyway, it’s like a thing of the past for sure again, unless it’s, like, so ugly that I can’t stand to watch it.
And it’s like a true Valgus collapse where it’s not controlled that I’m not. That’s when I’ll step in and queue, fix that sort of stuff and try to find more gluten hip control more often than not, that’s not necessary. You can allow them to have, like, that little bit of valgus whether the knee goes in and they’re totally fine and totally safe if anything, as soon as you start driving like that external rotation abduction type strategy, that’s when you start to get too much compensation. So that’s probably been the biggest thing for me in recent years.
James Cerbie: So what are some tactics or strategies or ways that people can approach this for themselves? What are some things that they can do to start working on? Like, let’s just make the assumption that if you’re listening to this podcast, I would be willing to bet that you’re probably lacking hip internal rotation, abduction and extension.
Dr. Jonathan Gardner: Right.
James Cerbie: I’ve done enough table tests. I’ve seen enough people that’s unanimously what walks in the door.
Dr. Jonathan Gardner: Exactly. Right.
Reclaiming Range of Motion in Your Hips
James Cerbie: So what are some strategies we can start to use to win this back for people? Because a lot of times people are going to be like, oh, I just need to stretch more and a lot of times it’s probably not the best of strategies that you could be using it. I would love to be like, how do you think about reclaiming this range of motion and option and control for people?
Dr. Jonathan Gardner: Right. So I tell kids all the time, like, it’s great to have all this range of motion, but if you can’t control it, it doesn’t matter. I haven’t gone full FRC, but, like, I definitely use some, like, FRC principles and stuff like that. So I do a lot of 90 90 work where you’re doing in range, lift off and stuff like that. And even if these kids can’t completely reclaim, like, 30 to 40 degrees of hip by art, like, if they’re actively feeling what I need them to feel with some of these drills, then we’re moving in the right direction.
So I mean, if you’re in a simple, like, 90 90 position, like, we’re going to focus on the back leg side. You’re going to drive that knee into the floor. So you’re going to find a little bit of adductor type stuff. And then you’re going to actively try to internally rotate the foot. And again, you can do these different contract relax techniques. You can do lift offs and holds and stuff like that. But I’m just trying to basically put it back together again, like we talked about earlier, like, I’m giving you the constraints early, so that no matter where I put you, you’re going to feel what I need you to feel.
So we start with a lot of ground based stuff like that 90 90 type stuff where you have those constraints of the floor and you can feel the adductor turn on. You can feel those internal rotators fire to try to lift that foot up on the back side. And then it’s simple. I’ve had kids squat with, like, a ball between their knees and people like, what are you doing? I need them to feel what it’s like to have, like, a true vertical vector as opposed to, like, that driving knees out type stuff.
I mean, having them do stuff with a closer stance. And then a lot of it’s an education standpoint, too, because again, it’s all over Instagram the booty bands on everybody, like driving knees out to find glutes and stuff like that. Like if you can’t keep everything in line with, like, femur acting like hammer on nail and things staying straight and allowing that hip internal rotation, external rotation type stuff like you’re never going to find your glute Congrats on your thousand clam shells and frog pumps and stuff like that.
And you feel like a burn there because you’re pushing into resistance and stuff like that. But if you want, like, actual changes in hip strength and control and that sort of thing like you’ve got to be able to go the other direction as well. So I think a lot of it’s an education standpoint. And then again providing as many constraints in 90 90 positions. And then as they gradually get more coordination of those movements and they feel what I need them to feel, then we start removing those constraints and then we’re doing more like hip cars and pals and rails and all that sort of stuff.
But that’s the basic one that I send every kid home with because it doesn’t take it doesn’t take any equipment. And again, I’m going to put you in the position. Is that 90 90 type stuff where you rotate over the back leg and then you try to lift that foot off the floor while keeping the knee down. That’s been the biggest one for me. And again, whether they’re coming in with the Tel ephemeral type stuff where they’re coming in with a true tenant Opty. If they’re one of my basketball guys or volleyball girls, they feel better after they do that, and it typically cleans up movement the longer that they do it for sure.
James Cerbie: I think one other one there that has had some success in the past, and it’s a little bit higher up the chain a little bit more applied. I found that variations on split squats are huge.
Dr. Jonathan Gardner: Oh, my gosh.
The Impact of Variations on Split Squats
James Cerbie: In this realm, if you’re good with coaching queuing and setting up a split squat, figuring out whether I want to go front foot elevated, rear foot elevated. Maybe I want to drive my back foot into the wall like simple manipulations on the coaching and queuing up a split squat. Or maybe I’m intentionally going to try to internally rotate into my front side and do these different strategies, like, there’s so many ways that you can utilize the split squat to really went back and reclaim some of this motion, this control and then strengthen different positions so that’s another one I was going to throw out.
It is higher up that chain. Split squats, I think, are just so phenomenal in this realm. And so people need to get past thinking that split squat is just this knee strengthening because there’s way more going on than sorry, the squad strength here. There’s way more going on than just, like, quad stuff.
Dr. Jonathan Gardner: And I exactly. I mean, squat. Right? Like, you’re gonna find hamstring glute and adductor. Like that’s what I’m after with most squads. Again, unless I’m putting you on a decline board and having you get that anterior excursion of that knee over that lot more often than not. Like you’re saying, like, I’m trying to find a hamstring. I’m trying to keep my knee in, like, big toe, as opposed to driving out over Pinky toe kind of stuff. Get that doctor in like, that true control. And then again, more often, not if you’re doing a split squat, right, you get up, you don’t have sore quads.
You have a store gluten hamstring the next day. So again, that’s what we were talking about in terms of removing those constraints. Like, find that muscle on the floor when you can only activate it there, and then let’s stand up, remove some of those constraints, put you in a split squat, and have you keep find those same muscles that I had to find on the floor, and then we’ll go from there and then gradually remove all constraints totally and then get into more athletic movement.
James Cerbie: Yeah, for sure. It’s funny, because a lot of times on a split squat, if we set it up correctly to where on the backside. So like, let’s say your left foot forward, right foot’s back. And we’re not going to do anything fancy here. We’re not going to put heel wedges or anything on the front. We’re not going to elevate one versus the other. We’re not going to be pressing at all. So we’re super basic split squats, right. That backside, that right leg if you actually set it up correctly and I stack ears over ribs over pelvis, over knee.
And I maintain that and I can go straight down. The biggest thing that you’re going to hear from people is the fact that the hardest part of that movement is the back quad. Yeah.
Trying to manage this really stiff back quad. Like if I do split squats, my back quad gets annihilated. Right. Sure. If you do a good job with that stack position that we talk about and so you can get what you want out of it. It just depends how you decide to set it up and coach it and queue it. There’s just so many tools and options with a split squat that are not I’m not being utilized effectively.
Dr. Jonathan Gardner: Exactly. Yeah. And then even then, like, if I’m targeting the front leg, like, getting people to not use that back leg is always key, too, because, I mean, just going back to the initial conversation, like the foot and ankle type stuff, making sure they feel the pressure where I want them to feel and that they’re using again, they’re using that front femur as that hammer on that nail and that tibia as opposed to just again, they’re going to compensate and try to get it done. So if you hear that split
squat roll squeaking as they try to push themselves up, or if you see that back leg just like shaking because it’s taking the load and all that sort of stuff, being able to appropriately queue and get them out of that has been huge.
And then they’re like, oh, that’s how I work my front leg on a lot and stuff like that.
Utilizing the Step Up to Improve Control
James Cerbie: Yeah. And then other options in this realm, step up variations, I think, are really good also, that’s like a really integrated combination of foot ankle train control hit mechanics of you being I don’t really care about the going up as much as I do about getting you to the top and see if you can lower yourself under control. And things are just totally falling apart. Right. The step up to another place where people really mess that one up. It just turns into a glorified calf extension on the back and you watch these people do a step up and the front legs on the box.
And realistically, when you’re doing a step up, your back leg should just be paralyzed. It should act like it’s not even there. And the front leg is trying to push the box through the floor. You see all these people where it’s just like, this hop off the back leg. And I’m like, Well, you’re not getting anything out of this exercise. Use the front leg, and if you really do it correctly, it’s hard to do with £5. It’s hard to do with body weight.
Dr. Jonathan Gardner: Right.
James Cerbie: But a step up is another good, higher level integration of these ideas we’ve been talking about. I feel like, yeah.
Dr. Jonathan Gardner: I mean, that’s probably like, one of my end stage type things, as opposed. If we’re not talking like, true, like, return to for, like, cutting and all that kind of stuff, I do an active foot step up where I have them lift that front foot off the box and then I tell them I want this to make noise. I want you to top that foot down. I have them push through the mid foot. They can’t let their heel collapse below the level of the box.
So again, we’re getting that proper foot ankle complex, stiffness and preparedness for the step up that’ll generate the force first and again, they have to drive down through the box. I think a lot of this comes down to appropriate queuing and stuff like that. It’s not just a step up, like you are going to push that box through the floor while keeping pressure through your mid foot and not letting your knee fly to the right. You’re just going to push straight down to the floor and then you can really start to see, like, a change in, like and the ability to apply that force quickly and explosively without compromising the position and stuff like that.
James Cerbie: Yeah. I mean, that’s a big one for people. If they can actually learn how to be a pusher. If they can learn to push, what pushing actually feels like, because most people aren’t good pushers, they just write the pullers. Essentially, if you can learn what a push actually feels like, that ends up being a massive light bulb moment for a lot of people like, oh, this is what this feels like, right?
Dr. Jonathan Gardner: I mean, I think that’s always the biggest thing for me is I need you to. That’s why I was like, your front foot does everything. That the foot that’s on the floor, doing everything. Like if you’re not pushing through the floor, then we’re not getting what you need to get out of this exercise. So that’s the biggest thing. And that’s where you get into, like, the coordination difficulty and just knowing where your foot is in space and that sort of thing for sure, man.
James Cerbie: Well, John, this has been a fantastic conversation. I think we did a really good job, please, my own biased opinion. So I did a pretty good job here, hitting some broad spectrum things concerning this knee joint and being able to Zoom in and talk about stuff going on at the foot and ankle. Zoom back up, talk about things going on with the hip complex. And hopefully everybody listening here, I think, is walking away with some pretty good action items, some steps, some ways in which they can think about building themselves, these bulletproof knees that can perform at a really high level.
So for sure, let’s close. And where can people go to find you if you would like to be found?
Where to Find Dr. Jon Gardner
Dr. Jonathan Gardner: Sure. So I guess the easiest place to find me is on Instagram @drjohngardner23. I think he’s got a shot at is the two three and two three was my college number. What years were those? My junior through fifth year, I had to throw that on there. And the doctor just sounds cool. So I spent enough money to get that degree, so I might as well throw it in my hand.
James Cerbie: You earned it.
Dr. Jonathan Gardner: But yeah, Instagram is probably the best place to find me again. I’ll post anything from, like, my rehab type stuff to me and my wife to my dogs. I am attempting to remain an athlete in meathead.
James Cerbie: So I love it. Well, thank you so much going on today, man. This was fantastic. Everybody listening, I hope you enjoyed it. Be sure to go check out John, all the really cool shit he’s got going on. They give him a follow on Instagram. Otherwise have an amazing rest of your week and we’ll be back and talk soon.
Dr. Jonathan Gardner: All right.
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