The Move On The Daley Blog

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Nov 07, 2021

Ever had a pain start up that you recognized, because it’s in the exact same spot as before, but then you went to do the exercises/treatment that helped last time, and it didn’t work this time?? Or have you ever been describing what’s going on to a friend and they say “OMG, I had that EXACT thing! Do this! It was a game changer!” And then you do and it doesn’t work??

This can happen for a multitude of reasons. But the main one is this: Pain is far too complex to be a one-size-fits all approach.

One of the reasons is simply that pain in any one particular area of the body has several possible origins. And unless you target where it’s coming from, it’s not gonna go away. A very generalized example of this could be pain in the right sacral area (around that bony spot that’s between your low back and your glutes): It could be coming from the glutes directly, but it could also be referred from your lumbar spine. Or possibly coming from your pelvic floor. Or sometimes even from your mid back. There are other possibilities, too, but I think you get the point. You could roll out the glutes and do all the activation drills you wanted to, but unless you address that actual issue, you might get some short term relief, at best, but then it’ll come back. Another example is the shoulder. I had someone recently who came in with a very similar symptom presentation as previously and it was some of the same movements that bothered them. Pain with strict press and HSPU mostly, pointing to the top of the shoulder and some into the outside of the shoulder. The last time it had been tendinopathy of the supraspinatus (one of the rotator cuff muscles) and had cleared up pretty quickly with some dry needling and intentional strengthening drills. This time, when it flared up, they tried those same drills to no avail. They messaged me and I was able to get them in for an assessment and found that this time it was subscapularis, which while it is still within the rotator cuff family, actually has a very different function and needed to be addressed with vastly different exercises. Once we had that figured out and treated it, they were quickly able to progress back into all the things.

So by all means, if you’ve had something similar before and have some tools (in the form of exercises, etc) that worked, try them! But if you don’t see changes fairly quickly, pivot!! What’s that saying about continuing to try the same thing and expecting a different outcome? That applies here, too.

If this sounds like what you’re dealing with, jump on a discovery call with me. I offer 10 min free ones where I can give you quick advice, and only if it warrants PT and we’re a good fit will I suggest setting up an appointment. I can also help you find a provider in your area or even the right kind of provider if it isn’t PT! But don’t keep trying something that just isn’t working.

Now there are other reasons as to why it’s not working other than it’s actually a completely different cause - Though with all of those reasons, the best advice is gonna basically be the above paragraph - when in doubt, consult a healthcare practitioner that you know just wants to help you get better regardless of whether it’s them you see or not. Another possible reason is that it IS the same thing but you just kinda got lucky the last time. Meaning that you might have improved regardless of the treatment. This does happen. Our bodies are very resilient; often more so than we give them credit. So if it was something relatively minor (though the symptoms may not have felt that way), and you were healthy enough (including mental and emotional health), it might have just healed on it’s own with time. Now with that said, there are generally things you can do to speed up that process. I often see the above scenario happen in a case like a CrossFitter who’s having shoulder pain and gets an MRI that shows a rotator cuff tear (for the record I don’t recommend imaging 99% of the time. AND physician guidelines are also starting to say they shouldn’t be recommending imaging.) Now, whether or not that’s what’s causing their pain is something we honestly CANNOT say (research has proven this. Plenty of people have tears with full function and no pain.) But that sure as hell doesn’t seem to stop some providers from saying it. If you see the more “traditional” PT where you get maybe 20 min with them and they tell you to “hold off on lifting for awhile and in the meantime do these yellow/red theraband exercises…”. Now from a research and clinical experience standpoint, that should simply NOT work. Namely because tendon injuries do not respond well to rest, and a theraband exercise for someone who’s got some strength is simply not enough loading to cause any positive adaptations in the tissues. With that said, someone who’s young and healthy and sleeps well and otherwise active, etc, may get lucky and be able to slowly get back to all of the things regardless. Why? Because they still were able to get inflammation down enough to allow the tissues to calm down enough to function properly and slowly strengthen as they got back into lifting. Now, I’m not gonna dive into the science behind that too much because I don’t wanna make this blog super dense. I will make a quick note, though, that the “young” aspect of that is because of our body’s fluid content being higher at younger ages, and more mobility allowing better fluid movement, therefore more dilution of any inflammatory chemicals. But no one gets away with age as an excuse for not being able to the things you love doing. You can and will get back there if you want to. There are other ways to “flush out inflammation.”

It could also be that you’ve gotten stronger since the last time (or you’re stronger than the person giving you what they did) and therefore the exercises simply aren’t enough. My point is, another thing that might be going on is you need more LOADING than what you’re doing. Far too often, we rest or underdose loading when it comes to recovery. For example, if you can squat 200 lbs, sidelying clamshells simply ain’t gonna cut it if you’re trying to load up the glutes. Again, that where it’s really helpful to have someone in your corner (me or whoever) guiding you and progressing exercises based on YOU and meeting you where you currently are.

Now I do wanna make a quick note that I don’t completely hate “basic low level” exercises like yellow theraband ER. They have their place. They can be helpful for getting some muscle activation without ticking off the tissues and increasing pain. But they are really only appropriate in the acute phase (first few weeks) if at all. And even when they are, there are honestly better ones and by better, I mean more effective, efficient, and fun (though admittedly there is some bias there in that last bit). You HAVE to move on from those and continue to build strength in order to become more resilient and decrease the chance of flare ups!

So to summarize, the “old stuff” or suggested things aren’t working because:

  • It’s something completely different that just has a similar presentation and you’re missing the true underlying issue

  • You’re on the right track but not loading/challenging the tissues adequately

  • There are other non-physical factors on board that need to be addressed as well

  • Inflammation is on board still more than last time, which isn’t allowing the drills to do what they’re meant to

Again, these are very generalized, but hopefully this information helps! If this resonated, please share this on whatever platform you prefer! Questions? Drop them below in the comments!

And if you found yourself wanting to have someone help guide you in finding the underlying cause and/or appropriate loading, etc…

Oh, and one last bit…if you are having any “red flag” symptoms along with the pain this time, DM me or your PCP or some healthcare provider ASAP (may be nothing, but this is definitely a rather safe than sorry situation). The list of red flags are a little different in the case of headaches or abdominal pain, but this list covers the big generalized ones, particularly for low back pain:

  • unexplained/unintentional weight loss (over 10lb in 3 months)

  • unrelenting night pain that doesn’t change with position/activity

  • bowel and bladder changes

  • night sweats (new onset)

Because I have to make sure this is clear: Reminder that this blog is not intended to be individualized medical advice. Please consult a healthcare practitioner directly for individualized care

Much love,

Dr. Megan


"Your knees are shot and if you keep up all the activity you're doing, you won't walk at 30"- what I was told by medical professionals at age 18 after my 3rd knee surgery. Fast forward to today, and I'm 32 and not only do I Crossfit 4-5 days a week, but my off days are usually spent trail running and/or hiking. And the only time I have knee pain is when I take 4 or more days off from activity. You see, the stronger the muscles around a joint are, the more they can unload the joint - i.e. the ligaments, meniscus, and cartilage in the knee don’t have to absorb quite as much force as they would otherwise. And less pressure = less risk of damage or pain. 


For years, I avoided squatting below parallel, catching heavy weight in a squat such as full cleans and snatches, and had a crazy wide squat stance. I also avoiding running and would get nervous hiking downhill. Why? Because I let the nocebo (negative thoughts) given to me medical professionals dictate my movement. You see, I've had three knee surgeries, with the 1st one being in 5th grade and the last being a cartilage graft during college. Most of my knee injuries have been due to Osteochondritis Dissecans (Rare condition. Lack of blood flow to bone causing cracks to form in the cartilage and underlying bone. Cause unknown). Though one surgery was an ACL reconstruction where they took out part of my patellar tendon and put it where the ACL should be.


With each of these instances (a few others didn't require surgery), I was told yet again that I should stop doing any high impact activity, never run on hard ground, that I should never do heavy squats, and definitely don't go below parallel even without weight. This is devastating news to a very active and athletic fifth grader. And let's be real, still devastating to an active college student. Thankfully, I'm stubborn. I agreed to quit all hard court sports like basketball (though to be fair, as soon as everyone else hit their growth spurt, I probably wouldn't have lasted) and gymnastics. But I refused to give up soccer. And with that came weight training once I got to high school.


I still lift and do Crossfit 4 days a week and trail run or hike in the off days. I honestly LOVE heavy squats and deadlifts, and I am constantly challenge myself! And you know what I realized once I left soccer but was still in the gym doing weightlifting? My knees only bothered me when I did one of 2 things: wayyyyy overdid it or skipped the gym and hiking several days in a row.

Two main takeaways from this bit:


1. Don't let a doctor's opinion dictate your own opinion or your life.

Every profession has it's bad and good apples. And a certain degree does not make one infallible.


2. Heavy squats fix everything (read: your body wants to be loaded. Strength training has countless benefits and should definitely be a part of your life)


So I bet you’re like “Sweet, so strength is important. Got it. But what are some ways to build up strength?” Here ya go:


First, I should explain that it’s not always as simple as “get stronger.” Mobility and technique also need to be considered when figuring out the cause of knee pain. And it’s almost never directly the knee. Typically, if a mobility issue is at play, it is either from the hips or ankles, though it could be from further up as well. This will be it’s own blog (or maybe Eboko!) soon

As far as technique goes, it really kind of depends on when you’re having pain. For example, if it’s just with running, maybe you’re not keeping enough bend in your knee throughout the gait cycle, causing increased stress on the knee. If it’s just at the transition point at the bottom of a squat, maybe you’re only going to parallel, which is actually the knee angle with the highest amount of pressure on the knees. Or maybe you’re letting your knees come inward even just slightly with squats or sumo deadlifts and causing undue stress. If you are having pain with a certain lift/movement and want it assessed, or just want to dial in technique, I do offer movement assessments. Ok, gonna get nerdy and dive a bit deeper to include some research on technique for the next few paragraphs...(if you don’t care about research and just want the takeaways…skip to the next bolded line)

Research by Bloomquist et al showed that deep squats improved strength throughout the range of motion while shallow squats did improve strength a little more at shallow depth, but minimal strength increase at deeper positions. In other words, if you constantly squat above parallel, you;ll get stronger in that position, but not really improve strength  for things like getting up and down from the floor, squatting down to pick up heavy items off the ground, catching nd standing a clean or snatch at full depth. Squat jump strength also improved only with full depth squats, not quarter squats according to research by Hartmann et al.

Hartmann et al also found that the compressive forces in the knee are highest at 90 degrees and have little quad tendon support, yet when you squat deeper, there is actually a protective wrapping effect around the knees! My mom can attest to that. One of my biggest recent “wins” is finally getting my mother to listen to me (seriously, it’s like pay back for not listening as a child) about squats. She does not have ACLs in either knee and then retore an MCL about 10 years ago while waterskiing. She has at least listened to me for awhile that the best thing she can do for her knees is keep up strength to create the extra support needed in lieu of those ligaments. About a  month ago, I finally got her to start doing a few exercises I wrote including some goblet squats with increased weight. However, she’s been scared to squat below parallel. So she called me up and told me her knees were achy. I explained the above research and told her to just give going below parallel a shot for a few days and call me back. Guess what?! Her knee pain was GONE!

The other major lie that we’ve all heard is that your knees can’t past your toes. Absolute BS. In fact, I can personally say that the first time I really felt my quads fire during a squat was when I finally let my knees go past my toes. It’s also the first time I didn’t end of having soreness in my low back after a bunch of squats. Here’s why: Fry et al did some research looking at joint forces at the hips and knees when knee movement is restricted to avoid going past the toes or allowed to do so. They found that if it is restricted, there’s a 1000% increase in hip forces. One thousand y’all! It also caused your torso to come more forward since the hips had to stay back. This then places more pressure on your back. Between those factors, it’s no wonder my back was getting sore with back squats! Some of whether or not your knees need to come forward and the degree to which they do is definitely dependent on your specific anatomy.


Okay, now for the fun stuff. Strength. Note that this is specific for the person dealing with knee pain with squatting…

As I mentioned earlier, if you have strength surrounding the joint, it will unload it and you won’t deal with pain that comes from pressure on the internal structures (for example, osteoarthritis bone changes won’t cause pain) But…how do you build strength if you’re dealing with knee pain already?? The following exercises will be a great start!! 

Even better if you mix in things to spike your heart rate like a 30” arm only bike sprint…gets your heart rate going, thereby increasing fluid circulation to the legs/knees which will drastically help “flush out” any inflammatory chemicals. Therefore, decreased swelling and pain!

There are plenty of great drills not listed here, but this is a great start:


-Knee Gapping. 

Ok this one is for you if you just feel a lot of pressure in your knee when you squat and feel like it limits you. You know that feeling when your knee is even a little swollen and it won’t quite bend all the way back into full flexion? Yea, this helps with that. A ton. You can use a small ball, like a lacrosse ball, or a tightly rolled up towel like I am here. This helps glide the tibia (the lower leg bone) forward as you go into end range motion, which is what’s needed, and increase the joint space so it doesn’t get as much of that pressure feeling. Help yourself into end range flexion by grabbing your lower leg and pull it in, as shown. Make sure to get some calf motion in by moving your ankle around as the gastroc does cross up over the knee and assist in this motion. (side note: please ignore the squeeky ball in the background from the pups)
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- Spanish squats. 

Easily my favorite exercise to not only get a quick solid quad burn, but to unload the knee and allow better movement. I’ve used this countless times with acute knee pain, chronic arthritis, post surgical, and a whole host of other people (and myself) to be able to squat sooner and build/maintain strength. The band is placed directly behind the knees. You want to make sure there is solid tension in the band throughout the movement - as you can see in this video, the band can hold my weight. Unlike a normal squat, you keep your shins perpendicular to the ground. The kettlebell is mostly to counterbalance and help me keep my chest upright. Shoutout to Zach Long, PT, DPT (aka @thebarbellphysio) for introducing me to these several years ago while we were at a course together. 
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- Copenhagen Planks.

So it may not be readily obvious how these help your squat, but the truth is the inner thigh muscles play a HUGE role in full depth squats, and if their capacity isn’t adequate, it can cause knee pain, particularly on the inside of the knee. Now, this exercise is MUCH harder than it looks, so I highly recommend starting it where you have the top knee supported on the bench (or couch or whatever you’re using). If that’s still too much, you can leave the bottom leg on the ground and allow it to help support as much as needed, but as little as possible (don’t cheat yourself!)
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- Bulgarian Split Squats.

Not just for lifters. This is a fantastic exercises for hikers and trail runners as it not only works on the muscles you use in your sport, but it also challenges single leg and trunk/core stability which are very important. Get into a lunge position with the back leg up on a box/bench/couch/whatever and then drop your trunk straight down while both knees bend. I’m using a kettlebell in a goblet hold here, but you can also do a barbell in the front/back/Zercher position
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- Hip Thrusters 

Yes, I know, this is a butt exercise. But without strong glutes, your knees will be trying to compensate for lack of stability. No bueno. Besides, lets be real, is there a downside to having a nice ass? No. 
In this video, my fiancé is demonstrating with both legs, but going single leg is a great option as well! Please note, he’s also going absurdly light with the weight here. You want to go HEAVY on this exercise. You’ll probably surprise yourself with how heavy you can go…I have multiple patients over 65 that do this one well over 100, if not 200 pounds for reps. Just make sure you can actually hit full extension at the top (meaning your hips finish in line with your knees and shoulders)

No barbell? That’s fine! Use a super heavy dumbbell or kettlebell…just know you’ll be limited by getting the weight on/off your lap and will need to up the reps to have any benefit. 

Video Poster Image

Ok, hopefully these exercises are helpful!


One last quick note that I’d be remiss if I didn’t mention: When discussing knee pain, you have to consider lifestyle factors. All too often, knee pain is due to any increase in the body’s inflammatory response. And I’m not just taking about the injury response. If our diet, our sleep, and/or our stress is trash, it affects our entire system. So while I don’t wanna vilify the occasional cup of ice cream (that would make me a hypocrite), I do want to point out that if you’re crushing a whole pizza, McDonalds, and M&Ms every day, then it’s not entirely surprising that you feel lie you have “bad knees”…but if you take away the inflammatory-inducing foods, get 8 hrs of sleep, and move your body regularly, I bet you would find that you actually have good knees! They were just mad at you and letting you know they were mad…


Alrighty, drop any comments/questions below! 

And please share this blog with anyone you think would find it helpful! 


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