Knee Pain in Rowing

Knee pain is the second highest cause of pain in adolescent rowers with 18.8% of injuries reported in a study by Smoljanovic (et al.). Lower back pain was reported at 32.3%, for your interest!

Knee pain of the overuse variety has a range of causes, but the most common is patellofemoral pain. Patellofemoral pain is caused by a shift in the homeostasis (the state of happiness and balance) in the knee cap joint, usually by increases in training load. Activities such as running, stairs and squatting – movements that require the knee to be bent whilst bearing weight – can load up this joint and cause sensitivity (NOT inflammation, generally speaking). This sensitivity can translate into the boat, where the knee joint is bent up to 140 degrees in some cases, making the knee cap joint susceptible to overload and continued sensitivity.

I tend to see patients presenting with this injury when there is an imbalance of strengthening or conditioning (usually unaccustomed heavy squatting for males, and lots of running and stairs for females), usually early in the season.

What does it feel like?

• Some common symptoms of patellofemoral pain include a vague ache anywhere around the knee cap – you generally wouldn’t be able to point to a specific painful spot.
• No Mechanism of injury – although it sometimes can be the result of deconditioning from another injury to the knee or quadriceps.
• It is usually painful to perform a squat, single-leg squat or go up steps, but despite this, you will likely have full range of motion if you bend your knee if there is no weight on it.  
• Sometimes you will have pain when standing up after sitting for an extended period of time (AKA “Movie-goers Knee”), others will have pain from running (“Runner’s knee”).
• Patellofemoral pain is a diagnosis of exclusion, so it is important to rule out other causes, especially other injuries in the knee, hip or back.
• The pain can be on both sides, one more than the other or one side only.

What can we do to treat it?

• Strengthening of the quadriceps and gluteal muscles – This helps to restore homeostasis in the joint through a number of different mechanisms. Your physiotherapist can facilitate these exercises. My favourites are the classic “Bridge” exercise, but some other popular exercises include clamshells, hip hitches and leg raises on your side.

• Taping the knee cap – Known as the McConnells Tape. It consists of pulling the knee cap in towards the midline. Here is a video of Jenny McConnell taping the knee herself! https://www.youtube.com/watch?v=WbHXYnwUwws  For Rowing, we generally need to have more range to bend, so I will typically use a stretchy tape, “Dynamic tape”.

• Substitute Running and Stairs for bike sessions or swimming  – These are lower impact and will put less load through the knee cap joint.

• Row with a band around your knees – Particularly on the erg, drive your knees outwards against the band to activate your glute (buttock) muscles. Ensure you do not feel the muscles at the front of the hip working. This will help to keep your knees in line with your hips during the drive phase instead of the knees tracking inwards, a common error.

• Tinker with the angle of the footplates *Speak to  your coach first* to make the angle more horizontal by moving the bottom runner towards you. This will reduce the amount of compression and force through the joint, potentially improving the equilibrium in the joint again. NOTE: It is essential to realise that when making adjustments in the boat, it may change the distribution of force on other joints or muscles, loading them more or less and potentially leading to injury. Ensure that you have adequate time to adjust to these changes without strenuous training, so these muscles and joints have time to adapt.

In more extreme or strenuous cases, a small amount of time off rowing may be beneficial. This will depend on the stage of the season – earlier in the season is usually more conservative than later in the season when the big races occur.

What else causes Knee Pain?

Traumatic knee injuries and swelling in the knee should be assessed by a health professional, particularly as the diagnoses and treatments are varied.

“Overuse” or non-traumatic pain on the outside of the knee is likely to be a different issue – Iliotibial Band Syndrome which may respond better to rest, taping and strengthening of the gluteal muscles.

The best way to know what is causing your knee pain is to get an assessment!

Key Message

Ensuring that the hips – particularly the gluteals and hamstrings – are contributing to the stroke is vital in spreading the force through the lower legs and not just through the knee. A strengthening program should include an exercise for both of these muscle groups, performed on a bi-weekly basis with good technique.

Bodyweight exercises are sufficient for most young rowers: e.g. squats, lunges, bridges, push-ups, step-ups, pull-ups, inverted rows. Once mastered, weights under supervision can be added (there is no evidence to suggest it contributes to stunting your growth), but once again, technique is the focus!

References

Smoljanovic, T., Bojanic, I., Hannafin, J. A., Hren, D., Delimar, D., & Pecina, M. (2009). Traumatic and overuse injuries among international elite junior rowers. The American journal of sports medicine, 37(6), 1193–1199. https://doi.org/10.1177/0363546508331205.

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