Knee Pain Assessment Process for Personal Trainers

Most knee pain stories sound the same: a new running plan, a few hard workouts, and then an ache that won’t leave. We take that familiar frustration and turn it into a practical roadmap. Starting with a clear scope—what coaches can do and when to refer out—we break down the anatomy that actually drives decisions, the screens that reveal load bottlenecks, and the progressions that build resilient knees.

We lean into a joint-by-joint approach: verify ankle mobility so the knee doesn’t become a substitute hinge, then probe hip rotation and control with the 90-90 position. From there, we show how calf capacity underpins every step—most people aren’t near twenty-five single-leg calf raises—and why the frontal plane is a silent deal-maker for runners and lifters. Expect actionable strength work like side planks with abduction, standing abductions, seated and standing calf raises, and carefully dosed plyometrics once tissue tolerance is ready.

Soft tissue isn’t a fix, but it is a useful window. We explain how targeted work on the adductors and surrounding tissues can calm sensitivity so better movement sticks. We also demystify scary imaging, remind you that MRIs find “something” in almost everyone, and focus on what changes pain: load management, smart progression, and consistent retesting. The thread through all of it is collaboration—building a dependable relationship with a physical therapist, documenting assessments, and using simple benchmarks to show progress your clients can feel and see.

If you coach people who run, squat, lunge, or just want to move without wincing, you’ll walk away with a simple, repeatable system: assess, address, load, retest, and refer when in doubt. Subscribe for more coach-first education, share this with a trainer who needs a clear plan, and leave a review to tell us the biggest knee question you want answered next.

Want to become a SUCCESSFUL personal trainer? SUF-CPT is the FASTEST growing personal training certification in the world!

Want to ask us a question? Email info@showupfitness.com with the subject line PODCAST QUESTION to get your question answered live on the show!

Website: https://www.showupfitness.com/
Become a Successful Personal Trainer Book Vol. 2 (Amazon): https://a.co/d/1aoRnqA
NASM / ACE / ISSA study guide: https://www.showupfitness.com

Chapters

• 0:00 Welcome And Big Picture
• 0:30 Knee Pain Myths Vs Reality
• 1:31 What’s In A Trainer’s Scope
• 3:20 Mastering Knee Anatomy
• 6:00 Assessment Mindset And Red Flags
• 9:30 Joint-By-Joint: Start At The Ankle
• 13:10 Building Calf Strength Progressions
• 16:40 Hip Mobility And 90-90 Screening

Transcript

SPEAKER_00: 0:00

Welcome to the Show Up Fitness Podcast, where great personal trainers are made. We are changing the fitness industry one qualified trainer at a time with our in-person and online personal training certification. If you want to become an elite personal trainer, head on over to showufffitness.com. Also make sure to check out my book, How to Become a Successful Personal Trainer. Don't forget to subscribe, rate, and review. Have a great day and keep showing up. Howdy, y'all. Welcome back to the Show Up Fitness Podcast. Today we're going to talk about knee discomfort. What is it? What causes it? And what is in our scope as personal trainers? We need to do a better job as coaches at implementing a thorough assessment process versus what you see online, you have knee issues. Why don't you just walk backwards? Knee pain is very similar to nutrition in the sense it's very complex, but people try to simplify it. For example, as I just said, you got the knees over toes guy, someone's had some knee pain for the last year. They start walking backwards on a treadmill, their knee pain goes away. Therefore, walking backwards is the best way to help with knee pain. And that's the correlation causation effect. And that's not always the case. If you had a hundred people do it, maybe 10 people got results. What about those other 90? If they would have gone through a more thorough assessment process with a qualified trainer who has a physical therapist on their team. So if you need to refer out, you can. That is going to be a lot more systematic and effective versus throwing random exercises out there. So we need to establish: is it knee pain? Is it knee instability? Is it patellar tendinopathy? Is it osteoarthritis? There's a lot of stuff that goes into the knee because it's very complex. Let's begin with mastering the anatomy. There are 13 muscles around the knee, maybe 14. Let's name them. You got the four quad muscles, the biarticulate rectus femoris, it crosses the hip and the knee joint. Then you have your other three vasts, so vastus lateralis, medialis, and intermedius on the posterior side. We have the biceps femoris, we have the semimembranosis, semi-teninosus. Some people will say it's a fourth one because the short head, long head. The hamstrings are three for the most part for this thought experiment. And then we have the gastrocnemius, because that is also biarticulate, crosses the knee as well as the ankle. The soleus is not a knee muscle. It's strictly a calf muscle. We have two small muscles on the posterior side behind your knee, the poplitius as well as the plantaris. And then we have some around the hip, the gracillus, which starts at the hip, ischial tuberosity, comes down to the tibia on the medial side. We have my favorite muscle, startups, starts on the lateral side of the hip, comes in medially, inserts into the tibia on the medial side. And then we have the TFL. Now, from a structural standpoint, that would be 13. But when we look at biomechanics and functionality, you could argue that the gluteus maximus does have an impact on the knee because it goes into the IT band, which is going to go to your tibia. Iliotibial tract. If you stand on one leg and you have knee valgus, so your knee collapses inward and you drive your knee out and you feel your ass, oh that's a big cake right there. That sucker is stabilizing the frontal plane. So I would argue that the gluteus maximus, the upper fibers, are part of the knee as well. That's why you'll see a lot of hip exercise when it comes to knee pain. And we'll get there in a second. What I like to do is start with a very thorough assessment. Always when your client comes in, ask them questions, medical history. I like to have a little chart of a person so they circle what's wrong. And if they have knee issues, talk to me more about that in a positive voice. That's that biopsychosocial model of pain. It's like, oh, you have knee pain. Oh my God, give me a hug. You're gonna die. No, knee pain's awesome. It's telling you something's wrong. If you're driving on the freeway and your gas light comes on, you don't start banging on the dashboard. Fuck you, you idiot. Why are you doing that? No, it's an awesome sign. Let's get it checked out. So come to a trainer who's qualified. Let's see if it's in our scope. If your client said they heard it over the weekend, they're playing pickleball and they heard a snap and it's swollen, that's out of our scope. Probably an ACL, could be meniscus, could be an unhappy triad, which is the medial ACL, as well as a meniscus tear. Not a fun one. So we need to screen appropriately if it's in our scope. If they've been running the last three months in the last couple of weeks, it just started irritating them. That's within our scope. If it's radiating, if it's shooting, and you're not sure if it's from the hip or it's like a numbness around the knee, again, when in doubt or for out. That's the beauty of the soft tissue mobilization certification because we help you build your team. You should have a physical therapist. Worst case scenario, ask your clients permission, take a photo, video, they could point to the stuff. And if you're a newer trainer, this is just a great learning experience because you're building your career capital. You could pay for an assessment with the therapist, sit in and learn about that process. It doesn't mean in the future that you're going to replace the therapist. And the next time that situation presents itself, you do those screens and assessments that the therapist does. No, you're just learning more about the injury process and what they're doing because therapists are pain experts. We are like nurse practitioners in the sense that we can do a lot, but we can't prescribe, we can't diagnose. But we should be able to eliminate red flags and start going down the rabbit hole to implement some strategies to see if they work, with the efficacy being significantly higher than just throwing random exercises at clients. I'm headed to our seminar today in Orange County at Lakeshore. And I'm going to ask all the trainers, what is your process for knee evaluation? And most people will just start naming exercises. It's not to knock those trainers, but if you ask a therapist, they're going to sit down and they're going to analyze and they're going to have a very thorough process to have a better idea of what caused it or what is causing it. And then they're going to be able to implement some strategies to see if that helps. The conversation in the assessment, that par Q is hands down the most important part. And being confident, taking notes, eye contact, letting your client know that worst case scenario, I'm going to get you out of knee pain because I can refer you to my therapist. Maybe they just got an MRI and they have degeneration and they're freaked out. Well, let me let's have you meet up with my therapist because that's not a death sentence. If you take 10 people off the street and you do an MRI on their knee, they're probably going to have something wrong because the MRI is trying to find something wrong. But that's not necessarily why you have that pain. So have that open conversation and you start with the lowest hanging fruit, which is going to be the ankle. That's that joint-by-joint approach. The ankle should be very mobile, the knee stable, the hips mobile. And if one is not what it's supposed to be doing, so for example, the ankle is not mobile, well, then it's going to steal some range of motion from the knee, which should be stable. So that's why we like to do the mobility screen with putting your hand against the wall, roughly four inches. Can you get your knee to touch the wall without your calcaneus, which is that heel bone where your gastroc and soleus insert into coming off the ground? And if it can touch the wall, that means you have the requisite, roughly 30 to 35 degrees of range of motion that a lot of sport and movement requires. Just for walking, it's like 12 to 15 degrees, I believe. And then when you start having less than 20, it could be problematic. But again, you have to look at the individual because that tightness could be advantageous for someone who uses it as a spring, jumpers, triple jumpers, sprinters, and so forth. It's always a case-by-case analysis. So if they pass that test, then we want to look at strength. How do they do with a single-leg calf race for 25 reps? Check out our Instagram. We'll be posting this, what we do at the seminar today. And if you cannot get 25, how far are you away? If you're like at 23, 24, it's pretty damn close. But a lot of your clients who are moving significantly more than they used to because they want to start running or sign up for a marathon, they can't even do 10. So then the body's just going to start breaking down because of tissue capacity. Those muscles can't handle the load and demand that you're putting onto it. So if they don't have the range of motion, you get into soft tissue, the gastroc and the soleus. You could do some ankle drills as well. If they don't have the strength, implement single leg calf raises, seated, standing. And I like to do these as a warm-up, also within the accessory. Make sure it's an appropriate progressive overload. You don't want to go from zero calf raises to all three of the circuits with the accessories doing three by 20. That would be significantly too much. If you take like a 20 to 30% volume increase per week, so if they're doing zero calf raises, implement three to five this week. And then next week, progress, get to five to eight, and then get up to 10 to 12. And then play around with the load. Implement some more ballistic polymetric aspects that can help with the explosivity in those type two muscle fiber. If they pass both of those, I like to move to the hip. So then what I like to do is we should do it supine, which would be looking up to the ceiling or on a table. But if you don't have that, I like to do the hip 90-90. Now, most therapists and trainers will probably disagree, but the reason I do it is because I'm always going through how I can check off those 10 checkpoints in human movement. And most of my clients who come in with need discomfort, they want a full body workout. So I'll do the hip 9090 drill, screening deficiencies in hip internal and external rotation, passively bringing them to where they can get and they should get, which is about 40 to 45 degrees. And if they can't hold that eccentrically and you notice a 20% drop, meaning you get it to 45, they hold it and they take their hand away and it just drops to the floor. That dead space means you cannot control it neurologically. So when you're running or playing pickleball, you're creating instability at the knee. That is why it's being affected. I call it the hose approach. I use a lot of analogies that are not in textbooks, but it makes sense to my simple, dumb trainer mind. So if you have a hose and you're sprinkling your water, whatever the hell you're doing in your backyard, and there's no water coming out, you don't start banging the end of the hose. You go and find the kink and then you untangle it. So it's the same thing with the system. Why don't we have hip stability? Why don't we have hip strength? Why don't we have hip mobility? If we don't have that mobility, we got to look at the arc. So not just one aspect. Oh, we don't have 30 to 45 degrees of internal rotation, and therefore we have to start doing all these drills. Well, it could be hip retroversion, antiversion. That's why you can do a hip scour test, and that's something we'll take you through at the seminars. So there's a step-by-step process. My pops was coughing up blood the other day. He doesn't go in there and just, oh, here's some pills, take them. Oh, they're gonna take blood, analyze it, what's going on? Oh, there's some medication. Oh, maybe it's because of that. And they do another test, and they do another test, and they do another test. They try to eliminate worst-case scenarios and then have a better idea of what's causing it. In his case, it was the medication, luckily. So he was discharged and now he's back to his everyday life. But for your clients with the knee, it's the same thing. We test the ankle. Now let's go to the hip. Is it mobility? Do we have that strength and stability? I like to do a side plank. Can you lift your leg in the frontal plane? A lot of your clients can't even take their ankle off their other ankle. So this is a frontal plane exercise. So if you want to regress it and you put your bend your knee, they can't even do 10 A-Bductions. So if we don't have that frontal plane strength and stability, your knee is going to be the affected joint. When we run, there's a lot of frontal plane stability. A thousand, twelve hundred, fifteen hundred reps per mile. So if you have someone who's been running a lot and prior last three months they weren't, that's an overload issue. So let's strengthen the hip and the frontal plane. So now you can incorporate some mobility drills, part of the warm-up, part of the accessories within the CCA. And all of a sudden their knee starts feeling better. If they pass the mobility drills and you don't notice a discrepancy within internal, external arc of the hip, let's go into some soft tissue. We teach the stecko technique, which is from an Italian physical therapist, the stecko method. You're going to get into the adductor magnus. Find that cuss word spot, hurts like holy hell. On the medial aspect, it will help with lateral, anterior, posterior, referred pain. So now the nervous system calms down because it's more of a central amplification effect. So we calm the nervous system down, strengthen the hip, strengthen the knees. There's so many exercises you can choose from. That's why we like the prehab guys exercise video library, because you can choose the ones you like, three to five, send it to your clients, they get access to it, and then you can see when they're doing it. And again, that just levels up your professionalism because your clients are seeing you as that Sherpa. You're their guide. If they have discomfort, they're going to go to you, the trainer, to see what's going on. And if you're like, I don't freaking know, that's crazy. Let me take a video, send it to my therapist. You screenshot that text reply within 30 minutes, an hour, and they're like, wow, this is a really effective system. I love my trainer because they can literally take care of all aspects of wellness. It's almost a trillion-dollar industry now. Everyone's talking about recovery and these mobility drills that we should be doing. Having a competent, qualified coach is what's going to make you indispensable 100%. I do not fear AI whatsoever. I build my team, I level up my knowledge. Notice how I started out with the 14 muscles. That gives me the confidence to have a conversation with the physical therapist. Because as I've interviewed many people on our podcast who are DPTs, if you don't have that basic competency, they're like, why would I want to send you clients? Because you don't even know what the freaking meniscus is. You don't know what bursa sacs are, and you don't know a couple muscles around the knee. You just said the hamstrings have six muscles. I once had a trainer tell me there were seven muscles of the quads. What the hell? Quad means four. Where are you coming up with that, bud? That lack of confidence, your clients will absolutely be able to sniff out. So they're not confident in your ability because your client comes in with knee discomfort and you say, Oh, we're just gonna do upper body today. I can't deal with knee pain. That's out of my scope. That's false. I'm not talking about doing joint manipulations or a lockman test to see if they really blew out their ACL. No, but we can do a lot. And then when we implement those correctives and your client feels better, holy shit, here's my black Amex. I'll sign up for a hundred sessions. I've had students come to our seminars, they've had knee discomfort for 10 years. We implement these strategies, and within a few minutes, we're like, holy shit, it's gone. The next day they'll come back and they'll be like, yeah, it's it's back a little bit, but it's significantly better. It's not a one magic trick pony show. It's a process to build strength, but psychologically to empower your clients. They are not doomed. You can implement strategies to help your clients' knee discomfort go away. Let's check out some anterior core strength, some lateral core strength, because a lot of times that will clear up the mobility issues at the hip. As I've posted numerous times, client has five degrees of hip internal rotation with the hip 90-90. You do some lateral core strengthening for the obliques, external obliques, internal obliques, also the TVA, transverse abdominis, and then you do some abductions for the hip. And then you go back and retest and you notice that now they have 30 to 40 degrees. Well, great. We found a solution. We warm up, get into some soft tissue, do those stability and strengthening exercises, then you train, and then they get stronger. And then the knee discomfort over time comes down. That is what the process should look like when it comes to being a qualified trainer. All things that we teach within our three certifications, get certified for life. If you need to pass a textbook cert, that's included. We'll send you all the material to pass those easy textbooks within 30 days. So then you can level up with the certification for life. We have the soft tissue mobilization cert. That's what we do at the seminars with our partnership with Lifetime. We're going to be at two per month in 2026. Atlanta, Phoenix, Red Bake, New Jersey, Dumbo, New York, Houston. That's our first quarter. If you're interested in getting to one of those seminars right now for 2025, all$4.99. We have deals where if you want to get three for the next 18 months, get that bundle and you can go to three in the next 18 months. We have an upper body one now and a lower body. This is just for the knee. At the low body seminar, we're also going to take a look at the ankle, do soft tissue drills there, and also the low back. Most of our clients have low back issues, and we don't just say plank, you need to do lateral walks or whatever it may be. There's a system for it. You go through an effective assessment process, eliminate red flags, when in doubt, refer out to your team physical therapist. We help you reach out and get one on your team. I have so many success stories with SUF CPTs where they have a therapist who's sending them regular clients and they're actually training the therapist. Most therapists don't have a background in programming and periodization. They just give simple exercises. So if you start training that therapist and they start getting jacked, they're like, oh my God, this is a great system. I'm going to make it a requirement for my clients once they finish their prescription from me to start working with you. You can even make it a monthly protocol where you make your clients go to the therapist. You're not making them with a gun to their head, but you are highly suggesting, just like with getting your teeth cleaned, you do this monthly to make sure that we're ahead of the curve versus being reactive when we have knee, ankle, low back, shoulder, elbow, neck issues come up. So let's implement these strategies, part of the accessory. And your life is going to be so much easier because you know what you're doing. You don't have that imposter syndrome. Your confidence is growing because you have an amazing team. And most importantly, you're helping your clients get results. Remember, big quads are better than small ones, and keep showing up.