Fixing your Knees Without Surgery Part 2
When you feel like your body has failed you, maybe you should consider the notion that it might really be the other way around. In what way have we failed our knees? It mostly comes down to chairs and shoes, both of which make it impossible to move correctly.
Pain caused by movement in any joint means that joint is likely doing more work than it should. Why is it overworked? Because the muscles supporting the neighboring joints aren’t pulling their weight. Shoes inhibit movement of the foot to the detriment of the ankle and knee joints, while chairs inhibit the hip joint to the detriment of the knee and lumbar spine.
Let's talk about ankle mobility. A lever needs to rotate around the fulcrum and if there isn’t enough movement at the axis to accomplish this, then you'll have to compensate by moving differently.
The image below shows a goal for ankle range-of-motion. The plantar-flexed ankle is how the foot should look right before the "toe off" moment in the gait cycle. The axis of the ankle and the pulley system of the posterior leg muscles require a straight foot to generate the most force without friction.
Then there are the mechanics of the foot itself. Too often in a shoe-wearing population, the foot is no longer supple enough to conform to the ground, but stiff and chronically everted when bearing weight. This forces the subtalar joint (located below the ankle) to wobble side to side while walking.
Pointing the foot outward decreases the ankle's range of motion. In the outward-pointing foot, the ankle rocks left to right as opposed to flexing front to back. In such a case, if you want to save the knee, it's necessary to realign, and stabilize the ankle joint while helping the foot acquire the suppleness it needs to be a functional foundation. Did you know that you should be able to rotate the forefoot independently of the heel? Try and see if you have this movement available to you.
Slowly start asking both the ankle joint, the tissues of the foot AND the toes to flex more when stretching, as in the example below.
Next stimulate the intrinsic muscles of the foot by allowing them to conform first on a tennis ball, and over months progressing to a large superball, then a golf ball and finally a marble.
Make sure you do this corrective with the heel planted firmly on the floor and the foot pointing forward. Then let various parts of the forefoot and arch drape over the object. You could also just go outside and walk on rocks. You’ll know your foot is starting to perform properly when you look forward to taking your shoes off after a hard day’s work and relaxing your foot over the most pointy thing you can find.
That takes care of the foot and ankle. But no discussion of the knee would be complete without examining the hip joint. We are a population of chronic sitters. The first offense to the hips is that we sit too much, the second offense is that we sit in the same position every time. Most chairs are designed to keep you in 90 degrees of hip flexion and 90 degrees of knee flexion. What do we know about joints that aren’t moved? Eventually they no longer CAN move. When your hamstrings, calves and hip flexors are in a chronically shortened position, you are essentially engaged in a training program to maintain this shortened position.
So, say from hours of sitting and a lifetime of fashionable shoes, your hip joints only like to be in flexion and your feet are immobile. Great! You can get up out of your chair and walk with shortened hip flexors, wobbly ankles, and stiff feet. The body is an amazing organism and it can compensate, you’ll just have to bend your knees more—perfect!
Except for the pain.
You aren’t technically walking in this position. It’s more like a series of small falls. That bent knee is absorbing the shock of the fall with each step. You can use the position of the torso to determine whether you are falling or walking. Look at the images below. One pair of (Nordic) walkers is landing on extended legs and their torsos are upright—they're walking. The others are landing on flexed knees and you can see the angled position of the torsos—they are falling.
Let's go back to the shank for a second. The externally rotated shanks force the femurs (the bones of the thigh) to rotate in the opposite direction (internally) over time—an orientation like a wrung towel and the knee pays the price. This style of walking is too reliant on quadriceps (muscles in the front of the thighs) and requires little or no use of the hamstrings or glutes (the muscles in the backs of the leg). The byproducts are big, bulging quadricep muscles and a flat butt.
The gait pattern that preserves the knees requires hip extension. Supporting your body weight on one leg while actively extending the hip behind you, referred to as a "posterior push-off", requires really strong glutes. If you are walking on level terrain, your knee shouldn’t have to bend. Can you walk with straight legs on level terrain and NOT elicit quizzical looks from passersby? The muscle-action necessary for a posterior push-off begins with a contraction of the gluteus medius on one side, allowing the foot of the other side to float off the ground. This movement is NOT happening above the waist, the lever system is in the pelvis and hip joint, as illustrated below. You can try it. The contraction you are looking for is on the outside of the hip, towards the back. The stronger the gluteus medius, the less you have to lean to perform the move.
Once the non weight-bearing leg is floating, the hamstring of the weight-bearing leg contracts pulling it behind the hip, and keeping the knee straight at the same time. Finally the gluteus maximus contracts right before the heel lifts off the ground. At this same moment the heel of the floating leg strikes the ground and the muscles fire in the same way on the opposite side, completing the gait cycle.
I find it helpful to imagine that my heel is the bottom of a gondola pole, the longer it can stay planted on the ground with my knee extended the more powerful my stride feels. Just remember to push backward to move forward. Swinging a limb forward to move forward is falling.
Below the knee, it is important to have a foot that can point straight ahead in every one of the positions requisite for knee-preserving gait: heel strike, foot flat, heel off, toe off. Walking this way helps your body stay upright and strong, and encourages a nice round butt. It's important to note that optimal gait is ONLY possible when the foot isn't hindered by stiff-soled or high-heeled shoes. I suggest practicing barefoot and indoors to start.
Here are some correctives to turn off the quadriceps, retrain the posterior legs and lateral hips to achieve posterior push-off and let you shift from falling to walking. The more you do it, the better your knees will feel.
Knee Cap Release: First learn to turn off your overworked Quadriceps and stop the patella from constantly drilling in the tissue of the knee joint. Stand in your "alignment stance." Really bring the weight into the heels, keep the knee fully extended and see if you can relax the quads so the patella drops. If you are having trouble lean your butt against a wall with your legs out in front of you (so your weight is REALLY behind you) and bend forward at the pelvis a little. This will put some slack in the quads and let you relax more.
Double Calf Stretch: Next let's unlock the pelvis by asking the hamstrings to lengthen. This corrective can be done with or without a block. Starting in your alignment stance, with your side to the mirror, observe the curve of your back. Hopefully it is an S-shape like the model below. Now bend forward, but ONLY from the hip joint. That means that you should see no change in the curvature of the spine. The limit is the point at which the lumbar curve begins to flatten. You are attempting to isolate the hamstrings (muscles on the back of the thighs). Hold this for about a minute and repeat throughout the day. If you perform this movement very slowly, it acts as a nice hamstring-strengthening exercise.
Strap Stretch: Lie with the upper shoulders and head propped so that the back of the ribs, tailbone, and thighs are flush with the floor. Using a canvas strap or belt wrapped under the ball of one foot, raise the leg by pulling with the arms. Your limit is the point at which the thigh of the other leg lifts off the floor. Dorsi-flex the foot to increase the stretch. Hold for one minute. Then cross leg over center line of body, keeping the pelvis on the floor (no rolling). Hold for a minute, unless you have had a hip replacement, in that case, don't cross over the midline, just skip to this: Lastly let the leg fall out to the side. Hold for one minute.
Monster Walk: Place rubber ring or resistance band around ankles. You can bring your toes in a hair more than in alignment stance. It really engages the lateral hip to lead with the heels. Keep your feet about hip-width apart, and keep continuous tension on the ring. Weight in the heels. Facing forward, keeping knees straight, walk sideways in one direction for about six steps, and then the opposite direction for six steps. Repeat 3 times in each direction. Watch for cheating. This corrective is difficult. You will fatigue and then the leading leg will rotate and the toes will point outward, engaging the quadriceps, which we are trying to turn off, and shutting down the lateral hip, which we are trying to strengthen. If you've had a hip replacement, or you find your lateral hip muscles are too weak, do this exercise without the band. It's still challenging. By the way, take a look at the model's knees in this image. See how the knee on the weight-bearing leg is pointing inward, rather than straight ahead like the knee of the floating leg? That's because her foot can't support the leg correctly. The stiff foot forces the knee to compensate.
Pelvic List: This corrective can be performed on flat ground (those with hip replacements, chose this option), a yoga block or a stair step. Make sure feet are pointing forward aligned on the outside edge, and your weight is in your heels. Push the heel of the weight-bearing leg into the floor or block and allow the floating leg to rise. Hold for 45 seconds to a minute. If on a block, you can work on just keeping both feet at the same level. Repeat 3 times on each side, or until fatigued. Look at the model's face. It's MUCH harder than it looks. Try it.
Anyone who wants a printable version of this protocol can purchase it here. Of course it is always available on the blog for free! The next post will talk about how to address the internal rotation of the femur, patella tracking asymmetrically and how to strengthen the inner thigh and further strengthen the glutes.
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