By Marek Wyszynski, PT, GCFPCM
What is the knee joint for anyway?
The primary job of the knee is to control the distance between the foot and hip dynamically. It allows us to bring our feet toward our body so we can do things like put socks on. Our knee joints let us move our body toward and away from our feet so we can squat, stand up, jump, and run. Can you imagine how awkward it would be to get up from the floor if we didn’t have this incredible joint? Or climb up or down the stairs? Without the knees walking would resemble ambulating on stilts. Not much fun!
Our knee joint is what’s technically called a “modified hinge” that permits a large amount of bending and straightening but only a tiny amount of rotations when the knee is bent. Ideally, our joint surfaces remain parallel to each other. The knee joint is vulnerable to overuse and injury, especially when forced to move outside its intended range of motion. Particularly dangerous are side-to-side movements and twisting. Dr. Feldenkrais called such a side-to-side misalignment “gapping of a joint” where joint surfaces are compressed excessively on one side and separated on the other. Lateral gapping of the knee contributes to overstretching ligaments, muscular imbalances, tearing of menisci, damage of the cartilage, and excessive loading of one side of the joint – likely precursors of osteoarthritis.
The first component of this common faulty postural and movement pattern is a knee joint shifting inward toward the midline or a lateral placement of the foot. Some call this predisposition “knock-knees,” “K-leg,” or “X-legs,” but the medical term is “knee valgus.”
The second part of the pattern concerns a relative twist within the knee, between the shin bone (tibia) and the thigh bone (femur). Combining these two components creates a perfect storm that may contribute to initial injuries and flare-ups, slowing down the healing process.
I frequently see this pattern in my practice as my clients perform everyday tasks like getting up from a chair, squatting, lunging, climbing stairs, walking, running, or jumping. After all, how we do anything is how we do everything. Such is the nature of patterns! Watch the video illustrating the postural and movement pattern.
Studies show that one-in-four adult Americans suffer from chronic knee pain. The number of people with symptomatic knees has approximately doubled among women and tripled among men over 20 years, according to National Health and Nutrition Examination Surveys and the Framingham Osteoarthritis (FOA) Study. (1)
Although significant, strength & flexibility are not enough
For decades strengthening and stretching of the muscles around the knee was the primary conservative treatment approach to the troubles of the knees. Recently, the concept of neuromuscular re-education and optimization of movement patterns is gaining traction in rehabilitation medicine and physical therapy. In his fresh-off-the-press New York Times article from November 19, 2021, “To Keep Knees Healthy, It Pays to Stay Active,”(2) Alex Hutchinson mentions the importance of focusing on well-organized movement. The question, however, arises: How can we change the ways we move? HOW does one go about optimizing their movement patterns?
Experts still tend to fall back on the familiar stretching and strengthening methods to improve movement patterns. The philosophy and body of work pioneered by Dr. Moshe Feldenkrais, with robust developments in the science of habits and neuroplasticity, point to the previously overlooked role of the brain and the nervous system in our self-use. Once we make the decision to complete an action, our brain communicates it to our skeleton, muscles, and fascia. Movement patterns start here. Learning through awareness can modulate and affect change, opening new doors for creating successful treatment approaches. We need to re-evaluate and update how we view movement patterns with a drastic focus shift from the muscles to the brain.
What causes the misalignment?
Congenital and acquired factors play a role. Weakness of the hip muscles, over-pronation of the foot (flattened inner arches), ligamentous laxity, and fatigue all contribute to poor posture. Even social norms dictate our posture. In our culture, girls and young women are often taught to sit with their knees together. What a terrible idea for the health of the knee joints! Bad habits of knees migrating inward influence the way they play soccer, jump, lunge, or squat. Such a movement pattern developed and enforced early in life may contribute to difficulties in the knee joint later in life.
Sometimes even minor leg injuries create a cascading series of events. It is normal and automatic to take the weight off the injured leg. But that response only works temporarily. Long-term, such a strategy contributes to forming very troubling postural and movement habits that perpetuate long after the original injury.
Try this experiment: Stand on both legs. Shift 80% of your weight onto your left foot. Can you feel how your right foot stays on the ground, but the whole body moves left? Observe the shift of your right knee. Your right foot is not under your knee anymore; the knee migrated inward, to the left over the planted foot. Imagine the consequences of using such a misaligned knee in walking and other everyday functions.
There goes the ACL
I recently started working with an Olympic Heavy Lifter, who sustained a common, yet serious knee injury (ACL tear). Her issue was definitely not due to inadequate strength. In the first session, she showed me a video of her workout when the accident occurred—focusing on strength and endurance by stepping on and off a large box. If we could only go back in time and scream, “STOP!!!”. In the video, she lands on her left foot out to the side with a hint of the above-described pattern. First jump, second jump, third jump – each one with her knee drifting inward and the foot out to the left. She begins to tire, but she’s no quitter, a hallmark of high-achieving athletes. One more jump, she lands, and craaack! The knee buckles, she falls back, and the ACL is gone!
I cringe every time I see footage of athletes tearing their ACLs. It’s a visceral response for me, a memory of a similar experience. Twenty-five years ago, I tore my ACL during a basketball game. A similar mechanism, the very same pattern: knee in, foot out. At that time, I thought it was an unfortunate accident. Nowadays, I don’t believe in accidents.
Playing sports, dancing, or performing other demanding activities with even a hint of the gapping pattern is a ticking time bomb that will soon cause a future “accident.”
Global understanding is necessary for a successful approach.
When it comes to our body, nothing exists in isolation. Local treatments focused just on the knee often prove ineffective. The following is a more detailed, foot-to-head description of the observed pattern that breaks so many knees.
The pattern is present in sitting as well as standing positions – the placement of the foot out to the side or pulling the knee inward relative to the planted foot is frequently accompanied by:
- Hip adduction – the thigh closer to the midline
- Problems with hip internal rotation – difficulty rotating the thigh inward
- Elevation of the pelvis (hip hike) on the same side
- Tendency to rotate the pelvis away from the knee
- Lateral bending of the spine toward the problematic knee
- Compression (shortening) of the waistline and rib cage on the same side
- Tendency to tilt the head
- Rotating the shoulders and rib cage away from the knee
What can be done?
Awareness is the key to the improvement of posture and movement patterns. In the Feldenkrais Method® of somatic education, we aim to improve your “self-use” through learning to feel what is right for you. There is a limited value of teaching by telling or demonstrating from the outside (extrinsic learning). Learning needs to be reinforced through deep, internal experience (intrinsic learning).
First, you need to discover and sense your habits of standing or walking. Then, clearly discern a difference between various options. Sensing and feeling how you use your legs is different from any abstract ideas or external models. Sensing is different from thinking.
Sensing means processing and integrating various sensations through:
- Touch – for example, how your foot touches the floor.
- Proprioception – detecting the position of your hip, knee, ankle, and foot in space relative to each other.
- Kinesthetic sense – an internal sense of movement.
- Vestibular sense – balance and equilibrium.
- Carriage of the head including all telereceptors (sight, smell, hearing, and taste) – vital to improving movement and posture.
Now try this: Sit on the front of the chair. Close your eyes. Sense the distance between your feet. Is it wider than your knees? How about the distance between your hips? Open your eyes and check. Then, place your hands behind the right knee, interlace your fingers. Using your hands, lift your right leg and allow it to hang. Gravity helps the leg to dangle, pendulum-like in the lowest position. Your ankle and foot will find proper alignment spontaneously. Slowly bring your foot until it touches the floor. Close your eyes and re-check the sensation of the distance between your feet, knees, and hips. Now, they are in a healthier alignment. Perform the same on the other side.
Tips for dealing with injury
Learning to have the foot and ankle under the knee and the knee under the hip is essential. The sooner you achieve it, the better. But it needs to be done pain-free, without irritation of the healing tissues.
Use of crutches or Nordic Poles to avoid the lateral shift of the body. It is better to take some weight off the leg by using crutches or poles. Proper use of the crutches allows you to keep the vertical alignment of the limb.
Walking in water can be an excellent way of training to initiate proper loading of the leg with the help of water’s buoyancy. As healing progresses, we increase weight bearing through the well-aligned leg.
Only perfect practice makes perfect.
It is better to take several shorter walks than one long-distance pushing through the pain. It is essential to avoid any form of limping as bad movements can easily become ingrained in your nervous system in the form of habits.
How you get up from a sitting position and sit back down is essential. Watch for the tendency of one knee (or both) to deviate inward as you rise from a chair. If needed, use an armrest to assist, but try to maintain the vertical alignment of your legs. As you get stronger, practice awareness of the position of the knees and get up without using your hands.
Don’t forget about your feet. Simple exercises like picking marbles with your toes or curling a towel under your foot can be valuable tools. Many Feldenkrais Awareness Through Movement® lessons help you not only develop excellent strength, suppleness, and flexibility of your feet and ankles but train your sensory awareness, which is essential for balance and posture.
The preference is to restore the foot’s intrinsic structures (muscles and ligaments) to maintain a robust platform for the whole body to stand. Sometimes, however, inserts in the shoes and orthotics are necessary to prevent the structures of the foot from collapsing. Flattening of the inside arch of the foot (pronation) is common and may cause leaning and the inward twist of the knee.
The flexibility of the hips plays a crucial role in maintaining healthy knees. Limited internal rotation of the hip joint frequently contributes to excessive hip hiking, leading to overcompensating and shortening of the same side of the torso and ribs, solidifying the pattern of misalignment of the leg.
Take care of the strength of your hips and buttock muscles. While walking, you alternate periods of standing on one leg. Sufficient strength of these muscles is necessary for maintaining the stability of the pelvis and, therefore, proper alignment of your knees and legs.
It is not “what” but “how” that matters. For years a belief perpetuated that low-impact activities are better for our knees. Running was on a no-no list. However, several studies challenge these old beliefs. A recent systematic review shows no evidence that running causes knee arthritis or damages the knee cartilage. In fact, running creates rhythmical loading and unloading of the cartilage, which can help strengthen and heal the lining surfaces of the knee(3)(4).
Our cartilage, like a sponge, depends on movement; changes in the loads allow in-flow and absorption of the nutrients and oxygen and squeezing out of the waste products. We may need to re-evaluate our assumptions on which activities are good or bad for us. In the Feldenkrais® approach, we shift the focus from what to how you do what you do. If you love running, don’t hang up your running shoes yet.
The future is bright
Many injuries and a lot of pain and suffering could be avoided by resolving the problem of misaligned joints and faulty movement patterns. While this article’s focus was the most common one, there are other patterns contributing to the injuries and wear and tear of the knee joints such as hyperextension or bowing of the legs. We can learn much from the methods originally developed to improve how we use our bodies and minds, including Feldenkrais, Alexander, Pilates, Yoga, meditation, and many others.
(2) Alex Hutchinson. To Keep Knees Healthy, It Pays to Stay Active. The online version of the article is titled How to Save Your Knees Without Giving Up Your Workout.
Marek Wyszynski, PT, GCFP is President and Clinical Director of Physical Therapy and Feldenkrais® NYC, a member of the Hospital for Special Surgery Rehabilitation Network. He is a co-founder of the Feldenkrais® Foundation and the Feldenkrais Institute of New York. He is author of a number of popular courses including the Healthy & Dynamic Legs audio series consisting of essential 21 Feldenkrais® lessons for restoring the healthy and efficient function of your hips, knees, feet, and ankles. His website is www.bettermovement.com