I have a client who has dislocated both knees several times. She has been to physios before, but none of them have written programs for her or have told her what to do to fix her troubled knees. Both knees are very hyperextensive, and she gets a lot of pain when performing most knee exercisers. I have started with very basic step ups and step throughs, which seem to be fine. Is there anything you recommend I do to help her out?
First of all, it must be made clear exactly what you mean by "dislocated." What degree of trauma/separation has occured? What tissues were damaged (ACL, PCL, LCL, MCL, MENISCI)? For this information, you as the fitness/performance professional must maintain a close relationship with your client's physician, which would involve the particulars of the injury as well as clearance to begin an exercise protocol. You may even want to do your own research on sports medicine professionals in your area who may specialize in the type of injury your client has and set up a referral system. Remember, we as "fitness/performance" professionals must maintain our integrity by recognizing when we are in a situation with a client that is "over our head" and lies outside of our realm of practice.
That being said, let's look at your options, assuming you've completed the above tasks. From a kinetic chain standpoint, research has demonstrated that many injuries/traumas at the knee joint can be traced back to limitations in function at the joints above (hip) and below (ankle). More specifically, it may be found that the actions of hip extension and dorsiflexion are quite often restricted, causing compensation to occur throughout the chain (specifically at the knee in this case). These limitations may be evident in the individual's movement patterns.
Remember, the body works in a "chain-like" fashion. If a lack of range of motion is observed and attributed to the musculature, there must be an excessively short muscle(s) creating this lack of ROM, as well as an excessively long muscle(s) allowing the lack of ROM. What's important to understand here is that these muscular imbalances have potential to create reciprocal inhibition, synergistic dominance and altered joint arthrokinematics (joint movement) such as the ones experienced by your client. By simply restoring muscular balance (which is not always a simple task) through the proper flexibility and strength protocols, you may greatly increase strength and function due to the fact that the body's agonists, antagonists, synergists, stabilizers and neutralizers are all working together and therefore are in a better position to perform their jobs!
EXAMPLE: An excessively shortened Psoas (as well as other hip flexors) may cause the gluteus maximus to be in a excessively lengthened state and therefore reciprocally inhibited from performing efficient hip extension (as well as other tasks such as deceleration of hip flexion). This in turn may cause synergistic dominance in the hamstrings to perform hip extension, finally resulting in altered joint arthrokinematics and possibly pain, more importantly in this case, at the knee.
If nothing else, this should get you thinking more holistically about the body. Rather than simply, "How do I strengthen the knee?" (i.e., the symptom), perhaps ask, "What created this faulty movement pattern in the first place" (i.e., the cause). To begin learning how to assess your client's flexibility statically and transitionally and recognize common muscular imbalances that may be causing joint pain, I recommend reading the following three PTontheNET.com articles by Lenny Parracino:
- Postural Profile
- Overhead Squat: Total Body Profile
- Muscle Balance or Flexibility Profile
Thank you for your question!