I have a client who has had six scopes on her left knee and wears a knee brace. She likes to work hard, but I am very limited in what I can do (i.e., no lunges, wall sits, etc.). The exercises she can do are not challenging enough for her (i.e., squats, dead lifts). It's almost as if she has no feeling in her legs. She’s also extremely flexible in her hams and quads. Do you have any suggestions for targeting her quads and hamstrings without risk of injury?
You pose an interesting and at times perplexing question. However, there are some questions I have regarding this issue:
- How recent was her last scope?
- Does she have full extension of her knee?
- What type of brace is she wearing and for what reason?
Answers to these questions can have a significant impact upon knee function. Yet there are biomechanical considerations we must address before further problem solving. Too often the knee is the culprit for complaints that are not the knee’s “fault.” If we keep in mind the knee is stuck between the foot and the hip and will be greatly influenced by foot and hip actions, we then start to understand the environment that can make the knee successful. To further elaborate, the foot controls the tibia and the hip controls the femur, yet the foot can influence the hip and vise versa. If the foot is pes planus (flat foot), then the tibia typically is internally rotated. If the foot is a cavus structure, the tibia usually is externally rotated. Likewise, if the hip (i.e., gluteals) is tight, this can externally rotate the femur. Any of the above situations can negatively impact the knee. For the knee to be successful, the foot must go through calcaneal eversion, which enhances ankle dorsiflexion, tibial internal rotation, femoral internal rotation and hip internal rotation and most often eccentrically loads the calf, quadriceps, hamstrings and gluteal complex. As the subject moves through the gait cycle, namely through mid-stance and the initial phase of heel lift, the calcaneus inverts, thereby allowing the ankle to plantar flex. It also allows the tibia, femur and hip to externally rotate, and concentrically unloads or contracts the musculature producing a propulsive action. If the client stays too long at any point during these phases, overuse issues can develop.
For example, I am currently working with a professional bowler who had a right knee scoped in July and is still having considerable knee pain. The surgery result is very good, but he is suffering from vastus medialis tendonitis. After a functional assessment, I discovered he had very flat feet, which was causing his tibia to excessively internally rotate. Also, his same side hip and gluteal complex was very tight, especially when compared to his left hip (about 25 degree less internal rotation on the affected side). I suggested he use an over-the-counter insole to place his foot into a more neutral environment, and his knee pain immediately was greatly reduced and gone within two days. Additionally, he has started an integrated flexibility program as well as a tri-plane strengthening regimen that is designed to eccentrically load the structures while at the same time lengthening the muscle and fascial tissue. Also, he has been advised to perform integrated flexibility two times per day.
As far as your client is concerned, I suggest you first look and see her foot type. If she has flat feet, it may be advisable to have a podiatric evaluation done to investigate her need for any foot control issues. Also, check to see what her range of motion is at her hips to verify she has the ability to attain adequate internal rotation.
Considering the above information, I suggest having your client try sagittal plane lunges (forward lunges) with both arms reaching medially to the lead or lunging leg. This will influence the calcaneus to evert, dorsiflex the ankle, internally rotate the tibia, femur and hip, thereby eccentrically loading the gluteals. If her foot is already a flat foot, then try having her reach with her arms laterally or outside her lead leg. This can cause the calcaneus to invert and externally rotate the tibia, femur and hip and get the desired affect. You can also do these lunges in the frontal plane (as side lunges) using the same reaches.
If these are too easy for her, trying doing these movements stepping up on or down from a 12 inch box. The step down movement will add a greater degree of eccentric loading, so proceed cautiously.
These are only a few basic movement patterns that can be tried first. There are various methods to use to get the desired results. However, without seeing your client’s movements, it becomes rather difficult to be as specific as possible based upon her situation. I hope this information helps. Good luck!