I am working with a friend to help strengthen his knee. Over a year ago, he fell off of a ladder, but his left leg was entangled in the ladder and his over six feet tall body was hanging upside down. He has had two arthroscopic surgeries. I do not know all of the specifics of how he was injured and what they did in the surgeries (I will be questioning him regarding that), but his left leg is incredibly weak. His quadriceps constantly causes him pain, and it appears his IT band has been overloaded and also causes an incredible amount of pain. A mutual friend works on pressure point massage therapy and remarked that his glutes are also causing problems. My question is how far should I push his knee? His knee doesn't cause him pain, just his muscles. Where exactly should I start? From what I have read, I have to strengthen his glutes, more than likely his adductors, to try and take the attention off of the IT band, but with the quad… that is where I don't know exactly where to start.
You pose an interesting issue, especially considering you have established his weak gluteals. The first point of concern is how are his feet functioning? The feet have to work properly through three planes of motion and allow for adequate calcaneal eversion, dorsiflexion, tibial internal rotation and forefoot abduction to allow his lower extremity to be loaded through internal rotation and knee flexion, which ultimately will activate the glutes when working in weight bearing activities. If his foot is flat or if he has a high arch, this can create inadequate chain reaction listed above.
When the gluteals are weak, I often see the IT band become over reactive as it must assume a greater role to decelerate hip adduction and internal rotation. Additionally, I see the hamstrings and deep external hip rotators become over reactive as well. Therefore, gluteal strengthening is a priority. As far as the knee is concerned, it will be greatly affected by the hip and foot and is really a “dumb” reactor to the hip and foot. Once the hip foot/ankle complex has adequate strength and range of motion, the knee typically has more proper motion, and the quadriceps will become stronger.
The exercises and movement patterns are dependent upon which plane of motion he is more successful in and elicits the least amount of discomfort. If the sagittal plane is better for him, have him do a forward lunge with either an opposite hand to the opposite lateral reach to waist of knee height (for example, lunge with the left leg and reach to the left, lateral to the lunge leg to knee or waist height). This often is effective for people who have a planus or flat foot. If he has a cavus or high arch foot, he may want to try a left leg forward lunge with a left arm to right lateral reach to waist or knee height. Reaching to the opposite lateral side will create relative calcaneal eversion, while a reach to the same side of the lunging leg will enhance calcaneal inversion. Both or either of these approaches can create an environment for the knee to become successful. If the sagittal plane is problematic, try a side or frontal plane lunge with the same strategy of arm reaches, and see if this is more comfortable and successful for him. Also, it is very important that you address his range of motion of the hip and foot and ankle complex to achieve greater function. Therefore, a massage therapist may be an integral part of his program.