I am currently working with a 34 year old male client who came to me in good shape. However, lately he has been complaining of a stiffness/dull pain in the lateral, inferior area of his left knee. This stiffness occurs a few hours after doing any squatting or lunging or after sitting at his desk at work for any length of time. An initial overhead squat assessment showed a low back arch and an asymmetrical weight shift to the right during the eccentric phase of the squat. Upon completion of the assessment, I began working with him on a stretching program (primarily SMR and static) to correct the imbalances. To correct the arch in the low back, I am focusing on the psoas, hamstrings and erector spinae. For the asymmetrical weight shift to the right, I am focusing on the calves, hamstrings, left IT band and hip flexors. I am also working with him to strengthen his glutes and TvA. Rather than treating the symptom, I have tried to define the possible causes looking at the joint mobility, both above and below the left knee. The stretching seems to temporarily alleviate the stiffness, but it comes back after any kind of squatting, lunge pattern or sitting. Any advice on how I could further help alleviate this issue is greatly appreciated. Thanks very much!
Thanks for your client concern! I hope to add some ideas to your thought process so you can develop different techniques. One important principle is the fact that muscles function as REACTORS in all three planes of motion; therefore, we must develop strategies that are based on how the body reacts in three planes as opposed to traditional agonist/antagonist function. In simple terms, the body must be proprioceptively stimulated as a whole for it to function efficiently. You can still emphasize the parts as you integrate the whole, providing you understand how to properly position and move your client. Problem: Three dimensional function isn’t the easiest to describe so I will do my best to a) describe a three dimensional movement for your client’s symptom and yet still integrating the whole b) give you a progression and c) leave you with a reference to purchase for information to learn more about the possible cause, compensation and symptom.
Three dimensional movement for lower extremity (ITB emphasis):
- Position left leg ahead of right in a left stride stance (so right hip is being extended). Be sure feet stay straight.
- Position left leg on a slight angled platform to create calcaneal eversion (collapsing of the foot – keep weight to inside of left foot).
- Slightly bend the left knee.
- “Slide” the pelvis to the left creating left hip adduction.
- In addition to emphasize the glute maximus division of the ITB, lean forward creating increased hip flexion. To emphasis the TFL division, lean backwards creating increased hip extension. Note: This is performed while you are in the above positions.
- Compare the left with the right as an assessment analysis. Be sure he not only has the motion but also the ability to transform from one direction to the next (transformation).
Instead of a traditional holding technique, oscillate the different planes of motion to search for where your client is successful (what plane is most to least successful). Successful means he is able to move in and out of the motion(s) efficiently. Always focus on his success first and then move into the less successful. Once motion is smooth, start increasing his speed of motion thus creating a more life-like reaction. If you find this movement helps his complaint, ask him to perform frequently throughout the day. Sometimes just working out with you is not enough to recondition a de-conditioned area.
The above is obviously a “stab” at what is wrong with your client; however, I hope you see how we used a three dimensional thought process as opposed to looking at the parts in isolation. A powerful tip: Most knee problems are driven from the foot/ankle and/or the hip NOT the knee. The knee is taking on the “hit” for what other parts are not able to do. Be sure the entire chain is able to load and unload efficiently in the specific task you’re attempting to improve. For more information, please see Gary Gray’s Functional Video Digest Vol 1.1 - The Knee. This DVD will explore various ways to assess and address this situation. Good luck!