Question:

I have a new client who recently dislocated his patella. His knees hyperextend and need corrective stabilization. Your thoughts please.

Answer:

As always, I will begin by making mention that referring out to a sports medicine professional is the first step. Rehabilitation may be necessary before any fitness training begins. That being said, let's look at your client's knee injury and instability from a kinetic chain standpoint.

Assessing your client's static (standing) and transitional (overhead squat) posture, as well as doing at least a basic muscular balance assessment (flexibility/ROM) will be vital to your success. Research has shown that certain common muscular imbalances can contribute to injuries such as those experienced by your client. If you're not familiar with these assessment techniques, I would recommend reading the "related articles" at right. These three articles will introduce you to a systematic method of discovering serial postural distortion patterns in your clients. After all, the "program" is only as good as the "assessment!"

Research has also shown a correlation between restrictions in function at the hip and ankle joints and knee injury such as in pronation distortion posture. During your static and transitional phase of the assessment, you may notice excessive knee adduction and internal rotation as well as excessive foot pronation and external rotation (flat feet). Likewise, during your muscular balance/flexibility phase of the assessment, you may notice decreased hip extension as well as decreased ankle dorsiflexion and inversion (supination). Here is a guide to understanding the muscles that commonly cause these patterns:

• PRONATION DISTORTION POSTURE:
  • Characterized by excessive foot pronation and knee adduction/internal rotation
• SHORT MUSCLES TO BE STRETCHED:
  • Iliopsoas, Rectus Femoris, Adductors, Peroneals, Gastroc/Soleus
• LENGTHENED MUSCLES TO BE STRENGTHENED:
  • Glute Max/Med, Post/Ant Tibialis, Vastus Medialis
• POSSIBLE DYNAMIC FLEXIBILITY/CORE STABILITY/BALANCE EXERCISES:
  • Rotational Lunges: Lunge to safe depth that client can maintain alignment and with arms straight out ahead, rotate trunk toward the front leg in the beginning and progress to rotating away from the front leg, again, with optimal alignment!
  • Tubing Shuffle: Place tubing or elastic around ankles, stand in quarter squat, engage core and glutes, maintain neutral spine, step laterally preventing and shoulder and/or hip hiking as well as maintaining neutral at the ankle joint.
  • Supine Bridging: On back, feet on floor, knees at 90 degrees, engage core, squeeze glute, raise pelvis into hip extension.
  • Four Point TVA Trainer: Client on all fours, neutral spine/neck, maximum core engagement on the exhale, hold each rep for 10 sec. May eventually add shoulder flexion and opposite hip extension.
  • Single Leg Balance Progressions: Single leg stance, single leg stance with external hip rotation, single leg dead lifts, single leg squats, single leg multi-planer squats, etc. All while maintaining knee alignment over second and third toe with core and glute engagement.

To learn more about progressing your client from stability based exercises to strength and finally to power, check out Mike Clark's series "Essentials of Integrated Training" (under "related articles" at right).