STAY ON TRACK

“Alignment, Balance, Results” … the tagline for my favorite fitness method (The Dailey Method – of course!) and a great mantra to follow for success and longevity in any fitness program you choose.  For me there is no joint in the body for which this is more important than the knee.  The knee joint is the largest and, unfortunately, most frequently injured joint in the human body. 

Your knee joint is made up of four bones:      

• Femur (thigh bone)
• Tibia (shin bone)
• Fibula (smaller of the two lower leg bones)
• Patella (kneecap)

 In addition to the bones, a network of ligaments, tendons, and cartilage serve to stabilize the joint during knee flexion and extension, and to support the weight of the body during impact.

The knee joint is unique in that, unlike other hinge joints in our body (i.e. the elbow), the knee has a specialized fulcrum (the patella).  The patella helps to increase the power of the quadriceps muscles during knee extension.  The patella lies deep to the quadriceps/patellar tendon and slides in the groove at the base of the femur during knee flexion and extension.

In order to ensure a smooth ride for the patella, articular cartilage lines the back of the patella as well as the ends of the femur and tibia bones.  The muscles and ligaments that support the knee joint play a crucial role in ensuring that the knee stays on track.

The muscles that support the knee include the quadriceps, the hamstrings, and the muscles of the lower leg.

The ligaments (connecting bone to bone) and the tendons (connecting muscle to bone) work together with the muscles to maintain proper knee alignment.

So what happens when the patella goes off track??

In people younger than 50 years old complaining of knee pain, Patellofemoral Pain Syndrome (a.k.a. “Runner’s Knee) is the most frequently diagnosed condition.  PFPS presents as anterior knee pain that usually occurs with activities involving knee flexion.  Sometimes pain also occurs after long periods of sitting.  PFPS can be caused by overuse, trauma, and/or by an imbalance in the forces that stabilize the patella.  When the patella is not sliding smoothly in the femoral groove, the cartilage underlying the patella and covering the surfaces of the femur and tibia can be injured.  A subset of people with PFPS also has softening of the articular cartilage (chondromalacia).

ALIGNMENT

Correct alignment of the femur and the tibia is step one for proper knee tracking.  A good start to keeping your knees on track is visual inspection of your knee alignment. 

Stand in the mirror with your feet hip distance apart in a parallel position.  First notice your foot posture.  Are your feet truly parallel or are they turned out or in?  Notice where your weight is in your feet (many people tend to roll to either the inside (pronation) or outside (supination) of their feet.

Once you have your feet parallel and your weight evenly distributed in your feet, bend your knees.  Notice if your kneecaps point straight forward or if they tend to deviate medially or laterally. Straighten your legs, and again, notice if your kneecaps travel straight up and down or if they tend to move medially or laterally.

Although no one biomechanical factor has been proven to be the cause of PFPS, the following factors may all play a role:

• Over pronation of the feet (“flat feet”)  
•  Over supination of the feet (“high arches”)
• A stance resulting in increased Q-angle (the angle from the hip to the knee) 
• Muscular weaknesses (most often the quadriceps, and in particular the vastus medialis)
• Poor flexibility of the quadriceps, hamstrings, and/or iliotibial (IT) band

BALANCE

Whatever your preference for exercise, make sure that you are strengthening and stretching the muscles that support the knee joint in an aligned and balanced way.  Listen to your body and always work within a pain free zone.  During stretching exercises you want to feel heat and tension in your muscles but not discomfort.  During strengthening exercises you want to feel the “burn” in the belly of the muscle as opposed to the joint insertions.

Targeting the medial most quadriceps muscle (vastus medialis) is a great way to begin finding better balance in the strength of your quadriceps.  Straight leg lifts are a standard exercise for strengthening this muscle.  This muscle works at the endpoint of extension so make sure your leg is all the way straight in a straight leg lift. 

You can also work the innermost quadriceps muscle with some standard yoga poses.  This article is a really nice review and pays some specific attention to using the quadriceps in the warrior poses of yoga:
http://www.himalayaninstitute.org/yoga-international-magazine/asana-articles/yoga-therapy-for-your-knees/

Knee bends & squats (and variations thereof) are commonly seen exercises for quad strengthening. This is a simple comparison of deep knee bends vs. squats: http://www.livestrong.com/article/261835-plies-vs-deep-knee-bends/.  Both have their place in a balanced fitness program and the choice of which or when to perform these exercises should depend on each individual’s knee health, strength, and ability to maintain alignment.

This final link is a fantastic description of the “shins in/thighs out” principle in anusara yoga: 

http://yogagroundwork.com/alignment_knee.htm

I first saw the manual shins in /thighs out exercise at an anatomy training with Martin Kirk (http://www.kirkyoga.com/).  I love this exercise as both a self-diagnostic and rehabilitative tool for knee alignment.  When performing this exercise it becomes quickly self evident where weaknesses and imbalances may lie. 

RESULTS

Finally – your hard work and attention to detail pays off --- results!!!  By putting in the time to focus on alignment and balance in your exercise program you will reap the benefits of a healthy, toned, pain-free physique that will allow you to continue with your favorite fitness program for years to come!

References:
Dixit, S. et. al. (2007) Management of patellofemoral pain syndrome. American Family Physician, 75, 194-202,204.
Farr, J.N. et. al. (2010) Progressive resistance training improves overall physical activity levels in patients with early osteoarthritis of the knee:  a randomized controlled trial. Physical Therapy, 90, 356-366.\
Juhn, M.S. (1999) Patellofemoral pain syndrome: a review and guidelines for treatment. American Family Physician, 60 (7), 2012-2018

Start with a strong foundation

Success begins with a strong foundation.  This is true in business, in relationships and in health and fitness.  Your feet are your foundation for a strong, aligned, and integrous physique.  With close to 30 bones and more than 30 joints in each foot, the feet contain a quarter of all the bones in the human body!  Surprisingly, many fitness enthusiasts take their foundation for granted and wind up paying a large price in the long run with multiple injuries higher up the kinetic chain.

Lets take a look at the purpose and structure of this often neglected but oh so important body part:

• Your feet have the dual purpose of weight bearing & propulsion
• In addition to the multiple bones of the foot, an amazing network of connective tissues (tendons, ligaments, fascia) allow for that “spring in your step” with the construction the foot arches
• The arches of your feet are critical to shock absorption & transmission of force during walking and running
• Our bodies are connected from toe to head, without interruption, through the deep fascia. 
• Misalignment in one part of the body creates a domino effect along the entire kinetic chain.

A closer look at the arches of the feet and the muscles that support these arches can help shed some light on proper “foot posture”.

The multiple bones in our feet allow for flexibility to adjust to variable walking surfaces:

credit:  www. Bandhayoga.com (Dr. Ray Long & Chris McIvor)

credit:  www. Bandhayoga.com (Dr. Ray Long & Chris McIvor)

In addition to the medial and lateral arches, some describe a transverse (or metatarsal) arch.  Although the literal presence of this third arch continues to be debated in the literature, it’s theoretical presence can be helpful in learning how to truly ground through the foundation of your feet and find proper weight distribution and foot alignment.

The muscles of your feet include the intrinsic muscles within the foot and in-between the toes that flex and extend your toes.  In addition, the extrinsic muscles of the lower leg, whose tendons attach distally in the foot, allow for range of motion at the ankle joint as well as support for the medial and lateral arches.

credit:  www. Bandhayoga.com (Dr. Ray Long & Chris McIvor)

Intrinsic muscles:  Hallucis longus and brevis (big toe flexors)

credit:  www. Bandhayoga.com (Dr. Ray Long & Chris McIvor)

Extrinsic muscles:  Tibialis posterior, peoneus longus and brevis

Here are a couple of quick exercises to help you find the muscles of your feet and lower legs and begin your path to a stronger more stable foundation:

1. Find your arches:  in a standing or seated position align your feet in a parallel position.  Visualize the arches of the foot as you ground down through the ball of the foot (big toe & pinky toe side) and the outer edges of your heel.  Stay grounded and begin to lift up through the center of your foot (a suction cup-like action).  Make sure your toes do not scrunch up as you do this.
2. Ankle range of motion:  Your ankle joint can move in four distinct ways.  You can add resistance (using your hand pressing on the foot or a theraband) to take these exercises to the next level, strengthening and stretching all the muscles of your lower leg:

                        Eversion / Inversion:

                        Dorsiflexion / Plantarflexion:

Once you’ve learned how to access the muscles of your feet and lower leg you can take this knowledge with you into any activity you choose creating a stronger foundation and resulting in a safer and more effective workout.