Ok, time to get technical

What is the most important component of knee health? Symmetry within the body. If one side of your body is weaker. Side to side or front to back it’s going to put excess strain somewhere around the joint.

The knee is stuck between the foot and the hip. It needs symmetry in:

  1. Mobility

  2. Movement

  3. Strength

Other things are important but the come in under the above in some aspect or another.

The main point here is that if your form sucks you’re screwed.

Types of knee injuries, get proactive not reactive

  1. Acute trauma – this is what most people think of as knee injury

    1. Torn ACL, MCL, PCL, torn meniscus etc.

    2. Contact vs. Non-contact – in contact sport injuries happen in collisions, it’s just a fact. So if you plant the foot because you’re making a sudden change in direction and someone hits your knee in a position of vulnerability something bad may happen. In non-contact sports and situations there isn’t an excuse for injury!

      In this situation injury comes from weakness. In the same situation, a plant and change of direction, if the muscles in the hip, thigh and knee do not have the strength required to absorb the force and actively stabilise the joint then the body is forced to rely on passive stability. This means that the ligaments, tendons and menisci are put under pressure. Too much pressure and they snap!

      As a rugby player, the injuries you get should be limited to ONLY contact injuries because you’re training should prevent you from getting non-contact ones.

  2. Chronic myofascial issue

    1. lateral knee pain – Often tight IT bands compressing the fat pads. This is mostly seen in long distance athletes and cyclists but also in athletes who have to run a lot in there sport.

    2. Tendinopathy – mostly in athletes who jump a lot, basketball, volleyball etc, and do not get into full knee flexion (completely bending the legs) enough.

  3. Chronic joint issue

    1. arthritis – hopefully only in elderly people

The question posed is: Are all these injuries actually chronic? Has the causes of them developed over time? Excluding the contact injury. The answer is yes, asymmetry and weakness is a result of incorrect action and inaction.

The goal is actually really simple for healthy knees you need

  1. Healthy tissue – muscles, tendons,ligaments, fascia

  2. Healthy joints – a healthy joint for a 16 year old is different to a 35 year old, it’s a little subjective

  3. Optimal muscle function – the right muscles need to work at the right time with the right application of strength

  4. The ability to train pain free – this is the end goal.

The bottom line to knee health is this:

  • Improve your mobility

  • Improve your motor control

  • Improve you strength

legs

 

Improving your mobility

What we mean by have the correct mobility is the ability for your muscles to be able to function optimally in their sporting environment.

Where’s the first location you need to get adequate mobility from?

It’s not hips and ankles! It’s the knee! Of course the hips and ankles should have more freedom of movement but the knee is still a joint and must be able to move through it’s full range of motion. Imagine a situation where you’d lost the ability to flex your knee. Any amount of hip and ankle movement wouldn’t make that much better.

In regards to knee mobility the first thing that is needed is equal flexion and extension capabilities on each side

Next the hip gets addressed.

Why do we need hip mobility?

  • We know the patella/femoral joint is “slaved” to the hip joint. This means that the knee joint doesn’t have the capacity to “disconnect” from the hip joint. i.e. if you twist you hip the your knee twists with it.

  • The hip is a ball and socket joint. It’s built to do a TON of stuff.

  • Following a joint-by-joint approach, if you don’t have hip mobility then where does the body steal the mobility from? The back (with accompanying back pain) and the knees (with the accompanying knee pain)

  • Sitting all day causes adaptive shortening in hip flexors.

If hip mobility is that important how do we then improve it?

  • Train for it – however, could be changing behaviour, static stretching, lifting through full ROM. Everything has to reinforce hip mobility

  • 2-3/week all the way up to daily (the decade rule) – if someone has good mobility then the number of decades they have lived should dictate the number of days they need a week to reinforce hip mobility. Given poor mobility the athlete needs to work on hip mobility 4, 5 and maybe 6 days a week to get to that maintenance level before the decade rule comes in.

  • Train multiple movements in multiple planes – Use as many of the movements that the hip is capable of as possible in order to train the hip optimally.

  • Lift Weights for improved mobility and to reinforce already good mobility

    • Full Squats

    • Front Squats

    • Overhead Squats

What muscle group/movement pattern in the lower body is the least trained yet one of the most important?

Dorsi-flexion (pulling your toes up to your shin). What this really boils down to is ankle mobility

Why?

  • Poor mobility at the ankle leads to problems further up the kinetic chain

  • The patella femoral joint is not built for mobility we only want symmetrical flexion and extension in the knee

  • What are we looking for

    • mix of closed and open chain movements

    • Sagittal plane mobility (the ability to get knees over toes)

    • Symmetry between sides

  • Train the dorsiflexors

For practical application these are our ankle exercises.

  • Knee to Wall

  • Toes raised bilateral knee to wall

  • So you can see unilateral comes before bilateral so asymmetry can be fixed

The Role of Tissue Quality

  • Tissue quality work has a great ROI than static Stretching or mobility work

  • Methods:

    • ART

    • SMR

    • Massage

    • Self Instrument Massage

What is the role of static stretching?

  • Mobility – Range of motion under specific circumstances (specific to a movement)

  • Flexibility – Range of motion about a joint (non-specific)

  • Mobility = active control (nervous system, see stuff by Bommarito) + tissue length + movement capacity of joints

  • Tissue length (and therefore static stretching) is a critical piece of the puzzle

Can you stretch too much?

  • Well yeah but not often.

Improving your motor control

Glutes

  • When the glutes really come into play:

    • Hip Extension

    • Hip External Rotation

    • Hip Abduction

    • AND they help resist the opposite movements eccentrically

    • They key is in muscle balance and motor control.

      We noted before when talking about non-contact injury that the muscles is the thigh and hip were active stabilises working to prevent injury. In the case of the glutes it is in resisting internal rotation and adduction of the hip (the knee caving in)

  • Why focus on glutes?

    • Deceleration in sports (non-contact injuries)

    • Better muscular balance around the knee and hip joints

    • Abductors (~26%) and external rotation (~36%) is typically week in those with knee pain (P/F)

    • Makes you stronger (this is the money maker) !

Psoas/Illiacus complex Motor control

  • Why?

    • It’s the glutes of the front of the body (yes front bum is funny) so very important

    • Psoas is typically shortened, inhibited and weak so it needs …. ?

    • Leads to other muscles dominating the movement, can do 2 ways

      • TFL – IT Band – Lateral Knee Pain

      • Rectus femoris – Anterior knee pain

        Thomas Test
        Thomas Test, A) Good B) BAD

        • Testing

          • Thomas Test assesses length

          • Strength is tested by greater than 90 degree hip flexion for 20 seconds (needs to be clean (no compensation) and symmetrical).

          • If not achievable then psoas/iliacus needs training

What movements typically occur at the hip and knee during an ACL tear?

Hip adduction, Hip Internal rotation, over-pronation of the foot and a valgus force. The glutes will help stop these!

What glute movements can help with these (all movement must not show compensations)

  • Side-lying Clam : Trains Hip ER and resists Hip IR (compensation is usually lower back)

  • X-Band Walk: Trains Hip Abduction and resists Adduction (compensation with feet and ER)

 

To move between the above and full movements

  • Mini-band squat (band around knee): counters knee valgus

    Find a way to force compensation into the correct movement pattern.

 

Improve you strength

Which areas are the most important to strengthen w/regards to keeping the knees healthy? All of them really

  • Everything needs to be strong!

    • Quads/hip external rotators are generally week in the case of knee (patella/femoral) pain

    • Glutes/hams are generally weak in the case of ACL tears and quad tedinopathy

    • Deficiencies must be fixed. Which means a needs analysis.

    • Must be a rationalised progression.

The order of a knee health program which goes from post-rehab to performance could look like

  1. Single-leg – removes asymmetries in regards to mobility, motor control and strength

  2. Posterior Chain Dominant

  3. Knee Dominant

 

Post-Rehab to Performance Rules for Progression:

  • What originally causes pain?
    Usually knee flexion, dorsiflexion and loading

  • Loading Standpoint – Low to High Loading

  • Mobility standpoint – Minimal knee flexion and dorsiflexion at the start

  • Can even start with isometrics (minimal joint wear)

Single-leg Work:

  • It’s important but must be done correctly.

  • Quality must be first. No compensations patterns lads

The next steps (for beat up knees)

  • Loading

    • Isometric holds

    • Concentric only movements

    • Decrease Flexion

Posterior Chain Dominant

  • As little knee flexion as possible working to more knee flexion

    • Good Mornings

    • RDLs

    • Box Squats

Box-Squatting

 

Knee Dominant

  • Again work from minimal knee flexion to most knee flexion

    • Box Squats

    • Back Squats

    • Front and Overhead Squats

 

Conclusion

I know that was very wordy lads, but the point is this – move well and get strong.

If you can’t move well, learn to move well.
If you can, make sure that as you get stronger, you don’t sacrifice or ignore this.

In the Academy we have “Solidarity” a little plugin that can be used as a session on it’s own or a warm up.

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