A friend of minewent on a bicycle ride with me, and after about an hour started to experience severe knee pain. After checking her lower extremity I found she had “knock knees”. The clinical term for “knock knees” is Genu Valgum. The opposite would be “bowlegged” or Genu Varum. Since Genu Varum isn’t normally associated with pain or problems, we’ll concentrate on my friend with Genu Valgum. However, both of these conditions are the resultant of the Q-angle.
The Q-angle is determined in the frontal plane by drawing a line from the anterior superior spine of the ilium to the middle of the patella, and a second line from the middle of the patella down to the tibial tuberosity. A normal Q-angle for quadriceps femoris function is usually 10 -14 degrees for males and 15 -17 degrees for females.
Anyway, back to my friend…
When assessing the lower extremity you have to “get out of the box” sort of speak, says Ruben Salinas PT, OCS. Ruben is the clinical director of the Fortansce and Associates Physical Therapy clinic in Arcadia, CA. “Don’t just focus where the pain lies look at the whole picture. Remember, the lower extremity is a closed chain, especially in cycling.”
Normally associated with Genu Valgum you’ll find pronation or flat feet, tight gastrocnemius and in some cases trochanteric bursitis.
Let’s look at one at a time:
At the ankle, the body will try and compensate for the valgus stress at the knee (tensile forces on the medial side of the knee; compressive forces on the lateral side) by pronating. In gait you have to dorsiflex one ankle in order to swing through with the other leg.
If your clients gastroc is tight, they won’t be able to dorsiflex, which will cause the foot to cave in. This will indeed affect the knee and then the hip. To lengthen the gastroc, have your client stretch. Be careful to insure their foot doesn’t cave in while stretching. If needed, support the inside of their foot with a wooden block so their foot won’t pronate.
For the tibialis posterior (which is an inverter and crosses the ankle) have your client perform “windshield wipers.” By strengthening the inverters, (see diagram) you’ll cause the foot to supinate which is the opposite of pronation.
Here’s how:
Lie a light weight on a towel. With their feet flat on the floor have the person slide the weighted towel inwards towards their other foot. There are other ways of helping the foot out, but that’s a whole other article.
My friend wasn’t complaining about her feet though, the pain was on the lateral or outside part of her knee.
So let’s examine the knee:
Because of the excessive Q-angle there will be more compressive forces on the lateral side and more tensile or distraction forces on the medial side of the knee. So how do you fix that?
“This is topic a large grey area in the physical therapy world,” says Ruben Salinas. He is an expert on knees. VMO weakness or the inability to fire has been suggested as the culprit for patella – femoral dysfunction. The experts still can’t agree. It’s definitely worth trying though. To increase VMO activity, try quad sets in all directions or have your client put a small ball or rolled up towel between their legs when the perform leg extensions. Have them squeeze tightly or adduct at the top of the extension.
Another method Ruben suggests is Bio-feedback. Have the client put their hands on both the Vastus lateralis and Vastus Medialis, then have them contract their leg. Through their fingers they should be able to feel which side contracts first. Try and get them to “fire” the inside (vastus medialis) first. It would be nice if you had some surface EMG’s, but hey, we’re just trainers!
At the hip, you’ll often find weak external rotators. It’s almost as if the head of the femur has rolled forward and inward. When this happens, the greater trochanter starts to smash up against a bursa which eventually could lead to bursitis.
The external rotators of your hip are the key here. Concentrate on the gluteus maxims and not the gluteus medius. Remember, the medius is an internal rotator. Don’t forget the deep external rotators either. By performing external rotation with a cable or tubing attached around the ankle, you will strengthen the piriformis, superior and inferior gemellus, obturator externus and internus as well as the quadratus femoris. This will help stabilize the hip so that smashing of bone against bone doesn’t occur.
Be aware, some clients may have an aversion. This is the angle of the femoral neck in the frontal plane. (see diagram). Anteversion will turn the toe turn inwards, increase mechanical advantage of the gluteus maxims as an external rotator, increase the Q-angle and cause more pronation at the foot. Anteversion is structural, so you can’t repair that without a scalpel and a chain saw.
In conclusion, I hope you can see that in the case of the lower extremity you must take a holistic approach. Ask a lot of questions. How did they get this way? Is the condition acute or chronic? Is it congenital? Is it structural or muscular? Examine their gait.
If there is pain when performing these exercises, refer them out and get a medical release.
I hope this will help you and your clients, and I sincerely hope you’ll assess their posture before you load anyone with a weight.
By the way, after a little RICE, (rest, ice, compression, elevation) my friend was able to walk again. Now she just needs one of you to train her.