Forward Lunges To Strengthen Your Knees?

Lunges by our 3 physios

A patient came in complaining of knee pain after running. Since she also did strength training with a personal trainer, she was instructed to do forward lunges (FL) to strengthen the muscles "around the knees" to avoid knee pain. Yes, the lunge is a very popular strengthening and loading exercise that is often prescribed by many health professionals. 

Alas, the front lunges made her knee pain worse.

After examining her, I explained that her knee pain was more likely coming from her hip. Meaning, she feels the pain in her knees, but the cause of her problem is her hips.

In addition, FL exert a much greater load on the patellofemoral joint compared to backward lunges (BL). I recall just reading a published article where researchers studied a group of young healthy females comparing front and back lunges.

47 body markers were placed on different parts of their bodies to record data from two force platforms in addition to 15 motion analysis cameras. The female subjects performed 10 consecutive forward and backward lunges and the researchers analyzed the middle six. 

The researchers found that peak patellofemoral joint (PFJ) reaction forces were 18.1 percent higher in FL compared to BL during the upward phase. Peak PFJ stress was 9.55 percent higher in FL compared to BL.

Peak quadriceps (or thigh) force was 18.3 percent higher in FL.  Knee bending angles were 5.85 percent larger in the upward phase of FL compared to BL. Most importantly, average PFJ loading rate was 124 percent higher in FL compared to BL. 

These results suggest strongly that there is much higher PFJ loading in the FL compared to BL. Exactly why my patient's knee pain got worse after doing her lunges. 

So if you're having knee pain, it may be best to avoid doing forward lunges until it settles. It may also be wise to strengthen your calf muscles instead.

Reference

Goulette D, Griffin P, Schiller M et al (2021). Patellofemoral Joint Loading During The Forward And Backward Lunge. Phy Ther in Sport. 47: 178-184. DOI: 10.1016/j.ptsp.2020.12.001

Clam Shell Exercises?

Clam shell exercises?

My patient came in complaining of knee pain after running. She had seen another physiotherapist who after treating her knee, prescribed clam shell exercises for her to do as well. But she still had knee pain after running and climbing stairs despite doing them regularly.

How many of you have been asked to do clam shell exercises to make your Gluteus Medius (or hip) muscles stronger? If you have, maybe you need not bother any more.

Latest research (Moore et al, 2019) shows that clam shell exercises do not activate your Gluteus Medius as much as you think.

Right Gluteus Medius muscle

The Gluteus Medius muscle is very important for female runners, especially if they have knee pain. You can treat their knees but their pain will not go away until you have addressed the weakness  in their Gluteus Medius muscle.

View from the back, Left Gluteus Medius

In that small study, three sets of six common lower limb exercises were performed by ten healthy adults after a short warm up. They did single leg squats, single leg bridging, hip abduction (lifting) in side lying, clam shell exercise in side lying, running man exercise (simulates running motion of running one leg at a time) and resisted hip abduction-extension exercise.

The participants had electromyography or EMG electrodes to measure muscle activity attached to all three parts of the Gluteus Medius muscle (in front, middle and posterior).

Results showed that clam shell exercises were not effective in activating any part of the Gluteus Medius muscle. Highest levels of overall activity were seen in the single leg squat, single leg bridging and the resisted hip abuction-extension exercise.

Other than the knee, you need to know that weakness in your Gluteus Medius can also contribute to pain or problems in your Achilles. Make sure you are doing the strengthening correctly.

Reference

Moore D, Pizzari T et al (2019). Rehabiliation Exercises For The Gluteus Medius Muscle Segments: An Electromyography Study. J Sp Rehab. DOI: 10.1123/jsr.2018-0340.

My Patient Was Told Her Knee Alignment was "Off"

Have a look

My patient came in complaining of pain in both her knees after running. She had been to another physiotherapist who told her that her "kneecap alignment was off". He proceeded to give her some strengthening exercises for her quadriceps and asked to return for another session. He checked on her exercises and did some ultrasound and "electric current" therapy.

After the two sessions, she didn't get any better doing the quadriceps exercises and was referred by her friend to see me. I told her that all of us have highly variable alignment in our knees and she shouldn't worry too much about what the other physiotherapist told her.

Yes, just in case some other healthcare professional tells you the same, there is a very good article published on this topic. In fact the article is a systematic review, which means a search aided by computer for all randomized and clinically controlled trials. When it comes to quality, there is none higher than a systematic review or meta-analysis.

The systematic review concluded that healthy knees have a highly variable alignment, although this may be due to variables when doing x-rays/ MRI scans, measuring techniques and the people studied.

The exact role of knee joint alignment in development of knee pain/ symptoms remains unclear.

So we should not be telling patients that their knee joint alignment is in any way abnormal at all, not if we do not even know what normal alignment is.


Reference

Hochreiter B, Hess S et al (2019). Healthy Knees Have A Highly Variable Patellofemoral Alignment: A Systematic Review. Knee Surg Sp Trauma Arthr. pp 1-9. DOI: 10.1007/s00167-019-05587-z.

Is this knee's alignment abnormal?

I know some of you will be asking what did I do to make my patient better? After assessing the knee joint, I usually make sure there is no hip dysfunction or shortening in the calf muscles. In this particular patient's case I started with her Superficial Back Line (SBL) and her Spiral Line.

Superficial Back Line

Since she runs, I made sure I checked her running style/ technique too.

Spiral Line

Can Your Calf Muscle Cause Your Knee To Hurt?

Now that's some very defined soleus muscles

Really? You must be wondering how and why after looking at the title of this week's post. Well, my last patient today had knee pain caused by her soleus (or calf) muscle. She had recently been doing a lot of step ups in her gym classes and her knee pain started soon after.

Runners' knee or patellofemoral joint pain (pain under the kneecap) is very common in runners. I've written before about how this may be due to heel striking, heavy landing and hip dysfunction.

There is also some evidence where the length of the soleus muscle can influence patellofemoral joint pain (PFP). It has been suggested that in runners with PFP, there is a greater activation in the muscle compared to runners without knee pain (Piva et al, 2005).

See soleus after you cut away gastrocnemius

Your calf muscles consist of the more superficial gastrocnemius muscles and the deeper soleus muscle. If you peel off the gastrocnemius muscles, the soleus muscle lies underneath. Together they end as the Achilles tendon finishing at the heel bone (picture above).

The soleus muscle is largely thought to help with our posture as it is mostly made up of Type I slow twitch muscle fibres. The gastrocnemius muscle is made up of mainly Type II fast twitch fibres.

The fast twitch muscles of the gastrocnemius allows you to sprint. However, the gastrocnemius muscles tire easily.

The slow twitch soleus muscle is very important for your walking and running. Since they're more fatigue resistant, you use them a lot chalking up mileage whenever you run.

One of the main functions of the calf muscles is to absorb shock. If they're overused, they can't absorb shock well, your knee takes more of the load and you get knee pain.

A very simple way to take load off your soleus muscle is to take smaller steps when walking or running. Increasing your step rate, especially while running will ensure you're not over striding and heel striking. This reduces impact loading and lessens your chances of knee pain.

Reference

Piva SR, Goodnite EA et al (2005). Strength Around The Hip And Flexibility Of Soft Tissues In Individuals With And Without Patellofemoral Pain Syndrome. JOSPT. 35(2): 793-801. DOI: 10.2519/jospt.2005.35.12.793.

Knee Pain In Female Runners

More evidence that your knee pain (especially in female runners) is a result of weakness in your hip/ gluteus (or buttock) muscles in a recently published paper (Wilson et al, 2012). Also have a look here.

In the paper, the researchers studied twenty male and twenty female healthy runners. The runners all ran regularly and had 5-6 years of running under their belts. The female runners were found to have 40 percent greater peak gluteus maximus (or buttock) muscle activation and 53 percent higher average gluteus activation compared to the male runners.

The researchers concluded that with the greater gluteus activation, fatigue will set in faster (in the glutes) such that it alters the lower extremity running biomechanics (greater hip adduction and less knee internal rotation) leading to knee pain.

Come see us at Physio Solutions or Sports Solutions, we'll help you run without knee pain.

Reference

Wilson JD, Petrowitz I et al (2012). Male and Female Gluteal Activity and Lower Extremity Kinematics during Running. Clinical Biomechanics. 27(10): 1052-1057.

* Picture from Flickr.com

Ladies, Your Knee Pain May Be Coming From Your Hips

How many of you ladies have knee pain? Well, you may be interested in this then. I have seen quite a few women runners/ triathletes the last couple of weeks, both elite and recreational with knee pain in the clinic. And guess what? Majority of my patients knee pain came as a result of weakness in the hips. Yes, some of them do have contributing factors coming from the knee itself, but the main cause was the hip weakness. So the hip weakness basically led to knee pain.

Well, you do know that at Physio and Sports Solutions we are really good at treating the cause of your pain rather than just treating the pain itself. So besides treating the patients' knee pain, the main thing was to explain the rationale of the treatment plan to them and then teach them how to specifically strengthen the hip muscles.

The strange thing is I've actually noticed this trend quite a while earlier from treating previous patients. So I was really pleased to find an article that was published earlier this year that confirms what I thought.

The study had 19 female runners with knee pain and a separate control group of another 19 female runners as well without knee pain. The group of women with knee pain had greater average hip internal rotation range and reduced hip muscle strength compared to the other group.

The authors concluded that it is the abnormal hip mechanics and decrease strength levels rather than the difference in hip shape and structure of women (as compared to men) that caused their knee pain.

So ladies, if your knees are causing you grief while running, please come in and see us and we will treat the cause of it to prevent it from coming back. And then you can run, pain free of course.


Reference

Souza RB and Powers CM (2009). Predictors of Hip Internal Rotation during Running: An Evaluation of Hip Strength and Femoral Structure in Women With and Without Patellofemoral Pain. Am J Sp Med. 37(3):579-587.