Getting Better...Better - Part 6 - Going up the Chain
Last time, we covered the ideas behind Joint Centration and introduced how an actively stable or "centrated" foot presents under load.
Ironically, as we make our way up the chain to the knee, some of the first things we look at when dealing with knee pathology are foot mechanics. The knee never tends to originate its stabilization strategies, and instead relies on the foot and the hip to dictate loading patterns.
It is commonly accepted in both the medical and performance fields, that knee pathology is often a result of poor mechanics, the most common of which is uncontrolled knee valgus, or the knee crashing to an inward position. This valgus position can cause all sorts of problems including, ACL and MCL tears and sprains, on the acute side of the spectrum, and menisci/articular cartilage degeneration, patellar tracking issues, IT band syndrome, amongst a host of other issues on the chronic side of the spectrum.
This has led to a wide range of "umbrella" prescriptions that are often well-intentioned but misguided. These include cues such as "keep your knee inline over your second toe," "keep your knees behind your toes," unending isolation strengthening of the Glute Med and VMO, and even more recently the "knees out," cue that has grown in popularity as Crossfit and strength sports in general have begun to explode.
Cues and exercises are inherently neither good nor bad. They are just a tool, the validity of which depends entirely on its application. A cue or exercise that is magic for one individual, may be ineffective or even detrimental for another. A proper understanding of the brain's stabilization strategy(remember Panjabi in part two?) is imperative to the proper application of a cue or an exercise.
An actively stable knee is reliant on an actively stable foot/ankle complex and an actively stable hip. Regardless of the the strength of the VMO and Glute Med, if the foot and ankle find their stability passively through excessive pronation or supination(remember part 5?) the knee will follow suit and manage load along its valgus or varus end ranges. Additionally, the hips manage load actively when the pelvis is a neutral and the hip is externally rotated(to be discussed next time), and this again dictates what the knee does from an upstream perspective. If the hip slams into internal rotation as a stabilization strategy, the knee will again rely on its valgus end range to manage the load, regardless of respective strength at the hip and knee.
As an individual acquires the skill of managing load actively at the foot(read: short foot) and hip(neutral pelvis, external rotation), the knee will most often fall into "alignment" in a position that is most actively stable for their anatomy. For some individuals this indeed does present as their "knee over their second toe," or results with the knee staying behind the toes. For many(dependent on ankle mobility, femur length, etc etc) it does not. Regardless of how the knee presents visually, usually once the knee is able to manage load actively, it automatically reduces risk for non-contact acute injuries to the knee, such as the dreaded ACL tear, or acute meniscus tears, and often reduces or resolves chronic issues such as pain from premature joint/cartilage degeneration, and patellar instability.
Once an individual is able to create a short foot and maximally externally rotate the hip, without losing the short foot, the maintenance of this position is usually more reliant on skill and kinesthetic awareness, vs strength.
As with any movement pattern or skill, the goal is to get the individual to be able to create this actively stable position unloaded, then loaded, then loaded dynamically, adding load and speed as their skill improves(ie: seated, then standing, then walking/running).
Obviously it depends on the context - different people have different goals, different anatomy, and different medical histories. If you are having pain, please, PLEASE go talk to a qualified medical professional who can evaluate YOUR problem. In parts 7 and 8 we will attempt to tackle the hip and the low back, and as always the goal is to help make you better. Better.
If there is any specific topic you would like to see addressed or if you have any questions feel free to reach out to me(Jon) directly at firstname.lastname@example.org or contact our clinic at 816-554-6003.
Thanks for reading!!
Frank C, Kobesova A, Kolar P. DYNAMIC NEUROMUSCULAR STABILIZATION & SPORTS REHABILITATION. International Journal of Sports Physical Therapy 2013;8(1):62-73.
Page, P., Frank, C., & Lardner, R. (2010). Sensorimotor Training Progression. In Assessment and Treatment of Muscle Imbalances: The Janda Approach(pp. 163-164). Champaign, IL: Human Kinetics.