Tutorial #2373

Knee Pain

30 min - Tutorial
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In this tutorial, Sherri Betz teaches a progression of exercises to help with knee pain. She starts by looking at the feet and hips so you can find good alignment for functional movement. She also shows how you can determine whether the pain is caused by a structural problem or a strength problem, and then she shows how you can strengthen the muscles around the knee.
What You'll Need: Cadillac, Small Tennis Ball, Pilates Pole

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Nov 22, 2015
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Hi, I'd like to share with you, uh, a focus on the knee. And um, a lot of times I'm teaching PyLadies especially the introduction to Pilati courses, which is a six week series that we do at our studio for introducing people to the plotters method. And one of the goals in that course is to help people avoid needing physical therapy or having to go to the doctor for certain makes and pains. And I know that you're my volunteer for this, this, um, topic and you don't have knee pain or foot pain or any lower extremity pathology, but I'm going to just go through the body and, and as if you were learning about the knee and the foot and the hip and doing movement and prevention of knee pain, hopefully would, would be our goal. So one of the first things I look at when somebody tells me they have knee pain is do they um, have foot problems or pronation in the feed or any issues in the feet.

I'm looking for either a tension disorder or a, what we call a floppy foot disorder. And those are not technical terms. Those are just my terms and I'm looking to see if someone holds more tension in their feet or less tension in their feet. So when I look at Candace's feet, um, I'm seeing there's a little bit of gripping in this right foot and that's what we call sort of Hammertoe. And this can lead to things like plantar fasciitis or hammertoe dysfunction where the foot gets kind of stuck like that. And the, and the toes tend to rub on the top of shoes. So there's also a little bit of a Bunyan on this side there. There's Bunyan's on both, but a little bit more on the left and the right and sometimes as are hereditary and sometimes they're caused by foot, um, sort of pathologies or just defamation. Um, she has pretty good arches if you want to face the front. Um, uh, you have, uh, a nice arch just being relaxed.

You've been standing there for a few minutes already and the arches are not collapsed. Um, which is probably one of the reasons that you don't have any pain, right? So I'm going to have you lift your toes up toward the ceiling and notice how that increases the arch of the foot and then coming back down. So why does the foot have such an influence on the knee? Um, if she were to pronate. So I'm gonna Demonstrate in my feet, because I am, I tend to be a pronator. So if I roll my feet in like this, I have very floppy sort of loose tone feet. I have very mobile feet, my feet are like loose bag of bones. And if I roll my feet in, you notice that my right foot, um, has a lot more motion in the arch. And you can see that in my foot, right? You can say that this arch is a lot closer to the floor and certainly rolls in.

Now, I had an injury as a gymnast many years ago where I tore ligaments in the arch of my foot. So I don't have a lot of control over that ligamentously or, or with a joint structures. But what I have learned to do is control my feet with the muscles of the feet. And we've got four layers of muscles under there and we want to make sure that we keep those muscles active so I don't stand around and just let that arch collapse. So why that's so important for the foot is that if your arch is collapsed, then you get stress to the medial collateral ligament of the knee and you might get stressed on the medial meniscus of the knee. Most common area to have knee pain is the medial meniscus or the medial side of the knee. And also the patellofemoral joint too.

So a collapsed arch can certainly put stress on the knee. It can also disrupt the biomechanics of the quadricep and patellofemoral joint relationship. The one of my colleagues says that the knee is just the dumb joint in between the foot and the hip and, and um, and so it's, if the need has a problem, it's not his fault, right? It's the foot's fault or the hips fall. So the reason why is because the foot actually helps the tibial plateaus stay level. And that's just the shelf of the Tibia where there's little dishes that, that the femur glides in.

So there's these round sort of condyles of the femur that roll on top of the Tibia and then these wonderful cushions in there, the meniscus and the, and the cartilage that we love. We love that cartilage to be nice and fluffy and oily. When we move, we stimulate synovial fluid. Now if we move with compression all the time or with poor mechanics, we rub the cartilage away like a mortar and pestle. And then we have grinding and cracking and all of that. So lucky you don't have that, right?

So what does the hip have to do with the knee? So the hip, the hips job is to determine what direction the foot points, right? If my foot goes one way and my knee goes another, that's the problem, right? We don't want that. That could tear an ACL with the anterior cruciate ligament. That can actually have a big repercussions. So, um, the other thing I'll share with you is that the knee is controlled by muscle in 80% of the shock absorption for the knee is through muscle. So that's what we want to have strong muscles to support the knee.

But what do people do when they have knee pain? They baby it, right? They get knee surgery, right? Or they get knee surgery or they baby it and they and they go, oh no, no I can't do squats or lunges. So the minute somebody tells me, especially in my older adult classes where I teach people that have poor balance and are maybe using walkers and canes and crutches is that um, they tend to stop doing the very thing that they need to be doing. So they, that they don't want to do squats or lunges. Are they saying, my doctor said don't do squats or lunges because that's going to damage your knee. Well how did they get off the toilet in the morning? How'd they get out of bed? How did they get in the car?

How do they get out of the car to come into the studio? Right. How do they get down onto the reformer and back up again? So we have to squat all day long, whether we like it or not. Cause we were not going to be able to do it like this. Right. And not bend the knees. So we have to bend our knees.

So my goal is to try to help you with knee bending that's appropriate. That's good alignment that that has 'em good functional, you know, capabilities for carrying you into the future for the rest of your life. So really making sure that you know about that alignment. And that's part of what you learn in Pele's when your teacher says, okay, keep your knee over your second toe. And when you're doing your reformer work, you keeping everything in alignment. And that's part of the strengthening process so that you strengthen the muscles that are in the right alignment. Okay?

So one of the things I think would be great for your feet is the tennis ball massage. Now for my feet, that would not be a great thing because I already have really floppy feet and really loose muscles in my feet. And if I start massaging my feet, um, they're going to get looser and more floppy. So that would not be a great exercise for me. My, my best exercise with using the tennis ball is going to be like the parakeet action. So I'm wrapping my toes around the ball, trying to get all five metatarsal heads to show. And then I'm really trying to get the arts to strengthen. So I need strengthening for my arch. You don't need a lot of strengthening for your arch. Yours looks pretty good.

You look like you have a strong foot. But what would be good is to do a little massage with your foot. So I often give people a dowel when they, when they'd start doing standing on, on one leg. So let's start by just putting the ball between the big toe and the second toe and put your heel down. And what I want you to notice if you could face the front so the camera can see, um, what I want you to see, put this dial out to the side. There we go.

Is that when she puts pressure right between the second and third toes. Um, hopefully that's going to spread that Bunyan out just a little bit. And then the other thing I want to address is this, um, reflect the reflection at the, the pip joint here. And what that means is proximal interphalangeal joint, she's got extension at the MTP joint. These are long words, right? Metatarsal Phalangeal joint, and she's got flection at the next joint up. So what we want is this joint to go into more flection and this one to go into more extension. So first we separate the feet and then our, the the second and the first and second metatarsal and roll forward and roll the ball forward all the way to the arch and just stretch out your toes. That's it.

And then come back and you're trying to see if you can separate each metatarsal and relax your toes as you do it. That's it. And then go to the next one. Oh yeah. So you're trying to separate the bones of your feet. You go wonderful. And then you go to the fourth and fifth.

Got this now good. Yeah. So you just spend a little bit of time paying attention to your feet. And then on the next exercise, I do think that the [inaudible] would be for her, but for a different reason than what I was doing at four. So put your a ball of your foot on the, on the tennis ball and yeah, perfect position right there. And you want your even a little bit farther forward right there.

And then you want your feet, your toes kind of hanging over the ledge. And what I want to see, I don't want to hurt you, but I want, I want, I want to see you be able to flex right there. See how that joint is kind of stuck. Yeah. So you've been trying to work on it. So the foot bar is actually really good for that, but if she doesn't do a [inaudible] on the reformer, then she wouldn't have that, that influence here on the flection of that joint. So yeah, doing that. There it is, it starting to come and then you're going to wrap the, the, the toes around the ball. Yeah. There you go. Starting to get better. Excellent.

Now you can start seeing those knuckles. Wonderful. That's it. So you can do that motion. It's not stuck [inaudible] that, that sometimes they're stuck and you can't do anything. They're frozen. Right. But you still got motion there. That's wonderful. Okay. And then the next thing is, um, when you do say I'm on your tippy toes, and of course you do that on the other side too. But for time sake, we won't do the both sides. Um, you would try to straighten this one out and you want to try to get that, that next joint there to be, oh no, no, no, no, no, no, don't, all right. Yo, you gonna mess up my video here.

Okay. And then pressing down, that's it. There you go. And try not to grip flora with those toes. So one of the things that's going to help is that one of the exercises we're going to do is a lunge and you're going to wrap the, the ball of the foot towards the floor and you can stretch those joints. Okay? So we'll, we'll practice that in a moment, but I'll be watching your feet to see what is, what are your feet doing and every exercise that we do. And, and that has such an influence on the knee that people not realize so, so many times. Okay. So now our next goal is to make sure that your hips are working.

And then, um, I can take that away now for right now and put your feet all the way together. And what I want you to notice when your feet are all the way together is that your, you have to work a little bit harder to stand up. It makes your balance challenged a little bit. So put your hands on the outside of your hips and heels of the hands in the Gluteus Medius, which is like the haunches of your hips up here. All right? And then shift your weight back and forth and you're going to notice a muscle contract right into your fingers as you shift side to side.

And it doesn't take much of a shift. Good. Now separate your feet quite a bit and then shifts side to side. Notice how it takes a long time for that muscle to kick in. So, so often when people have either knee pain or they start to lose balance reactions, they tend to stand with their feet farther apart. They walk with their feet farther apart and then their hip muscles are not working. So is a very important muscle that helps control the pelvis and the neck relationship to the knee. Okay, so now break, bring your feet together.

So one of my first homework assignments is to have you stand with your feet together more often. Now what I want you to do is go up on your tippy toes and then she's doing a great job with that. Most of the time what I see is people splaying their, their ankles apart like that, but she's doing a very good job of that. And usually when I see people do that, I'll take a tennis ball and have them put it right between the ankles. The other thing, yeah, you're doing a great job. So I can use a business card or maybe a Neiman Marcus credit card would be a good motivation with an unlimited balance. Right. Right. In between your heels, I guarantee you get ahold back together. Right. Okay.

And then separate your feet just a little bit. So say she had Valgus, which is the knock knee position. I really hate that word, knock me. So valgus is not much better either. It's not a pretty word, but, but put the feet all the way together again and then hug that tennis ball so you can see that there's a little bit of a spacer and then she, she can still connect those feet together as she goes up and down. So one of the things that's really tricky about the knee is people don't think about calf strength. And calf strength is so important for fast walking, climbing stairs, climbing hills, you know, all the kinds of things that we do in life. And um, people don't tend to want to work on their calves because women don't want to have big calves. So it doesn't mean that your calves are going to get giant if you do some Catholics or sizes, it just means that you're going to be strengthening the muscles that cross the back of the knee. So working on that is one of the first things I do with knee pain because they don't even have to bend their knee. Good. Okay. Then immediately, as soon as you can do that, we're going to give you the doll again.

And I want you to stand on one leg. Okay. And lift your knee up a little higher. That's a, and then could you hold the dowel up and still balance. So that's the next thing I'm going to look at. How is their balance, how is your balance and can you, can you balance in one place? Now could you turn your head to one side and then the other? Yeah, she's got great balance. This is good. Ya know, so harder to turn the head. I know cause you're really challenging your vestibular system.

So then standing on one leg is one of the next assignments. So feet together, stand on one leg and then rise up on your tippy toe with one foot. So again, you might be holding something at first and then up and down. So going up and down quickly is usually easier than slowly and you're going to work up to 10 repetitions. And then once you can do 15 repetitions, then you might do something like put weights in your hand or use therabands to increase the amount of resistance. Right. I know. But you know, older adults should be able to actually do 25 of those. It's shocking how people are surprised that we've, the calves are all right. So then we'll do the other side as well. But, but again, for time sake we won't, we won't do the other side. And then, um, then the next exercise would be to keep the legs straight and then lift the leg forward. And then let's do this one. Yeah.

And so which leg do you think is getting the work for your knee? Your standing leg? Yeah. That's the one that's getting the help because the knee is not a problem. Usually if it's not in weight bearing. So I'm, the problem child is when the knee is and weightbearing you try to stand up and sit down and squat and lunge and pick things up. Okay. So then you're gonna go out to the side like this, and then you're trying to keep the pelvis level, your keep your spine lengthened. Yeah, you have lovely posture that looks great. And then you get to feel these muscles right here, mostly on this side though it working.

And then you're gonna extend the leg back. Now another thing I'm looking for with knee pain is hip extension. So if they don't have really good hip extension, a turn to the side, please canvas. Okay. And um, yeah, so that you change legs. So it's OK. I know that leg got tired. Okay, so extend your leg and what you're going to see is one of two things. If they have decreased hip extension, you're going to either see the back arch, which tends to make the back hurt, or you're going to see the knee bent. So the hamstrings have a type a personality disorder.

They'll do everything if they can. And the glutes will be like, oh, we're going to Jamaica. You know, we're going on vacation. So what we want is to keep that and they really straight and then lift the leg. So she's only got about 10 degrees of hip extension, so she might do better with increasing that length of that hip, hip flexor. Okay, so that looks good. Once she progress's on that. Usually I tell people with me paying to do that routine for three weeks.

So they do feet together, stand on one leg, heel raises either two or one depending on how strong they are and then the leg forward, side and back. So they don't bend the knees for three weeks. In three weeks you're going to have a lot better feeling in your knee most of the time. I mean, almost every patient I've ever given this to, even without physical therapy has done great and they get rid of their knee pain because it's usually a strength problem. Now, as a Polonius teacher, how is it that you're going to figure out whether or not it's a structural problem that needs physical therapy or is it a strength problem? And I'm going to show you how to do that in just a moment. All right, so let's put this on. And so sometimes people have a hard time with with getting those legs to bend and being able to do that without pain. So I start by having them in this side. We just, so you'll have the outside working and then give some resistance here.

So this is just like a straight leg raise. So I don't know if you know about physical therapy where they lay you on the mat and then you, you do the straight leg raise, you put a weight on the end. Well what I love about this is that it's really the standing leg that's getting the work. So you're lifting up, you're keeping the knee straight, you're going to really use that muscle above the kneecap to work the knee and lift. That's it. So you're, so you're seeing a really good response in that quadricep muscle and then face the front. So we can see that. Mostly what I want you to see is that she's keeping the knee very straight. If she bends the knee, that muscle will not work at all.

So if she keeps that knee straight, you're going to see that VMO working very nicely. I find that's really hard to get people to do is to get that knee really straight when they extend. You've got a lot of the the tools already, which is probably why your knee functions really well. You can keep your knee straight really well. You have good balance. Your feet have good arches. So so far you've passed all the May tests. Okay. All right.

Now extend the leg out to the side and so this is going to target more the Gluteus medius and outer hip muscles and you want that foot to stay straight ahead so that you're really targeting the abductors, the AB doctors. Oh yeah. So it's easy to cheat on that. Excellent. Okay, now face me and then extend the leg back again. So now she's got resistance there. She's probably really going to want to help with that hamstring. Then we're going to try to keep that knee straight, flex the foot helps, and then extend back.

So I call that phase one because phase one is just doing all the strength thing that you can possibly do without bending the knees. Okay. Then phase two is going to help us understand. Let's go ahead and step out of that, whether or not they have a strength problem or a structural problem. Okay, so let's, let's have you do a squat for me and I'm, I'm just going to let you interpret that however you want. Okay, good. Now face the camera and do it again. All right, so what I'm looking for in the squat is many things, feet, pronating, supinate, ing, you know, what is, what are her feet doing as she does the squat?

What direction do her knees point, right? Then what does the pelvis do? Okay, so face me again as a, when I look at the front, I'm looking at what the knees and feet do. When I see her from the side, I'm looking at what the pelvis does. Okay? So go ahead and the spine, right? So if the knees come together or the pelvis tends to art too much or flex too much, that could be a problem for the back. Okay? So here's the deal is that when you stick your butt out and do a squat, the knees love that. If you talk your tail and do a squat. So tuck really, really hard. Um, tell me what you feel in your knees. Nothing different. Really. Okay.

So a lot of people that have patellofemoral problems will have pain when they do a tuck squat, right? So if you do that, that whatever tendency the patient or client has is what I work on. You know, to see if, if the Tuck is causing knee pain, if you hinge at the hips and fold at the hips, keeping the spine in neutral as you squat, does that cause me pain? Now the next goal is, can you do a full squat? So I think of this as a camping in the woods, squats, or you're trying to go all the way down and to see if you can do that. So try that. [inaudible] so she needs a little help and then come back up. Right? So it may be that your calves are tight, the does it feel like this?

Could you step out and do it again so you don't hold on to something and you can let your heels come up if you need to. I know you didn't know you were volunteering for this, did you? Okay. So she really has to flex her spine in order to get all the way down and it's probably that she doesn't have a lot of calf or ankle range of motion. Right? So if you let your heels come up, see if that feels better. Yeah. So then she can keep her spine in neutral, which means that she's limited by the ankle range of motion. Okay.

Go ahead and come up. Not, not something huge that you can do. Okay. That you can do anything about. Sometimes, sometimes the ankle has whatever range of motion it's going to have and then that's it. All right. Now next what we're going to do, if you had pain with a squat, okay. And nothing I did made it better, right? Um, I would have to add some support. So I would bring you to the trapeze table and I'm going to give you some support. All right? So we'll use the blue springs to help de weight the body to see if this is either a structural problem or a strength problem. If the pain goes away, if I do the lunge or a squat with the blue springs to help de weight your body and give you assistance with the squat, then I know it's a strength problem. Okay. So stepping back into your squat position, feet pointed straight ahead and then bend the elbows, armpits down.

That's it. Then I remember your shoulder mechanics and then then back into your squat and go as deeply as you can using the springs to help you. Beautiful. That looks great. And then coming back up. All right. If there was pain still with that, then I would either give her an additional amount of assistance, which could be using a doorframe. So we're gonna use the portable doorframe here.

So if I put her into a next to a doorframe and then have her lean back against it and then do your squat. Okay. Lean back onto the pole and use it for help. I'm going to stabilize it and then, and then scoot back. Yeah. So let's come back a little bit further. So you could do like a wall squat. Okay. And then bend your elbows and use the springs to help you. There you go.

That's it. And then come back up. So if it were truly a doorframe at home, she could actually lean against it and get some support. Now I have had people go into their garage, throw either ropes over the garage door opener, you know, or something from above a swing set outside and do the squats with ropes to help and start to build their strength. Right? So let's try one more exercise that I love for building strength in the knee. We're going to do it without the springs first. And what I want you to do is step forward at least three feet and then square off the hips so that the back heel is lifted. [inaudible] that's it.

So you want both feet pointed straight ahead because if you've got the back foot turned out and then you bend your knee, that's gonna strain the inside of your knee, possibly. So we're going to stretch back and then lift up. And so keeping both legs straight. Um, so this is another exercise for people with decreased hip mobility that they can do early on in I call phase one that they could actually do pretty early on to prepare for lunges cause this helps to get the ankle more mobile and to increase the mobility of hip extension. So now lift up and stay. All right, now what I want you to do is be able to bend that back knee without dropping the pelvis at all. There you go. Hold my hand, hold my hand. Let me give you the doll. That's why it's here. Good cause as we're practicing alignment, that's sometimes hard.

So now straighten the leg and then bend it. I call it the secret knee bend as if it's like, um, a secret from your torso that you're bending your knee so that your pelvis doesn't move at all as you vent. All right. Now pretend like you're going straight down a pole and then go straight down a quarter of the way and then back up if there's pain with that. We stopped there, we give her the springs, we let her unload a little bit, see if that helps. All right, now go halfway down and then back up again. And then let's lengthen those toes on the front foot. There we go.

And then three quarters. Excellent. And then back up and then see if you can go all the way down and touch the floor with your back knee and backup. So she's got very strong legs. So say that she had a hard time without her head pain. With that stay where you are. Don't move.

I'm going to trade you so I can give you the springs. So say she had pain with that. I'm going to have her use the springs to unload a bit and bend quarter of the way down and back up. Exactly. And bend halfway down and up. So that would be her work in the studio and her work at home would be to do the same thing.

Getting into the doorframe against the door frame so that she has a way to extend that that hip as if she was against a wall. She wouldn't be able to extend her hip. So pretending like this pole was a doorframe. Keep your head against the pole. That's it. There you go. It's a, it's surprising how the head wants to come forward and held and there's a lot more load on the back knee with this type of lunge. Beautiful. One more time. Inhale to bend.

Now keep your ribs down in the front a little bit. Yeah. She tends to want to extend through the upper back. That's it. All right. I said one more time, but I want you to do one more just like that. Think of your rib cage swinging like a bell backwards. That's it. So you keep that connection in the front. Beautiful and then step together.

Great. I hope that gives you some wonderful tools to use in the studio to determine whether or not someone has a response to knee pain with exercise that doesn't, that doesn't have to necessarily go to physical therapy or the doctor in order to deal with the knee pain. Remember that going with a structural problem versus a strength problem requires unloading of their own body weight. Because if they're too weak to manage their own body weight, which Candace was not, she has great strength. Um, if they're too weak to manage their own body weight, then they need to use springs to assist them until they progress. So you would start with maybe red springs and then go to blue and then go to yellow to progress them in the studio and then progress them at home to actually adding weight eventually to, um, to increase their strength.

Okay. That also helps to build bone strength as well. Thank you very much for joining me.

Comments

1 person likes this.
Great video. Very informative. Reaffirmed what I knew but gave me lots more to work on as well.
3 people like this.
Really enjoyed the tutorial. Very informative, but I'm still not clear on how to determine that it's a structural problem vs. a strength problem. Is it possible to clarify? Thanks!
2 people like this.
Another great tutorial! Your clients correction improv with the gondola pole was cute. Might you consider a break down of squats for many have problems with those?
2 people like this.
Excellent as all of your tutorials. Thank you.
Thank you. If you have cued the client into ideal alignment of feet, knees, hips and pelvis and unloaded the affected joint by increasing the spring tension to red or blue springs in spring assisted squats and that takes the pain away, it is a strength problem. If the client is in good form and alignment and using the heaviest springs and a pole or support behind the back does not take the pain away, it is often a joint derangement and may need the treatment skills of a physical therapist or surgeon.
3 people like this.
Fantastic Sherri! Just had a client who complained of pain in her knees, great timing. Your explanations and cues and what options to use and progress too were so helpful.
Helping us to understand structural and strength awarenesses so valuable. Thank you for sharing your expertise.
1 person likes this.
Excellent tutorial , so informative , thank you
1 person likes this.
Great tips, Sherri! I have two new clients who overweight the right knee and feel a lot of pain. In this particular case should I do the same number of repetitions on both sides? Especially the standing on one leg? Thank you and all blesses!
7 people like this.
So GLAD and Happy for PilatesAnytime and Internet! I didn't have the chance to learn more from you while you where in Miami...
Invaluable information! I always quote you on " Knees have no personality, they will do whatever your hips or feet are doing...SHerry Betz"
Thank you... and hugs
That's a great quote Emily/Sherri!
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