By Doug
Keller via Yoga International
If you have chronic pain in your knees, if they “snap, crackle, and pop” when
you bend or extend them, or if they tend to hyperextend, you may have improper
tracking or “dislocation” of the kneecap. This misalignment causes the most
common kind of chronic knee pain and damage to the knee joint, which develop
slowly over time.
Here’s a simple anatomy lesson: The kneecap is designed to slide along a
groove in the femur, and it has to move smoothly within that groove to do its
job well. If it goes “off track” (and it often does), it grinds away at the
cartilage underneath and destabilizes the knee. The ensuing wear and tear is a
key reason for knee replacement surgery, which a lot of people believe is
necessary because they think the cartilage is “gone.” But the truth is that
cartilage can grow back, albeit slowly. The main problem is that if we don’t
correct the imbalanced pull of muscles on the kneecap, we will continue to grind
our cartilage down faster than our body can replenish it.
So why does the kneecap go off track? The cause lies mainly in the
quadriceps, a group of four muscles that merge just above the knee into a single
quadriceps tendon. This tendon surrounds and attaches to the kneecap, continuing
down below the kneecap as the patellar ligament, where it attaches to the tibia
(shin bone). The kneecap serves an important mechanical function. The quadriceps
tendon passes over the kneecap like a rope over a pulley, and the kneecap—like a
pulley—increases the strength of the quadriceps to straighten the leg by 30
percent. Together, the quadriceps and the kneecap form the “extensor mechanism”
for straightening the leg. Misalignments come when the “rope” of the quadriceps
exerts a sideways pull on the kneecap “pulley,” creating friction in the
mechanism.
Hatha yoga has a lot to offer to correct this misalignment; the standing
poses are especially effective. But be forewarned: Misalignments of the knee in
various asanas can amplify the imbalances that lead to injury and can aggravate
existing problems instead of correcting them. The good news is that good
alignment and proper tracking are easy to achieve—once you know what to pay
attention to.
Why Are We
Prone to Knee Problems?
Our bodies are predisposed to injuries of the
extensor mechanism because the hip joints are wider than the knees in a neutral
standing position. The natural Y-shaped configuration to the leg bones promotes
uneven contraction of the quadriceps, and problems such as hyperextension of the
knees make these natural imbalances even worse. As a result, when we contract
the quadriceps to straighten the leg, the unevenness of the contraction tends to
pull the kneecap to the outside, thanks to the greater pull of the outermost
quadriceps (the vastus lateralis).
The innermost quadriceps (the vastus medialis) is most responsible for
counteracting this pull. This muscle tends to be weak and underused, while the
outer thigh muscle tends to be stronger from overuse. So if you want to keep the
knee healthy (i.e., tracking properly in its femoral groove), you need to learn
to strengthen the vastus medialis. In fact, physical therapists consider
exercises to strengthen this neglected muscle key in the rehabilitation of knee
injuries.
The Challenge of Working with the Inner Quad
Yoga students are often told to “lift the kneecaps” in straight-legged poses
to engage their quadriceps and, ostensibly, protect their knees from
hyperextension. But lifting the kneecaps in a healthy and balanced way requires
focused attention, especially if you already have problems in your knees.
This is easy enough to check. Sit or stand with your legs straight and your
feet parallel to each other, then engage your thigh muscles so that your
kneecaps “lift” or pull toward your hips. Do your kneecaps move up in a straight
line, or do they move in an angle toward the outside of your knees? If the
latter is the case, then you need to strengthen the vastus medialis, the inner
quad, and learn how to use it properly.
This has its challenges. First, it can be difficult to find and isolate this
muscle, because you can feel the vastus medialis firming most only in the last
10 to 20 degrees of knee extension. So it takes focused attention to even feel
and understand what the muscle does.
VASTUS LATERALIS (left) and VASTUS MEDIALIS
(right).
Second, structural misalignments that cannot be changed (like being
knock-kneed or bowlegged) tend to limit the vastus medialis’s proper
functioning—and can even weaken it in relation to the other quadriceps muscles,
making it even harder to work with.
Finally, although engaging the vastus medialis properly can prevent
hyperextension of the knee, doing so is essentially useless if the knee is
already hyperextended. Consequently, it’s important to consciously avoid
hyperextension in the first place, rather than relying on the strengthening
exercises to prevent it. This is critical, because the habit of hyperextension
will otherwise pull you right back into your imbalanced patterns of knee
extension even after you do the work of strengthening the vastus medialis.
Here’s what you can do to keep your kneecaps tracking properly:
- Find your vastus medialis, the inner quadriceps muscle.
- Strengthen it with small extension exercises.
- Continue to strengthen the vastus medialis in bent-knee warrior poses.
- Incorporate that work into straight-legged asanas.
Strengthening
Your Inner Quad
Isometric extensions will help you identify the inner
quad and its action as you strengthen it. To do this, sit in
dandasana
(staff pose) with your legs extended forward. Support your upper back against a
wall if that’s more comfortable. Roll up a small blanket or sticky mat and place
it under your knees to prevent hyperextension while your quadriceps are
contracted. Next, rotate your right leg out 10 to 15 degrees (if the sole of
your foot were on a clock face, your toes would be pointing to one o’clock). To
find the vastus medialis, place your fingers about one inch above the inner (or
medial) corner of your kneecap, and then walk your fingers about one and a half
inches toward the inner thigh. Straighten your leg slowly to feel the quadriceps
engage. You’re looking in particular for the firming of the teardrop-shaped
muscle just under your fingers. This is the vastus medialis, the inner
quadriceps. You will feel it fully engage as your leg straightens completely.
Hold the contraction for 8 to 10 seconds, then release. Repeat this for two more
rounds, making sure you don’t extend the leg so hard that you feel locking or
pinching in the knee. Repeat this exercise with the left leg.
Next, do the same exercise without rotating the leg out. Keep your leg
aligned so that your kneecap faces straight up toward the ceiling. Extend your
leg fully and see if you can engage the inner part of the quadriceps—where
you’re touching with your fingers—as strongly as you can engage the outer part
of the quadriceps. Watch how your kneecap moves in a straight line along the
center of the knee joint when your quads are engaged in a balanced way, rather
than pulling to the outside. Repeat on the other leg. You can do these exercises
several times a day—just be careful not to fatigue the muscle by doing too many
sets at a time.
The Warrior
Poses
Among the traditional asanas, the warrior poses
(
virabhadrasana I and II), in which the front leg is bent and the back
leg is straight, are particularly effective for strengthening the vastus
medialis, if done with proper alignment and action. Because although it’s
easiest to isolate this muscle’s action when the leg is fully extended, it is
also engaged and strengthened when the knee is bent at a 90 degree angle and the
leg is bearing weight—as long as the knee is positioned vertically over the heel
and the inner heel remains grounded. This is the case in a well-aligned warrior
pose.
To come into the pose, step your feet wide apart, while extending your arms
out to either side. Your feet should be roughly beneath your wrists. Turn your
left foot in about 30 degrees and your right leg out 90 degrees. Keep your torso
upright as you bend your right knee. Make sure your knee does not go beyond your
ankle and toes: Keep the shin vertical while striving to bring the thigh
parallel to the floor, so the leg is bent at a right angle. If the knee goes
beyond your ankle and your weight shifts into your toes, widen the distance
between your feet. Turn your head to look out over your right fingertips.
Even when your stance is the proper width and your knee bends to a right
angle, a common—and harmful—misalignment is to let the thigh turn inward so that
the knee points more toward the big toe. This happens especially when the arch
of the foot collapses, which places stress on the inner knee and prevents you
from strengthening the quadriceps in a balanced way. A less common misalignment
is to shift the weight to the outer edge of the foot, so that the knee turns
more toward the little toe. In this case the muscles along the outer thigh
tighten, and the outer (lateral) side of the knee is stressed. In this case,
too, the vastus medialis doesn’t function properly.
TO PROTECT THE KNEE make sure it’s above the second toe and that both
the toe and the knee are on the same plane as the sit bone. If the
vastu medialis is not properly engaged the knee falls inward. The vastus
laterialis then pulls the kneecap outward, stressing the inner knee. When the
weight shifts to the lower heel, the knee splays out over the little toes and
stresses the inner knee.
Proper alignment in the warrior pose allows the vastus medialis to work in
harmony with the other quadriceps to align and strengthen the extensor mechanism
of the knee. Misalignments, on the other hand, disable the vastus medialis and
increase the muscular imbalances that cause wear in the knee. You can protect
your knees and strengthen the vastus medialis by following three basic rules for
the warrior poses.
First, make sure your knee is bent
properly to a right angle, so the weight is centered in your heel. If your toes
are gripping, it’s a sign that your knee is going too far beyond your heel.
Second, don’t let the inner arch of your foot collapse, for
this is a sign that your knee is turning inward too much. We sometimes
compensate for this collapse by shifting weight to the outer edge of the foot,
causing the inner heel to lift. But this stresses the outer knee and defeats the
purpose of the pose. The challenge of aligning the knee is to keep your inner
heel and big toe mound grounded while keeping the inner arch of the foot lifted.
These two actions—grounding and lifting—will keep the knee from turning inward
or outward too much. Lift your toes to help engage and lift the inner arch; as
you bend your knee, draw the energy from the inner arch up through the calf to
your inner knee, so that your knee remains directly over your heel and does not
turn inward.
Third, make sure that the heel, kneecap, and hip joint of
your bent leg are in the same plane by allowing a slight turn of the hips. (If
you were doing the pose next to a wall, your outer right ankle, knee, and hip
would all be touching it.) To achieve this, when you bend your knee, let your
outer hip descend toward the floor (as if you had something heavy in your hip
pocket) as you lift energy from your inner arch up through your inner knee. This
will make your leg spiral out as you bend it, until your heel, kneecap, and hip
joint are all aligned.
The purpose of these three actions in the bent leg is to ensure that all four
quadriceps muscles are working harmoniously to stabilize the knee. As a result,
the vastus medialis gets a much-needed workout that brings it into balance with
the other quadriceps. To confirm this, gently pinch your thigh above the inner
knee to check that the muscle there—the vastus medialis—is as firm as the thigh
muscles at the outer knee.
Trikonasana
Proper alignment of the knee in the warrior poses
automatically gives the vastus medialis a healthy workout. Now you can apply
these same actions to the straight-legged poses like trikonasana, in which
working the vastus medialis consciously is more challenging.
Step your feet wide apart, turning your left foot in 45 degrees and your
right leg out 90 degrees, toward the edge of your mat. Bend your right knee
slightly and align your heel, knee, and hip as in warrior pose. Then straighten
the leg mindfully, engaging the vastus medialis, especially in the last 20
degrees of extension. If you engage this muscle properly and your leg is aligned
as you straighten it, you’ll see your kneecap draw straight up your leg, and
you’ll find it nearly impossible to lock your knee. But if you let go of the
vastus medialis even for an instant, the knee can easily hyperextend and lock
into that position.
Fold at the hip crease to take trikonasana to the right. Keep the vastus
medialis firm and lift along your inner thigh, maintaining the straightness of
your leg without locking the knee. If you feel pressure in the knee joint,
you’ve probably relaxed the vastus medialis and hyperextended your knee. Come
out of the pose and try again. As a bonus for good alignment, you’ll feel a
stronger stretch along the inner edge of your thigh, from your inner knee back
toward your sit bone. Be careful not to overstretch: use the support of a block
for your hand if you need it.
Conclusion
The standing poses of hatha yoga provide
powerful and effective means for strengthening and stabilizing our knees,
helping us to overcome structural imbalances that might otherwise lead to
chronic wear and tear (and ensuing pain) in your knees. A little extra
mindfulness in aligning and working our legs in these poses will enhance the
natural therapeutic benefits these poses have to offer.
Doug Keller’s yoga
journey includes 14 years of practicing in Siddha Yoga ashrams, intensive
training in the Iyengar and Anusara methods, and nearly a decade of teaching in
the United States and abroad. Asana instruction, essays, and other enlightening
information is available on his website.
