Some of you’ve seen it before. You might even have some “knee valgus” yourself. It’s when the knee(s) looks like it is twisted inward. If it happens on both legs, this is culturally called “knock(ed) knees”. But I want you to understand one crucial fact, knock knees have actually nothing to do with your knees. In fact, they have everything to do with what’s above (pelvis) and what’s below (feet).
So when a knee creates this twisted inward presentation, it’s telling us that it needs some help from the pelvis and feet to straighten out. You see, the pelvis is the foundation of all lower (and most upper) mechanics of our body. The pelvis sets the stage for movement to occur. If the pelvis is stiff and not moving properly, say good bye to efficient movement strategies from mostly everything else.
The feet are a bit different. The feet react to the environment around us. They are our “sensing” organs. They feel and then react to that feeling. They also are easily persuaded of what to do or how to best orient themselves from the femur and pelvis. Think about it this way, the feet are going to do anything they need to, so that we can walk straight and stand upright. This might mean turning themselves all the way out (out-toeing), it might mean overly flattening their medial arch (flat foot). It might even mean twisting their big toe to make pushing off the ground easier (bunion). So think of the feet as the things that “sense” and “react” to the demands of ground and the demands of the bones above them.
So let’s take it back to knocked knees now.
For this type of twisted inward presentation, the femurs (thigh) are stuck in way too much internal rotation and the tibias (shin) are stuck in way too much external rotation. This creates this representation of a twisted inward knee. At the feet, you can see a couple different compensations. The feet might want to turn out , to fight the inward twist of the knees. The feet might want to overly lift up their arch because they are fighting the inward collapse of the knee. But you might also see a different presentation all together. The feet are compensators. So they will compensate differently for each person they are under.
Ok , so how do we fix this issue! We always start with the pelvis. Why? Because it’s reliable. We know what position it is in. We know what exercises to perform to improve that position. We know how to progress through a program to affect how the knee is stabilizing, from above. We wouldn’t want to start with the feet because those guys are all over the place. They are compensators so we can’t trust to start with them. But we will definitely introduce them to our program sooner than later.
So for the pelvis, we need to create more external rotation at the femur, and many times, more abduction of the femur. We give patients exercises that involve turning the knee outward while pushing the pelvis into a forward translation. This forward shift is key to creating space at the femur and pelvis to move into external rotation without compensating. We also give exercises where the leg is stretched out side-ways. This is called abduction. Working on abduction allows us to, while weight bearing, properly accept our weight over that leg and also properly get off the leg. This is huge for someone with knocked knees. They don’t know how to properly get on, and mostly, off their leg. They twist at the knee to push off and usually that’s where they are having their pain.
After we attack the position of the pelvis, we then need to strengthen the muscles to hold it there. That really is the gluteus medius, gluteus Maximus, and in lesser ways, the hamstring and adductor muscle groups.
Once we strengthen them, we can confidentially assume that the person knows how to properly and efficiently walk (we must make sure we do walking-like exercises with those muscles to insure this).
After all of this, we focus on attempting to change the foot position. Lucky for us, many times after doing all of the things from the pelvis and hip perspective, the feet will just line up and like good little soldiers, take their orders and change their orientation, without even specifically being told to do so. If they don’t do this, then we can work on re-sensing. Because remember at the end of the day, the feet are our “sensing” organs. They sense the ground and learn how to react well to it. For someone with knocked knees we want to facilitate and waken up the sense to feel the mid-foot and heel. These two things will insure proper heel strike, and proper pronation through the stance phase of their gait cycle. We want to practice the coordination and timing of these senses (mid foot and heel) as the person is doing some type of movement- based walking exercise. After the person changes their pelvis position, changes the muscles to insure that position is maintained, and begin to retrain their feet to sense the proper references into the ground, we should be able to visually see a difference in their knock knee presentation!
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