Chapter 9
THE WEIGHT BEARERS – OUR KNEES
True alignment means that the inner mind reaches every cell and fibre of the body.
~ BKS Iyengar
I had never imagined knee pain could be such a common issue. It is not only the middle aged and the elderly who come complaining about it; knee pain is surprisingly prevalent even among teenagers and young adults. I have finally given up counting the various types of knee problems – osteoarthritis, patellofemoral syndrome, bursitis, chondromalacia, locked knees. What I know is this – all these maladies are directly related to the condition that the knees are subjected to. The condition may occur either due to problems in other weight-bearing joints or due to the functional health of the muscles that support the knees.
The knee joint is a very fragile structure with a disposition to pain, disability and restricted movement, more than any other joint in the body. It would be valuable to understand its basic structure and mechanism.
The knee joint is formed at the lower end of the thigh bone and the upper ends of the two lower leg bones. The kneecap or the patella is a small, oval-shaped bone, which is embedded in the muscles that cover the knee. It is designed to protect the knee, increase smooth movement and reduce friction. When the leg moves, the kneecap glides up and down in a groove at the lower end of the thigh bone. It ideally remains centred or 'tracked' in its groove as the leg bends or straightens.
Structure of the knee joint
The suppleness, the strength and the balance of the muscles around the knees automatically reduces the friction in the joint. This keeps the knees in a healthy condition. The stronger the supporting muscles, the better the stability of the frame.
Front Thigh Muscles or the Quadriceps: Better known as 'quads', their contraction straightens the leg at the knee. The quadriceps group is made of four muscles, which meet at the knee joint. The kneecap is wrapped inside the lower end of the quadriceps muscles.
Back Thigh muscles or the Hamstrings: Hamstrings are a group of muscles that start behind the hips and run through to the back of the knees. Together they contract to bend the leg at the knee.
Other important things to understand the knee joint better are:
- It supports the entire body's weight.
- It has no bony structures to support it unlike, for example, the hip joint that is well-supported by strong pelvic bones.
- Given that the knee is a hinge joint (with movement like that of a door on hinges), it is very mobile. This structure makes it unstable and vulnerable to damage.
- Knees participate in most movements – walking, sitting, standing, bending, kneeling, rising up from the chair, and so on – in varied degrees.
- The axis of transmission of bodyweight through the knee joint shifts due to incorrect postural habits and muscular imbalances.
- Obesity puts extra load on the joint.
- Sedentary lifestyle and weak, imbalanced muscles misalign the bones and lead to faster wear and tear.
Ask someone to mark a dot at the centre of each of your kneecaps. Have them make another set at the end of your lower leg (shin) in the front. This would be exactly where the foot starts. Ideally, the line that joins the dots on each leg is vertical and perpendicular to the ground. In case the knees are dysfunctional, they are either inside or outside of this vertical line. The other questions you need to answer are:
- Where do the knees point – forward, or are they turned in or out?
- Are both knees at the same level in relation to each other?
- Are the knees hyper-extended, that is, pushed behind (locked)?
- Track your knees as you bend them simultaneously. Do they face the front, converge towards each other (knock knees) or diverge from each other (bowed legs) with the bend?
Knee alignment – locked knees and bow legs
Seen from the side, the knees should be in an easy, neutral position – neither too bent nor pushed behind in a locked position. The back of the knees should feel soft unlike the discomfort experienced when standing with absolutely stretched-out knees.
Seen from the front, the kneecaps are a guide to the alignment of the knees. They should point in the front, straight ahead. The knees should be in line with the second toe of the respective feet. If the knees get angled, inward or outward, or if they come together on bending, or separate widely when straightened, then there is an imbalance in the muscles that bend and straighten the knees.
Depending on the assessment of your knees, you will find a solution/correction in the next chapter.
Common Observations
Women are more susceptible to an early onset of age-related knee pain in comparison to men.
- Mechanics: The wider dimensions of the hip (pelvic) region in a woman's body increase the angle at the hip joint. This predisposes the knee joint to greater stress.
- Hormones: Strong muscles act as a protective mechanism for the joints. However, women lack androgen hormones, which help in the development of powerful muscles. Also, in the post¬menopausal phase of life, the vital oestrogen hormone reduces, leading to further loss of muscle mass and tone.
Men too are prone to knee pain, but the reasons tend to be different. Due to their natural hormonal composition, men are blessed with stronger muscles. However, the downside is that their muscles are prone to become tight and short with overuse. Thus, it becomes more difficult for men to straighten their tight knees.
Men or women follow set patterns and lifestyles that affect their knee joints. However, because the causes are different, different solutions are in order.
Locked knees: Over-straightened and pushed back knees are known as locked knees. Knees are locked when we stand with all our weight on the heels. This happens due to the muscles behind the knees being weak, which makes the weight shift to the bones instead of to the muscles. The kneecaps push behind to smash into the joint space.
Other consequences of locked knees:
- Locked knees weaken the quads by making them lose tone and become loose. As the quads lose strength, they become flabby and soft. This sags the kneecap further into misalignment.
- Major nerves and veins pass from behind the knee. These get compressed when the knees are locked, leading to chronic leg pain, trouble with varicose veins, and other problems.
- Locked knees do not engage abdominal muscles, causing them to weaken. This then makes the lower back sway behind and form an unhealthy arch. Needless to say, the weight-bearing axis gets disturbed.
Incorrect Standing Habits: As mentioned in the previous chapter, the chain reaction to incorrect standing habits passes through the knees. When the feet are placed like a V, both the knees get pushed back in the locked position. This shifts the weight-bearing axis inward – from the centre of the knee joint towards the midline of the body – making the inner side of the knee joint bear more weight. This is why pain is felt on the inner side of the affected knee.
Patellofemoral Syndrome: Often misunderstood as knee arthritis, this is a very common and an easily manageable cause of knee pain. Here, the kneecap gets pulled horizontally to one side. Usually, there is an imbalance between the inner and the outer thigh muscles that form part of the quads group. In the tug-of-war between the two, the kneecap gets pulled to the side of the comparatively stronger muscle. This causes gritting and friction with the ends of the thigh bone, and results in inflammation and pain. Activities like walking, bending knees, using stairs, squatting or bending down hurt. What seems to be a case of arthritis is in all probability a case of patella maltracking. The answer to the problem lies in strengthening the quadriceps in a balanced way.
Patellofemoral syndrome: misalignment of the kneecap (patella) in relation to the thigh bone (femur)
Sitting in a Chair for Long Hours: Our 'chaired' and se¬dentary lifestyle encourages tightened and shortened hamstrings as they remain contracted to keep the knees bent. The front thigh muscles, or the quads, get weakened since they are not used at all. This imbalance created between the short hamstrings and the under-toned quadriceps gets worse with time and impacts the knees.
Sitting with Crossed Legs: As mentioned earlier, crossing one knee over the other while sitting on a chair is fashionable and makes a style statement, but it eventually causes great damage to the knees. This position of the legs damages the lower knee, which tightens under the weight of the leg placed over it. The knee which crosses over also gets affected but in a different way.
You can try this for yourself. Sit with your right leg crossed over the left. Notice the right foot. It rotates and turns outward. Sitting in this position puts a strain on the ligaments inside the knee joint and, if done for long hours, creates an imbalance between the muscles that rotate the knee joint. The left knee too can suffer due to the constant inward pull on the left thigh with the weight of the right thigh on it.
The chair – perhaps the most commonly used furniture – has inadvertently brought in a host of postural maladies. It may be wise to introduce a daily practice of squatting on the floor.
The knees are the most misused but also the most easily corrected joint. Unknowingly, we push our knees behind, thereby locking them and over-stretching the muscles behind the knees. This unhealthy practice however is very simple to rectify.
- Spread your weight evenly over your feet by bringing the weight of your body slightly to the front part of your feet.
- The knees will feel soft and relaxed rather than taut and tense.
Do It Right – Bring Back Lost Tone
As we know now, a joint is not an independent entity. We have to strengthen the muscles that hold the said joint in place. It is just a matter of bringing in a gentle tone to the muscles that support the knee by doing the following:
Hip Clench – Refer to page 47, Chapter 6.
This practice:
- Tones the weak thigh muscles at the front (quads).
- Makes the sagging kneecap pull up automatically.
Cartilage damage, softened kneecap, damaged ligaments, cysts, and more problems can all be treated with medicines and surgical interventions, provided that the root cause is identified and treated. However, the secret to healthy knees is to develop strong yet supple, supporting muscles around the knees that will keep the knees aligned with the other weight-bearing joints. From years of experience, I have found the answer in yoga.