Friday Practical Pointers: Who Should Avoid Certain Knee Movements?

by Baxter

Flexion and Eternal Rotation by Melina Meza

Our tour through the body’s major joints continues today with a look at who should avoid certain knee movements. When it comes to possible movements, the knee joint is a quite a bit simpler than the hip and the shoulder as it is mostly about bending and straightening. But because of its role in standing, walking, and running, the knee is one of the most commonly injured joints and very frequently affected by the wear and tear of osteoarthritis. 

Movements of the Knee Joint

Flexion: Bending your knee (moving the lower leg bones backwards toward the upper leg). You make this movement when you move into bent-knee standing poses such as Warrior 1, 2 and Side Angle Pose when the front leg goes from straight to bending the knee over the ankle. The movement is also essential for bending your knee more deeply, such as when sitting in Hero pose (Virasana) or Child’s pose (Balasana). 

Extension: Starting from a bent knee position, straightening your knee (moving the lower leg bone forward and away from the upper leg). The opposite movement of flexion is extension, so anytime your knee is bent and moves towards straightening, your knee is going into extension. You make this movement when you exit from Warrior I or 2 (Virabradrasana 1 or 2) or Extended Side Angle pose (Utthita Parsvokanasana) or in the transition from Warrior 1 to Warrior 3. You also make this movement when you lift your back leg in Hunting Dog pose, come into Cobra pose (Bujangasana) from Child’s pose (Balasana), or move into Downward-Facing Dog pose (Adho Mukha Svanasana) from all fours. 

Internal Rotation: When your knee is bent, rolling the lower leg bones in, towards the midline of your body. The lower leg can internally rotate a small amount at the knee joint only when the knee is in flexion. You make this movement in Hero pose (Virasana), both seated and reclined versions, as well as in the many seated poses that have one leg in Hero pose. 

External Rotation: When your knee is bent, rolling the lower leg bones outward, away from the midline. The lower leg can externally rotate a small amount at the knee joint when the knee is in flexion. You make this movement in many bent-knee seated and reclined poses, including simple ones like Cobbler’s pose (Baddha Konasana), both seated and reclined, more complex ones like Half and Full Lotus poses (Padmasana). 

Note: When the knee joint is in full extension, such as in Mountain pose (Tadasana), your lower leg cannot independently rotate from the knee, either internally or externally. In this case, when your upper leg rotates from the hip, your lower leg goes along for the ride. You can see this when you turn your front leg out to prepare for pose a standing pose like Triangle pose (Trikonasana) or in a straight leg seated pose, such Wide-Angle Seated Forward Bend (Upavista Konasana).

Cautions for the Knee Joint

Now let’s look at who should avoid or minimize certain knee movements. Keep in mind, however, that we want to maintain as much of our full range of movement of the knee joint as possible. So, in many instances, my caution will not mean “don’t” or “never,” but rather approach cautiously and stop if the movement worsens pain. In general, you should avoid or minimize any knee movement if you have:

1. Acute painful injury to the knee area that gets worse with that movement, whether from a sports activity, such as acute ligament sprains, or a problem like acute bursitis that is the result of bumping your knee cap or over use.
2. Chronic issues that flare with that movement, such as those with knee joint arthritis or those with meniscal and ACL ligament injuries that have not been repaired or even, in some cases, that have been surgically repaired. 

Now for the specific movements. Who should avoid or minimize the following movements?

Flexion

1. Those with significant swelling in the joint, whether from an acute injury or the flare of a chronic condition, such that the swelling actually inhibits movement or elicits significant pain when movement takes place.
2. Those with Patellar Femoral Syndrome, a fairly common condition affecting the knee cap and knee joint, which often is worse with flexion.
3. Those with arthritis of the knee that become more painful with flexion.
4. Those with bursitis at the kneecap area or with a Baker’s cyst at the back of the knee.
5. Those with ACL repairs who need to avoid extreme flexion, such is in full Child’s pose (Balasana).

Extension

1. Those with tears to the ACL ligament need to avoid sudden strong extension, such as stepping from Lunge pose (Vanarasana) to Downward-Facing Dog pose (Adho Mukha Svanasana), or jumping from Standing Forward Bend (Uttanasana) to Downward-Facing Dog pose.
2. Those with hyperflexible knees may want to avoid full extension in straight leg poses to avoid wear and tear on the internal knee structures and ligament over-stretching.

Internal Rotation 

1. Those who experience increase pain in the knee in poses where the knee is both flexed and internally rotating, such as Hero pose (Virasana), both seated and reclined, and the seated twists where one leg is in Half Hero pose (Adra Virasana).
2. Those with tears to the meniscus (the half moon cushion of the knee) where increased pain or locking of the knee occurs with flexion and internal rotation.

External Rotation

1. Those who experience pain in the knees where the knee is both flexed and externally rotating, such as Cobbler’s pose (Baddha Konasana), both seated and reclined, Half and Full Lotus poses (Padmasana). 
2. Those with tears to the meniscus (the half moon cushion of the knee) where increased pain or locking of the knee occurs with flexion and external rotation.

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Friday Q&A: Creaky Knees

Q: I just started working with a student who has a lot of issues with her knees, and also has a total hip replacement. Whenever she flexes her knees even the smallest amount while weight bearing they make this loud creaking noise. What is the cause of this and how should I work with her from a yoga standpoint?

A: The sound that joints make when they move can often be scary. When do we need to be concerned about these sounds? Whether or not we should ignore them is the crux of this question and our medium of exploration is asana.

It would seem that if you asked this question to a physician or other health practitioners, you would probably get an answer that sounded like this (now remember I now have my physical therapist’s hat on). Often sounds in knees are called crepitus. Crepitus may show up suddenly with no associated pain and it may be persistent every time the motion is performed. These joint noises are considered “benign” because there is no associated pain. Some theories of what causes these sounds (and the medical term is cavitation) are that when the knee joint moves there are changes in joint pressure in the synovial fluid. The changes in joint pressure cause tiny bubbles of gas to form slowly in joints. When these gas bubbles burst quickly, they make a popping sound similar to when you pop bubble wrap. The myth that states that these joint sounds will lead to arthritis is not medically proven.

Okay, so now let’s explore the sounds a bit more. Remember, the ends of the bones in the knees are covered with cartilage. This cartilage protects the joints as we bend and straighten them. If this cartilage becomes worn or frayed, the normal and smooth sensation that accompanies knee motions can become rough, leading to catches or popping sensations. If the cartilage becomes severely damaged, severe painful catches and swelling can occur.

Another cause of joint noise is the snapping of tendons or scar tissue as they are stretched slightly as they go over a prominence around the knee joint and then snap back into place making that popping sound. Again, medical opinion is that there is no harm with this knee popping as long as it isn’t causing pain, and it will not put you at risk or make you more prone to injury.

Finally, sounds in the knee may be due to small fragments of cartilage or other tissue that move freely around the joint, and these small bodies can cause complaints of popping and catching although they are most often associated with pain with movement or loss of movement due to catching.

But now let’s address this teacher’s question. She states that the student “has a lot of issues with her knees, and also has a total hip replacement.” Well, “a lot of issues with her knees” is pretty vague, but after a hip replacement it is probably that this student’s mobility has been limited for quite some time. When hips are in pain, it significantly changes how we walk and stand. Our physical abilities decline and we become much more sedentary. So we have the surgery to fix the main limiting problem but our body has to learn how to move again without the fear of causing the pain that we had for such a long time prior to surgery.

I would recommend that you first look at your student in Tadasana (Mountain pose) to get an idea how she distributes her weight on her feet and her knees and whether her kneecaps (patellas) are facing in the same directions. Looking for asymmetries in her knees and feet will help you learn what might need to be addressed in her asana practice. I also would watch her walk, and see how she moves in space and how easy and smooth her walking is. I would also assess her balance.

Of course, knowing her hip limitations and restrictions is paramount before she begins an asana practice, and if she herself doesn’t know, she may have to either give you permission to call her surgeon. or you can ask her to call herself (but be specific in the questions she has to ask).  As to her particular practice limitations, I might start her practice in a chair first so she can learn how to move her body with support. By having her practice in a chair, you can figure out if moving her knees in sitting has the same effect on the knee noise as loading her knees (standing in weight-bearing positions). Next, have her progress to standing poses but only with small, partial knee bending not full bending, seeing if there is a point that no noise occurs in the movements. She can work this way until she is ready to move onto the full poses.

—Shari

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Arthritis of the Knee and Yoga

by Baxter

While in Montreal for a weekend workshop, I found myself attending a modern dance performance. I’d say the average age of the performers was about 30, and all looked very fit and flexible. As part of their performance, they did a move in which they leapt forward while spinning and landed on the floor in a Pigeon-pose like stance. The first time they did this, I found myself wincing, as I imagined the impact on their knees on the firm, uncarpeted dance floor. I’d have to guess they did this at least five more times, and usually always landing on the same knee. My host and I spoke about this after the show, and we were both of the opinion that no good could come of this for the future health of these dancers’ knees.

Trauma to the knee is one of several risk factors for the development of arthritis of the knees later in life. It was no coincidence that one of the attendees at my weekend Anatomy and Yoga workshop has arthritis in his knees at the ripe age of 40, as he had been dancing for over 20 years and had suffered numerous injuries to both knees over that time. But since starting his yoga a few years back, his knee pain had improved to the point that after a hiatus of almost 10 years, he was gradually returning to some dance.

In addition to trauma, other risk factors for developing osteoarthritis (the most common form of arthritis) of the knee include: 

• weight, as in more body weight, more stress on the knee joint 
• sedentary lifestyle, as it seems that some activity is better for the knee joint than no activity 
• work or hobbies that involve repetitive demands on the knees, such as horseback riding, which encourages a bowing outward at the knee joint and places unusual stress on the knee joint 
• bone abnormalities, which some people are born with and could include skeletal issues such as bow legs or knock knees 
• other diseases like hypothyroidism and Paget’s disease, which could lead to arthritis over time advancing age 
• gender, that is, women, for reasons that are not yet clear, have a higher incidence of arthritis than men 

Typically, in a healthy knee joint, just as in the hips, the surfaces of the top bone, the femur, and the bottom bone, the tibia, are covered in a layer of protective connective tissue known as cartilage. The cartilage acts as both a shock absorber when the bones move close to one another, as when you are walking or running, and also as a smooth, slick surface for the bones to slide over one another when you are doing any knee bending activities.

If any or several of the risk factors are present, the usually smooth surfaces can become rough, like sandpaper, which may or may not produce pain, but could produce some grinding sounds from the knees. Eventually, the cartilage could wear through and expose the underlying bone, which is even rougher. When bone on bone contact starts to occur, it usually results in inflammation in the joint, which then swells, can become hot to touch and limited in movement and painful. Since the condition usually worsens over time, especially if you don’t seek help for it, it could eventually lead to significant immobility and pain. I am going to assume you have had the common sense to see you family MD to get an accurate diagnosis and have tried some of the western treatment options, such as medications, physical therapy, and braces, and such and are looking for alternative ways to work with the knees to avoid worsening of your situation and surgery.

Yoga is both helpful in addressing the acute problems of swelling and pain, and the longer-term issues of improving mobility, strength and stability of the knee joints. 

In acute situations, restorative practices or reclining sequences can allow for you to maintain some gentle movement of the knee while reducing the effects of gravity on the knee that occurs when you stand. A regular favorite when the knee is swollen is any reclining posture that elevates the leg higher than the chest. My personal favorite is Legs Up the Wall pose (Vipariti Karani). Another is the door jam version of Reclined Leg Stretch (Supta Padangustasana_, where you lie down on the floor on your back at a doorway, your hips lined up with the doorway, and take the affected leg up in the air and rest the heel on the door jam. This allows for a more passive approach to this pose that we usually do with a strap on the foot of the lifted leg.

In addition, a whole slew of other reclining poses can be performed that are safe for the knee and allow you to get some of the stress-reducing benefits of a regular home practice (see Timothy’s post from yesterday Home Practice: The Best Way to Improve Your Health and Well-Being). On top of helping to quiet down an inflamed knee, you can use your practice to strengthen the muscular/tendonous support around the knee. Engaging the muscles that surround the knees simultaneously has been shown to benefit the joints, as Shari noted in a post a while back on hips. So I recommend starting with poses in which the knees are extended or straight, as this reduces sheering actions on the cartilage. This includes Mountain pose (Tadasana), Triangle pose (Utthita Trikonasana), Pyramid pose (Parsvottanasana), Wide-Spread Standing Forward Bend (Prasarita Padottanasana), and such. If these are done successfully, without aggravating your knees, and are hopefully bringing some gradual improvement in your symptoms, you can add in standing poses with knees bent. This will require that you pay special attention to the trajectory of the knee as you flex it. Ideally, you will want to bend the knee directly in line with your mid-foot, so the knee is tracking in the most anatomically correct way. You may want to have your local yoga teacher help you to figure this out, as it is a bit difficult to sense on your own at first.

Another potential way to modify seated poses to allow you to do them pain free is to use some sort of a spacer tucked into the back of your knees before you deeply flex (bend) the knees. You can use a rolled up washcloth, or a thinly folded yoga blanket. Once you place the spacer in the fold of the back of the knee, mindfully bend the knee and see how it feels. There should be no pain. If you have a history of ACL repair (anterior cruciate ligament), then never use a spacer, as it could loosen this precious repaired tear.

Since every arthritic knee is going to be a bit different, these suggestions are offered to get you thinking about ways yoga could be helpful for you. As I always say, it would be a good idea to do some one-on-one work with an experienced teacher to guide you safely on your way.

And skip the Flying Twist Dropping Pigeon from your repertoire until next lifetime!

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Happy, Healthy Knees!

by Baxter

Since we started this blog in September, we have covered quite a bit of territory. Yet when I went back to look through our archives today, I was surprised that I had not dedicated a post to the subject of our knees! Our knees are one of the body’s most amazing architectural feats, allowing us to stand upright each morning, walk, run, jump and participate in life’s many and varied activities. And at the same time, the human knee, by virtue of the immense loads and stresses it endures each day, is also subject to the slow wear and tear of aging as well as the sudden vulnerability to injury, which many of us have encountered in our lives.

My own knees have allowed me to run races, bike long distances, climb mountains and hike incredible valleys, play basketball, baseball, tennis and a myriad other sports over the years, and for the most part have done a commendable job. But I have also suffered periodic flares of pain and swelling, especially in my left knee, stemming from an initial twisting incident on an icy ski run back in my thirties. X-rays show evidence of narrowing of the medial side of the joint, which implies I may have done some damage to the medial meniscus, the spongy cartilage pad designed to cushion the femur and tibia bones as they stack one on the other. And I have a family history of arthritis in hips and knees on my mom’s side of the family. Mom had both knees replaced in her seventies.

Yoga, especially hatha yoga, with its contemporary emphasis on yoga postures, can be both a blessing and a possible curse to your knees. As always, a mindful approach to your practice will help you tip the scales towards the blessing side. In fact, I have found that patient attention to my yoga poses following a flare of knee pain that was unrelated to my yoga practice allowed me to gradually calm and resolve the pain, and reclaim my full range of motion of the joint.

There’s a lot we could say about knees, but today I just want to start out our exploration of knees by considering how your yoga practice can ensure healthier, happier knees for you, especially for the athletes out there who enjoy running and biking. Although the stresses and demands on knees differ with the two activities, yoga’s dual benefits of strengthening and stretching around knee joint can prove helpful for both activities. In addition, the more essential skill of increased concentration and overall mindful awareness that yoga fosters can improve performance and reduce the likelihood of injury while enjoying these sports. And in the unfortunate circumstance of injury resulting from running and biking, yoga can be a part of your rehab program to get you back in action in a timely fashion. On top of all that, a well-rounded, balanced yoga practice can address issues above and below the knees, in the ankles and feet as well as hips and lower back, which can have significant impact on effective running and biking.

A few of my favorite poses and practices for runners and cyclists with a focus on the knee joint include Dynamic Reclined Hip Stretches (see here), Reclined Leg Stretch pose (Supta Padangusthasana), and Sun Salutations, as well as standing poses such as Warrior 1 pose, Triangle pose, Extended Side Angle pose, and Standing Forward Bend. For runners, I like to throw in psoas muscle stretches, such as drop knee lunges and Half Frog pose, from which cyclists can get some benefit as well. For cyclists, due to the tendency to have the spine in forward flexion (rounding forward), I recommend a passive backbend over a roll or block.

In future posts on the knees, I will discuss yoga for arthritis of the knees, as well as how to address certain injuries that can arise in this essential joint! In the meantime, I’m teaching two workshops that may be of interest to those concerned about their knees. In Oakland, I’ll be teaching a workshop at Mountain Yoga called “Knees if you Please,” on Saturday, June 9, from 2 to 5 (see Mountain Yoga for more information). And in Cincinnati, Ohio, I’ll be teaching a workshop at The Yoga Bar for runners and cyclists Saturday,  June 16, from 1 to 3 (see The Yoga Bar for more information).

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Arthritis, Exercise and Yoga

by Nina

Hey, I heard this really nice little piece on arthritis and exercise on NPR that I wanted to share with you. Fortunately, NPR has both the audio and a transcript of the piece on their web site (see here). What I liked so much about this particular piece was how simple and clear it was about why it is important to continue to exercise when you have arthritis (even though most people don't) because exercising, while it cannot reverse arthritis, is the only way to prevent the arthritis from getting worse. Here's why:

1. Arthritis breaks down your cartilage, the natural shock absorbers in your joints. As a result, blood doesn't circulate as freely and doesn't deliver adequate nutrition to your cartilage. Exercise massages the joints, improving the blood supply to the joints, providing your cartilage with more nutrition.

2. The stronger the muscles are around the joint, the more protection your body can provide for the joint. Your muscles take up the weight and pressure, instead of the joint itself.

The end of the piece even mentions yoga as a good way to improve the strength of the muscles around your joints! (That's refreshing because most people are under the misconception that yoga is only about stretching.) But yoga is also a good way to massage your joints to get the blood flowing because in a well-rounded practice you move your joints in every direction. Just think of all the directions in which your hip joints move in the various standing poses. And your knee joints are bent or straight, turning out to the side or even turning in slightly (such as in Eagle pose). Your shoulder joints really get a workout, too, as you hold your arms overhead, out to the side, behind your back, or across your body (again, as in Eagle pose).

For strength building, it's easy to think of standing poses (especially those with bent knees) and balancing poses that strengthen the muscles around the knees and hips. But what about your shoulder joints? Downward-Facing Dog and Plank pose spring immediately to mind because you are bearing weight on your arms as they extend forward. But there are also other poses that you can use to strengthen your shoulder joints in which you bear weight on your arms reaching sideways (such as Vashistasana, sometimes called Sideways Plan pose) or behind you (such as the backbend Purvottanasana, sometimes called Upward Plank pose). Here's Esther doing Purvottanasana:

That looks like it does a good job strengthening the hip joints, too! Yeah, it can definitely be a challenge to practice with pain in your joints or to practice modified versions of poses you used to be able to do without props (I know because I have mild arthritis in one of my hip joints), but enjoying more mobility in your daily life and possibly avoiding joint replacement surgery, well, that's a pretty big payoff.

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