Knock-Knees, Lady Gaga, and Yoga

by Baxter

Lady Gaga Bares Her Knock-Knees*

Don’t know if Nina mentioned it yesterday, but this interest in knees all started with the following question we got last week:

I have a student who has knock knees (genus valgus), a condition that I gather is quite common in women. She reports that aligning her knee with her second toe in standing poses gives her knee pain. Do you or Baxter have a suggestion for her, as well as for an appropriate cue in classes that might include people with this condition?

Also, many men have bow legs (genus varus); I have not yet heard complaints about problems aligning their second toe with their knee but suspect that some compensation might be necessary. If so, do you have a suggestion for them?

Whether you are a yoga teacher or a yoga student, if you don’t have knock-knees or bowlegs yourself, you have probably noticed someone in your public class (or a celebrity like Lady Gaga) who has one of these fairly common variations in leg bone relationships. And it turns out that more women are “knock-kneed” than men, and more men are “bowlegged” than women. However, I have seen cases of the reverse for both. 

Without going into to too much detail (but at least a little!), depending on the shape of the upper part of your thighbone, the femur bone, where the short neck of the femur (the part often broken in a “hip fracture,” especially in those with osteoporosis) meets the longer shaft of the lower part of the femur, a person might veer away from the normal angle enough to lead to one of our two conditions. When the femurs move further away from the midline of the space between your legs, referred to as “abduction” in anatomical circles, you end up with bowlegs. When the femurs move closer to the midline space between the legs, referred to as “adduction,” you end up with knock-knees.

In the case of knock-knees, when the femur meets the two lower leg bones, the tibia and the fibula, the inner knee joint tends to open up towards the inside of the knee joint and the outer or lateral joint tends to compress together more than normal. Tight inner thigh muscles and weaker outer hip and leg muscles can contribute to this situation. And with the knees knocking towards one another, you can get more wear and tear on the lateral joint, and the skin of the inner knees can even sometimes rub together in an uncomfortable way on the opposite side of the joint. Julie Gudmestad put it this way in an Taking Care of the Knee for Yoga Journal on keeping the knees healthy: 

“…knock-knees … put increased pressure on the lateral compartment cartilage and strain the soft tissue of the medial, or inner, knee. This problem is more common in our society, and is associated, as you might expect, with arthritis in the lateral compartment.” 

The strain of the soft tissue of the inner knee she refers to could mean an over-stretching of ligament on that side of the joint whose job it is to keep the bones in a healthy close relationship. And the increase in the chance of arthritis is why we care about these variations in anatomy!

In knock-knees, in addition to causing the inner bowing the legs of knock knees, the femur bone tends to roll or rotate inwardly, so that when you are standing in Mountain pose the knee caps end up pointing a bit toward one another instead of pointing straight ahead (or in line with second toe, as some yoga teachers recommend). Many yoga students are told to bring the inner edges of their feet very close together at the same time they are told to align the kneecaps with their second toes. In those with knock-knees, this can exacerbate the alignment even more. So, one of the first things I suggest for these practitioners is to separate the feet about hips-distance apart, sometimes with the aid of a block between the mid-thighs. I suggest they hold the block lightly between their thighs (as they may already have tight adductor muscles and we don’t want to encourage more tightness) and imagine that the block is pushing out against the inner thighs. I’d check in at this point and see if the student’s knee pain has disappeared. If it has, I’d recommend they adopt this new stance for future practice.

For Mountain pose (Tadasana) and variations, Standing Forward Bend (Uttanasana) and Downward-Facing Dog pose, Donald Moyer suggests keeping the feet a bit closer together and using a block between the knees. This closer foot position will let the block push the knees apart in the bowlegged direction.

Another option is to forgo the block, but keep your legs hips-distance apart, and place a looped strap around both legs, either mid-thigh or mid-calf, and press outward against the strap, feeling the strap resist that pressure. You are essentially taking the knees a bit towards the bowlegged direction, encouraging a bit of muscular strength in the outer leg muscles and a bit of stretch to the adductors of the inner thigh. You could apply this to other poses with two straight legs such as Standing Forward Bend and Seated Forward Bend (Paschimottanasana).

In his book Structural Yoga Therapy, Muktananda Stiles notes that those with genus valgus (knock-knees) usually have tight adductors (inner thigh muscles), and parts of gluteus medius often are weak. The external rotators of the hip can also be weak and allow for both the knocking and the internal rotation of the thighbone I mentioned above. Muktananda Stiles also relates his personal experience with long standing knock-knees and a pivotal practice session in which he worked with Warrior 2 pose, holding it with close attention to keeping his desired knee alignment, and consciously softening and lengthening the inner thigh muscles and strengthening the outer thigh muscles of his front leg to exhaustion. He claims that as he continued to work with this over time, his knock-knees resolved! 

In her article, Julie Gudmestad suggests using the Reclined Leg Stretch pose version with the leg out to the side to lengthen the inner thigh muscles. This works in the standing version of this pose as well.

To strengthen outer gluteal muscles and the external hip rotators, she suggests Warrior 2 with close attention to the knee position and the alignment of the front thighbone with the long edge of your sticky mat.

Other poses to stretch the adductors include:

• Triangle pose (Trikonasana), front leg
• Extended Side Angle pose (Parsvakonasana), front leg
• Widespread Standing Forward Bend (Prasarita Padottanasana), both legs, possibly using your elbows to press your inner knees 
• Wide-Angle Seated Forward Bend (Upavista Konasana)
• Cobblers Pose (Baddha Konasana)

Other poses that could assist in strengthening the outer gluteal muscles and the hip external rotators include:

• Half Moon pose (Ardha Chandrasana), both legs (plus, if you get the correct external rotation of the bottom thigh, you will also get some good adductor stretch)
• Tree pose (Vrksasana), top leg
• Pyramid pose (Parsvottanasana), front leg action at hip
• Warrior 1 (Virabhadrasana I), front leg action at hip

I hope these suggestions—while in no way exhaustive—can give you a few ideas on working with knock knees to not only eliminate pain that you or your students have now, but also hopefully reduce the chances of early development of osteoarthritis down the road!

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Bowlegs, Doctor Who, and Yoga

by Nina

I see your bowlegs, Doctor!

When Matt Smith became the eleventh incarnation of Doctor Who, I had a surprising reaction. I didn’t think oh, he’s so cute or, oh, he’s way too young to play Doctor Who or, oh, when are they going to have a female Doctor Who (okay, I did think that). Mainly I thought, oh, my, what bowlegs you have, Doctor! That’s because since taking Donald Moyer’s course called Seeing and Understanding Bodies, I notice a lot of interesting variations in human bodies, and I could see Matt Smith’s bowlegs even through his pants.

Bowlegs (Genum varum) is a condition in which when a person stands with his or her feet together, the knees remain wide apart (see Doctor Who above). Did you know that we all start out life bowlegged because of our folded position in our mother's wombs? By around age three, we can usually stand with our ankles apart and our knees just touching when our feet are together. Hyperextended knees resemble bowlegs in this way, however, so if you’re not sure which you have (or which your student has), see Hyperextension of the Knees and Yoga, which contains a simple test you can do.

I was going to go into a whole long thing about what causes bowlegs (diseases, such as rickets, some professions, like being a jockey—maybe the reason so many Japanese people are bowlegged is because of the way they sit—and possibly the natural anatomical structure of the hip joint and the position of the thighbone within it). But the real question is: why do we care if someone has bowlegs? The answer is that because people with bowlegs tend to bear weight unevenly on their hips, knees and feet (the outer sides of these joints bear more weight), uneven stress and wear on those joints could lead to the early onset of arthritis. 

By working with your alignment in your yoga poses, you can learn to bear your weight more even in your asanas and, with that new awareness, in your daily life as well. My teacher Donald has bowlegs himself, so I decided to chat with him about his ideas about working with this condition in yoga practice. And the result is this post.

Bowlegged people tend to stand on the outer edges of their feet with their feet slightly turned out and your feet are your foundation in your standing poses (and while you are walking!), so I’m going to begin with some suggestions about the feet. After that, I’ll make some suggestions for working with your legs.

Working with Your Feet

In Mountain pose (and variations of it), stand with your feet in line with the center of your hip joints, rather than touching each other. This way your legs will be less bowed and you’ll carry your weight a bit more evenly. Then, align your feet by making the second foot bones (the second metatarsal that connects to the second toe) rather than your toes parallel with each other. Once your feet are aligned, consciously bring some weight onto the ball of your big toes and roll your first foot bone (the first metatarsal that connects to your big toe) toward the midline of your body. 

In all your standing poses, align your front foot so your second foot bone is parallel with the edge of your mat using the same techniques described above. And for both feet, consciously bring more weight onto the inner edges of your feet, also as described above.

Because people with bowlegs tend to walk on their outer feet, use this new awareness of distributing your weight more evenly on your feet while you move through your day, so you walk on your inner as well as your outer feet.

Working with Your Legs

In your standing poses, after aligning your feet, you should focus on strengthening your inner legs, taking some of the weight off the outer legs. Using props can help you focus on the inner leg muscles.

In Downward-Facing Dog pose (Adho Mukha Svanasana) and Standing Forward Bend (Uttanasana), you can put a block turned on its narrowest side between your upper thighs (and, if you wish, a strap around the thighs to help keep the block in place and give you awareness of your outer thighs). To use this propping in Downward-Facing Dog, you’ll need to place your feet closer together than usual. Then use the touch of the block against your thighs to activate your inner thigh muscles. Use the awareness you develop in these two poses to activate these same muscles in all your standing poses.

You can also use Tree pose (Vrksasana) to help activate your inner thigh muscles, as you press your inner thigh against your raised foot at the same time you press the foot against your thigh.

In standing poses in which you can’t place a block between your legs, such as Extended Side Angle pose (Utthita Parsvakonasana) and Triangle pose (Trikonasana), you can work with a partner. Have your partner stand behind your back foot, and then use a strap around the upper inner thigh of your back leg to gently pull back your inner thigh toward the thighbone.

Because your outer calves are also overdeveloped compared with your inner calves, you can also work on strengthening your inner calves. You can stand with a block between your calves to learn how to activate this area in the same way you did with your inner thighs.

In your everyday life, you can bring this your new awareness of your inner legs into your movements as you walk and go about your day.

In all standing poses, you can bring your legs into a straighter alignment by consciously moving your leg muscles so that the median line of your calves is aligned with the median line of your hamstrings. To do this, move your inner calves toward your inner leg and outer calves toward your outer leg, Likewise, move your inner hamstrings toward your inner legs and outer hamstrings toward your outer leg. How does that feel to you? Is your weight more evenly distributed? You can practice also these same techniques to align your straight leg or legs in seated poses, such as Seated Forward Bend (Paschimottanasana), when you can get a good look at your legs and how your movements affect the alignment.

In general, with all these suggestions, just experiment and see if any of the techniques feel good to you. For example, many people with bowlegs feel a burning sensation on their outer feet in Widespread Standing Forward Bend (Prasarita Padottanasana). Shifting some of your weight to your inner feet (as described above) may alleviate that pain, making you feel more comfortable in the pose. Sometimes the good feeling you have may be just a sensation of energy moving more freely through you. And if anything causes pain or serious discomfort, please come out of the pose or return to another way of practicing it.

If you have other suggestions for working with bowlegs, please let us know!

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